Guiding the Implementation of Wastewater-based Surveillance for Carceral Infection Control with Perspectives from People with Lived Experience of Incarceration during the COVID-19 Pandemic.

Background Little guidance exists on best practices for implementing and sustaining wastewater-based surveillance (WBS) for SARS-CoV-2 in carceral settings. To ensure alignment with priorities of stakeholders, we aimed to understand the perspectives of persons with lived experience (PLE) of jail who were incarcerated during the height of the COVID-19 pandemic on infection control. Methods We recruited two PLE at each of four jails: Cook County (IL), Fulton County (GA), Middlesex County (MA), and Washington DC. Focus Group Discussion (FGD) guides followed the Consolidated Framework for Implementation Research (CFIR). Two FGDs focusing on lived experience with jail infection control protocol and WBS were conducted, and six Key Informant (KI) interviews followed to gain insights on communicating WBS results. We used a combination of deductive thematic analysis based on CFIR constructs and inductive analysis to capture emergent themes. Results Themes from FGDs included: (1) variable experiences with COVID-19 infection control protocols including intake processes, individual testing, isolation and quarantine, (2) the perceived attitudes of fellow residents and staff surrounding COVID-19 mitigation in a carceral setting; and (3) perceived benefits and challenges involving WBS implementation and messaging. KIs emphasized 1) The importance of straightforward health messaging and trustworthiness in the communication of WBS results, 2) Support for enhanced health education around outbreaks, and 3) Receptiveness to WBS being used as a tool to measure common infectious agents (i.e., influenza) but hesitancy regarding its application to conditions such as HIV and illicit drug use. PLE articulated support of robust infection control programs and receptiveness to expanding WBS if conducted in a non-stigmatizing manner. Conclusion Perspectives from PLE can help shape the infection control programs for future outbreaks and inform the expansion of WBS implementation in carceral facilities. It will be important to consider the voices of current and former residents, as receivers of care, to promote an environment conducive to comprehensive infection control. In addition to having infection control programs consistently execute set protocols and educate all stakeholders, PLE identified collaboration between jail staff and residents, and clear communication around program expectations as priorities. Findings from this qualitative study can be shared with jail decision makers and the perceived engagement of stakeholders can be measured.

Correlation of SARS-CoV-2 in Wastewater and Individual Testing Results in a Jail, Atlanta, Georgia, USA.

Institution-level wastewater-based surveillance was implemented during the COVID-19 pandemic, including in carceral facilities. We examined the relationship between COVID-19 diagnostic test results of residents in a jail in Atlanta, Georgia, USA (average population ≈2,700), and quantitative reverse transcription PCR signal for SARS-CoV-2 in weekly wastewater samples collected during October 2021‒May 2022. The jail offered residents rapid antigen testing at entry and periodic mass screenings by reverse transcription PCR of self-collected nasal swab specimens. We aggregated individual test data, calculated the Spearman correlation coefficient, and performed logistic regression to examine the relationship between strength of SARS-CoV-2 PCR signal (cycle threshold value) in wastewater and percentage of jail population that tested positive for COVID-19. Of 13,745 nasal specimens collected, 3.9% were COVID-positive (range 0%-29.5% per week). We observed a strong inverse correlation between diagnostic test positivity and cycle threshold value (r = -0.67; p<0.01). Wastewater-based surveillance represents an effective strategy for jailwide surveillance of COVID-19.

Impact of public health policy and mobility change on transmission potential of severe acute respiratory syndrome coronavirus 2 in Rhode Island, March 2020 - November 2021.

To study the SARS-CoV-2 transmission potential in Rhode Island (RI) and its association with policy changes and mobility changes, the time-varying reproduction number, Rt, was estimated. The daily incident case counts (16 March 2020, through 30 November 2021) were bootstrapped within a 15-day sliding window and multiplied by Poisson-distributed multipliers (λ = 4, sensitivity analysis: 11) to generate 1000 estimated infection counts, to which EpiEstim was applied to generate Rt time series. The median Rt percentage change when policies changed was estimated. The time lag correlations were assessed between the 7-day moving average of the relative changes in Google mobility data in the first 90 days, and Rt and estimated infection count, respectively. There were three major pandemic waves in RI in 2020-2021: spring 2020, winter 2020-2021 and fall-winter 2021. The median Rt fluctuated within the range of 0.5-2 from April 2020 to November 2021. Mask mandate (18 April 2020) was associated with a decrease in Rt (-25.99%, 95% CrI: -37.42%, -14.30%). Termination of mask mandates on 6 July 2021 was associated with an increase in Rt (36.74%, 95% CrI: 27.20%, 49.13%). Positive correlations were found between changes in grocery and pharmacy, Rt retail and recreation, transit, and workplace visits, for both Rt and estimated infection count, respectively. Negative correlations were found between changes in residential area visits for both Rt and estimated infection count, respectively. Public health policies enacted in RI were associated with changes in the pandemic trajectory. This ecological study provides further evidence of how non-pharmaceutical interventions and vaccination slowed COVID-19 transmission in RI.

Dynamic Contact Networks of Residents of an Urban Jail in the Era of SARS-CoV-2.

Background: In custodial settings such as jails and prisons, infectious disease transmission is heightened by factors such as overcrowding and limited healthcare access. Specific features of social contact networks within these settings have not been sufficiently characterized, especially in the context of a large-scale respiratory infectious disease outbreak. The study aims to quantify contact network dynamics within the Fulton County Jail in Atlanta, Georgia, to improve our understanding respiratory disease spread to informs public health interventions. Methods: As part of the Surveillance by Wastewater and Nasal Self-collection of Specimens (SWANSS) study, jail roster data were utilized to construct social contact networks. Rosters included resident details, cell locations, and demographic information. This analysis involved 6,702 residents over 140,901 person days. Network statistics, including degree, mixing, and turnover rates, were assessed across age groups, race/ethnicities, and jail floors. We compared outcomes for two distinct periods (January 2022 and April 2022) to understand potential responses in network structures during and after the SARS-CoV-2 Omicron variant peak. Results: We found high cross-sectional network degree at both cell and block levels, indicative of substantial daily contacts. While mean degree increased with age, older residents exhibited lower degree during the Omicron peak, suggesting potential quarantine measures. Block-level networks demonstrated higher mean degrees than cell-level networks. Cumulative degree distributions for both levels increased from January to April, indicating heightened contacts after the outbreak. Assortative age mixing was strong, especially for residents aged 20-29. Dynamic network statistics illustrated increased degrees over time, emphasizing the potential for disease spread, albeit with a lower growth rate during the Omicron peak. Conclusions: The contact networks within the Fulton County Jail presented ideal conditions for infectious disease transmission. Despite some reduction in network characteristics during the Omicron peak, the potential for disease spread remained high. Age-specific mixing patterns suggested unintentional age segregation, potentially limiting disease spread to older residents. The study underscores the need for ongoing monitoring of contact networks in carceral settings and provides valuable insights for epidemic modeling and intervention strategies, including quarantine, depopulation, and vaccination. This network analysis offers a foundation for understanding disease dynamics in carceral environments.

Estimates of Hepatitis C Seroprevalence and Viremia in State Prison Populations in the United States.

BACKGROUND: Prior studies demonstrate that eliminating hepatitis C virus (HCV) in the United States (US) heavily depends on treating incarcerated persons. Knowing the scope of the carceral HCV epidemic by state will help guide national elimination efforts. METHODS: Between 2019 and 2023, all state prison systems received surveys requesting data on hepatitis C antibody and viremic prevalence. We supplemented survey information with publicly available HCV data to corroborate responses and fill in data gaps. RESULTS: Weighting HCV prevalence by state prison population size, we estimate that 15.2% of the US prison population is HCV seropositive and 8.7% is viremic; 54.9% of seropositive persons have detectable RNA. Applying prevalence estimates to the total prison population at year-end 2021, 91 090 persons with HCV infection resided in a state prison. CONCLUSIONS: With updated and more complete HCV data from all 50 states, HCV prevalence in state prisons is nearly 9-fold higher than the US general population. The heterogeneity in HCV prevalence by state prison system may reflect variable exposure before arrest and/or differences in treatment availability during incarceration. Elimination of HCV in the country depends on addressing the carceral epidemic, and one of the first steps is understanding the size of the problem.

HIV testing in jails: Comparing strategies to maximize engagement in HIV treatment and prevention.

Despite 15,000 people enter US jails yearly with undiagnosed HIV infection, routine HIV testing is not standard. Maximizing the yield and speed of HIV testing in short-term detention facilities could promote rapid entry or re-entry of people living with HIV (PLWH) into care. The goal of this study was to evaluate the impact of third generation, rapid point-of-care (rPOC) vs. fourth generation, laboratory-based antigen/antibody (LBAg/Ab) testing on the HIV care cascade in a large urban jail during a planned transition. We used aggregate historical data to compare rPOC testing and LBAg/Ab testing in the D.C. Department of Corrections. We examined two time periods, January to August 2019 when rPOC testing was performed, and October 2019 to January 2020 after LBAg/Ab testing began. We calculated monthly rates of HIV tests performed, HIV test results received, HIV test results received among those tested, antiretroviral therapy (ART) initiation, and proportion of PLWH receiving discharge planning prior to release. We then conducted an interrupted time series analysis to assess the differences between testing periods. There were 14,237 entrants during the first time period and 7,569 entrants during the second. Transitioning from rPOC to LBAg/Ab testing increased the rate of test uptake by 38.5% (95% CI: 14.0, 68.3), decreased the rate of test results received among those tested by 13.1% (95% CI: -14.0, -12.1), and increased the combined rate of HIV tests performed and results received by 20.4% (95% CI: 1.5, 42.8). Although the rate of HIV testing was greater under LBAg/Ab, PLWH received results immediately through rPOC testing, which is critically important in short-stay enviroments. Increasing rPOC uptake would increase its value and combined testing may maximize the detection of HIV and receipt of results among persons passing through jails.

Opinions of former jail residents about self-collection of SARS-CoV-2 specimens, paired with wastewater surveillance: A qualitative study rapidly examining acceptability of COVID-19 mitigation measures.

In year one of the COVID-19 epidemic, the incidence of infection for US carceral populations was 5.5-fold higher than that in the community. Prior to the rapid roll out of a comprehensive jail surveillance program of Wastewater-Based Surveillance (WBS) and individual testing for SARS-CoV-2, we sought the perspectives of formerly incarcerated individuals regarding mitigation strategies against COVID-19 to inform acceptability of the new program. In focus groups, participants discussed barriers to their receiving COVID-19 testing and vaccination. We introduced WBS and individual nasal self-testing, then queried if wastewater testing to improve surveillance of emerging outbreaks before case numbers surged, and specimen self-collection, would be valued. The participants' input gives insight into ways to improve the delivery of COVID-19 interventions. Hearing the voices of those with lived experiences of incarceration is critical to understanding their views on infection control strategies and supports including justice-involved individuals in decision-making processes regarding jail-based interventions.

Stakeholder-engaged research is necessary across the criminal-legal spectrum.

People with lived experience of incarceration have higher rates of morbidity and mortality compared to people without history of incarceration. Research conducted unethically in prisons and jails led to increased scrutiny of research to ensure the needs of those studied are protected. One consequence of increased restrictions on research with criminal-legal involved populations is reluctance to engage in research evaluations of healthcare for people who are incarcerated and people who have lived experience of incarceration. Ethical research can be done in partnership with people with lived experience of incarceration and other key stakeholders and should be encouraged. In this article, we describe how stakeholder engagement can be accomplished in this setting, and further, how such engagement leads to impactful research that can be disseminated and implemented across disciplines and communities. The goal is to build trust across the spectrum of people who work, live in, or are impacted by the criminal-legal system, with the purpose of moving toward health equity.

Coping with COVID in corrections: a qualitative study among the recently incarcerated on infection control and the acceptability of wastewater-based surveillance.

BACKGROUND: Correctional settings are hotspots for SARS-CoV-2 transmission. Social and biological risk factors contribute to higher rates of COVID-19 morbidity and mortality among justice-involved individuals. Rapidly identifying new cases in congregate settings is essential to promote proper isolation and quarantine. We sought perspectives of individuals incarcerated during COVID-19 on how to improve carceral infection control and their perspectives on acceptability of wastewater-based surveillance (WBS) accompanying individual testing. METHODS: We conducted semi-structured interviews with 20 adults who self-reported being incarcerated throughout the United States between March 2020 and May 2021. We asked participants about facility enforcement of the Centers for Disease Control and Prevention (CDC) COVID-19 guidelines, and acceptability of integrating WBS into SARS-CoV-2 monitoring strategies at their most recent facility. We used descriptive statistics to characterize the study sample and report on acceptability of WBS. We analyzed qualitative data thematically using an iterative process. RESULTS: Participants were predominantly Black or multiple races (50%) and men (75%); 46 years old on average. Most received a mask during their most recent incarceration (90%), although only 40% received counseling on proper mask wearing. A quarter of participants were tested for SARS-CoV-2 at intake. Most (70%) believed they were exposed to the virus while incarcerated. Reoccurring themes included (1) Correctional facility environment leading to a sense of insecurity, (2) Perceptions that punitive conditions in correctional settings were exacerbated by the pandemic; (3) Importance of peers as a source of information about mitigation measures; (4) Perceptions that the safety of correctional environments differed from that of the community during the pandemic; and (5) WBS as a logical strategy, with most (68%) believing WBS would work in the last correctional facility they were in, and 79% preferred monitoring SARS-CoV-2 levels through WBS rather than relying on just individual testing. CONCLUSION: Participants supported routine WBS to monitor for SARS-CoV-2. Integrating WBS into existing surveillance strategies at correctional facilities may minimize the impact of future COVID-19 outbreaks while conserving already constrained resources. To enhance the perception and reality that correctional systems are maximizing mitigation, future measures might include focusing on closer adherence to CDC recommendations and clarity about disease pathogenesis with residents.

Video Directly Observed Therapy for Tuberculosis Treatment in Haitian Prisons: A Pattern of Group Adherence.

Classification: Research paper. Purpose: Haitian provincial prisons historically were strapped to provide directly observed therapy (DOT) for persons with TB (PwTB) due to healthcare understaffing. A non-governmental organization addressed this gap via correctional officer-administered video DOT (VDOT). Approach: A 16-month, quasi-experimental trial of officer-facilitated VDOT started in March 2019 at four prisons. Officers delivered doses directly without video when VDOT was inaccessible. Healthcare staff remotely tracked VDOT adherence asynchronously. Three fully-staffed prisons were controls. Our primary objective was to measure VDOT effectiveness for PwTB who began VDOT within 2 weeks of starting treatment. Our secondary objective was to measure program reach, implementation and maintenance through July 2023. Findings: Reach-55 PwTB on VDOT met study criteria. Effectiveness: median/mean VDOT adherence for 55 individuals enrolled in the pilot were 70.8% and 60.2% respectively. Median/mean total adherence, including doses delivered by officers, were 100% and 93.5%. Implementation: VDOT adherence varied by site but not demographic characteristics; similarity of adherence patterns between subjects within a facility was high. Nursing staff reported that adherence in controls was 100%. Correctional officers reported high comfort with the program technology. Maintenance: Since the pilot, 387 PwTB have received TB medications via VDOT in the Haitian prison system. Originality: VDOT for PwTB in low-resource Haitian prisons enabled close monitoring and follow-up; it could expand treatment options elsewhere. Total adherence neared that in control prisons. VDOT adherence varied by treatment day predominately in a group pattern, reflecting facility-level, rather than individual-level, factors.

Late Surges in COVID-19 Cases and Varying Transmission Potential Partially Due to Public Health Policy Changes in 5 Western States, March 10, 2020, to January 10, 2021.

OBJECTIVE: This study investigates the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission potential in North Dakota, South Dakota, Montana, Wyoming, and Idaho from March 2020 through January 2021. METHODS: Time-varying reproduction numbers, R t , of a 7-d-sliding-window and of non-overlapping-windows between policy changes were estimated using the instantaneous reproduction number method. Linear regression was performed to evaluate if per-capita cumulative case-count varied across counties with different population size or density. RESULTS: The median 7-d-sliding-window R t estimates across the studied region varied between 1 and 1.25 during September through November 2020. Between November 13 and 18, R t was reduced by 14.71% (95% credible interval, CrI, [14.41%, 14.99%]) in North Dakota following a mask mandate; Idaho saw a 1.93% (95% CrI [1.87%, 1.99%]) reduction and Montana saw a 9.63% (95% CrI [9.26%, 9.98%]) reduction following the tightening of restrictions. High-population and high-density counties had higher per-capita cumulative case-count in North Dakota on June 30, August 31, October 31, and December 31, 2020. In Idaho, North Dakota, South Dakota, and Wyoming, there were positive correlations between population size and per-capita weekly incident case-count, adjusted for calendar time and social vulnerability index variables. CONCLUSIONS: R t decreased after mask mandate during the region's case-count spike suggested reduction in SARS-CoV-2 transmission.

Vaccine confidence among people who use drugs: A cross-sectional survey.

Adult immunization coverage remains low in the US, particularly for people who use drugs (PWUD), a population that experiences a disproportionate burden of vaccine-preventable diseases. The extent of and characteristics associated with vaccine confidence (VC) held by PWUD is poorly understood. As VC strongly correlates with vaccine uptake, this cross-sectional study identifies mutable factors associated with VC and quantifies its relationship to immunization status within a highly vulnerable, underimmunized population of PWUD. Using a community-engaged research strategy with select partner organizations hosting syringe exchange programs in Atlanta, Los Angeles, and Las Vegas, USA, we surveyed participants ages 18-69 years served by these organizations from 2019 to 2020. Survey measures included sociodemographics, health behavior including immunization receipt, and vaccine confidence in adult vaccinations using a modified Emory Vaccine Confidence Index (EVCI). The findings reflect relatively low VC among the 1,127 recruited participants, with 56% expressing low VC (EVCI 0-12), 35% medium (EVCI 13-20) and 10% high (EVCI 21-24). EVCI varied by city, with lowest confidence in Atlanta and highest in Las Vegas. VC was associated with past receipt of specific vaccines, including hepatitis A, MMR, Tdap, and influenza. VC varied by specific sociodemographic correlates such as housing insecurity (reduced confidence) and receipt of public benefits or disability (increased confidence). This study identified correlates associated with VC based on site and sociodemographic characteristics for this priority population, highlighting the need for specific interventions to raise VC among PWUD, especially among those experiencing housing insecurity and without public benefits.

Prevalence and Management of Sexually Transmitted Infections in Correctional Settings: A Systematic Review.

Admissions to jails and prisons in the United States number 10 million yearly; persons entering locked correctional facilities have high prevalence of sexually transmitted infections (STIs). These individuals come disproportionately from communities of color, with lower access to care and prevention, compared with the United States as a whole. Following PRISMA guidelines, the authors present results of a systematic review of literature published since 2012 on STIs in US jails, prisons, Immigration and Customs Enforcement detention centers, and juvenile facilities. This updates an earlier review of STIs in short-term facilities. This current review contributed to new recommendations in the Centers for Disease Control and Prevention 2021 treatment guidelines for STIs, advising screening for Trichomonas in women entering correctional facilities. The current review also synthesizes recommendations on screening: in particular, opt-out testing is superior to opt-in protocols. Carceral interventions-managing diagnosed cases and preventing new infections from occurring (eg, by initiating human immunodeficiency virus preexposure prophylaxis before release)-can counteract structural racism in healthcare.

Spatially refined time-varying reproduction numbers of SARS-CoV-2 in Arkansas and Kentucky and their relationship to population size and public health policy, March - November 2020.

PURPOSE: To examine the time-varying reproduction number, Rt, for COVID-19 in Arkansas and Kentucky and investigate the impact of policies and preventative measures on the variability in Rt. METHODS: Arkansas and Kentucky county-level COVID-19 cumulative case count data (March 6-November 7, 2020) were obtained. Rt was estimated using the R package 'EpiEstim', by county, region (Delta, non-Delta, Appalachian, non-Appalachian), and policy measures. RESULTS: The Rt was initially high, falling below 1 in May or June depending on the region, before stabilizing around 1 in the later months. The median Rt for Arkansas and Kentucky at the end of the study were 1.15 (95% credible interval [CrI], 1.13, 1.18) and 1.10 (95% CrI, 1.08, 1.12), respectively, and remained above 1 for the non-Appalachian region. Rt decreased when facial coverings were mandated, changing by -10.64% (95% CrI, -10.60%, -10.70%) in Arkansas and -5.93% (95% CrI, -4.31%, -7.65%) in Kentucky. The trends in Rt estimates were mostly associated with the implementation and relaxation of social distancing measures. CONCLUSIONS: Arkansas and Kentucky maintained a median Rt above 1 during the entire study period. Changes in Rt estimates allow quantitative estimates of potential impact of policies such as facemask mandate.

Aiming for Zero: Reducing Transmission of Coronavirus Disease 2019 in the D.C. Department of Corrections.

BACKGROUND: Washington, District of Columbia lowered severe acute respiratory syndrome coronavirus 2 transmission in its large jail while community incidence was still high. METHODS: Coordinated clinical and operational interventions brought new cases to near zero. RESULTS: Aggressive infection control and underlying jail architecture can promote correctional coronavirus disease 2019 management. CONCLUSIONS: More intensive monitoring could help confirm that in-house transmission is truly zero.

Costs and Consequences of Eliminating a Routine, Point-Of-Care HIV Screening Program in a High-Prevalence Jail.

INTRODUCTION: This study aims to assess the public health impact of eliminating a longstanding routine HIV screening program and replacing it with targeted testing. In addition, costs, outcomes, and cost effectiveness of routine screening are compared with those of targeted testing in the Fulton County Jail, Atlanta, Georgia. METHODS: A published mathematical model was used to assess the cost effectiveness and public health impact of routine screening (March 2013-February 2014) compared with those of targeted testing (January 2018-December 2018) from a health system perspective. Costs, outcomes, and other model inputs were derived from the testing programs and the published literature, and the cost effectiveness analysis was conducted from 2019 to 2020. RESULTS: Routine screening identified 74 more new HIV infections over 1 year than targeted testing, resulting in an estimated 10 HIV transmissions averted and 45 quality-adjusted life-years saved, and was cost saving. The missed opportunity to diagnose infections because routine screening was eliminated resulted in an estimated 8.4 additional HIV transmissions and $3.7 million in additional costs to the healthcare system. CONCLUSIONS: Routine HIV screening in high-prevalence jails is cost effective and has a larger impact on public health than targeted testing. Prioritizing sustained funding for routine, jail-based HIV screening programs in high-prevalence areas may be important to realizing the national HIV prevention goals.

Health Behavior Survey Among People Who Use Opioids: Protocol for Implementing Technology-Based Rapid Response Surveillance in Community Settings.

BACKGROUND: In 2018, 2 million Americans met the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition diagnostic criteria for an opioid use disorder, and 9.9 million Americans had misused prescription pain relievers the previous year. Despite a rapid increase in opioid misuse, opioid use disorders, and overdoses, data are limited on the behavioral and contextual risks as well as the protective factors fueling the opioid epidemic in some hard hit US cities-Atlanta, Los Angeles, and Las Vegas. Opioid use also contributes to the risk of other health problems such as HIV and hepatitis C virus infections or mental health disorders and is linked to behavioral and environmental risks (eg, homelessness, experiences of violence, involvement in the justice system). Knowledge of the relationships between these linked vulnerabilities and how they influence service utilization is critical to effective policy and interventions. OBJECTIVE: This survey explores the relationships between demographic and economic characteristics, behavioral and environmental risk factors, and service utilization of people who use opioids to inform public health practice, policy, and future efforts to mitigate the risks faced by this population experiencing multiple health, social, and economic vulnerabilities. The results of this survey will be used to identify needs and intervention points for people who use drugs currently served by public health organizations. METHODS: We implemented a community-engaged strategy that involved development and execution of a two-stage purposive sampling plan involving selection of partner organizations (syringe exchange programs in urban settings) and recruitment and enrollment of participants aged 18-69 years served by these organizations in Atlanta, Los Angeles, and Las Vegas from 2019 to 2020. The recruited participants completed a survey, including a variety of measures to assess health (physical and mental) and health behaviors such as sexual behavior, vaccine receipt, and HIV/ hepatitis C virus infection testing. Additional items assessed drug use and misuse, syringe exchange and health service utilization, sex exchange, histories of interpersonal violence, and vaccine confidence. RESULTS: This protocol was successfully implemented despite challenges such as real-time technology issues and rapidly finding and surveying a difficult-to-reach population. We sampled 1127 unique participants (248 in Atlanta, 465 in Los Angeles, and 414 in Las Vegas). CONCLUSIONS: The establishment and utilization of strong community partnerships enabled the rapid collection of data from a typically difficult-to-reach population. Local efforts such as these are needed to develop policies and practices that promote harm reduction among people who use opioids. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/25575.