Factors Associated with HIV Testing Among People Who Inject Drugs: Findings from a Multistate Study at the Start of the COVID-19 Pandemic.

Few studies have examined HIV testing among people who inject drugs (PWID) during the COVID-19 pandemic. This study examines factors associated with PWID who have been recently (past six months) tested for HIV during the COVID-19 pandemic. PWID were recruited between August 2020 and January 2021 from 22 drug treatment and harm reduction programs in nine states and the District of Columbia. We used logistic regression to identify correlates of recent HIV testing among PWID (n = 289). Most (52.9%) PWID reported having been recently tested for HIV. Factors associated with recent HIV testing included: having attended college [adjusted odds ratio (aOR) 2.32, 95% confidence interval (95% CI) 1.32-4.10], weekly hunger (aOR 2.08, 95% CI 1.20-3.60), crystal methamphetamine injection (aOR 2.04, 95% CI 1.05-3.97), and non-metropolitan residence (aOR 0.33, 95% CI 0.13, 0.88). Findings suggest HIV testing initiatives should be expanded during times of crisis, such as global pandemics.

Criminalization and coercion: sexual encounters with police among a longitudinal cohort of women who exchange sex in Baltimore, Maryland.

BACKGROUND: The criminalization of sex work and drug use creates unequal power dynamics easily exploited by police. Women who exchange sex (WES) in settings around the globe have reported coerced sex and sexual assault by police, and some have reported police as paying clients. Little research has examined nuances underlying WES's sexual interactions with police. METHODS: A cohort of cisgender WES (N = 308) was recruited through targeted sampling in Baltimore, Maryland and completed a structured survey every 6 months for 18 months. Follow-up surveys included detailed questions about recent sexual encounters with police. In bivariate and multivariate models using generalized estimating equations to account for intra-person correlation, we examined correlates of reporting recent sex with police over time. RESULTS: One-third reported recent sex with police at any study visit. At each time point, about 90% of women who reported sex with police reported any uniformed or non-uniformed police had paid for sex. Between 72 and 85% had been solicited for paid sex by uniformed police. Between 41 and 50% of women who reported recent sex with police indicated they had done so because they feared arrest otherwise; one-third were directly pressured for sex by police to avoid arrest or trouble. In the final adjusted model, severe food insecurity [adjusted odds ratio (aOR) = 2.05; 95% confidence interval (CI) 1.13-3.71], Black race (vs. white, non-Hispanic; aOR = 1.90; 95% CI 1.13-3.17), recent arrest (aOR = 1.51; 95% CI 1.01-2.27), nonfatal overdose (aOR = 1.94; 95% CI 1.24-3.01), and client- or non-paying intimate partner-perpetrated violence (aOR = 2.46; 95% CI 1.63-3.71) were significantly independently associated with recent sex with police. CONCLUSIONS: Sexual encounters between WES and police in Baltimore are common and often coerced to avoid arrest in a setting where both drug use and sex work are criminalized. Recent sex with police was more prevalent among WES who were racially marginalized, highly structurally vulnerable, and/or at high risk for drug overdose-and therefore subject to the dual-criminalization of sex work and drug use. This indicates deep power imbalances and their exploitation by police as the root of such sexual encounters and adds to the evidence regarding the need for decriminalization to support the health and wellbeing of WES.

High willingness to use overdose prevention sites among suburban people who use drugs who do not inject.

INTRODUCTION: Overdose prevention sites (OPS) are evidence-based interventions to improve public health, yet implementation has been limited in the USA due to a variety of legal impediments. Studies in various US settings have shown a high willingness to use OPS among urban and rural people who inject drugs, but data among people who use drugs (PWUD) via non-injection routes of administration in suburban areas are lacking. METHODS: We utilized cross-sectional data from a sample of suburban PWUD who have not injected drugs in the past 3 months (N = 126) in Anne Arundel County, Maryland. We assessed PWUDs' likelihood of using a hypothetical OPS and perceived potential barriers to accessing OPS. We tested for associations between sociodemographic characteristics, drug use, service access, and overdose experiences with willingness to utilize OPS. FINDINGS: Participants' median age was 42, and the majority were men (67%) and non-Hispanic Black (79%). Sixty-six percent reported willingness to use an OPS. Concerns about confidentiality (29%), arrest (20%), and transportation costs (22%) were the most anticipated barriers to using OPS. Men (75% vs 55%, p = 0.015), participants who used heroin (53% vs 32%, p = 0.017), and participants who used multiple overdose prevention behaviors (e.g., using fentanyl test strips) (36% vs 19%, p = 0.006) were more likely to report willingness to use OPS. CONCLUSION: Most suburban non-injecting PWUD in the sample were willing to use an OPS. OPS implementation strategies in suburban settings should be tailored to reach PWUD via non-injection routes of administration while meeting the unique needs of suburban contexts.

Factors associated with receptive injection equipment sharing among people who inject drugs: findings from a multistate study at the start of the COVID-19 pandemic.

BACKGROUND: Receptive injection equipment sharing (i.e., injecting with syringes, cookers, rinse water previously used by another person) plays a central role in the transmission of infectious diseases (e.g., HIV, viral hepatitis) among people who inject drugs. Better understanding these behaviors in the context of COVID-19 may afford insights about potential intervention opportunities in future health crises. OBJECTIVE: This study examines factors associated with receptive injection equipment sharing among people who inject drugs in the context of COVID-19. METHODS: From August 2020 to January 2021, people who inject drugs were recruited from 22 substance use disorder treatment programs and harm reduction service providers in nine states and the District of Columbia to complete a survey that ascertained how the COVID-19 pandemic affected substance use behaviors. We used logistic regression to identify factors associated with people who inject drugs having recently engaged in receptive injection equipment sharing. RESULTS: One in four people who inject drugs in our sample reported having engaged in receptive injection equipment sharing in the past month. Factors associated with greater odds of receptive injection equipment sharing included: having a high school education or equivalent (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [95% CI] 1.24, 3.69), experiencing hunger at least weekly (aOR = 1.89, 95% CI 1.01, 3.56), and number of drugs injected (aOR = 1.15, 95% CI 1.02, 1.30). Older age (aOR = 0.97, 95% CI 0.94, 1.00) and living in a non-metropolitan area (aOR = 0.43, 95% CI 0.18, 1.02) were marginally associated with decreased odds of receptive injection equipment sharing. CONCLUSIONS: Receptive injection equipment sharing was relatively common among our sample during the early months of the COVID-19 pandemic. Our findings contribute to existing literature that examines receptive injection equipment sharing by demonstrating that this behavior was associated with factors identified in similar research that occurred before COVID. Eliminating high-risk injection practices among people who inject drugs requires investments in low-threshold and evidence-based services that ensure persons have access to sterile injection equipment.

A qualitative exploration of barriers and facilitators to drug treatment services among people who inject drugs in west Virginia.

BACKGROUND: The opioid overdose crisis in the USA has called for expanding access to evidence-based substance use treatment programs, yet many barriers limit the ability of people who inject drugs (PWID) to engage in these programs. Predominantly rural states have been disproportionately affected by the opioid overdose crisis while simultaneously facing diminished access to drug treatment services. The purpose of this study is to explore barriers and facilitators to engagement in drug treatment among PWID residing in a rural county in West Virginia. METHODS: From June to July 2018, in-depth interviews (n = 21) that explored drug treatment experiences among PWID were conducted in Cabell County, West Virginia. Participants were recruited from locations frequented by PWID such as local service providers and public parks. An iterative, modified constant comparison approach was used to code and synthesize interview data. RESULTS: Participants reported experiencing a variety of barriers to engaging in drug treatment, including low thresholds for dismissal, a lack of comprehensive support services, financial barriers, and inadequate management of withdrawal symptoms. However, participants also described several facilitators of treatment engagement and sustained recovery. These included the use of medications for opioid use disorder and supportive health care workers/program staff. CONCLUSIONS: Our findings suggest that a range of barriers exist that may limit the abilities of rural PWID to successfully access and remain engaged in drug treatment in West Virginia. Improving the public health of rural PWID populations will require expanding access to evidence-based drug treatment programs that are tailored to participants' individual needs.

Overdose Experiences among People Who Inject Drugs in West Virginia: Personal Loss, Psychological Distress, Naloxone, and Fentanyl.

Background: As overdose remains a major public health concern in the United States, it is important to understand the experiences people who inject drugs (PWID) have with overdose. Past experiences during such emergencies are an important determinant of future behavior, including help seeking, which can be lifesaving. Methods: We explored experiences with overdose, using data from 21 in-depth interviews collected from PWID in a rural county in West Virginia (Cabell County). We used an iterative, modified constant comparison approach to synthesize resulting interview data. Results: Participants reported pervasive experiences with overdose, including through their own personal overdose experiences, witnessing others overdose, and losing loved ones to overdose fatalities. Experiencing emotional distress when witnessing an overdose was common among our participants. Many participants reported regularly carrying naloxone and using it to reverse overdoses. Multiple participants described believing the myth that people grow immune to naloxone over time. Concerns about the presence of fentanyl in drugs were also common, with many participants attributing their own and others' overdoses to fentanyl. Conclusions: Our findings have important implications for naloxone access and education, as well as policies and practices to encourage help seeking during overdose events among rural PWID. Participant concerns about fentanyl in the drug supply highlight the need for access to drug checking technologies.

Implementation of Overdose Prevention in Maryland: Implications for Resource Allocation, Program Scale-Up, and Evaluation.

Overdose mortality in the United States continues to climb, with Maryland being one of the hardest hit states. We summarized implementation of overdose prevention and response programs in Maryland and identified associations between opioid overdose deaths by jurisdiction in 2019 and implementation of overdose programs by 2021. Data on program implementation are from Maryland's Opioid Operational Command Center (OOCC) Program Inventory. OOCC coordinates the state's response to overdose, and their Program Inventory tracks implementation of 145 programs across 12 domains (e.g., public health, education, and judiciary), including 10 programs designed to broaden naloxone access. The level of program implementation was dichotomized as substantial implementation versus other levels (i.e., partial, planned, and none). We estimated associations between per capita opioid overdose deaths and substantial implementation of: all 145 programs in the Inventory, programs within each of 12 domains, and 10 naloxone programs. Data on program implementation and overdose mortality are summarized at the jurisdiction level. Across jurisdictions, the median proportion of programs with substantial implementation was 51% across all programs and 70% among naloxone programs. Overdose mortality was associated with subsequent substantial implementation of programs within the public health domain (p = .04), but not in the other 11 domains. We did not find evidence that per capita overdose deaths in 2019 spurred overdose program implementation by 2021, with the exception of public health programs. The OOCC Program Inventory is a novel way to track implementation across jurisdictions. Findings can inform the implementation and evaluation of overdose programs in other jurisdictions across the United States.

Trends in heroin use and injection drug use among high school students in five urban school districts in the US (2005-2017).

Background. We describe the prevalence of and changes in heroin use and injection drug use (IDU) among high school students in five large, urban school districts in the US (2005-2017); nearly three-fourths of the students were Black and/or Hispanic/Latino.Methods. Data are from the Centers for Disease Control and Prevention's "Youth Risk Behavior Survey" program, which includes biennial surveys in urban school districts. We pooled data across districts and survey years, and then generated weighted prevalence estimates (and 95% CIs) for any lifetime heroin use and IDU. Joinpoint regression modeling was used to estimate changes in prevalence over the study period.Results. Biennial prevalence estimates (2005-2017) for heroin use and IDU were above 1.8% for all seven timepoints. In 2017, prevalence of heroin use and IDU were 2.9% and 2.5%, respectively. Both heroin use and IDU were higher among boys than girls. There were statistically significant increases in heroin use and IDU among girls from 2005-2009, whereas changes over time were stable among boys.Conclusions. High school students in large, urban school districts may have higher rates of heroin use and IDU than US high school students in general, and there is little evidence of increases since 2009. This study suggests that adolescence may be a critical period for initiation of heroin use among adolescents in large urban school districts, the majority of whom are Black and/or Latino.Supplemental data for this article is available online at https://doi.org/10.1080/15332640.2021.1992327 .

Mapping Interests in Event-Driven and Long-Acting Pre-exposure Prophylaxis Formulations onto the HIV Risk Environment of Street-Based Female Sex Workers: A Latent Class Analysis.

Despite growing availability, HIV pre-exposure prophylaxis (PrEP) uptake and adherence remains suboptimal among female sex workers (FSW) in the United States. Using cross-sectional data from a survey of 236 street-based cisgender FSW in Baltimore, Maryland, we examined interest in event-driven and long-acting PrEP formulations. Latent class analysis identified discrete patterns of interest in five novel PrEP agents. Multinomial latent class regression then examined factors associated with probabilistic class membership. A three-class solution emerged as the best-fit latent class model: Injectable Acceptors (~ 24% of sample), Universal Acceptors (~ 18%), and Non-Acceptors (~ 58%). Compared to Non-Acceptors, Universal Acceptors had significantly (p < 0.05) higher odds of reporting condomless vaginal sex with clients, client condom coercion, and client-perpetrated physical violence. Relative to Non-Acceptors, Injectable Acceptors were distinguished by significantly higher rates of condomless vaginal sex with clients and injection drug use. Expanding PrEP options for FSW could help overcome barriers to PrEP initiation and persistence.

Factors Associated with Likelihood of Initiating Others into Injection Drug Use Among People Who Inject Drugs in West Virginia.

People who inject drugs (PWID) play a critical role in injection-naïve individuals transitioning to injection drug use. We investigated factors associated with future likelihood of initiating injection-naïve individuals using multivariable logistic regression among 418 PWID in rural Appalachia (Cabell County, West Virginia). Less than 10% reported they were likely to initiate someone in the future. Acquiring syringes from a syringe services program was associated with decreased odds of being likely to initiate someone in the future (adjusted odds ratio [aOR] 0.46, 95% CI 0.23, 0.95), while having previously initiated someone into injection drug use was associated with increased odds (aOR 8.65, 95% CI 4.07, 18.41). Among our sample of PWID in Appalachia, a small proportion reported that they would be likely to initiate an injection-naïve individual in the future. Efforts to reduce injection initiation assistance should focus on this subpopulation of PWID who indicate a willingness to engage in this behavior.

Selling sex in the context of substance use: social and structural drivers of transactional sex among men who use opioids in Maryland.

BACKGROUND: Transactional sex is an important driver of HIV risk among people who use drugs in the USA, but there is a dearth of research characterizing men's selling and trading of sex in the context of opioid use. To identify contextually specific factors associated with selling or trading sex in a US population of men who use drugs, we cross-sectionally examined social and structural correlates of transactional sex among men who use opioids (MWUO) in Anne Arundel County and Baltimore City, Maryland. METHODS: Between July 2018 and March 2020, we used targeted sampling to recruit men reporting past-month opioid use from 22 street-level urban and suburban recruitment zones. MWUO completed a 30-min self-administered interview eliciting substance use histories, experiences with hunger and homelessness, criminal justice interactions, and transactional sex involvement. We identified correlates of recent (past 3 months) transactional sex using multivariable log-binomial regression with cluster-robust standard errors. RESULTS: Among 422 MWUO (mean age 47.3 years, 73.4% non-Hispanic Black, 94.5% heterosexual), the prevalence of recent transactional sex was 10.7%. In multivariable analysis, younger age (adjusted prevalence ratio [aPR] 0.98, 95% confidence interval [95% CI] 0.97-0.99, p < 0.001), identifying as gay/bisexual (aPR = 5.30, 95% CI 3.81-7.37, p < 0.001), past-month food insecurity (aPR = 1.77, 95% CI 1.05-3.00, p = 0.032), and injection drug use in the past 3 months (aPR = 1.75, 95% CI 1.02-3.01, p = 0.043) emerged as statistically significant independent correlates of transactional sex. CONCLUSIONS: Synergistic sources of social and structural marginalization-from sexuality to hunger, homelessness, and injection drug use-are associated with transactional sex in this predominantly Black, heterosexual-identifying sample of MWUO. Efforts to mitigate physical and psychological harms associated with transactional sex encounters should consider the racialized dimensions and socio-structural drivers of transactional sex among MWUO.

Intersecting substance use treatment and harm reduction services: exploring the characteristics and service needs of a community-based sample of people who use drugs.

BACKGROUND: Substance use treatment and harm reduction services are essential components of comprehensive strategies for reducing the harms of drug use and overdose. However, these services have been historically siloed, and there is a need to better understand how programs that serve people who use drugs (PWUD) are integrating these services. In this study, we compared treatment and harm reduction services offered by a multistate sample of substance use service providers and assessed how well they align with characteristics and needs of clients they serve early in the COVID-19 pandemic. METHODS: We recruited a convenience sample of programs that deliver harm reduction and/or treatment services in ten US states. Program directors participated in a survey assessing the services offered at their program. We also recruited clients of these programs to participate in a survey assessing a range of sociodemographic and health characteristics, substance use behaviors, and health service utilization. We then cross-compared client characteristics and behaviors relative to services being offered through these programs. RESULTS: We collected and analyzed data from 511 clients attending 18 programs that we classified as either offering treatment with medications for opioid use disorder (MOUD) (N = 6), syringe service programs (SSP) (N = 8), or offering both MOUD and SSP (N = 4). All programs delivered a range of treatment and harm reduction services, with MOUD & SSP programs delivering the greatest breadth of services. There were discrepancies between services provided and characteristics and behaviors reported by clients: 80% of clients of programs that offered MOUD without SSP actively used drugs and 50% injected drugs; 40% of clients of programs that offered SSP without MOUD sought drug treatment services. Approximately half of clients were unemployed and unstably housed, but few programs offered direct social services. CONCLUSIONS: In many ways, existing programs are not meeting the service needs of PWUD. Investing in innovative models that empower clients and integrate a range of accessible and flexible treatment, harm reduction and social services can pave the way for a more effective and equitable service system that considers the long-term health of PWUD.

Social norms and prevention behaviors in the United States early in the COVID-19 pandemic.

The current study assessed how social norms were associated with the three effective Covid-19 prevention behaviors of social distancing, handwashing, and wearing protective face masks during the early stages of the pandemic in the US. Study participants were recruited online. Data from the present study was from a baseline quantitative survey administered from March 25th-27th, 2020. The 808 study participants were recruited for a longitudinal study online. Eligibility requirements included age 18 or older, living in the United States, English speaking and reading had heard of the Coronavirus or Covid-19, and provided informed consent. The three outcome variables were handwashing, mask wearing, and social distancing. Injunctive and descriptive norms were assessed. The injunctive norm of perceiving friends would find them rude if they did not affiliate with them because Covid-19 was associated with all three outcomes in both the bivariate and multivariate logistic regression models with adjusted odds ratios ranging from (aOR) = .80 for handwashing to aOR = .63 for social distancing and aOR = .77 for mask wearing. The descriptive cognitive norm of friends worrying about becoming infected was associated with all three outcomes in the bivariate analysis but only mask wearing in the multivariate models (aOR = 1.74). The study findings suggest there are strong social factors that correlate with behaviors to prevent the transmission of SARS-CoV-2. These findings also suggest that public health communication campaigns should focus on more than heightening risk perceptions. They should include attention to social norms and perceptions of social risks to significant others.

Patterns of Sex Work Client Solicitation Settings and Associations with HIV/STI Risk Among a Cohort of Female Sex Workers in Baltimore, Maryland.

Female sex workers' (FSWs) risk for HIV/STIs is influenced by their work environments. While previous research has characterized vulnerability in a single workplace, many FSWs solicit clients from multiple settings. Using latent class analysis (LCA), we examined client solicitation patterns and associated HIV/STI-related behaviors (consistent condom use with clients, asking clients about HIV/STIs, and past 6-month HIV/STI testing) among 385 FSWs in Baltimore, Maryland. The LCA yielded a three-class solution: predominantly street (61.2%), mixed street/venue (23.7%), and multisource (street, venue, and online) (15.1%). Consistent condom use differed significantly (p < 0.01) by class, with the mixed street/venue having the lowest (40.6%) rate and the multisource having the highest (70.6%). Classes differed on HIV/STI testing (p < 0.01), with the predominantly street class having the lowest testing rate (56.2%) and multisource with the highest (85.7%). These findings underscore the importance of considering how solicitation patterns are linked to HIV/STI susceptibility of FSWs and adapting interventions accordingly.

Syringe Coverage Among People Who Inject Drugs in West Virginia, USA.

Ensuring people who inject drugs (PWID) have ≥ 100% sterile syringe coverage (i.e., persons have access to a sterile syringe for all injections) is optimal for HIV prevention. Existing syringe coverage literature is informative, yet little work has examined syringe coverage among PWID in rural communities. Using data from a 2018 PWID population estimation study conducted in a rural county in West Virginia, we used logistic regression to identify correlates of adequate sterile syringe coverage (at least 100%). A minority (37%) of PWID reported having adequate syringe coverage. Factors inversely associated with adequate syringe coverage included having recently (past 6 months): engaged in transactional sex work, shared syringes, and injected fentanyl. Having exclusively acquired syringes from a syringe services program was associated with increased odds of adequate syringe coverage. Rural PWID may benefit from tailored interventions designed to increase sterile syringe access.

Awareness of and interest in oral pre-exposure prophylaxis (PrEP) for HIV prevention and interest in hypothetical forms of PrEP among people who inject drugs in rural West Virginia.

Injection drug use-associated HIV outbreaks have occurred in rural communities throughout the United States, which often have limited HIV prevention services for people who inject drugs (PWID). Pre-exposure prophylaxis (PrEP) is one tool that may help fill gaps in HIV prevention programing in rural settings. Oral PrEP has been approved for use, and new PrEP formulations are under development. Research is needed to better understand interest in oral and possible forthcoming PrEP formulations among PWID. We used survey data from 407 PWID in rural West Virginia. We asked if participants had heard of, taken, and were interested in taking PrEP, and about interest in several hypothetical forms of PrEP (arm injections, abdomen injections, implants, intravenous infusions). We estimated the prevalence of interest in each formulation and assessed correlates using Chi-squared tests. A minority had heard of oral PrEP (32.6%), and few had used it (3.7%). Many were interested in using oral PrEP (58.3%). Half were interested in arm injections (55.7%). Common correlates of interest across PrEP formulations were sexual minority status, comfort talking to a doctor about sex, sex work, and sharing injection equipment. Oral and injectable PrEP have the potential to fill HIV prevention gaps for rural PWID.

"People Don't Just Start Shooting Heroin on Their 18th Birthday": A Qualitative Study of Community Stakeholders' Perspectives on Adolescent Opioid Use and Opportunities for Intervention in Baltimore, Maryland.

Initiation of non-medical prescription opioid use (NMPO) during early adolescence is tightly linked to heroin and other drug use disorders and related sequelae in later adolescence and young adulthood. Few studies explore stakeholders' perspectives on the burden and determinants of youth opioid use and barriers and facilitators to engaging youth in opioid use prevention and treatment services in urban settings with longstanding opioid epidemics. In-depth interviews were conducted with 22 stakeholders representing health and social service agencies in Baltimore, Maryland from May 2018- February 2019, to examine their perspectives on the burden and context of adolescent opioid use and identify barriers and facilitators to preventing and responding to adolescent opioid use. Transcripts were analyzed using the constant comparison method to identify themes. Most respondents described a recent uptick in opioid use independently, and in combination with other substances. As compared to heroin, NMPO was perceived to be more frequently used and less stigmatized among youth. Stakeholders perceived the process of transitioning from using NMPO to heroin as more common among White vs. Black youth and was perceived as occurring faster among White vs. Black youth. Some stakeholders believed racial differences in internal stigma against heroin use, and differential health service use among Black youth and White youth may have influenced these differences. Trauma and poverty were noted determinants of youth opioid use. Barriers to service provision included youth cognitive development, stigma and structural factors (e.g., disinvestment, lack of youth-centered and integrated services). Stakeholders perceive prevalent NMPO among Baltimore youth and identify multilevel barriers to delivering prevention, treatment and harm reduction services to this population. These findings encourage further investigation of determinants and consequences of opioid use among diverse racial/ethnic groups of youth in urban settings, and development of multilevel, youth-driven and youth-centered approaches to prevention and treatment.

Health Beliefs and Preventive Behaviors Among Adults During the Early COVID-19 Pandemic in the United States: a Latent Class Analysis.

The objectives of this study are to (1) characterize patterns of preventive behaviors 3 months after the COVID-19 pandemic was declared a national emergency in the USA and (2) identify how health beliefs (e.g., perceived risk of infection, perceived risk of death upon infection, and perceived effectiveness of CDC-recommended preventive behaviors) and sociodemographic characteristics are associated with preventive behaviors. Data were obtained from two waves of the Understanding America Study (UAS) conducted in March (wave 1) and May to June of 2020 (wave 2) (n = 4445); UAS is a nationally representative panel of US adults. We conducted a latent class analysis (LCA) using wave 2 data to identify our outcome, patterns of 10 COVID-preventive behaviors (e.g., wearing a facemask, handwashing, social distancing), and then used a three-step regression (R3STEP) to test associations between the likelihood of class membership with (1) health beliefs and sociodemographic characteristics (age, sex, race/ethnicity, and educational attainment) in bivariate models and (2) health beliefs adjusted for sociodemographic characteristics in multivariate models. The LCA identified a three-class model of preventive behaviors characterized by high likelihood of engagement in the set of preventive behaviors ("high"), low likelihood of the preventive behaviors ("low"), or engagement in some behaviors ("mixed"). Respondents of older age (i.e., age 50 or older) and those with higher levels of educational attainment (i.e., a 4-year college degree or higher) were less likely to be in the low engagement versus the mixed engagement class compared to those who are younger (18-29) and have lower levels of educational attainment (i.e., high school), respectively. Women (compared to men) and respondents who were Black and/or Hispanic/Latinx (compared to White) were more likely to be in the high (vs. mixed) engagement class. In separate models adjusted for sociodemographic characteristics, respondents with a high perceived risk of infection, high perceived risk of death, and high perceived effectiveness of COVID-preventive behaviors were statistically significantly less likely to be in the low engagement relative to the mixed engagement class. Engagement in COVID-preventive behaviors varies by sociodemographic characteristics (i.e., age, sex, race/ethnicity and educational attainment) and health beliefs (i.e., perceived risk of infection, perceived risk of death, and perceived effectiveness of CDC-recommended behaviors). Our findings highlight the potential utility of using health beliefs to inform targeted prevention efforts to help reduce the spread of COVID-19 and future pandemics.

Practical implications of naloxone knowledge among suburban people who use opioids.

BACKGROUND: Naloxone distribution programs have been a cornerstone of the public health response to the overdose crisis in the USA. Yet people who use opioids (PWUO) continue to face a number of barriers accessing naloxone, including not knowing where it is available. METHODS: We used data from 173 PWUO from Anne Arundel County, Maryland, which is located between Baltimore City and Washington, DC. We assessed the prevalence of recently (past 6 months) receiving naloxone and currently having naloxone, the type(s) of the naloxone kits received, and the perceived ease/difficultly of accessing naloxone. We also assessed participants knowledge of where naloxone was available in the community. RESULTS: One third (35.7%) of participants had recently received naloxone. Most who had received naloxone received two doses (72.1%), nasal naloxone (86.9%), and education about naloxone use (72.1%). Most currently had naloxone in their possession (either on their person or at home; 78.7%). One third (34.4%) believed naloxone was difficult to obtain in their community. Only half (56.7%) knew of multiple locations where they could get naloxone. The health department was the most commonly identified naloxone source (58.0%). Identifying multiple sources of naloxone was associated with being more likely to perceive that naloxone is easy to access. DISCUSSION: Our results suggest that additional public health efforts are needed to make PWUO aware of the range of sources of naloxone in their communities in order to ensure easy and continued naloxone access to PWUO.

Correlates of recent nonfatal overdose among people who inject drugs in West Virginia.

AIM: Experiencing a nonfatal overdose (NFOD) is a significant risk factor for a subsequent nonfatal or fatal overdose. Overdose mortality rates in rural Appalachian states are some of the highest in the USA, but little is known about correlates of overdose among rural populations of people who inject drugs (PWID). Our study aimed to identify correlates of experiencing a recent (past 6 months) NFOD among rural PWID in Cabell County, West Virginia. METHODS: Using data from a June-July 2018 cross-sectional survey that was designed to estimate the size and characteristics of the PWID population in Cabell County, West Virginia, we used log binomial regression to identify correlates (e.g., structural vulnerabilities and substance use) of NFOD in the past 6 months. RESULTS: The majority of our sample of 420 PWID were male (61.2%), White, non-Hispanic (83.6%), and reported recent heroin injection (81.0%). More than two-fifths (42.6%) experienced a recent NFOD. Independent correlates of NFOD included witnessing an overdose in the past 6 months (adjusted prevalence ratio [aPR] = 2.28; 95% CI 1.48-3.50), attempting to quit using drugs in the past 6 months (aPR = 1.54; 95% CI 1.11-2.14), and the number of drugs injected (aPR = 1.16; 95% CI 1.10-1.23) CONCLUSIONS: A large proportion of rural PWID in Appalachia reported having recently overdosed. The associations between witnessing an overdose, attempting to quit using drugs, and number of drugs injected with recent nonfatal overdose underscore the need for expanded access to overdose prevention resources that are tailored to the needs of this population. Expanding access to evidence-based overdose prevention strategies-such as take-home naloxone programs, treatment with methadone or buprenorphine, and harm reduction services-may decrease overdose morbidity and mortality among rural PWID in Appalachia.