Racialized risk environments in a large sample of people who inject drugs in the United States

Racialized environments and syringe services program implementation: County-level factors

OBJECTIVE

Racialized health inequities in substance use-related harms might emerge from differential access to syringe service programs (SSPs). To explore this, we examined the association between county-level racialized environments, other factors, and (1) SSP presence, and (2) per capita syringe and (3) naloxone distribution.

METHODS

2021 US National Survey of SSP data (n=295/412;72 % response rate) was used to identify SSP presence and the sum of syringes and naloxone doses distributed in 2020 by county. Study measures included racial residential segregation (RRS; i.e., divergence and dissimilarity indexes for Black:Non-Hispanic White & Hispanic:Non-Hispanic White) and covariates (i.e., demographic proportions, urban/suburban/rural classifications, 2020 US presidential Republican vote share, and overdose mortality from 2019). We used logit Generalized Estimating Equations to determine factors associated with county-level SSP presence, and zero inflated negative binomial regression models to determine factors associated with per capita syringe and naloxone distribution.

RESULTS

SSPs were reported in 9 % (283/3106) of US counties. SSP presence was associated with higher divergence and dissimilarity indexes, urban and suburban counties, higher opioid overdose mortality, and lower 2020 Republican presidential vote share. Per capita syringes distributed was associated with lower RRS (divergence and Hispanic:White dissimilarity), lower racially minoritized population proportions and rural counties, while per capita naloxone distribution was associated with lower Hispanic and "other" population proportions, and rural counties.

CONCLUSIONS

Racialized environments are associated with SSP presence but not the scope of those programs. Preventing HIV and HCV outbreaks, and overdose deaths requires addressing community level factors that influence SSP implementation and accessibility.

Estimation of place-based vulnerability scores for HIV viral non-suppression: an application leveraging data from a cohort of people with histories of using drugs

The relationships between place (e.g., neighborhood) and HIV are commonly investigated. As measurements of place are multivariate, most studies apply some dimension reduction, resulting in one variable (or a small number of variables), which is then used to characterize place. Typical dimension reduction methods seek to capture the most variance of the raw items, resulting in a type of summary variable we call "disadvantage score". We propose to add a different type of summary variable, the "vulnerability score," to the toolbox of the researchers doing place and HIV research. The vulnerability score measures how place, as known through the raw measurements, is predictive of an outcome. It captures variation in place characteristics that matters most for the particular outcome. We demonstrate the estimation and utility of place-based vulnerability scores for HIV viral non-suppression, using data with complicated clustering from a cohort of people with histories of injecting drugs.

Injection Behaviors and Use of Syringe Service Programs over Time among People Who Inject Drugs in Baltimore, Maryland

Introduction: People who inject drugs (PWID) are at increased risk for infectious disease transmission, including hepatitis C and HIV. Understanding trends in injection risk behaviors and syringe service program (SSP) use over time can help improve infectious disease prevention and other harm reduction services. Methods: Using National HIV Behavioral Surveillance System data from Baltimore, Maryland, we examined changes in receptive sharing of (1) syringes, (2) injection equipment, (3) syringes to divide drugs; and (4) receipt of syringes from SSPs among PWID from 2009 to 2018 (n = 518 in 2009, n = 638 in 2012, n = 586 in 2015, and n = 575 in 2018) using unadjusted and adjusted logistic models calculated across time for the total sample. Results: The conditional probability of receptive sharing of syringes and receipt of syringes from SSPs remained relatively stable, while receptive sharing of injection equipment and receptive sharing of syringes to divide drugs dropped substantially after 2009. White race and daily injection frequency were positively associated with sharing syringes and injection equipment and negatively associated with SSP use over time. In 2015, there was a notable shift such that women were twice as likely as men to receive syringes from SSPs and less likely than men to report the use of shared syringes or equipment. Conclusion: Findings indicate overall steady or decreasing trends in injection risk and steady trends in SSP usage over time, with some notable improvements among women and indications of shifting drug market patterns. Injection-related risk behaviors remain high among White PWID and may require targeted outreach and interventions.

Socioeconomic and racial/ethnic spatial polarization and incarceration among people who inject drugs in 19 US metropolitan areas, 2015

The purpose of this study is to test, for the first time, the association between spatial social polarization and incarceration among people who inject drugs (PWID) in 19 large U.S. metropolitan statistical areas (MSAs) in 2015. PWID were recruited from MSAs for the Centers for Disease Control and Prevention's 2015 National HIV Behavioral Surveillance. Administrative data were used to describe the ZIP-code areas, counties, and MSAs where PWID lived. We operationalized spatial polarization using the Index of Concentration at the Extremes (ICE), a measure that reflects polarization in race and household income at the ZIP-code level. We tested the association between spatial polarization and odds of past-year arrest and detainment using multilevel multivariable models. We found 37% of the sample reported being incarcerated in the past year. Report of past-year incarceration varied by race/ethnicity: 45% of non-Hispanic white PWID reported past-year incarceration, as did 25% of non-Hispanic Black PWID, and 43% of Hispanic/Latino PWID (N = 9047). Adjusted odds ratios suggest that Black PWID living in ZIP-code areas with a higher ICE score, meaning more white and affluent, had higher odds of past-year incarceration, compared to white PWID. In previous research, incarceration has been found to be associated with HIV acquisition and can deter PWID from engaging in harm reduction activities.

Differential risks of syringe service program participants in Central Ohio: a latent class analysis

BACKGROUND

Significant heterogeneity exists among people who use drugs (PWUD). We identify distinct profiles of syringe service program (SSP) clients to (a) evaluate differential risk factors across subgroups and (b) inform harm reduction programming.

METHODS

Latent class analysis (LCA) was applied to identify subgroups of participants (N = 3418) in a SSP in Columbus, Ohio, from 2019 to 2021. Demographics (age, sex, race/ethnicity, sexual orientation, housing status) and drug use characteristics (substance[s] used, syringe gauge, needle length, using alone, mixing drugs, sharing supplies, reducing use, self-reported perceptions on the impact of use, and treatment/support resources) were used as indicators to define latent classes. A five-class LCA model was developed, and logistic regression was then employed to compare risk factors at program initiation and at follow-up visits between latent classes.

RESULTS

Five latent classes were identified: (1) heterosexual males using opioids/stimulants with housing instability and limited resources for treatment/support (16.1%), (2) heterosexual individuals using opioids with stable housing and resources for treatment/support (33.1%), (3) individuals using methamphetamine (12.4%), (4) young white individuals using opioids/methamphetamine (20.5%), and (5) females using opioids/cocaine (17.9%). Class 2 served as the reference group for logistic regression models, and at the time of entry, class 1 was more likely to report history of substance use treatment, overdose, HCV, sharing supplies, and mixing drugs, with persistently higher odds of sharing supplies and mixing drugs at follow-up. Class 3 was more likely to report history of overdose, sharing supplies, and mixing drugs, but outcomes at follow-up were comparable. Class 4 was the least likely to report history of overdose, HCV, and mixing drugs, but the most likely to report HIV. Class 5 was more likely to report history of substance use treatment, overdose, HCV, sharing supplies, and mixing drugs at entry, and higher reports of accessing substance use treatment and testing positive for HCV persisted at follow-up.

CONCLUSIONS

Considerable heterogeneity exists among PWUD, leading to differential risk factors that may persist throughout engagement in harm reduction services. LCA can identify distinct profiles of PWUD accessing services to tailor interventions that address risks, improve outcomes, and mitigate disparities.

Activity Space Assessments to Investigate Neighborhood Exposure to Racism-Related Stress and Related Substance Use Among Young Black Men: Connecticut, 2019

Objectives. To use activity space assessments to investigate neighborhood exposures that may heighten young Black men's vulnerability to substance use and misuse. Methods. We surveyed young Black men in New Haven, Connecticut in 2019 on the locations (activity spaces) they traveled to in a typical week and their experiences of racism and any alcohol and cannabis use at each location. Results. A total of 112 young Black men (mean age = 23.57 years; SD = 3.20) identified 583 activity spaces. There was significant overlap between racism-related events and substance use (alcohol and cannabis use) at specific locations. Areas with a higher prevalence of violent crime also had a greater frequency of racism-related events and substance use. Conclusions. An activity space approach is a promising method for integrating objective and subjective experiences within neighborhood contexts to better understand the frequency and co-occurrence of racism-related stress and substance use among young Black men. (Am J Public Health. 2023;113(S2):S136-S139. https://doi.org/10.2105/AJPH.2023.307254).

The group-based law enforcement mistrust scale: psychometric properties of an adapted scale and implications for public health and harm reduction research

Background

Negative encounters with law enforcement—direct and vicarious—fuel mistrust. When considered as part of the ‘risk environment’ in public health and harm reduction research, law enforcement mistrust may have broad implications. For example, fearing arrest may prevent someone from calling 911 when witnessing an overdose or lead to syringe-sharing and community spread of HIV. For people in the US who identify as Black or African American, these effects may compound, given the ways in which communities of color have been overpoliced. The purpose of this study is to investigate the psychometrics of an adapted scale of law enforcement mistrust—the Group-Based Law Enforcement Mistrust Scale (GBLEMS)—and evaluate its associations with racial and ethnic identity and experiences with law enforcement.

Methods

This cross-sectional survey took place in a small city in the Western United States where only 3% of the population is Black or African American. The sample included Black or African American and Hispanic and Latina women at risk of HIV, and members of their social networks, yielding a diverse sample across racial, ethnic, and gender identities (N = 219). The GBLEMS is a 12-item scale adapted from the Group-Based Medical Mistrust Scale (GBMMS; Thompson et al. 2004). The current analysis evaluated the psychometric properties of the GBLEMS (reliability, exploratory factor analysis) and its associations with demographics, other race-based constructs, and experiences with law enforcement.

Results

The GBLEMS demonstrated strong reliability (Cronbach’s alpha = 0.92) and exploratory factor analysis indicated that items loaded onto two factors—mistrust and disparities in treatment. There was also support for the scale’s construct validity. As hypothesized, GBLEMS scores were higher among respondents who identify as Black or African American, and among those who reported other experiences of racial discrimination, medical mistrust, and negative encounters with law enforcement.

Conclusions

This study yielded support for the reliability and validity of the GBLEMS as a multi-item, two-factor scale measuring group-based law enforcement mistrust. When framing public health and harm reduction research in terms of the risk environment, law enforcement mistrust may be important to measure as part of a comprehensive approach that addresses persistent racial disparities.

"It's on every corner": assessing risk environments in Baltimore, MD using a racialized risk environment model

Physical, social, economic, and political environments can increase harm and risk among people who use drugs. These factors may be exacerbated in urban environments with a history of systemic inequality toward African Americans. However, racialized risk environment models have rarely been used within substance use research. To fill this gap, the current qualitative study sought to describe the racialized risk environment of an African American sample of 21 adults with a history of illicit drug use living in Baltimore, MD. Semi-structured interviews were conducted. Data were analyzed using qualitative content analysis to identify themes related to illicit drug use, neighborhood context, violence, social interactions, and income generation. Themes related to the physical (e.g., the increased visibility of drug markets), social (e.g., normalization of drug use within social networks), and economic (e.g., financial hardships) risk environments emerged from this sample. These perceptions and themes can aid in developing and refining substance use programming within racialized settings.

A Systematic Review of Neighborhood-Level Influences on HIV Vulnerability

A better understanding of the social-structural factors that influence HIV vulnerability is crucial to achieve the goal of ending the HIV epidemic by 2030. Given the role of neighborhoods in HIV outcomes, synthesis of findings from such research is key to inform efforts toward HIV eradication. We conducted a systematic review to examine the relationship between neighborhood-level factors (e.g., poverty) and HIV vulnerability (via sexual behaviors and substance use). We searched six electronic databases for studies published from January 1, 2007 through November 30, 2017 (PROSPERO CRD42018084384). We also mapped the studies' geographic distribution to determine whether they aligned with high HIV prevalence areas and/or the "Ending the HIV Epidemic: A Plan for the United States". Fifty-five articles met inclusion criteria. Neighborhood disadvantage, whether measured objectively or subjectively, is one of the most robust correlates of HIV vulnerability. Tests of associations more consistently documented a relationship between neighborhood-level factors and drug use than sexual risk behaviors. There was limited geographic distribution of the studies, with a paucity of research in several counties and states where HIV incidence/prevalence is a concern. Neighborhood influences on HIV vulnerability are the consequence of centuries-old laws, policies and practices that maintain racialized inequities (e.g., racial residential segregation, inequitable urban housing policies). We will not eradicate HIV without multi-level, neighborhood-based approaches to undo these injustices. Our findings inform future research, interventions and policies.

A qualitative study on pharmacy policies toward over-the-counter syringe sales in a rural epicenter of US drug-related epidemics

Background

Expanding access to sterile syringes in rural areas is vital, as injection-related epidemics expand beyond metropolitan areas globally. While pharmacies have potential to be an easily accessible source of sterile syringes, research in cities has identified moral, legal and ethical barriers that preclude over-the-counter (OTC) sales to people who inject drugs (PWID). The current study builds on prior urban-based research by elucidating (1) pharmacy OTC policies and (2) pharmacists’ rationale for, and barriers and facilitators to, OTC syringe sales in a US rural area hard hit by drug-related epidemics.

Methods

We conducted 14 semi-structured interviews with pharmacists recruited from two Eastern Kentucky health districts. Interview domains included experiences with, and attitudes toward, selling OTC syringes to PWID. Constructivist grounded theory methods were used to analyze verbatim transcripts.

Results

Most pharmacists operated “restrictive OTC” pharmacies (n = 8), where patients were required to have a prescription or proof of medical need to purchase a syringe. The remainder (n = 6) operated “open OTC” pharmacies, which allowed OTC syringe sales to most patients. Both groups believed their pharmacy policies protected their community and pharmacy from further drug-related harm, but diverging policies emerged because of stigma toward PWID, perceptions of Kentucky law, and belief OTC syringe sales were harmful rather than protective to the community.

Conclusion

Our results suggest that restrictive OTC pharmacy policies are rooted in stigmatizing views of PWID. Anti-stigma education about substance use disorder (SUD), human immunodeficiency virus (HIV), and Hepatitis C (HCV) is likely needed to truly shift restrictive pharmacy policy.

Assessing the relationship between syringe exchange, pharmacy, and street sources of accessing syringes and injection drug use behavior in a pooled nationally representative sample of people who inject drugs in the United States from 2002 to 2019

Provision of sterile syringes is an evidence-based strategy of reducing syringe sharing and reusing and yet, access to sterile syringes through pharmacies and syringe exchange programs (SEPs) in the United States remains inadequate. This nationally representative study examined associations between obtaining syringes from pharmacies, SEPs, and sterilizing syringes with bleach and risk of syringe borrowing, lending and reusing syringes in a pooled cross-sectional dataset of 1737 PWID from the 2002-2019 National Survey on Drug Use and Health. Logistic regression was used to produce odds ratios (OR) of the odds of injection drug behaviors after adjusting for obtaining syringes from SEPs, pharmacies, the street, and other sources and potential confounders of race, ethnicity, sex, education, and insurance coverage. Obtaining syringes through SEPs was associated with lower odds of borrowing (OR = .4, CI95% = .2, .9, p = .022) and reusing syringes (OR = .3, CI95% = .2, .6, < .001) compared to obtaining syringes on the street. Obtaining syringes from pharmacies was associated with lower odds of borrowing (OR = .5, CI95% = .3, .9, p = .037) and lending (OR = .5 CI95% = .3, .9, p = .020) syringes. Using bleach to clean syringes was associated with increased odds of borrowing (OR = 2.0, CI95% = 1.3, 3.0, p = .002), lending (OR = 2.0, CI95% = 1.3, 3.0, p = .002) and reusing syringes (OR = 2.4, CI95% = 1.6, 3.6, p < .001). Our findings support provision of syringes through pharmacies and SEPs as a gold-standard strategy of reducing sharing and reuse of syringes in the US.

Negotiating sex work and client interactions in the context of a fentanyl-related overdose epidemic

Despite awareness of the role of drug use in shaping sex worker/client interactions, these dynamics remain poorly understood in the context of illicit fentanyl-driven overdose epidemics. This study examined sex workers' experiences negotiating client interactions amidst a toxic drug supply in Vancouver, Canada. Findings draw from two ethnographic studies. The first, conducted between December 2016 and May 2017, examined the rapid implementation of several low-threshold supervised consumption sites. The second investigated experiences of women accessing a women-only site from May 2017 to June 2018. Data included 200 hours of fieldwork and in-depth semi-structured interviews with 34 street-based sex workers who use illicit drugs. Data were analysed thematically with attention to the risk environment. Participants described providing harm reduction services to clients as a means to reduce overdose-related risks, thus increasing sex workers' hidden labour. Participants, comments regarding criminalisation and stigma surrounding drug use and sex work indicated a reticence to report overdoses, thereby potentially increasing the risks of overdose-related harms, including death. There is an urgent need for sex worker-led overdose prevention strategies that prioritise health and safety of sex workers and their clients with specific attention to how the criminalisation of particular drugs, practices and people contributes to overdose-related risks.

Place-Based Correlates of Exchange Sex Among People Who Inject Drugs in 19 U.S. Metropolitan Areas, 2012

This study examined overall and gender-specific associations between place-based characteristics and opposite-sex exchange sex among people who inject drugs (PWID) in the U.S. PWID were recruited from 19 metropolitan statistical areas (MSAs) for the Centers for Disease Control and Prevention's 2012 National HIV Behavioral Surveillance. Administrative data were used to describe the economic, social, and political features of the ZIP codes, MSAs, counties, and states where PWID lived. Multilevel modeling estimated associations of place characteristics and exchange sex. We found that 52% of women and 23% of men reported past-year opposite-sex exchange sex (N = 7599). Female PWID living in states with stronger policies supporting working caregivers had lower odds of exchange sex (aOR = 0.80; 95% CI 0.69, 0.94). PWID living in ZIP codes with greater economic deprivation had higher odds of exchange sex (aOR = 1.10; 95% CI 1.03, 1.17). We found that a high percentage of male PWID exchanged sex with women; determinants and risks of this group merit exploration. If future research establishes that the relationships identified here are causal, interventions to reduce exchange sex among PWID should include policies supporting working caregivers and reducing poverty rates.

Decision-making by laypersons equipped with an emergency response smartphone app for opioid overdose

BACKGROUND

Targeted naloxone distribution to potential lay responders increases the timeliness of overdose response and reduces mortality. Little is known, however, about the patterns of decision-making among overdose lay responders. This study explored heuristic decision-making among laypersons equipped with an emergency response smartphone app.

METHODS

UnityPhilly, a smartphone app that connects lay responders equipped with naloxone to overdose victims, was piloted in Philadelphia from March 2019 to February 2020. Participants used the app to signal overdose alerts to peer app users and emergency medical services, or respond to alerts by arriving at overdose emergency sites. This study utilised in-depth interviews, background information, and app use data from a sample of 18 participants with varying histories of opioid use and levels of app use activity.

RESULTS

The sample included 8 people who used opioids non-medically in the past 30 days and 10 people reporting no opioid misuse. Three prevailing, not mutually exclusive, heuristics were identified. The heuristic of unconditional signalling ("Always signal for help or backup") was used by 7 people who valued external assistance and used the app as a replacement for a 911 call; this group had the highest number of signalled alerts and on-scene appearances. Nine people, who expressed confidence in their ability to address an overdose themselves, followed a heuristic of conditional signalling ("Rescue, but only signal if necessary"); these participants had the highest frequency of prior naloxone administrations. Eleven participants used the heuristic of conditional responding ("Assess if I can make a difference"), addressing an alert if they carried naloxone, were nearby, or received a signal before dark hours.

CONCLUSION

The deployment of specific heuristics was influenced by prior naloxone use and situational factors. Success of overdose prevention interventions assisted by digital technologies may depend on the involvement of people with diverse overdose rescue backgrounds.

Is the severity of the Great Recession's aftershocks correlated with changes in access to the combined prevention environment among people who inject drugs?

BACKGROUND

The 2008 Recession was a global event that led to funding cuts for programs and services in the United States; though this recession officially ended in 2009, its aftershocks continued through 2012. We evaluated the relationship between the severity of the Great Recession's aftermath and spatial access to combined prevention services (i.e. HIV testing, syringe service programs, substance use disorder treatment program) for people who inject drugs (PWID) living in 19 metropolitan statistical areas (MSAs) in the United States.

METHODS

The unit of analysis was the ZIP code; we sampled ZIP codes in these 19 MSAs where ≥1 PWID lived in 2009 and 2012, according to the CDC's National HIV Behavioral Surveillance. We used administrative data to describe the combined prevention environment (i.e., spatial access to HIV testing) for each ZIP code, and measured the severity of the recession's aftermath in each ZIP code, and in the counties and MSAs where these ZIP codes were located. Multilevel modeling estimated associations between changes in the aftermath of the Great Recession and ZIP code-level changes in spatial access to combined prevention services from 2009 to 2012.

RESULTS

675 ZIP codes located in 36 counties and 19 MSAs were included in this analysis. From 2009 to 2012, 21% of ZIP code areas lost access to combined prevention services and 14% gained access. ZIP codes with higher poverty rates relative to their respective MSAs were less likely to lose access (aOR: 0.91; 95% CI: 0.88, 0.95) and more likely to gain access (aOR: 1.05; 95% CI: 1.01, 1.09); there is some evidence to suggest the former association was attenuated for ZIP codes with higher percentages of non-Hispanic white residents.

CONCLUSION

Combined prevention services for PWID living in these 675 ZIP codes demonstrated resilience in the aftermath of the Great Recession. Future research should explore whether community-based and federal HIV prevention initiatives contributed to this resilience, particularly in areas with higher concentrations of people of color.

An application of agent-based modeling to explore the impact of decreasing incarceration rates and increasing drug treatment access on sero-discordant partnerships among people who inject drugs

BACKGROUND

People who inject drugs (PWID) lag behind other key populations in HIV care continuum outcomes. The impacts of criminal justice reform and increasing drug treatment access on HIV have been underexplored.

METHODS

We developed agent-based models (ABM) of sexual partnerships among PWID and non-PWID, and injection equipment-sharing partnerships among PWID in five US cities (Baltimore, Boston, Miami, New York City, San Francisco) over 3 years. The first set of ABM projected changes in partnership discordance among PWID as a function of decreasing ZIP code-level incarceration rates. The second set projected discordance as a function of increasing ZIP code-level drug treatment access. ABM were parameterized and validated overall, and by city and PWID race/ethnicity (Black, Latino, White) using National HIV Behavioral Surveillance data, administrative ZIP code-level data, surveillance reports and prior literature. Informed by research on prisoner release and community-level HIV prevalence, reductions in incarceration rates were fixed at 5% and 30% and respectively projected to increase ZIP code-level HIV prevalence by 2% and 12%. Increases in drug treatment access were fixed at 30% and 58%.

RESULTS

In each city, a 30% reduction in ZIP code-level incarceration rates and 12% increase in ZIP code-level HIV prevalence significantly increased sero-discordance among at least one racial/ethnic group of PWID by 1-3 percentage points. A 5% reduction in incarceration rates, and 30% and 58% increases in drug treatment access, led to isolated significant changes in sero-discordance among Black and White PWID that were less than 1 percentage point.

CONCLUSION

Reductions in incarceration rates may lead to short-term increases in sero-discordant partnerships among some PWID by increasing community-level HIV prevalence. Efforts to increase HIV testing, engagement in care and community reintegration post release, should be strengthened in the wake of incarceration reform. Additional research should confirm these findings and explore the lack of widespread impacts of drug treatment in this study.

The Past, Present, and Future of PrEP implementation Among People Who Use Drugs

PURPOSE OF REVIEW

Recent HIV outbreaks among people who use drugs (PWUD) necessitate additional HIV prevention tools. Pre-exposure prophylaxis (PrEP) is highly efficacious yet uptake among PWUD remains exceedingly low. To address multilevel, complex barriers to PrEP use among PWUD, a range of intervention strategies are needed.

RECENT FINDINGS

The literature on interventions to optimize PrEP use among PWUD is nascent, comprising small pilots and demonstration projects in early phases of intervention development. Initial studies suggest that structural, healthcare, interpersonal, and individual-level interventions can improve PrEP use for PWUD, and a number of efficacy trials are underway. Future studies are needed to optimize the use of new PrEP modalities (e.g., injectable PrEP), simultaneously target multilevel challenges to PrEP use, and evaluate the integration of PrEP into other service settings and substance use treatment modalities.

Legacies of the war on drugs: Next of kin of persons who died of opioid overdose and harm reduction interventions in Philadelphia

BACKGROUND

Between the years 2017-2019 in Philadelphia, more than 70% of all deaths from opioid overdose occurred in a private residence. To learn more about home-based opioid use and overdose, researchers conducted qualitative interviews with next of kin of overdose victims to learn their perceptions about the decedent's drug use and their opinions about city-led harm reduction efforts, specifically naloxone administration and collaborative efforts to open an overdose prevention site.

METHODS

In 2019, researchers conducted 35 qualitative interviews with next of kin of persons who died of opioid overdose in Philadelphia in 2017. Data were coded and analyzed using NVivo software.

RESULTS

Data reveal that while persons who use drugs may benefit from enhanced harm reduction interventions that target their family members and caregivers including naloxone education and public health messaging about overdose prevention, these efforts may be up against other realities that Philadelphia families navigate-in particular structural inequalities exacerbated by decades of "War on Drugs" policies.

CONCLUSION

Existing health disparities and structural barriers to care increase vulnerability to overdose and highlight the urgency to collaborate with impacted families and communities to design relevant harm reduction interventions. Without efforts to redress the consequences of war on drug policies, however, harm reduction interventions will not reach their full potential.

Geographic Differences and Social Determinants of Health Among People With HIV Attributed to Injection Drug Use, United States, 2017

OBJECTIVE

People who inject drugs are among the groups most vulnerable to HIV infection. The objective of this study was to describe differences in the geographic distribution of HIV diagnoses and social determinants of health (SDH) among people who inject drugs (PWID) who received an HIV diagnosis in 2017.

METHODS

We used data from the National HIV Surveillance System (NHSS) to determine the counts and percentages of PWID aged ≥18 with HIV diagnosed in 2017. We combined these data with data from the US Census Bureau's American Community Survey at the census tract level to examine regional, racial/ethnic, and population-area-of-residence differences in poverty status, education level, income level, employment status, and health insurance coverage.

RESULTS

We observed patterns of disparity in HIV diagnosis counts and SDH among the 2666 PWID with a residential address linked to a census tract, such that counts of HIV diagnosis increased as SDH outcomes became worse. The greatest proportion of PWID lived in census tracts where ≥19% of the residents lived below the federal poverty level, ≥18% of the residents had <high school diploma, the median annual household income was <$40 000, and ≥16% of the residents did not have health insurance or a health coverage plan.

CONCLUSION

To our knowledge, our study is the first large-scale, census tract-level study to describe SDH among PWID with diagnosed HIV in the United States. The findings of substantial disparities in SDH among people with HIV infection attributed to injection drug use should be further examined. Understanding the SDH among PWID is crucial to reducing disparities in HIV diagnoses in this population.

A randomized controlled trial of a brief behavioral intervention to reduce skin and soft tissue infections among people who inject drugs

BACKGROUND

People who inject drugs (PWID) are at high risk for skin and soft tissue infections (SSTIs), but few interventions have targeted their reduction. The goal of the current study was to test the effects of a brief skin and needle hygiene behavioral intervention (SKIN) in a two-group randomized controlled trial with 12-month follow-up.

METHOD

PWID (N = 252) were recruited from inpatient hospital units at a single urban medical center site and randomly assigned to an assessment-only (AO) condition or SKIN, which was a two-session intervention that included psychoeducation, behavioral skills demonstrations, and motivational interviewing. Mixed effects generalized linear models assessed the impact of the intervention on frequency of: 1) self-reported SSTIs, 2) uncleaned skin injections, and 3) injection.

RESULTS

Participants were 58.3 % male, 59.5 % White, and averaged 38 years of age. SKIN participants had 35 % fewer SSTIs compared to AO (p = .179), a difference of nearly one infection per year. The mean rate of uncleaned skin injections was about 66 % lower (IRR = 0.34, 95 % CI 0.20; 0.59, p < .001) among SKIN participants compared to AO. Almost one-third of participants reported no injection over follow-up and the mean rate of injection during follow-up was about 39 % lower (IRR = 0.61; 95 % CI 0.36; 1.02, p = .058) among persons randomized to SKIN than AO.

CONCLUSIONS

The SKIN intervention reduced uncleaned skin injections but did not reduce SSTIs significantly more than a control condition. Brief interventions can improve high-risk practices among PWID and lead to clinically meaningful outcomes.

Novel Routes of Potential Hepatitis C Virus Transmission among People Who Inject Drugs: Secondary Blood Exposures Related to Injection Drug Use

BACKGROUND

The US is in the midst of a national Hepatitis C Virus (HCV) epidemic that appears to be driven by new cases among people who inject drugs (PWID). While HCV transmission among PWID is believed to occur mostly through direct sharing of syringes, some infections may be spread via secondary processes and materials involved in injecting.

OBJECTIVES

Here, we present the prevalence of secondary blood exposures on clothing and nearby surfaces after injection episodes and examine the correlations of these exposures to lifetime HCV infection among a targeted sample of 553 PWID in Los Angeles and San Francisco, California in 2016-18.

RESULTS

In multivariate logistic regression models, higher odds of blood on clothing in the last 30 days was significantly (p < 0.05) associated with lifetime positive HCV status, opioids as primary drug, injecting with others, sharing cookers, and receptive syringe sharing. Higher adjusted odds of blood on nearby surfaces in the last 30 days was significantly associated with lifetime positive HCV status, sharing cookers, and receptive syringe sharing. Native American race was associated with significantly lower adjusted odds of both outcome variables. Conclusions/Importance: Results indicate the relevance of physical and social micro-environments to the potential for blood exposures secondary to injection episodes. Individuals with chronic HCV seropositivity are potentially more likely to expose others to blood due to decreases in the blood's ability to clot. This highlights the need for increased HCV testing at harm reduction sites and increased supply of first aid and wound-care materials to help stop potential blood exposures after injection episodes.

COVID-19 and the health of people who use drugs: What is and what could be?

SARS-CoV-2, the virus that causes COVID-19, has changed the world as we know it, and continues to do so. How COVID-19 affects people who use drugs, the environments in which they live, and capacities of response, warrants immediate attention. This special issue begins to map how COVID-19 is altering the health of people who use drugs, including in relation to patterns of drug use, service responses, harms that may relate to drug use, interventions to reduce risk of harms, COVID-19 health, and drug policies. We emphasise the need to envisage COVID-19 and its effects as a matter of intersecting ‘complex adaptive systems’: that is, the impacts of COVID-19 extend beyond the virus and related illness conditions to encompass multiple social, cultural, economic, policy and political effects; and these affect the health of people who use drugs directly as well as indirectly by altering the risk and enabling environments in which they live. We synthesize emergent evidence on the impact of COVID-19 on the health of people who use drugs. A key concern we identify is how to sustain policy and service delivery improvements prompted by COVID-19. We need to maintain an ethos of emergent adaptation and experimentation towards the creation of safer environments in relation to the health of people who use drugs.

Buprenorphine dispensing in an epicenter of the U.S. opioid epidemic: A case study of the rural risk environment in Appalachian Kentucky

BACKGROUND

Buprenorphine is a cornerstone to curbing opioid epidemics, but emerging data suggest that rural pharmacists in the US sometimes refuse to dispense this medication. We conducted a case study to explore buprenorphine dispensing practices in 12 rural Appalachian Kentucky counties, and analyze whether and how they were shaped by features of the rural risk environment.

METHODS

In this case study, we conducted one-on-one semi-structured interviews with 14 pharmacists operating 15 pharmacies in these counties to explore buprenorphine dispensing practices and perceived influences on these practices. Thematic analyses of the resulting transcripts revealed three features of the rural risk environment that shaped dispensing. To explore these three risk environment features, we analyzed policy documents (e.g., Attorney General lawsuits) and administrative databases (e.g., incarceration data). Textual documents were analyzed using thematic analyses and administrative data were analyzed using descriptive statistics; memoes explored relationships among risk environment features and dispensing practices.

RESULTS

Twelve of the 15 pharmacies limited dispensing, by refusing to serve new patients; limiting dispensing to known patients or prescribers; or refusing to dispense buprenorphine altogether. Concerns about exceeding a "Drug Enforcement Administration (DEA) cap" on opioid dispensing stifled dispensing. A legacy of aggressive and fraudulent marketing of opioid analgesics (OAs) by pharmaceutical companies and physician OA overprescribing undermined pharmacist trust in buprenorphine and in its prescribers. The escalating local war on drugs may have undermined dispensing by reinforcing stigma against people who use drugs.

CONCLUSIONS

Initiatives to increase buprenorphine prescribing must be accompanied by policy changes to increase dispensing. Specifically, buprenorphine should be removed from opioid monitoring systems; efforts to de-escalate the war on drugs should be extended to encompass rural areas; initiatives to dismantle aggressive OA marketing should be strengthened; and efforts to re-build pharmacist trust in physicians are needed.

Rural risk environments, opioid-related overdose, and infectious diseases: A multidimensional, spatial perspective

BACKGROUND

Much remains unknown in rural risk environments, despite a growing crisis in these areas. We adapt a risk environment framework to characterize rural southern Illinois and describe the relations of risk environments, opioid-related overdose, HIV, Hepatitis C, and sexually transmitted infection rates between 2015 and 2017.

METHODS

Over two dozen risk environment variables are summarized across zip-code (n = 128) or county levels (n = 16) based on availability and theoretical relevance. We calculate data attribute associations and characterize spatial and temporal dimensions of longitudinal health outcomes and the rural risk environment. We then use a "regional typology analysis" to generate data-driven risk regions and compare health outcomes.

RESULTS

Pervasive risk hotspots were identified in more populated locales with higher rates of overdose and HCV incidence, whereas emerging risk areas were isolated to more rural locales that had experienced an increase in analgesic opiate overdoses and generally lacked harm-reduction resources. At-risk areas were characterized with underlying socioeconomic vulnerability but in differing ways, reflecting a nuanced and shifting structural risk landscape.

CONCLUSIONS

Rural risk environment vulnerabilities and associated opioid-related health outcomes are multifaceted and spatially heterogeneous. More research is needed to better understand how refining geographies to more precisely define risk can support intervention efforts and further enrich investigations of the opioid epidemic.

Protocol of a randomized controlled trial to test the effects of client-centered Representative Payee Services on antiretroviral therapy adherence among marginalized people living with HIV

BACKGROUND

Client-Centered Representative Payee (CCRP) is an intervention modifying implementation of a current policy of the US Social Security Administration, which appoints organizations to serve as financial payees on behalf of vulnerable individuals receiving Social Security benefits. By ensuring beneficiaries' bills are paid while supporting their self-determination, this structural intervention may mitigate the effects of economic disadvantage to improve housing and financial stability, enabling self-efficacy for health outcomes and improved antiretroviral therapy adherence. This randomized controlled trial will test the impact of CCRP on marginalized people living with HIV (PLWH). We hypothesize that helping participants to pay their rent and other bills on time will improve housing stability and decrease financial stress.

METHODS

PLWH (n = 160) receiving services at community-based organizations will be randomly assigned to the CCRP intervention or the standard of care for 12 months. Fifty additional participants will be enrolled into a non-randomized ("choice") study allowing participant selection of the CCRP intervention or control. The primary outcome is HIV medication adherence, assessed via the CASE adherence index, viral load, and CD4 counts. Self-assessment data for ART adherence, housing instability, self-efficacy for health behaviors, financial stress, and retention in care will be collected at baseline, 3, 6, and 12 months. Viral load, CD4, and appointment adherence data will be collected at baseline, 6, 12, 18, and 24 months from medical records. Outcomes will be compared by treatment group in the randomized trial, in the non-randomized cohort, and in the combined cohort. Qualitative data will be collected from study participants, eligible non-participants, and providers to explore underlying mechanisms of adherence, subjective responses to the intervention, and implementation barriers and facilitators.

DISCUSSION

The aim of this study is to determine if CCRP improves health outcomes for vulnerable PLWH. Study outcomes may provide information about supports needed to help economically fragile PLWH improve health outcomes and ultimately improve HIV health disparities. In addition, findings may help to refine service delivery including the provision of representative payee to this often-marginalized population. This protocol was prospectively registered on May 22, 2018 with ClinicalTrials.gov (NCT03561103) .

Distance matters: The association of proximity to syringe services programs with sharing of syringes and injecting equipment - 17 U.S. cities, 2015

BACKGROUND

Syringe services programs (SSPs) have effectively limited the spread of HIV and hepatitis C (HCV) among people who inject drugs (PWID). Access to SSPs has been shown to reduce injection risk behaviors but the relationship between distance to an SSP and likelihood of sharing injection equipment is not well known.

METHODS

We analyzed a sample of 8,392 PWID from 17 U.S. cities recruited through the National HIV Behavioral Surveillance (NHBS) system in 2015. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) were estimated from log-linked Poisson regression to explore associations between injecting equipment sharing in the past 12 months and distance to the nearest SSP.

RESULTS

Regardless of SSP use, respondents who lived in zip codes further than the city-specific mean distance to nearest SSP were more likely to report sharing behavior. Among PWID who had not reported using an SSP in the previous 12 months, distributive sharing (aPR=1.13 95% CI=1.05, 1.21), receptive sharing (aPR=1.15, 95% CI=1.06, 1.24), and injection equipment sharing (aPR=1.08, 95% CI=1.03, 1.13) were more prevalent among residents who resided further than the average distance to the nearest SSP.

CONCLUSIONS

Greater distance to an SSP was associated with increased sharing behaviors. Improved access to an SSP and subsequent decreases in sharing behaviors could reduce transmission of HIV and HCV among PWID. Accessibility should be taken into account when planning provision of SSPs.

Mortgage Discrimination and Racial/Ethnic Concentration Are Associated with Same-Race/Ethnicity Partnering among People Who Inject Drugs in 19 US Cities

Racial/ethnic homophily in sexual partnerships (partners share the same race/ethnicity) has been associated with racial/ethnic disparities in HIV. Structural racism may partly determine racial/ethnic homophily in sexual partnerships. This study estimated associations of racial/ethnic concentration and mortgage discrimination against Black and Latino residents with racial/ethnic homophily in sexual partnerships among 7847 people who inject drugs (PWID) recruited from 19 US cities to participate in CDC's National HIV Behavioral Surveillance. Racial/ethnic concentration was defined by two measures that respectively compared ZIP code-level concentrations of Black residents to White residents and Latino residents to White residents, using the Index of Concentration at the Extremes. Mortgage discrimination was defined by two measures that respectively compared county-level mortgage loan denial among Black applicants to White applicants and mortgage loan denial among Latino applicants to White applicants, with similar characteristics (e.g., income, loan amount). Multilevel logistic regression models were used to estimate associations. Interactions of race/ethnicity with measures of racial/ethnic concentration and mortgage discrimination were added to the final multivariable model and decomposed into race/ethnicity-specific estimates. In the final multivariable model, among Black PWID, living in ZIP codes with higher concentrations of Black vs. White residents and counties with higher mortgage discrimination against Black residents was associated with higher odds of homophily. Living in counties with higher mortgage discrimination against Latino residents was associated with lower odds of homophily among Black PWID. Among Latino PWID, living in ZIP codes with higher concentrations of Latino vs. White residents and counties with higher mortgage discrimination against Latino residents was associated with higher odds of homophily. Living in counties with higher mortgage discrimination against Black residents was associated with lower odds of homophily among Latino PWID. Among White PWID, living in ZIP codes with higher concentrations of Black or Latino residents vs. White residents was associated with lower odds of homophily, but living in counties with higher mortgage discrimination against Black residents was associated with higher odds of homophily. Racial/ethnic segregation may partly drive same race/ethnicity sexual partnering among PWID. Future empirical evidence linking these associations directly or indirectly (via place-level mediators) to HIV/STI transmission will determine how eliminating discriminatory housing policies impact HIV/STI transmission.

The intersectional risk environment of people who use drugs

Current conceptual models for examining the production of risk and harm (e.g. syndemics, 'risk environment') in substance use research have been fundamental in emphasizing broader environmental factors that shape health outcomes for people who use drugs (PWUD). However, the application of these frameworks in ways that highlight nuance and complexity has remained challenging, with much of this research focusing on select social positions (e.g. race, gender) and social-structural factors (e.g. poverty, drug policies). It is crucial that we move to better accounting for these relations in the context of substance use research to enhance equity in research and ensure understanding of diverse and complex needs. Building on the risk environment framework and complementary approaches, this article introduces the 'intersectional risk environment' as an approach to understanding the interconnected ways that social locations converge within the risk environment to produce or mitigate drug-related outcomes. This framework integrates a relational intersectional lens to examine how differential outcomes across populations of PWUD are produced in relation to social location and processes operating across social-structural dimensions. In doing so, the intersectional risk environment highlights how outcomes are products of processes and relations that are embodied, reflected, and challenged while situated within social, historical, and geographic contexts. Incorporating this framework into future research may improve understandings of health outcomes for PWUD and better orient structural interventions and public health approaches to address differential risks and experiences of PWUD.

Rural risk environments for hepatitis c among young adults in appalachian kentucky

BACKGROUND

Rural Kentucky is an epicenter of hepatitis C(HCV), especially among young adults who inject drugs. While the Risk Environment Framework (REF) has been used widely to study and address socio-ecological determinants of infectious disease among people who inject drugs (PWID), it has been almost exclusively applied to urban environments. Applying REF to rural environments can enhance our understanding of the drivers of HCV epidemics in these hard-hit areas, and inform the creation and implementation of harm reduction interventions in this local context.

METHODS

Participants were recruited between March and August 2017 via community-based outreach methods (e.g., cookouts, flyers) and peer referral. Individuals who met eligibility criteria (aged 18-35, recently used prescription opioids and/or heroin to get high, lived in one of the 5 target counties) participated indepth, semi-structured interviews. The interview guide was informed by the REF, and covered HCV-related risk behaviors and environmental features that shaped vulnerability to engaging in these behaviors. Interviews were transcribed and analyzed using constructivist grounded-theory methods.

RESULTS

Participants (N=19) described multiple intersecting risk environment features that shaped vulnerability to HCV transmission. Economic decline generated intergenerational poverty, dwindling employment prospects, and diminished social enrichment opportunities that collectively contributed to substance misuse and risky injection practices. Geographic isolation, lack of collective knowledge about HCV transmission risks, scarce harm reduction services, familial poverty, and fear of law enforcement interacted to increase the odds of people injecting in "trap houses" (akin to shooting galleries) or secluded areas, spaces in which they rushed to inject and shared injection equipment. Pervasive stigma was a structural barrier to adopting, expanding, and using harm reduction services.

CONCLUSION

This exploratory study identified features of rural risk environments that may contribute to significant HCV burdens in Appalachian Kentucky. Findings signal the importance of expanding proven harm reduction strategies and anti-stigma interventions tailored to rural contexts.

Identifying Which Place Characteristics are Associated with the Odds of Recent HIV Testing in a Large Sample of People Who Inject Drugs in 19 US Metropolitan Areas

This exploratory analysis investigates relationships of place characteristics to HIV testing among people who inject drugs (PWID). We used CDC's 2012 National HIV Behavioral Surveillance (NHBS) data among PWID from 19 US metropolitan statistical areas (MSAs); we restricted the analytic sample to PWID self-reporting being HIV negative (N = 7477). Administrative data were analyzed to describe the 1. Sociodemographic Composition; 2. Economic disadvantage; 3. Healthcare Service/Law enforcement; and 4. HIV burden of the ZIP codes, counties, and MSAs where PWID lived. Multilevel models tested associations of place characteristics with HIV testing. Fifty-eight percent of PWID reported past-year testing. MSA-level per capita correctional expenditures were positively associated with recent HIV testing among black PWID, but not white PWID. Higher MSA-level household income and imbalanced sex ratios (more women than men) in the MSA were associated with higher odds of testing. HIV screening for PWID is suboptimal (58%) and needs improvement. Identifying place characteristics associated with testing among PWID can strengthen service allocation and interventions in areas of need to increase access to HIV testing.

Police violence among people who inject drugs in Baltimore, Maryland

BACKGROUND

Police violence is a deleterious public health and criminal justice issue that disproportionately affects people who inject drugs (PWID). Studies documenting the prevalence and correlates of physical police violence in this population are rare. The aim of this study was to examine the correlates of past year physical police violence among an urban sample of PWID.

METHODS

PWID participating in the 2015 wave of the National HIV Behavioral Surveillance (NHBS) system in Baltimore City, Maryland, completed a socio-behavioral survey. Multivariable logistic regression was used to detect the socio-demographic, place-based, law-enforcement and health behavior correlates of exposure to police violence as well as knowledge of violence directed towards other PWID.

RESULTS

Enrolled PWID (N = 570) were mostly male (72%), non-Hispanic Black (77%) and daily heroin injectors (86%). Seven percent had experienced past year physical police violence (Respondent-Driven Sampling [RDS] weighted estimate: 4%), and a quarter (24%) knew someone who had experienced physical police violence in the past year (RDS-weighted estimate: 17%). Male gender, homelessness, arrest, drug paraphernalia confiscation, and receptive syringe sharing were independently associated with police violence. Knowing someone who had experienced police violence was independently correlated with selling drugs, arrest, and attending a syringe services program.

CONCLUSION

Population differences in the extent of police violence exposure indicate that experiences of police violence are not uniform among PWID. Violent encounters with police were associated with disruptions in harm reduction strategies that can prevent HIV and HCV transmission. This study adds to the small body of public health literature on police violence and highlights the importance of monitoring and addressing this critical issue.

Endometrial cancer disparities: a race-conscious critique of the literature

Racial disparities in endometrial cancer are stark and have increased over the past decade. While the disparities are well documented, intervention work to address the mortality gap is nonexistent. This review critiques how race has been conceptualized to explain the causes of endometrial cancer disparities, assesses gaps in knowledge production, and proposes new research priorities. Using public health critical race praxis, a research approach for examining racial disparities and knowledge production processes, we reviewed the endometrial cancer disparities literature from 1995 through 2016. Using systematic search methods, 133 unique records were identified and 48 studies critiqued. We found that a narrow definition of race as a purely biological construct is common throughout the literature. This appears to result in an underemphasis on the role of modifiable, nonbiological contributors to racial disparities and a lack of follow-up work to address these contributors. Key knowledge gaps identified were the role of health care systems in early diagnosis, a lack of intervention studies to address persistent treatment inequity by race, and the near absence of qualitative work to understand the perspectives of Black women diagnosed with endometrial cancer. We conclude with an iterative demonstration of the public health critical race praxis and suggest new routes of inquiry to broaden the scope of research priorities to understand and improve the outcomes of Black women with endometrial cancer.

A Strengths-Based Case Management Intervention to Reduce HIV Viral Load Among People Who Use Drugs

Engaging highly marginalized HIV positive people in sustained medical care is vital for optimized health and prevention efforts. Prior studies have found that strengths-based case management helps link people who use drugs to HIV care. We conducted a pilot to assess whether a strengths-based case management intervention may help people who use injection drugs (PWID) or smoke crack cocaine (PWSC) achieve undetectable HIV viral load. PWID and PWSC were recruited in Oakland, California using targeted sampling methods and referral from jails and were tested for HIV. HIV positive participants not receiving HIV care (n = 19) were enrolled in a pilot strengths-based case management intervention and HIV positive participants already in HIV care (n = 29) were followed as comparison participants. The intervention was conducted by a social worker and an HIV physician. Special attention was given to coordinating care as participants cycled through jail and community settings. Surveys and HIV viral load tests were conducted quarterly for up to 11 visits. HIV viral load became undetectable for significantly more participants in the intervention than in the comparison group by their last follow-up (intervention participants: 32% at baseline and 74% at last follow-up; comparison participants: 45% at baseline and 34% at last follow-up; p = 0.008). In repeated measures analysis, PBO intervention participants had higher odds of achieving undetectable viral load over time than comparison participants (p = 0.033). Strengths-based case management may help this highly vulnerable group achieve undetectable HIV viral load over time.

Perceptions about supervised injection facilities among people who inject drugs in Philadelphia

BACKGROUND

People who inject drugs (PWID) are at high risk for infectious diseases, skin and soft tissue infections, and overdose. However, these harms are all avoidable when sterile injection equipment, hygienic places to inject, and medical care are accessible. Unfortunately, many PWID in the U.S lack these resources. The most vulnerable are forced to inject in public spaces, where individual risks are high and communal harms are sometimes many. Supervised Injection Facilities (SIFs) are an established intervention for reducing these harms. Despite positive experiences in other countries, little research explores how PWID in the U.S. perceive the value of such facilities.

METHODS

We conducted a freelisting exercise with PWID (n=42) and healthcare providers (n=20) at a syringe exchange program (SEP) that provides comprehensive clinical and social services in Philadelphia to inform in-depth semi-structured interviews with PWID (n=19) at the same location.

RESULTS

Participants expressed support for a potential SIF as a valuable public health intervention. They suggested that an SIF would improve PWID health while reducing the public disorder associated with injecting drugs in public. The latter was especially important to participants without stable housing, whose decision to inject furtively in secluded places was often motivated by desire not to upset community members, and particularly children. These participants acknowledged that such seclusion elevated the risk of fatal overdose. Despite similarly positive perceptions about an SIF, participants with stable housing reported that they would prefer to continue injecting at home.

CONCLUSION

Results both confirm and extend prior research about PWID and SIFs. Participants expressed support for SIFs as in prior survey research in the U.S. and in other countries. Facility location and housing status were identified as important determinants of facility use. Results extend prior research by illuminating PWID perceptions in the U.S. including motivations grounded in concern for public order.

Racial/Ethnic Disparities at the End of an HIV Epidemic: Persons Who Inject Drugs in New York City, 2011-2015

OBJECTIVES

To examine whether racial/ethnic disparities persist at the "end of the HIV epidemic" (prevalence of untreated HIV infection < 5%; HIV incidence < 0.5 per 100 person-years) among persons who inject drugs (PWID) in New York City.

METHODS

We recruited 2404 PWID entering New York City substance use treatment in 2001 to 2005 and 2011 to 2015. We conducted a structured interview, and testing for HIV and herpes simplex virus 2 (HSV-2; a biomarker for high sexual risk). We estimated incidence by using newly diagnosed cases of HIV. Disparity analyses compared HIV, untreated HIV, HIV-HSV-2 coinfection, HIV monoinfection, and estimated HIV incidence among Whites, African Americans, and Latinos.

RESULTS

By 2011 to 2015, Whites, African Americans, and Latino/as met both criteria of our operational "end-of-the-epidemic" definition. All comparisons that included HIV-HSV-2-coinfected persons had statistically significant higher rates of HIV among racial/ethnic minorities. No comparisons limited to HIV monoinfected persons were significant.

CONCLUSIONS

"End-of-the-epidemic" criteria were met among White, African American, and Latino/a PWID in New York City, but elimination of disparities may require a greater focus on PWID with high sexual risk.

Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility

Background

In Baltimore, MD, as in many cities throughout the USA, overdose rates are on the rise due to both the increase of prescription opioid abuse and that of fentanyl and other synthetic opioids in the drug market. Supervised injection facilities (SIFs) are a widely implemented public health intervention throughout the world, with 97 existing in 11 countries worldwide. Research has documented the public health, social, and economic benefits of SIFs, yet none exist in the USA. The purpose of this study is to model the health and financial costs and benefits of a hypothetical SIF in Baltimore.

Methods

We estimate the benefits by utilizing local health data and data on the impact of existing SIFs in models for six outcomes: prevented human immunodeficiency virus transmission, Hepatitis C virus transmission, skin and soft-tissue infection, overdose mortality, and overdose-related medical care and increased medication-assisted treatment for opioid dependence.

Results

We predict that for an annual cost of $1.8 million, a single SIF would generate $7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment.

Conclusions

We conclude that a SIF would be both extremely cost-effective and a significant public health and economic benefit to Baltimore City.

Structural inequalities drive late HIV diagnosis: The role of black racial concentration, income inequality, socioeconomic deprivation, and HIV testing

In the United States, research is limited on the mechanisms that link socioeconomic and structural factors to HIV diagnosis outcomes. We tested whether neighborhood income inequality, socioeconomic deprivation, and black racial concentration were associated with gender-specific rates of HIV in the advanced stages of AIDS (i.e., late HIV diagnosis). We then examined whether HIV testing prevalence and accessibility mediated any of the associations above. Neighborhoods with highest (relative to lowest) black racial concentration had higher relative risk of late HIV diagnosis among men (RR=1.86; 95%CI=1.15, 3.00) and women (RR=5.37; 95%CI=3.16, 10.43) independent of income inequality and socioeconomic deprivation. HIV testing prevalence and accessibility did not significantly mediate the associations above. Research should focus on mechanisms that link black racial concentration to HIV diagnosis outcomes.

Population-Attributable Risk Percentages for Racialized Risk Environments

Research about relationships between place characteristics and racial/ethnic inequities in health has largely ignored conceptual advances about race and place within the discipline of geography. Research has also almost exclusively quantified these relationships using effect estimates (e.g., odds ratios), statistics that fail to adequately capture the full impact of place characteristics on inequities and thus undermine our ability to translate research into action. We draw on geography to further develop the concept of "racialized risk environments," and we argue for the routine calculation of race/ethnicity-specific population-attributable risk percentages.

Socioecological factors influencing women's HIV risk in the United States: qualitative findings from the women's HIV SeroIncidence study (HPTN 064)

Background

We sought to understand the multilevel syndemic factors that are concurrently contributing to the HIV epidemic among women living in the US. We specifically examined community, network, dyadic, and individual factors to explain HIV vulnerability within a socioecological framework.

Methods

We gathered qualitative data (120 interviews and 31 focus groups) from a subset of women ages 18–44 years (N = 2,099) enrolled in the HPTN 064 HIV seroincidence estimation study across 10 US communities. We analyzed data from 4 diverse locations: Atlanta, New York City (the Bronx), Raleigh, and Washington, DC. Data were thematically coded using grounded theory methodology. Intercoder reliability was assessed to evaluate consistency of team-based coding practices.

Results

The following themes were identified at 4 levels including 1) exosystem (community): poverty prevalence, discrimination, gender imbalances, community violence, and housing challenges; 2) mesosystem (network): organizational social support and sexual concurrency; 3) microsystem (dyadic): sex exchange, interpersonal social support, intimate partner violence; and 4) individual: HIV/STI awareness, risk taking, and substance use. A strong theme emerged with over 80 % of responses linked to the fundamental role of financial insecurity underlying risk-taking behavioral pathways.

Conclusions

Multilevel syndemic factors contribute to women’s vulnerability to HIV in the US. Financial insecurity is a predominant theme, suggesting the need for tailored programming for women to reduce HIV risk.

Trial registration

Clinicaltrials.gov, NCT00995176

Associations of place characteristics with HIV and HCV risk behaviors among racial/ethnic groups of people who inject drugs in the United States

PURPOSE

Investigate whether characteristics of geographic areas are associated with condomless sex and injection-related risk behavior among racial/ethnic groups of people who inject drugs (PWID) in the United States.

METHODS

PWID were recruited from 19 metropolitan statistical areas for 2009 National HIV Behavioral Surveillance. Administrative data described ZIP codes, counties, and metropolitan statistical areas where PWID lived. Multilevel models, stratified by racial/ethnic groups, were used to assess relationships of place-based characteristics to condomless sex and injection-related risk behavior (sharing injection equipment).

RESULTS

Among black PWID, living in the South (vs. Northeast) was associated with injection-related risk behavior (adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.21-4.17; P = .011), and living in counties with higher percentages of unaffordable rental housing was associated with condomless sex (AOR = 1.02, 95% CI = 1.00-1.04; P = .046). Among white PWID, living in ZIP codes with greater access to drug treatment was negatively associated with condomless sex (AOR = 0.93, 95% CI = 0.88-1.00; P = .038).

CONCLUSIONS

Policies that increase access to affordable housing and drug treatment may make environments more conducive to safe sexual behaviors among black and white PWID. Future research designed to longitudinally explore the association between residence in the south and injection-related risk behavior might identify specific place-based features that sustain patterns of injection-related risk behavior.

Risky Substance Use Environments and Addiction: A New Frontier for Environmental Justice Research

Substance use disorders are widely recognized as one of the most pressing global public health problems, and recent research indicates that environmental factors, including access and exposure to substances of abuse, neighborhood disadvantage and disorder, and environmental barriers to treatment, influence substance use behaviors. Racial and socioeconomic inequities in the factors that create risky substance use environments may engender disparities in rates of substance use disorders and treatment outcomes. Environmental justice researchers, with substantial experience in addressing racial and ethnic inequities in environmental risk from technological and other hazards, should consider similar inequities in risky substance use environments as an environmental justice issue. Research should aim at illustrating where, why, and how such inequities in risky substance use environments occur, the implications of such inequities for disparities in substance use disorders and treatment outcomes, and the implications for tobacco, alcohol, and drug policies and prevention and treatment programs.

Structural Determinants of Antiretroviral Therapy Use, HIV Care Attendance, and Viral Suppression among Adolescents and Young Adults Living with HIV

BACKGROUND

The authors examined associations between structural characteristics and HIV disease management among a geographically diverse sample of behaviorally and perinatally HIV-infected adolescents and young adults in the United States.

METHODS

The sample included 1891 adolescents and young adults living with HIV (27.8% perinatally infected; 72.2% behaviorally infected) who were linked to care through 20 Adolescent Medicine Trials Network for HIV/AIDS Interventions Units. All completed audio computer-assisted self-interview surveys. Chart abstraction or blood draw provided viral load data. Geographic-level variables were extracted from the United States Census Bureau (e.g., socioeconomic disadvantage, percent of Black and Latino households, percent rural) and Esri Crime (e.g., global crime index) databases as Zip Code Tabulation Areas. AIDSVu data (e.g., prevalence of HIV among youth) were extracted at the county-level. Using HLM v.7, the authors conducted means-as-outcomes random effects multi-level models to examine the association between structural-level and individual-level factors and (1) being on antiretroviral therapy (ART) currently; (2) being on ART for at least 6 months; (3) missed HIV care appointments (not having missed any vs. having missed one or more appointments) over the past 12 months; and (4) viral suppression (defined by the corresponding assay cutoff for the lower limit of viral load at each participating site which denoted nondetectability vs. detectability).

RESULTS

Frequencies for the 4 primary outcomes were as follows: current ART use (n = 1120, 59.23%); ART use for ≥6 months (n = 861, 45.53%); at least one missed HIV care appointment (n = 936, 49.50); and viral suppression (n = 577, 30.51%). After adjusting for individual-level factors, youth living in more disadvantaged areas (defined by a composite score derived from 2010 Census indicators including percent poverty, percent receiving public assistance, percent of female, single-headed households, percent unemployment, and percent of people with less than a high school degree) were less likely to report current ART use (OR: 0.85, 95% CI: 0.72-1.00, p = .05). Among current ART users, living in more disadvantaged areas was associated with greater likelihood of having used ART for ≥6 months. Participants living in counties with greater HIV prevalence among 13-24 year olds were more likely to report current ART use (OR: 1.32, 95% CI: 1.05-1.65, p = .02), ≥6 months ART use (OR: 1.32, 95% CI: 1.05-1.65, p = .02), and to be virally suppressed (OR: 1.50, 95% CI: 1.20-1.87, p = .001); however, youth in these areas were also more likely to report missed medical appointments (OR: 1.32, 95% CI: 1.07-1.63, p = .008).

CONCLUSIONS

The findings underscore the multi-level and structural factors associated with ART use, missed HIV care appointments, and viral suppression for adolescents and young adults in the United States. Consideration of these factors is strongly recommended in future intervention, clinical practice, and policy research that seek to understand the contextual influences on individuals' health behaviors.

Advancing patient-centered care for structurally vulnerable drug-using populations: a qualitative study of the perspectives of people who use drugs regarding the potential integration of harm reduction interventions into hospitals

AIMS

To explore the perspectives of structurally vulnerable people who use drugs (PWUD) regarding: (1) the potential integration of harm reduction interventions (e.g. supervised drug consumption services, opioid-assisted treatment) into hospitals; and (2) the implications of these interventions for patient-centered care, hospital outcomes and drug-related risks and harms.

DESIGN

Semi-structured qualitative interviews.

SETTING

Vancouver, Canada.

PARTICIPANTS

Thirty structurally vulnerable PWUD who had been discharged from hospital against medical advice within the past 2 years, and hospitalized multiple times over the past 5 years.

MEASUREMENTS

Semi-structured interview guide including questions to elicit perspectives on hospital-based harm reduction interventions.

FINDINGS

Participant accounts highlighted that hospital-based harm reduction interventions would promote patient-centered care by: (1) prioritizing hospital care access and risk reduction over the enforcement of abstinence-based drug policies; (2) increasing responsiveness to subjective health needs (e.g. pain and withdrawal symptoms); and (3) fostering 'culturally safe' care.

CONCLUSIONS

Hospital-based harm reduction interventions for people who use drugs, such as supervised drug consumption services and opioid-assisted treatment, can potentially improve hospital care retention, promote patient-centered care and reduce adverse health outcomes among people who use drugs.

Risk Environments, Race/Ethnicity, and HIV Status in a Large Sample of People Who Inject Drugs in the United States

INTRODUCTION

We analyzed relationships between place characteristics and being HIV-negative among black, Latino, and white people who inject drugs (PWID) in the US.

METHODS

Data on PWID (N = 9077) were from the Centers for Disease Control and Prevention's 2009 National HIV Behavioral Surveillance. Administrative data were analyzed to describe the 968 ZIP codes, 51 counties, and 19 metropolitan statistical areas (MSAs) where they lived. Multilevel multivariable models examined relationships between place characteristics and HIV status. Exploratory population attributable risk percents (e-PAR%s) were estimated.

RESULTS

Black and Latino PWID were more likely to be HIV-negative if they lived in less economically disadvantaged counties, or in MSAs with less criminal-justice activity (i.e., lower drug-related arrest rates, lower policing/corrections expenditures). Latino PWID were more likely to be HIV-negative in MSAs with more Latino isolation, less black isolation, and less violent crime. E-PAR%s attributed 8-19% of HIV cases among black PWID and 1-15% of cases among Latino PWID to place characteristics.

DISCUSSION

Evaluations of structural interventions to improve economic conditions and reduce drug-related criminal justice activity may show evidence that they protect black and Latino PWID from HIV infection.