"They make it too hard and too many hoops to jump": system and organizational barriers to drug treatment during epidemic rates of opioid overdose.

INTRODUCTION: The United States is currently facing an opioid overdose crisis. Research suggests that multiple interventions are needed to reduce overdose deaths including increasing access and retention to medications to treat opioid use disorders (MOUD, i.e., methadone, buprenorphine, and naltrexone) and increasing the distribution and use of naloxone, a medication that can reverse the respiratory depression that occurs during opioid overdoses. However, barriers to MOUD initiation and retention persist and discontinuations of MOUD carry a heightened risk of overdose. Many times, MOUD is not sought as a first line of treatment by people with opioid use disorder (OUD), many of whom seek treatment from medically managed withdrawal (detox) programs. Among those who do initiate MOUD, retention is generally low. The present study examines the treatment experiences of people who use opioids in three states, Connecticut, Kentucky, and Wisconsin. METHODS: We conducted in-depth interviews with people who use opioids in a rural, urban, and suburban area of three states: Connecticut, Kentucky and Wisconsin. Data analysis was collaborative and key themes were identified through multiple readings, coding of transcripts and discussion with all research team members. RESULTS: Results reveal a number of systemic issues that reduce the likelihood that people initiate and are retained on MOUD including the ubiquity of detox as a first step in drug treatment, abstinence requirements and requiring patients to attend group treatment. MOUD-related stigma was a significant factor in the kinds of treatment participants chose and their experiences in treatment. CONCLUSIONS: Interventions to reduce MOUD stigma are needed to encourage MOUD as a first course of treatment. Eliminating abstinence-based rules for MOUD treatment may improve treatment retention and decrease overdose risk.

The Relative Influence of Perceived Immigration Laws and Consequences on HIV Testing Among US Latino Immigrants.

The CDC recommends that persons aged 13-64 receive an HIV test at least once in their lifetime and that some groups test annually or more frequently. Nearly one-half of US Latino immigrants have never been tested for HIV. To the extent that immigration-related laws deter documented and undocumented immigrants from engaging in communicable disease control measures, these laws undermine public health efforts. 1750 noncitizen adult, sexually active, Spanish-speaking Latino immigrants across four cities in the US completed a cross-sectional survey assessing perceptions of immigration-related laws and immigration consequences related to HIV testing and diagnosis. Participants were recruited in-person by staff in community settings, through flyers posted in places frequented by Latino immigrants, and by word-of-mouth through snowball sampling. Outcomes were whether participants had ever received an HIV test and whether they tested in the previous 12 months. Multivariable analyses examined the relative contribution of perceived immigration laws and consequences on HIV testing behaviors when considering established predictors of HIV testing. Perceptions of HIV-related immigration laws and immigration consequences was a significant predictor of never having had an HIV test even when considered relative to common predictors of HIV testing. The influence of perceived immigration laws and consequences on testing in the previous 12 months was not significant in multivariable analysis. Perceived HIV-related immigration laws and consequences appear to be a substantial contributor to reluctance to be tested for HIV among Latino immigrants who have never been tested. Effective interventions should be developed to address these.

RESUMEN: El CDC recomienda que las personas de 13 a 64 años se hagan una prueba del VIH al menos una vez en la vida y que algunos grupos se hagan la prueba anualmente o con mayor frecuencia. Casi la mitad de los inmigrantes latinos de los Estados Unidos nunca se han hecho la prueba del VIH. En la medida en que las leyes relacionadas con la inmigración disuadan a los inmigrantes documentados e indocumentados de participar en medidas de control de enfermedades transmisibles, estas leyes socavan los esfuerzos de salud pública. 1750 inmigrantes latinos adultos no ciudadanos, sexualmente activos y de habla hispana en cuatro ciudades de EE. UU. completaron una encuesta transversal que evaluó las percepciones de las leyes relacionadas con la inmigración y de las consecuencias de la inmigración relacionadas con las pruebas y el diagnóstico del VIH. Los participantes fueron reclutados en persona en contextos comunitarios, a través de volantes publicados en lugares frecuentados por inmigrantes latinos y de boca en boca a través de muestras de bola de nieve. Las variables dependientes fueron si los participantes se habían hecho una prueba del VIH alguna vez y si se habían hecho la prueba en los últimos 12 meses. Los análisis multivariados examinaron la contribución relativa de la percepción de las leyes de inmigración y de las consecuencias de inmigración sobre los comportamientos relativo a las pruebas del VIH, controlando por predictores conocidos de las pruebas del VIH. Las percepciones de las leyes de inmigración relacionadas con el VIH y las consecuencias de la inmigración fueron un predictor significativo de nunca haberse realizado una prueba del VIH, aun considerando los predictores comunes de la prueba del VIH. La influencia de la percepción de las leyes de inmigración y de las consecuencias de la inmigración sobre la prueba en los últimos 12 meses no fue significativa en el análisis multivariado. Las leyes de inmigración y las consecuencias percibidas relacionadas con el VIH parecen contribuir sustancialmente a la renuencia a hacerse la prueba del VIH entre los inmigrantes latinos que nunca se han hecho la prueba. Deben desarrollarse intervenciones efectivas para abordar esta renuencia.

Fight COVID Milwaukee protective behaviors and risk communications associated with the COVID-19 pandemic.

The COVID-19 pandemic has had a major impact on society, causing significant disruptions to everyday life. Risk communication strategies can play an important role in risk management as they allow individuals to prepare for and respond to public health emergencies appropriately. The aim of this study is to investigate public risk behaviors, perceptions of risk and risk communication, and experiences with COVID-19 to better understand the impact of COVID-19 on our community and to better inform public health decisions about communicating and reducing personal risk. Nine virtual focus groups were conducted with 79 residents of Milwaukee County. Audio transcripts of focus group recordings were qualitatively analyzed using MAXQDA. Predominant themes identified include public risk protective behaviors, the emotional toll associated with lockdown measures, and risk communication. Our findings provide a better understanding of how adults, African American and Hispanic groups in particular, viewed the risk communications and protective behaviors associated with COVID-19, how their lives were impacted by the pandemic, and how to effectively communicate public information about personal risk. These findings can help guide risk communication efforts and public health policy interventions for potential infection outbreaks in the future.

Latino migrants' healthcare use in the US and perceived immigration laws and consequences: A multivariable analysis.

BACKGROUND: Using healthcare, whether for routine preventative examinations, chronic condition management, or emergent conditions, is an essential element of achieving and maintaining health. Over 44 million migrants live in the US today and nearly half (44.6 %) are Latino. To the extent that immigration law-related concerns deter US Latino migrants from using healthcare, they jeopardize the health of a substantial though marginalized US subpopulation. METHODS: A multistate sample (N = 1750) of noncitizen adult, Spanish speaking Latino migrants (both undocumented and documented) living in the US completed a cross-sectional survey comprising a scale assessing perceptions of immigration laws and consequences related to healthcare use and whether they had received and/or needed but did not receive healthcare in the previous 12-months. Participants were recruited in community settings and by word-of-mouth. Univariate analyses examined associations among study outcomes and common predictors of healthcare use. Multivariable analyses examined the relative contribution of perceived immigration laws and consequences on healthcare use and unmet need. RESULTS: Perceptions of immigration laws and immigration consequences were a significant predictor of not having received healthcare in the previous 12-months and having needed and not received healthcare in the same period, even when considered relative to common predictors of healthcare use. Immigration documentation status and preferred language predicted healthcare use in univariate analyses but not in the multivariable model. CONCLUSIONS: Perceived immigration laws and consequences related to healthcare use may influence migrants' healthcare use. Effective interventions should be developed to address immigration-related concerns.

Spatial accessibility to health facilities among pregnant women with and without exposure to intimate partner violence in Uganda.

BACKGROUND: Poor physical access to health facilities could increase the likelihood of undetected intimate partner violence (IPV) during pregnancy. We aimed to determine sub-regional differences and associations between spatial accessibility to health facilities and IPV among pregnant women in Uganda. METHOD: Weighted cross-sectional analyses were conducted using merged 2016 Uganda Demographic and Health Survey and 2014 Uganda Bureau of Statistics health facility datasets. Our study population were 986 women who self-reported being currently pregnant and responded to IPV items. Outcome was spatial accessibility computed as the near point linear distance [< 5 km (optimal) vs. ≥ 5 km (low)] between women's enumeration area and health facility according to government reference cutoffs. Primary independent variable (any IPV) was defined as exposure to at least one of physical, emotional, and sexual IPV forms. Logistic regression models were sequentially adjusted for covariates in blocks based on Andersen's behavioral model of healthcare utilization. Covariates included predisposing (maternal age, parity, residence, partner controlling behavior), enabling (wealth index, occupation, education, economic empowerment, ANC visit frequency), and need (wanted current pregnancy, difficulty getting treatment money, afraid of partner, and accepted partner abuse) factors. RESULTS: Respondents' mean age was 26.1 years with ± 9.4 standard deviations (SD), mean number of ANC visits was 3.8 (± 1.5 SD) and 492/986 (49.9%) pregnant women experienced IPV. Median spatial accessibility to the nearest health facility was 4.1 km with interquartile range (IQR) from 0.2 to 329.1 km. Southwestern, and Teso subregions had the highest average percentage of pregnant women experiencing IPV (63.8-66.6%) while Karamoja subregion had the highest median spatial accessibility (7.0 to 9.3 km). In the adjusted analysis, pregnant women exposed to IPV had significantly higher odds of low spatial accessibility to nearest health facilities when compared to pregnant women without IPV exposure after controlling for enabling factors in Model 2 (aOR 1.6; 95%CI 1.2, 2.3) and need factors in Model 3 (aOR 1.5; 95%CI 1.1, 3.8). CONCLUSIONS: Spatial accessibility to health facilities were significantly lower among pregnant women with IPV exposure when compared to those no IPV exposure. Improving proximity to the nearest health facilities with ANC presents an opportunity to intervene among pregnant women experiencing IPV. Focused response and prevention interventions for violence against pregnant women should target enabling and need factors.

Healthcare provider experiences interacting with survivors of intimate partner violence: a qualitative study to inform survivor-centered approaches.

BACKGROUND: Intimate partner violence (IPV) remains a pervasive form of gender-based violence (GBV) that is largely undisclosed, especially among women seeking healthcare services in Uganda. Prioritizing survivor needs may improve IPV disclosure. This study explores healthcare worker experiences from provider-patient interactions with survivors seeking antenatal care services (ANC) in Uganda. METHODS: In-depth interviews were conducted among twenty-eight experienced healthcare providers in a rural and an urban-based ANC clinic in Eastern and Central Uganda. Providers were asked what they viewed as the needs and fears of women identified as having experienced any form of IPV. Iterative, inductive/deductive thematic analysis was conducted to discover themes regarding perceived needs, fears, and normalizing violence experienced by IPV survivors. RESULTS: According to healthcare providers, IPV survivors are unaware of available support services, and have need for support services. Providers reported that some survivors were afraid of the consequences of IPV disclosure namely, community stigma, worries about personal and their children's safety, retaliatory abuse, fear of losing their marriage, and partners' financial support. Women survivors also blamed themselves for IPV. Contextual factors underlying survivor concerns included the socio-economic environment that 'normalizes' violence, namely, some cultural norms condoning violence, and survivors' unawareness of their human rights due to self-blame and shame for abuse. CONCLUSIONS: We underscore a need to empower IPV survivors by prioritizing their needs. Results highlight opportunities to create a responsive healthcare environment that fosters IPV disclosure while addressing survivors' immediate medical and psychosocial needs, and safety concerns. Our findings will inform GBV prevention and response strategies that integrate survivor-centered approaches in Uganda.

Intimate partner violence and antenatal care utilization predictors in Uganda: an analysis applying Andersen's behavioral model of healthcare utilization.

BACKGROUND: Optimal utilization of antenatal care (ANC) services improves positive pregnancy experiences and birth outcomes. However, paucity of evidence exists on which factors should be targeted to increase ANC utilization among women experiencing intimate partner violence (IPV) in Uganda. OBJECTIVE: To determine the independent association between IPV exposure and ANC utilization as well as the predictors of ANC utilization informed by Andersen's Behavioral Model of Healthcare Utilization. METHODS: We analyzed 2016 Uganda Demographic and Health Survey data that included a sample of 1,768 women with children aged 12 to 18 months and responded to both ANC utilization and IPV items. Our outcome was ANC utilization, a count variable assessed as the number of ANC visits in the last 12 months preceding the survey. The key independent variable was exposure to any IPV form defined as self-report of having experienced physical, sexual and/or emotional IPV. Covariates were grouped into predisposing (age, formal education, religion, problem paying treatment costs), enabling (women's autonomy, mass media exposure), need (unintended pregnancy, parity, history of pregnancy termination), and healthcare system/environmental factors (rural/urban residence, spatial accessibility to health facility). Poisson regression models tested the independent association between IPV and ANC utilization, and the predictors of ANC utilization after controlling for potential confounders. RESULTS: Mean number of ANC visits (ANC utilization) was 3.71 visits with standard deviation (SD) of ± 1.5 respectively. Overall, 60.8% of our sample reported experiencing any form of IPV. Any IPV exposure was associated with lower number of ANC visits (3.64, SD ± 1.41) when compared to women without IPV exposure (3.82, SD ± 1.64) at p = 0.013. In the adjusted models, any IPV exposure was negatively associated with ANC utilization when compared to women with no IPV exposure after controlling for enabling factors (Coef. -0.03; 95%CI -0.06,-0.01), and healthcare system/environmental factors (Coef. -0.06; 95%CI -0.11,-0.04). Predictors of ANC utilization were higher education (Coef. 0.27; 95%CI 0.15,0.39) compared with no education, high autonomy (Coef. 0.12; 95%CI 0.02,0.23) compared to low autonomy, and partial media exposure (Coef. 0.06; 95%CI 0.01,0.12) compared to low media exposure. CONCLUSION: Addressing enabling and healthcare system/environmental factors may increase ANC utilization among Ugandan women experiencing IPV. Prevention and response interventions for IPV should include strategies to increase girls' higher education completion rates, improve women's financial autonomy, and mass media exposure to improve ANC utilization in similar populations in Uganda.

Institutional violence from police militarization and drug cartel wars as a 'Big Event' and its influence on drug use harms and HIV risk in people who inject drugs on the U.S.-Mexico border.

BACKGROUND: Globally, the US-Mexico Border is one of the largest drug trafficking regions, with Ciudad Juarez (CJ) and El Paso (EP) making up the second-largest border crossing in the world. Border communities are places where the risk of drug use harm and infectious diseases such as HIV are augmented due to the confluence of factors operating across the physical, social, economic and policy environment. Although the two cities are economically, culturally, and socially intertwined, each has distinct criminal justice systems and policy practices aimed at curtailing substance use. Between 2008 and 2011, the CJ/EP region experienced an unprecedented level of violence that stemmed from the intersection of police militarization and drug cartel wars, which profoundly shaped every aspect of life. Little research has documented the impact of drug cartel wars on the drug use and health harms of people who inject drugs (PWID) living in CJ and EP. The purpose of the study is to understand the effect that the drug cartel war had on the drug use harms and HIV risk of PWID. METHODS: We conducted 40 in-depth interviews with people who inject drugs who resided in CJ or EP and had used heroin or crack cocaine in the last 30 days, and asked how police militarization and drug cartel war affected their daily lives. The risk environment framework informed the analysis and interpretation of findings. RESULTS: Findings indicated that the risk environment was profoundly altered as PWID residing in CJ experienced profound changes in their daily lives that promoted engagement in behaviors that increased drug use and health harms including HIV risk, exacerbated trauma, and prevented use of substance use treatment and harm reduction services. The risk environment was also altered in EP, where PWID experienced drug supply shortages, violent policing practices, and reduced availability of harm reduction services. Findings underscore the permeability of risk environments across geographical borders. CONCLUSION: The intersection of law enforcement militarization and drug cartel wars can be conceptualized as a 'big event' because it disrupts the drug market economy, leads to drug shortages, promotes entrance into the drug market economy by people who use drugs, reshapes drug use sites, and constrains the provision of harm reduction services. The stability of the harm reduction system in CJ was negatively impacted and limited the ability of individuals to reduce harm. Our findings show that drug cartel wars render the CJ/EP region extremely susceptible to drug use and health harms, while also creating vulnerability by severely restricting its ability to respond. Traditional recommendations to intervene to limit the impact of risk environments on the drug use harms of PWID need to be reconsidered in the context of drug cartel wars.

Water, Sanitation, and Hygiene Challenges in Informal Settlements in Kampala, Uganda: A Qualitative Study.

Diarrhea causes 1.6 million deaths annually, including 525,000 children. Further, chronic diarrhea puts children at risk for mineral deficiencies, malnutrition, and stunting which, in turn, can result in cognitive deficits, poor performance in school, and decreased disease immunity in adulthood. Most diarrhea is caused by water contaminated by fecal matter. Interventions to improve clean water and sanitation can save lives; however, challenges persist in informal settlements. In this study, we explored the views of residents of informal settlements regarding water and sanitation in their communities. Focus group interviews were conducted with residents of 6 informal settlements in Kampala, Uganda (n = 165 people), and 6 key informant interviews were conducted with governmental and nongovernmental organizations that work to improve informal settlements or provide services to them. The results from this study demonstrate that, although these informal settlements had many infrastructure "upgrades" such as latrines and toilets, water taps, wells, and garbage collection and drainage systems, the water, sanitation, and hygiene (WASH) system and its components largely failed due to point-of-use charges of water taps and toilets and the difficulty of emptying cesspits. Our results suggest that WASH must be considered a system and that multiple upgrading efforts are needed for WASH systems to work, including road construction and better oversight of fecal sludge disposal.

US public charge policy and Latinx immigrants' thoughts about health and healthcare utilization.

OBJECTIVES: We examined Latinx immigrants' perceptions of US policy related to restrictions on immigrants' use of public resources and their thoughts about the influence of these on immigrants' healthcare utilization. DESIGN: A series of 16 focus group discussions with Latinx immigrant men and women (documented and undocumented) (N = 130) were conducted between May and July 2017 across four US cities. RESULTS: Four central themes emerged: participants attributed the limited resources available for affordable healthcare for many uninsured US immigrants (both documented and undocumented) to the US government's view of immigrants as burdens on public resources and its subsequent unwillingness to dedicate funds for their care; participants expressed concerns, some unfounded, about negative immigration ramifications arising from diagnosis with health conditions perceived to be serious and/or expensive to treat; participants noted that some immigrants avoided using health programs and services to which they were entitled because of immigration concerns; finally, participants described how access to information on immigration laws and healthcare resources, and conversely, misinformation about these, influenced healthcare utilization. CONCLUSIONS: Participants were acutely aware of the image of immigrants as public charges or potential burdens on government resources that underlies US immigration policy. In some cases, participants came to inaccurate and potentially harmful conclusions about the substance of laws and regulations based on their beliefs about the government's rejection of immigrants who may burden public resources. This underscores the importance of ensuring that immigrants have access to information on immigration-related laws and regulations and on healthcare resources available to them. Participants noted that access to information also fostered resilience to widespread misinformation. Importantly, however, participants' beliefs had some basis in US immigration policy discourse. Law and policy makers should reconsider legislation and political commentary that frame self-reliance, the guiding principle of US immigration policy, in terms of immigrants' use of publicly funded healthcare resources.

Intersectional Discrimination and PrEP uSe Among Young Black Sexual Minority Individuals: The Importance of Black LGBTQ Communities and Social Support.

Intersectional stigma and discrimination have increasingly been recognized as impediments to the health and well-being of young Black sexual minority men (YBSMM) and transgender women (TW). However, little research has examined the relationship between intersectional discrimination and HIV pre-exposure prophylaxis (PrEP) outcomes. This study with 283 YBSMM and TW examines the relationship between intersectional discrimination and current PrEP use and likelihood of future PrEP use. Path models were used to test associations between intersectional discrimination, resilience and social support, and PrEP use and intentions. Individuals with higher levels of anticipated discrimination were less likely to be current PrEP users (OR = 0.59, p = .013), and higher levels of daily discrimination were associated with increased likelihood of using PrEP in the future (B = 0.48 (0.16), p = .002). Greater discrimination was associated with higher levels of resilience, social support, and connection to the Black LGBTQ community. Social support mediated the effect of day-to-day discrimination on likelihood of future PrEP use. Additionally, there was a significant and negative indirect effect of PrEP social concerns on current PrEP use via Black LGBTQ community connectedness. The results of this study highlight the complexity of the relationships between discrimination, resilience, and health outcomes.

Navigating misinformation and political polarization of COVID-19: interviews with Milwaukee, Wisconsin county public health officials.

Introduction: The spread of misinformation combined with the political polarization of the COVID-19 vaccine created major challenges for public health officials responding to the COVID pandemic and vaccine roll-out. The challenges public health officials faced when making safety recommendations and promoting the vaccine only exacerbated the already exhausting work conditions they experienced since the start of the pandemic. Combating misinformation while receiving inadequate political support led to burnout for many public health officials. As such, they had to adapt and develop new strategies for increasing vaccine acceptance and decreasing vaccine hesitancies. Method: This study was conducted through qualitative interviews with seven Milwaukee County public health officials. This study aimed to determine how public health officials perceived misinformation and political polarization during the pandemic. Additionally, the study aimed to learn more about strategies county health officials used to combat misinformation while increasing vaccine uptake in their communities. Results: Thematic analysis of the interviews identified three major challenges faced by public health officials in promoting vaccination: dissemination of misinformation in media, political polarization of COVID and its contribution to vaccine acceptance and COVID fatigue, and assessment of the risks associated with disease severity versus vaccine safety considering limited public health resources. Discussion: Learning from public health officials allows us to better understand their perceptions of the extent of local vaccine hesitancies and their advice on how to counteract fears and misinformation and to promote COVID vaccine uptake. Political polarization of COVID and misinformation affected community vaccine acceptance and challenged local public health leadership.

Barriers to drug treatment in police diversion programs and drug courts: A qualitative analysis.

Drug treatment courts and police diversion programs are designed to divert people away from incarceration and into drug treatment. This article explores barriers in linking people who use drugs (PWUD) into drug treatment facilities in urban, suburban, and rural areas of Connecticut, Kentucky, and Wisconsin. Between December 2018 and March 2020, study teams in the three states conducted in-depth, semistructured interviews with key informants involved in programs to divert PWUD from criminal justice involvement including police, lawyers, judges, and others who work in drug treatment courts, and substance use disorder treatment providers who received referrals from and worked with police diversion programs or drug courts. Police diversion programs and drug treatment courts showed intraprogram variation in the structure of their programs in the three states and in different counties within the states. Structural barriers to successfully linking PWUD to treatment included a lack of resources, for example, a limited number of treatment facilities available, difficulties in funding mandated treatment, particularly in Wisconsin where Medicaid expansion has not occurred, and PWUDs' need for additional services such as housing. Many police officers, judges, and others within drug treatment court, including drug treatment specialists, hold stigmatizing attitudes toward medications to treat opioid use disorder (MOUD) and are unlikely to recommend or actively refer to MOUD treatment. Drug courts and police diversion programs offer a welcome shift from prior emphases on criminalization of drug use. However, for such programs to be effective, more resources must be dedicated to their success. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Role of Context in Integrating Buprenorphine into a Drop-In Center in Kampala, Uganda, Using the Consolidated Framework for Implementation Research.

BACKGROUND: Although Africa has long borne the brunt of the human immunodeficiency virus (HIV) epidemic, until recently, the continent has been considered largely free of illicit drug use and injection drug use in particular. In Uganda, the number of people who use or inject drugs (PWUD and PWID, respectively) has increased, and PWID are a key population at high risk for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection. However, harm reduction practices, including providing clean injection equipment and medication-assisted treatment (MAT), have only recently been piloted in the country. This project aims to integrate buprenorphine into a harm reduction drop-in center (DIC). METHODS: The Consolidated Framework for Implementation Research was used to guide our preparations to integrate buprenorphine into existing practices at a harm reduction DIC. We conducted key informant interviews with members of a community advisory board and DIC staff to document this process, its successes, and its failures. RESULTS: Results indicate that criminalization of drug use and stigmatization of PWUD challenged efforts to provide buprenorphine treatment in less regulated community settings. CONCLUSIONS: DIC staff and their commitment to harm reduction and advocacy facilitated the process of obtaining necessary approvals.

"You're Not Supposed to be on it Forever": Medications to Treat Opioid Use Disorder (MOUD) Related Stigma Among Drug Treatment Providers and People who Use Opioids.

Opioid use disorder (OUD) through prescription opioid misuse, heroin, and illicitly manufactured fentanyl use has increased dramatically in the past 20 years. Medications to treat opioid use disorder (MOUD) is considered the gold standard for treating opioid use disorders but uptake remains low. Recently, Madden has argued that in addition to the stigma assigned to substance use and people with SUD, MOUDs also are stigmatized, a process she labels intervention stigma to distinguish it from condition stigma (ie, stigma of SUD) . In this paper, we examine MOUD related stigma from the perspective of people who use opioids (PWUO) and key informants who play some role in providing or referring people to drug treatment. Providers and PWOU often viewed MOUD as one drug replacing another which discouraged providers from recommending and PWUO from accepting MOUD. MOUD stigma was also expressed by providers' exaggerated fear of MOUD diversion. The extent to which MOUD was accepted as a legitimate treatment varied and influenced treatment providers' perceptions of the goals of drug treatment and the length of time that MOUD should be used with many feeling that MOUD should only be used as a temporary tool while PWOU work on other treatment goals. This led to tapering off of MOUD after some time in treatment. Some providers also expressed mistrust of MOUD stemming from their previous experiences with the over-prescription of opioids for pain which led to the current crisis. Results from this study suggest that the proportion of PWUO on MOUD is unlikely to increase without addressing MOUD stigma among drug treatment providers and PWUO seeking treatment.

Understanding Barriers to Care for Refugee Patients: Lessons From Focus Groups.

BACKGROUND: Refugee populations resettled in the United States face health disparities and barriers to accessing care. Better understanding of the barriers this population faces may help clinicians address them. METHODS: Focus groups with refugees were held in Wisconsin. Discussion prompts such as "What could be done to improve health in your community?" were used. Notes from the focus groups were organized and coded using MAXQDA. RESULTS: Six themes were identified from the focus groups regarding health care barriers and experiences: language, interpretation, pharmacy, insurance, transportation, and respect. DISCUSSION: Clinicians working with refugee populations can strive to minimize barriers to care for refugee patients by being aware of the barriers, implementing changes in their practice, and/or community advocacy.

A qualitative examination of naloxone access in three states: Connecticut, Kentucky, and Wisconsin.

BACKGROUND: Prevention of opioid-involved overdose deaths remains a public health priority in the United States. While expanding access to naloxone is a national public health strategy, it is largely implemented at the state and local level, where significant variability in policies, resources, and norms exist. The aims of the current study were to examine the social context of naloxone access in three different states (Connecticut, Kentucky, Wisconsin) from the perspectives of key informants (first responders, harm reduction personnel, and pharmacists), who play some role in dispensing or administering naloxone within their communities. METHODS: Interviews were conducted with key informants who were in different local areas (urban, suburban, rural) across Connecticut, Kentucky, and Wisconsin. Interview guides explored the key informants' experiences with administering or dispensing naloxone, and their perspectives on opioid overdose prevention efforts in their areas. Data analysis was conducted using multistage inductive coding and comparative methods to identify dominant themes within the data. RESULTS: Key informants in each of the three states noted progress toward expanding naloxone access, especially among people who use opioids, but also described inequities. The key role of harm reduction programs in distributing naloxone within their communities was also highlighted by participants, as well as barriers to increasing naloxone access through pharmacies. Although there was general consensus regarding the effectiveness of expanding naloxone access to prevent overdose deaths, the results indicate that communities are still grappling with stigma associated with drug use and a harm reduction approach. CONCLUSION: Findings suggest that public health interventions that target naloxone distribution through harm reduction programs can enhance access within local communities. Strategies that address stigmatizing attitudes toward people who use drugs and harm reduction may also facilitate naloxone expansion efforts, overall, as well as policies that improve the affordability and awareness of naloxone through the pharmacy.

The effects of opioid policy changes on transitions from prescription opioids to heroin, fentanyl and injection drug use: a qualitative analysis.

BACKGROUND: Beginning in the 1990s, nonmedical use of prescription opioids (POs) became a major public health crisis. In response to rising rates of opioid dependence and fatal poisonings, measures were instituted to decrease the prescription, diversion, and nonmedical use of POs including prescription drug monitoring programs (PDMPs), pain clinic laws, prescription duration limits, disciplining doctors who prescribed an excessive number of POs, and the advent of abuse deterrent formulations of POs. This paper explores the unintended effects of these policies in the descriptions of why people who use opioids transitioned from PO to injection or heroin/fentanyl use. METHODS: We conducted 148 in-depth-interviews with people who use prescription opioids nonmedically, fentanyl or heroin from a rural, urban and suburban area in three states, Connecticut, Kentucky and Wisconsin. Interviews with people who use opioids (PWUO) focused on how they initiated their opioid use and any transitions they made from PO use to heroin, fentanyl or injection drug use. RESULTS: The majority of participants reported initiating use with POs, which they used for medical or nonmedical purposes. They described needing to take more POs or switched to heroin or fentanyl as their tolerance increased. As more policies were passed to limit opioid prescribing, participants noticed that doctors were less likely to prescribe or refill POs. This led to scarcity of POs on the street which accelerated the switch to heroin or fentanyl. These transitions likely increased risk of overdose and HIV/HCV infection. CONCLUSIONS: A careful analysis of how and why people say they transitioned from PO to heroin or fentanyl reveals many unintended harms of policy changes to prevent overprescribing and diversion. Results highlight the importance of mitigating harms that resulted from policy changes.

Intersectional Resilience Among Black Gay, Bisexual, and Other Men Who Have Sex With Men, Wisconsin and Ohio, 2019.

Objectives. To investigate resilience strategies used by Black gay, bisexual, and other men who have sex with men (MSM) to navigate racism and heterosexism. Methods. In 2019, we conducted in-depth interviews with 46 Black MSM in Milwaukee, Wisconsin, and Cleveland, Ohio. Thematic analysis, informed by intersectionality, was used to identify intersectional resilience within the context of participants' lives. Results. Our analyses revealed ways in which Black MSM respond to stigma and oppression. We identified the following themes that capture these experiences: pride in intersectional identities, perseverance, community advocacy, and social support. Our analyses reveal how men draw on these assets and resources to positively adapt despite experiences of racism and heterosexism. Conclusions. Intersectional resilience can support Black MSM in navigating racism and heterosexism. However, public health interventions at the institutional and system levels are needed to directly target the root causes of oppression and support resources that facilitate intersectional resilience. (Am J Public Health. 2022;112(S4):S405-S412. https://doi.org/10.2105/AJPH.2021.306677).

Validation of Brief Condom Use Attitudes Scales for Spanish-Speaking People Who Use Crack Cocaine in El Salvador.

People who use crack cocaine (PWUCC) are a population severely impacted by a concentrated epidemic of HIV. Behavioral interventions to prevent and treat HIV among PWUCC have been implemented around the world including in low- and middle-income countries which have been disproportionately affected by HIV. However, few studies have validated and assessed psychometric properties of measures on PWUCC, especially in transnational populations. Our sample was comprised of 1324 PWUCC, Spanish mono-lingual speakers, residing in the metropolitan area of San Salvador, El Salvador. Exploratory factor analysis and subsequent confirmatory factor analysis using statistical softwares SPSS and Amos were conducted on three abbreviated and translated condom use attitude measures (i.e., Condom Use Attitudes Scale-Spanish Short Form, Condom Use Social Norm-Spanish Short Form [CUSN-SSF], Condom Use Self-Efficacy-Spanish Short Form). Convergent validity was examined by computing bivariate correlations between the scales and condom use and sexually transmitted disease diagnosis. Results indicated that a two-factor, 8-item correlated model for the CUAS-SSF scale had an excellent fit and adequate reliability (α = .76). The confirmatory factor analysis for the 5-item CUSN-SSF scale indicated a satisfactory fit with 3 of 6 fit indices indicating adequate fit. Analysis of the two-factor 5-item CUSE-SSF scale indicated satisfactory fit and adequate reliability (α = .84). There were significant correlations between all measures and with self-reported condom use. Results indicate that these brief measures are reliable and valid and can be utilized to assess the effectiveness of HIV risk reduction interventions among Spanish-speaking PWUCC.