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Surratt HL, Brown S, Burton AL, Cranford W, Green C, Mersch SM, Rains R, Westgate PM. Examining HIV pre-exposure prophylaxis (PrEP) acceptability among rural people who inject drugs: predictors of PrEP interest among syringe service program clients. AIDS Care 2024:1-11. [PMID: 39137923 DOI: 10.1080/09540121.2024.2390067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 08/02/2024] [Indexed: 08/15/2024]
Abstract
Rural communities in the US have increasing HIV burden tied to injection drug use, yet engagement in pre-exposure prophylaxis (PrEP) care has been low among people who inject drugs (PWID). Syringe service programs (SSPs) are widely implemented in Kentucky's Appalachian region, presenting an important opportunity to scale PrEP services. This paper examines PrEP awareness, interest and preferences among PWID attending community-based SSPs in Appalachia. Eighty participants were enrolled from two SSP locations. Eligibility included: ≥ 18 years old, current injection drug use and SSP use, and an indication for PrEP as defined by CDC guidelines. Participants completed a structured baseline interview. Predictors of PrEP awareness, interest and formulation preferences were examined. 38.8% reported baseline awareness of PrEP, 50% expressed high interest in PrEP, and 48.1%reported a preference for injectable PrEP. Significant bivariate predictors of PrEP interest included: current worry about health, higher perceived HIV risk, higher community HIV stigma, and higher enacted substance use stigma in the past year; in the adjusted model, enacted substance use stigma remained significant. Findings demonstrate substantial interest in PrEP among rural PWID. Intrapersonal and social determinant factors were associated with PrEP interest, which suggests the importance of multi-level intervention targets to increase PrEP uptake.
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Affiliation(s)
- Hilary L Surratt
- University of Kentucky, Department of Behavioral Science, College of Medicine, Lexington, Kentucky, USA
| | - Sarah Brown
- Appalachian Regional Healthcare, Barbourville, Kentucky, USA
| | - Abby L Burton
- University of Kentucky, Department of Behavioral Science, College of Medicine, Lexington, Kentucky, USA
| | - Will Cranford
- University of Kentucky, Department of Biostatistics, College of Public Health, Lexington, Kentucky, USA
| | - Christie Green
- Cumberland Valley District Health Department, Manchester, Kentucky, USA
| | - Stephanie M Mersch
- University of Kentucky, Department of Behavioral Science, College of Medicine, Lexington, Kentucky, USA
| | - Rebecca Rains
- Knox County Health Department, Barbourville, Kentucky, USA
| | - Philip M Westgate
- University of Kentucky, Department of Biostatistics, College of Public Health, Lexington, Kentucky, USA
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2
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Zovich B, Freeland C, Moore H, Sapp K, Qureshi A, Holbert R, Zambrano J, Bhangoo D, Cohen C, Hass RW, Jessop A. Dismantling Barriers to Hepatitis B and Delta Screening, Prevention, and Linkage to Care among the PWUD Community in Philadelphia. Viruses 2024; 16:628. [PMID: 38675969 PMCID: PMC11054430 DOI: 10.3390/v16040628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/12/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
The prevalence of hepatitis B and delta viruses (HBV/HDV) among people who use drugs (PWUD) remains largely unknown. In the context of one Philadelphia-based harm reduction organization (HRO), this study aimed to assess HBV/HDV prevalence and facilitate linkage to care. Participants completed a demographic HBV/HDV risk factor survey and were screened for HBV and reflexively for HDV if positive for HBV surface antigen or isolated core antibody. Fisher's exact tests and regression were used to understand relationships between risks and HBV blood markers. Of the 498 participants, 126 (25.3%) did not have hepatitis B immunity, 52.6% had been vaccinated against HBV, and 17.9% had recovered from a past infection. Eleven (2.2%) participants tested positive for isolated HBV core antibody, 10 (2.0%) for HBV surface antigen, and one (0.2%) for HDV antibody. History of incarceration was associated with current HBV infection, while transactional sex and experience of homelessness were predictive of previous exposure. This study found high rates of current and past HBV infection, and a 10% HBV/HDV co-infection rate. Despite availability of vaccine, one quarter of participants remained vulnerable to infection. Findings demonstrate the need to improve low-threshold HBV/HDV screening, vaccination, and linkage to care among PWUD. The study also identified gaps in the HBV/HDV care cascade, including lack of point-of-care diagnostics and lack of support for HROs to provide HBV services.
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Affiliation(s)
| | | | - Holly Moore
- Hepatitis B Foundation, Doylestown, PA 18902, USA
| | - Kara Sapp
- Hepatitis B Foundation, Doylestown, PA 18902, USA
| | | | - Rachel Holbert
- HepTREC at Prevention Point Philadelphia, Philadelphia, PA 19134, USA
| | | | - Daljinder Bhangoo
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Chari Cohen
- Hepatitis B Foundation, Doylestown, PA 18902, USA
| | - Richard W. Hass
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Amy Jessop
- HepTREC at Prevention Point Philadelphia, Philadelphia, PA 19134, USA
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Scaramutti C, Hervera B, Rivera Y, Chueng TA, Forrest DW, Suarez E, Serota DP, Alkamli H, Ciraldo K, Bartholomew TS, Tookes HE. Improving access to HIV care among people who inject drugs through tele-harm reduction: a qualitative analysis of perceived discrimination and stigma. Harm Reduct J 2024; 21:50. [PMID: 38396017 PMCID: PMC10893685 DOI: 10.1186/s12954-024-00961-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 02/11/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Tele-harm reduction (THR) is a telehealth-enhanced, peer-led, harm reduction intervention delivered within a trusted syringe services program (SSP) venue. The primary goal of THR is to facilitate linkage to care and rapid, enduring virologic suppression among people who inject drugs (PWID) with HIV. An SSP in Miami, Florida, developed THR to circumvent pervasive stigma within the traditional healthcare system. METHODS During intervention development, we conducted in-depth interviews with PWID with HIV (n = 25) to identify barriers and facilitators to care via THR. We employed a general inductive approach to transcripts guided by iterative readings of the raw data to derive the concepts, themes, and interpretations of the THR intervention. RESULTS Of the 25 PWID interviewed, 15 were in HIV care and adherent to medication; 4 were in HIV care but non-adherent; and 6 were not in care. Themes that emerged from the qualitative analysis included the trust and confidence PWID have with SSP clinicians as opposed to professionals within the traditional healthcare system. Several barriers to treatment were reported among PWID, including perceived and actual discrimination by friends and family, negative internalized behaviors, denial of HIV status, and fear of engaging in care. Facilitators to HIV care included empathy and respect by SSP staff, flexibility of telehealth location, and an overall destigmatizing approach. CONCLUSION PWID identified barriers and facilitators to receipt of HIV care through the THR intervention. Interviews helped inform THR intervention development, centered on PWID in the destigmatizing environment of an SSP.
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Affiliation(s)
- Carolina Scaramutti
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Belén Hervera
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Yanexy Rivera
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Teresa A Chueng
- 2Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David W Forrest
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Edward Suarez
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David P Serota
- 2Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hatoun Alkamli
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Katrina Ciraldo
- Department of Family and Community Medicine & Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tyler S Bartholomew
- Division of Health Services Research and Policy, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hansel E Tookes
- 2Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
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Rotsaert A, Vanhamel J, Vanbaelen T, Vuylsteke B, van der Loeff MS, Hensen B, Kielmann K, Callens S, Reyniers T. HIV Pre-exposure Prophylaxis (PrEP) Care in Belgium: A mixed-methods Study on PrEP Users' Experiences and Service Delivery Preferences. AIDS Behav 2024; 28:393-407. [PMID: 38038778 DOI: 10.1007/s10461-023-04232-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 12/02/2023]
Abstract
In Belgium, HIV pre-exposure prophylaxis (PrEP) services are mainly provided through specialised HIV clinics. To optimise PrEP uptake and retention in care, we require insights into users' perspectives on PrEP care. We aimed to elicit experiences with, and preferences for, PrEP service delivery among PrEP users in Belgium, including willingness to involve their family physician (FP) in PrEP care. We adopted a sequential mixed-methods design. We used a web-based longitudinal study among 326 PrEP users that consisted of two questionnaires at six-month intervals, and complemented this with 21 semi-structured interviews (September 2020-January 2022). We conducted descriptive analyses and logistic regression to examine factors associated with willingness to involve their FP in PrEP care. Interviews were analysed using thematic analysis. Survey respondents reported high satisfaction with care received in HIV clinics [median score 9 (IQR 8-10), 10='very satisfied']. Interviews revealed the importance of regular HIV/STI screening, and the expertise and stigma-free environment of HIV clinics. Yet, they also contextualised service delivery barriers reported in the questionnaire, including the burden of cost and challenges integrating PrEP visits into their private and professional lives. Although 63.8% (n = 208/326) of baseline respondents preferred attending an HIV clinic for PrEP follow-up, 51.9% (n = 108/208) of participants in the follow-up questionnaire reported to be willing to have their FP involved in PrEP care. Participants reporting trust in FPs' PrEP and sexual health expertise, or who didn't feel judged by their FP, were more likely to be willing to involve them in PrEP care. Therefore, we recommend a differentiated PrEP service delivery approach, including involving FPs, to make PrEP care more client-centred.
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Affiliation(s)
- Anke Rotsaert
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, Antwerp, B-2000, Belgium
| | - Jef Vanhamel
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, Antwerp, B-2000, Belgium.
| | - Thibaut Vanbaelen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bea Vuylsteke
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, Antwerp, B-2000, Belgium
| | - Maarten Schim van der Loeff
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, The Netherlands
- Department of Internal Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity (AII), Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute (APH), Amsterdam, the Netherlands
| | - Bernadette Hensen
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, Antwerp, B-2000, Belgium
| | - Karina Kielmann
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, Antwerp, B-2000, Belgium
| | - Steven Callens
- Department of General Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Thijs Reyniers
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, Antwerp, B-2000, Belgium
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Bonett S, Mahajan A, da Silva DT, Williams J, Brady K, Bauermeister J, Wood SM. Advancing the community plan to end the HIV Epidemic in Philadelphia: a qualitative descriptive evaluation of low-threshold PrEP services in sexual health clinics. Implement Sci Commun 2024; 5:4. [PMID: 38183133 PMCID: PMC10768374 DOI: 10.1186/s43058-023-00543-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 12/21/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Pre-exposure prophylaxis (PrEP) is an effective HIV prevention method and a key component of Philadelphia's Community Plan to End the HIV Epidemic (EHE). However, significant barriers to accessing PrEP exist among people at risk for HIV. Low-threshold models for PrEP services that minimize barriers to entry and service engagement could help bolster access to PrEP through community-based clinics. This study aimed to describe the initial implementation of low-threshold PrEP services in three sexual health clinics funded by the Philadelphia Department of Public Health and explore strategies for delivering low-threshold PrEP services. METHODS We conducted three focus groups with staff (i.e., providers, prevention navigators, and administrative staff, N = 21) at each of three participating PDPH-funded sexual health clinics from November 2021 to January 2022. Discussion topics included details about the PrEP delivery process, clinic strengths and assets, resource gaps, and PrEP implementation goals. Follow-up interviews with staff members (N = 8) between March 2022 and May 2022 focused on identifying successful strategies for PrEP delivery and adaptations needed to optimize low-threshold PrEP service delivery. Rapid qualitative methods and the Consolidated Framework for Implementation Science were used to analyze data from focus groups and interviews. RESULTS Participants collaborated to create process maps that visualized the steps involved in delivering PrEP services within their respective settings. These maps highlighted several stages in PrEP service delivery, such as connecting individuals to services, providing prevention navigation, conducting clinical encounters, and ensuring follow-up care. Participants described effective strategies for implementing PrEP, which included integrating and co-locating services on-site, strengthening staffing resources and capacity, and addressing barriers experienced by clients. CONCLUSIONS Lessons from the implementation of low-threshold PrEP service delivery in Philadelphia can guide ongoing local adaptations and future scale-up of these models to improve access to PrEP and advance the goals of the EHE initiative.
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Affiliation(s)
- Stephen Bonett
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.
| | | | | | | | - Kathleen Brady
- Philadelphia Department of Public Health, Philadelphia, PA, USA
| | - José Bauermeister
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah M Wood
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Craig Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Dzinamarira T, Moyo E. The use of oral HIV pre-exposure prophylaxis among people who inject drugs: barriers, and recommendations. Front Public Health 2023; 11:1265063. [PMID: 37732092 PMCID: PMC10507712 DOI: 10.3389/fpubh.2023.1265063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/24/2023] [Indexed: 09/22/2023] Open
Affiliation(s)
- Tafadzwa Dzinamarira
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
- ICAP at Columbia University, Lusaka, Zambia
| | - Enos Moyo
- School of Nursing and Public Health, College of Health Sciences, University of Kwa-Zulu Natal, Durban, South Africa
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7
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Glick JL, Zhang L, Rosen JG, Yaroshevich K, Atiba B, Pelaez D, Park JN. A Novel Capacity-Strengthening Intervention for Frontline Harm Reduction Workers to Support Pre-exposure Prophylaxis Awareness-Building and Promotion Among People Who Use Drugs: Formative Research and Intervention Development. JMIR Form Res 2023; 7:e42418. [PMID: 37052977 PMCID: PMC10141312 DOI: 10.2196/42418] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 02/08/2023] [Accepted: 02/08/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND HIV prevalence among people who use drugs (PWUD) in Baltimore, Maryland, is higher than among the general population. Pre-exposure prophylaxis (PrEP) is a widely available medication that prevents HIV transmission, yet its usefulness is low among PWUD in Baltimore City and the United States. Community-level interventions to promote PrEP uptake and adherence among PWUD are limited. OBJECTIVE We describe the development of a capacity-strengthening intervention designed for frontline harm reduction workers (FHRWs) to support PrEP awareness-building and promotion among PWUD. METHODS Our study was implemented in 2 phases in Baltimore City, Maryland. The formative phase focused on a qualitative exploration of the PrEP implementation environment, as well as facilitators and barriers to PrEP willingness and uptake, among cisgender women who use drugs. This work, as well as the existing literature, theory, and feedback from our community partners, informed the intervention development phase, which used an academic-community partnership model. The intervention involved a 1-time, 2-hour training with FHRWs aimed at increasing general PrEP knowledge and developing self-efficacy promoting PrEP in practice (eg, facilitating PrEP dialogues with clients, supporting client advancement along a model of PrEP readiness, and referring clients to PrEP services). In a separate paper, we describe the conduct and results of a mixed methods evaluation to assess changes in PrEP-related knowledge, attitudes, self-efficacy, and promotion practices among FHRWs participating in the training. RESULTS The pilot was developed from October to December 2021 and implemented from December 2021 through April 2022. We leveraged existing relationships with community-based harm reduction organizations to recruit FHRWs into the intervention. A total of 39 FHRWs from 4 community-based organizations participated in the training across 4 sessions (1 in-person, 2 online synchronous, and 1 online asynchronous). FHRW training attendees represented a diverse range of work cadres, including peer workers, case managers, and organizational administrators. CONCLUSIONS This intervention could prevent the HIV burden among PWUD by leveraging the relationships that FHRWs have with PWUD and by supporting advancement along the PrEP continuum. Given suboptimal PrEP uptake among PWUD and the limited number of interventions designed to address this gap, our intervention offers an innovative approach to a burgeoning public health problem. If effective, our intervention has the potential to be further developed and scaled up to increase PrEP awareness and uptake among PWUD worldwide.
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Affiliation(s)
- Jennifer L Glick
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Leanne Zhang
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Joseph G Rosen
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | | | - Bakari Atiba
- Charm City Care Connection, Baltimore, MD, United States
| | - Danielle Pelaez
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Ju Nyeong Park
- Division of General Internal Medicine, Warren Alpert Medical School, Brown University, Providence, RI, United States
- Center of Biomedical Research Excellence on Opioids and Overdose, Rhode Island Hospital, Providence, RI, United States
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Corneli A, Perry B, Des Marais A, Choi Y, Chen H, Lilly R, Ayers D, Bennett J, Kestner L, Meade CS, Sachdeva N, McKellar MS. Participant perceptions on the acceptability and feasibility of a telemedicine-based HIV PrEP and buprenorphine/naloxone program embedded within syringe services programs: a qualitative descriptive evaluation. Harm Reduct J 2022; 19:132. [PMID: 36463214 PMCID: PMC9719634 DOI: 10.1186/s12954-022-00718-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/19/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND People who inject drugs (PWID) are at risk for HIV and opioid overdose. We piloted PARTNER UP, a telemedicine-based program to provide PWID with access to both oral pre-exposure prophylaxis (PrEP) for HIV prevention and medication for opioid use disorder (MOUD) through two syringe services programs (SSPs) in North Carolina. We conducted a qualitative evaluation to assess the acceptability and feasibility of PARTNER UP from the participant perspective. METHODS PARTNER UP participants met with a provider for an initial in-person visit at the SSP, followed by weekly telemedicine visits in month 1 and then monthly telemedicine visits until program end at month 6. Using a qualitative descriptive study design, we conducted in-depth interviews with a subsample of PARTNER UP participants at 1 month and 4 months. Informed by the technology acceptance model, we assessed participant perceptions of the usefulness and ease of use of PARTNER UP, as well as their intent to continue to use the program's components. We audio-recorded all interviews with participants' permission and used applied thematic analysis to analyze the verbatim transcripts. RESULTS We interviewed 11 of 17 people who participated in PARTNER UP-10 in the month 1 interview and 8 in the month 4 interview. Nearly all participants were motivated to join for consistent and easy access to buprenorphine/naloxone (i.e., MOUD); only a few joined to access PrEP. Most were comfortable accessing healthcare at the SSP because of their relationship with and trust toward SSP staff, and accessing services at the SSP was preferred compared with other healthcare centers. Some participants described that telemedicine allowed them to be honest and share more information because the visits were not in-person and they chose the location, although the initial in-person meeting was helpful to build provider trust and rapport. Most participants found the visit schedule to be feasible, although half described needing to reschedule at least once. Nearly all participants who were interviewed intended to continue with MOUD after the program ended, whereas none were interested in continuing with PrEP. CONCLUSIONS Participant narratives suggest that the PARTNER UP telemedicine program was acceptable and feasible. Future studies should continue to explore the benefits of embedding both PrEP and MOUD into SSPs with larger numbers of participants. Trial registration Clinicaltrials.gov Identifier: NCT04521920.
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Affiliation(s)
- Amy Corneli
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA ,grid.26009.3d0000 0004 1936 7961Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC USA ,grid.26009.3d0000 0004 1936 7961Department of Medicine, Duke University School of Medicine, Durham, NC USA
| | - Brian Perry
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA
| | - Andrea Des Marais
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA
| | - Yujung Choi
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA
| | - Hillary Chen
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA
| | - Rebecca Lilly
- North Carolina Harm Reduction Coalition, Wilmington, NC USA ,Present Address: Port City Harm Reduction, Wilmington, NC USA
| | - Denae Ayers
- Queen City Harm Reduction, Charlotte, NC USA
| | - Jesse Bennett
- North Carolina Harm Reduction Coalition, Wilmington, NC USA
| | | | - Christina S. Meade
- grid.26009.3d0000 0004 1936 7961Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC USA
| | - Nidhi Sachdeva
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA ,grid.10698.360000000122483208Present Address: North Carolina Association of County Commissioners, Raleigh, NC USA
| | - Mehri S. McKellar
- grid.26009.3d0000 0004 1936 7961Department of Medicine, Duke University School of Medicine, Durham, NC USA
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