Protocol for an economic evaluation of scalable strategies to improve mental health among perinatal women: non-specialist care delivered via telemedicine vs. specialist care delivered in-person.

BACKGROUND: Perinatal depression affects an estimated 1 in 5 women in North America during the perinatal period, with annualized lifetime costs estimated at $20.6 billion CAD in Canada and over $45.9 billion USD in the US. Access to psychological treatments remains limited for most perinatal women suffering from depression and anxiety. Some barriers to effective care can be addressed through task-sharing to non-specialist providers and through telemedicine platforms. The cost-effectiveness of these strategies compared to traditional specialist and in-person models remains unknown. This protocol describes an economic evaluation of non-specialist providers and telemedicine, in comparison to specialist providers and in-person sessions within the ongoing Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) trial. METHODS: The economic evaluation will be undertaken alongside the SUMMIT trial. SUMMIT is a pragmatic, randomized, non-inferiority trial across five North American study sites (N = 1,226) of the comparable effectiveness of two types of providers (specialist vs. non-specialist) and delivery modes (telemedicine vs. in-person) of a behavioural activation treatment for perinatal depressive and anxiety symptoms. The primary economic evaluation will be a cost-utility analysis. The outcome will be the incremental cost-effectiveness ratio, which will be expressed as the additional cost required to achieve an additional quality-adjusted life-year, as assessed by the EuroQol 5-Dimension 5-Level instrument. A secondary cost-effectiveness analysis will use participants' depressive symptom scores. A micro-costing analysis will be conducted to estimate the resources/costs required to implement and sustain the interventions; healthcare resource utilization will be captured via self-report. Data will be pooled and analysed using uniform price and utility weights to determine cost-utility across all trial sites. Secondary country-specific cost-utility and cost-effectiveness analyses will also be completed. Sensitivity analyses will be conducted, and cost-effectiveness acceptability-curves will be generated, in all instances. DISCUSSION: Results of this study are expected to inform key decisions related to dissemination and scale up of evidence-based psychological interventions in Canada, the US, and possibly worldwide. There is potential impact on real-world practice by informing decision makers of the long-term savings to the larger healthcare setting in services to support perinatal women with common mental health conditions.

The role of perinatal psychiatry access programs in advancing mental health equity.

This editorial presents: 1) a review of Perinatal Psychiatry Access Programs as an integrated care model with potential for promoting perinatal mental health equity; and 2) a summary of how the model has been and can be further adapted to help achieve perinatal mental health equity in geographically diverse settings. Within the editorial, we highlight Access Programs as a promising model for promoting perinatal mental health equity. This editorial is supported by original descriptive data on the Lifeline for Moms National Network of Perinatal Psychiatric Access Programs. Descriptive data is additionally provided on three statewide Access Programs. The Access Program model, and the accompanying Network of Access Programs, is a multi-level approach demonstrating promise in reducing perinatal mental health inequities. Access Programs demonstrate potential to implement interventions to address well-documented inequities in perinatal mental healthcare access at the patient-, clinician-, practice-, community-, and policy-levels. For Access Programs to leverage their potential to advance perinatal mental health equity, systematic efforts are needed that include partnership with impacted communities and implementation teams.

Assessment of biomarkers associated with rapid renal decline in the detection of retinopathy and its progression in type 2 diabetes: The Fremantle Diabetes Study Phase II.

AIMS: To determine whether biomarkers for diabetic kidney disease (DKD) can be used to determine the prevalence, progression and/or incidence of diabetic retinopathy (DR) complicating type 2 diabetes. METHODS: Proteomic biomarkers were measured in baseline fasting plasma from 958 Fremantle Diabetes Study Phase II participants whose baseline and, in those returning for follow-up (n = 764), Year 4 fundus photographs were graded for DR presence/severity. The performance of PromarkerD (three biomarkers and readily available clinical variables which identify prevalent DKD and predict incident DKD and estimated glomerular filtration rate decline ≥30% over four years) for detecting DR prevalence, progression and incidence was assessed using the area under the receiver operating curve (AUC). Logistic regression determined whether individual proteins were associated with DR outcomes after adjusting for the most parsimonious model. RESULTS: Plasma apolipoprotein A-IV (APOA4) was independently associated with moderate non-proliferative DR at baseline (OR (95% CI): 1.64 (1.01, 2.67), P = 0.047). Model discrimination was poor for all PromarkerD predicted probabilities against all DR outcomes (AUC ≤0.681). CONCLUSIONS: PromarkerD and its constituent biomarkers were not consistently associated with DR prevalence or temporal change. APOA4 was associated with prevalent DR, but not DR incidence or progression. Distinct pathophysiological mechanisms may underlie DKD and DR.

PromarkerD Predicts Renal Function Decline in Type 2 Diabetes in the Canagliflozin Cardiovascular Assessment Study (CANVAS).

The ability of current tests to predict chronic kidney disease (CKD) complicating diabetes is limited. This study investigated the prognostic utility of a novel blood test, PromarkerD, for predicting future renal function decline in individuals with type 2 diabetes from the CANagliflozin CardioVascular Assessment Study (CANVAS). PromarkerD scores were measured at baseline in 3568 CANVAS participants (n = 1195 placebo arm, n = 2373 canagliflozin arm) and used to predict incident CKD (estimated glomerular filtration rate (eGFR) <60 mL/min/1.73m2 during follow-up in those above this threshold at baseline) and eGFR decline ≥30% during the 4 years from randomization. Biomarker concentrations (apolipoprotein A-IV (apoA4), CD5 antigen-like (CD5L/AIM) and insulin-like growth factor-binding protein 3 (IGFBP3) measured by mass spectrometry were combined with clinical data (age, serum high-density lipoprotein (HDL)-cholesterol, eGFR) using a previously defined algorithm to provide PromarkerD scores categorized as low-, moderate- or high-risk. The participants (mean age 63 years, 33% females) had a median PromarkerD score of 2.9%, with 70.5% categorized as low-risk, 13.6% as moderate-risk and 15.9% as high-risk for developing incident CKD. After adjusting for treatment, baseline PromarkerD moderate-risk and high-risk scores were increasingly prognostic for incident CKD (odds ratio 5.29 and 13.52 versus low-risk, respectively; both p < 0.001). Analysis of the PromarkerD test system in CANVAS shows the test can predict clinically significant incident CKD in this multi-center clinical study but had limited utility for predicting eGFR decline ≥30%.

Contemporary Cardiovascular Risk Assessment for Type 2 Diabetes Including Heart Failure as an Outcome: The Fremantle Diabetes Study Phase II.

Background: Type 2 diabetes (T2D) cardiovascular disease (CVD) risk assessment has limitations. The aim of this study was to develop a risk equation adding heart failure (HF) to conventional major adverse cardiovascular events (MACE, myocardial infarction, stroke, and CVD death) and allowing for non-CVD death. Methods: 1551 community-based people with T2D (mean age 66 years, 52% males) were followed from baseline in 2008-2011 for five years to the first CVD event/death. Cox and competing risk regression identified predictors of three-point MACE and four-point MACE (including HF). Discrimination was assessed by the area under the receiver-operating characteristic curve (AUC) and calibration by the Hosmer-Lemeshow test. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined for a 10% five-year CVD risk cut-off. Results: 143 participants (9.2%) experienced a three-point MACE during 7,111 person-years of follow-up and 245 (15.8%) a four-point MACE during 6,896 person-years. The best model was the competing risk four-point MACE (221 predicted events (14.3%), AUC 0.82 (95% CI: 0.79-0.85), Hosmer-Lemeshow test, p = 0.17, sensitivity 79.2%, specificity 68.1%, PPV 31.8%, NPV 94.6%) with validation in 177 adults with T2D from an independent population (AUC 0.81 (0.74-0.89). Conclusions: A validated four-point MACE competing risk model reliably predicts key T2D CVD outcomes.

"It made me more confident that I have it under control": Patient and provider perspectives on moving to a two-drug ART regimen in the United States and Spain.

BACKGROUND: Two-drug regimens (2DR) to treat HIV infection have the potential to reduce long-term toxicity and increase therapeutic options for people living with HIV (PLHIV). Prior phase III trials, SWORD-1 and SWORD-2, as well as GEMINI-1 and GEMINI-2, have demonstrated that a dolutegravir-based 2DR is as effective as three- or four-drug regimens among virologically suppressed patients. Limited information exists, however, on patient and provider experiences with 2DR to inform roll-out and integration into routine clinical care. METHODS: We conducted 39 in-depth interviews with PLHIV currently on 2DR in the context of routine care and 8 of their clinical care providers in the United States (U.S.) and Spain. Participants included 33 male and 6 female PLHIV and 8 providers. Interview topics explored perceptions of and experiences with 2DR compared to prior anti-retroviral regimens (ARVs), side effects, patient satisfaction, and clinical performance. Interviews were audio-recorded, transcribed and analyzed using thematic content analysis. RESULTS: Participants viewed 2DR as a significant and positive advance, in terms of its ability to effectively treat HIV with reduced toxicity and essentially no reported side effects. Patients noted the central role providers played in the decision to switch to a 2DR regimen and, among U.S. participants, the importance of insurance coverage making this preferred option feasible. Patients and providers agreed that a 2DR regimen would be appropriate for any PLHIV regardless of whether they were treatment naïve or had significant experience with ARVs. CONCLUSIONS: Participants' experiences with a 2DR regimen were positive with no participants, reporting side effects and all reporting continued viral suppression. Providers valued the reduced toxicity offered by 2DR and served as the primary gateway to a transition to 2DR for patients in both settings. This study provides a foundation for further research on the transition to 2DR regimens in other populations and contexts including low- and middle-income settings.

Complementary medicine use and its cost in Australians with type 2 diabetes: the Fremantle Diabetes Study Phase II.

BACKGROUND: Few studies have examined complementary medicine (CM) use in diabetes. Australian data are inconsistent, limited in scope and have not considered cost. AIMS: To evaluate the prevalence, associates and costs of CM in a contemporary Australian urban, community-based cohort of people with type 2 diabetes. METHODS: Baseline CM use was determined as part of a detailed assessment in 1543 of 1551 Fremantle Diabetes Study Phase II (FDS2) participants with type 2 diabetes (mean age 65.7 years, 51.8% males, median diabetes duration 9.0 years) recruited to the FDS2 between 2008 and 2011 who self-reported medication use including CM defined as non-prescription medicinal products. RESULTS: A total of 672 FDS2 type 2 participants (43.6%) used at least one type of CM, 92% of which were nutritional supplements (omega-3 fatty acids/fish oil in 24% of CM users followed by calcium in 11%, glucosamine in 10% and others in <10%). Independent associates of CM use included older age, female sex, any mobility problem, and, inversely, Southern European or Indigenous Australian background, lack of English fluency, ex/current smoking status, taking oral glucose-lowering medications and higher HbA1c . The total annual estimated cost of CM used by FDS2 participants with type 2 diabetes was A$121 640 or A$79 ± 208 per person (range A$0-2993). Extrapolating these data, the 1 million Australians with type 2 diabetes spend A$79 million/year on CM. CONCLUSIONS: CM use in type 2 diabetes is both common and costly. Healthcare professionals should consider discussing safe and cost-effective use of CM with their patients with type 2 diabetes.

A comparison of obesity indices in relation to mortality in type 2 diabetes: the Fremantle Diabetes Study.

AIMS/HYPOTHESIS: This prospective association study aimed to compare the relationship between each of four obesity indices and mortality risk in people with type 2 diabetes. METHODS: The associations of BMI, waist circumference, WHR and A Body Shape Index (ABSI) with all-cause mortality were analysed in 1282 participants of the Fremantle Diabetes Study, followed for up to 20 years after baseline assessment. Models were adjusted for age and other confounders; assessments as continuous measures and by quintile were carried out for men and women separately. Sensitivity analyses were conducted to minimise reverse causality. RESULTS: When indices were assessed as continuous variables, there were significant bivariate associations with mortality for: ABSI, which was greater in both men and women who died (p < 0.001); WHR, which was greater in women only (p = 0.033); and BMI, which was lower in women only (p < 0.001). When assessed by quintile, there were significant bivariate associations with mortality for ABSI in men and women (p < 0.001) and BMI in women only (p = 0.002). In Cox models of time to death, adjusted for age, diabetes duration, ethnicity and smoking, ABSI quintiles showed a linear trend for both men (p = 0.003) and women (p = 0.035). Men in the fifth ABSI quintile had an increased mortality risk compared with those in the first quintile (HR [95% CI]: 1.74 [1.24, 2.44]) and women in the fifth ABSI quintile had an increased mortality risk that approached statistical significance (1.42 [0.97, 2.08], p = 0.08). Men in the fifth WHR quintile had an increased mortality risk (1.47 [1.05, 2.06]). There was no association between mortality and BMI or waist circumference in either sex. CONCLUSIONS/INTERPRETATION: ABSI was the obesity index most strongly associated with all-cause mortality in Australians with type 2 diabetes. There was no evidence for an obesity paradox with any of the assessed indices. ABSI may be a better index of central obesity than waist circumference, BMI or WHR when assessing mortality risk in type 2 diabetes.

Spray on skin for diabetic foot ulcers: an open label randomised controlled trial.

BACKGROUND: One Australian loses a limb every 3 h as a result of infected diabetic foot ulcers (DFU). This common condition accounts for substantial morbidity and mortality for affected individuals and heavy economic costs for the health sector and the community. There is an urgent need to test interventions that improve wound healing time, prevent amputations and recurrent ulceration in patients presenting with DFU whilst improving quality of life and reducing health care costs. METHODS: One hundred and fifty eligible participants will be randomised to receive an autologous skin cell suspension, also termed 'spray-on' skin (ReCell®) or standard care interventions for their DFU. The primary outcome is complete wound healing at 6 months, but participants will be followed up for a total of 12 months to enable secondary outcomes including total overall costs, ulcer free days at 12 months and quality of life to be assessed. DISCUSSION: Outpatient costs for dressings, home nursing visits and outpatient appointments are key cost drivers for DFU. If spray-on skin is effective, large cost savings to WA Health will be realised immediately through a shortened time to healing, and through a higher proportion of patients achieving complete healing. Shortened healing times may enable participants to return to work earlier. Any economic benefits are likely to be amplified across Australia and other similar demographic settings where aging populations with increased diabetes rates are considered major future challenges. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000511235. Registered on 9 April 2018.

The Mid-Atlantic Center for AIDS Research Consortium Scholars Program: A Multi-Institutional Approach to Mentoring the Next Generation of Underrepresented Scientists.

BACKGROUND: There is an urgent need to intentionally develop and expand mentoring for junior faculty from underrepresented communities in the area of HIV research. Such a goal is increasingly recognized as essential across all scientific fields because profound disparities exist regarding which doctorally prepared individuals ultimately end up entering research fields in academic settings. The purpose of this article is to describe a novel inter-Center for AIDS Research (CFAR) program designed to support underrepresented scientists in research to address the HIV epidemic in the Mid-Atlantic region. METHODS: Three CFARs in the Mid-Atlantic region (the District of Columbia, Johns Hopkins University CFAR, and University of Pennsylvania CFARs) developed a Scholars program designed for underrepresented minority scholars interested in studying the HIV epidemic in the region. The program provided resources for scholarship as well as cross-institutional mentoring and training. RESULTS: Scholars in the first cohort have been successful in implementing novel research that informs our understanding of the HIV epidemic in the region as well as increasing skills, publications, and grant submissions and funded applications. Lessons learned from the first cohort will inform future years of the MACC Scholars Program. CONCLUSIONS: The MACC Scholars Program offers a model for other inter-CFAR collaborations wishing to find novel ways to support the next generation of scientists.

Patterns of primary healthcare use among female exotic dancers in Baltimore, Maryland.

Female exotic dancers (FEDs) are often exposed to violence-, sex- and drug-related occupational harms and are precluded from employer-based health insurance. We examined access to primary health-care resources, correlates of use, and service needs among a sample of new FEDs (N = 117) working in 22 exotic dance clubs (EDCs) in Baltimore, MD. Self-administered surveys were completed between May and October 2014. Health care measures were aggregated and described, and correlates of use were evaluated using Fisher Exact and Poisson regression with robust variance, adjusting for race/ethnicity. The majority of dancers reported having health insurance (80%), a primary care provider (PCP) (68%), and having visited a PCP (74%). Among dancers with insurance, all were covered by Medicaid. Multivariable regression models demonstrated that having a regular PCP was associated with recent PCP use (adjusted prevalence ratio 1.5; 95% confidence interval: 1.1, 2.1). Despite a high level of health-care coverage and recent visits to PCP, dancers frequently sought services at the emergency department and reported needs for medical care, including mental health support services and drug treatment. Findings highlight that basic access to primary health care is available and used but may not be fully meeting dancers' complex needs.

Enhanced immigration enforcement in the USA and the transnational continuity of HIV care for Latin American immigrants in deportation proceedings.

In our work as clinicians, researchers, and immigrant rights advocates, we have noted increased anxiety about the possibility of deportation and disruptions in care among immigrants with HIV. Before the 2016 US elections, patients rarely asked about HIV treatment in their home countries. However, since the increase in anti-immigrant rhetoric and arrests by US Immigration and Customs Enforcement, patients have voiced concerns about the availability of HIV treatment in their home countries much more frequently. Although antiretroviral therapy is available throughout Latin America, access depends on economic, social, and political circumstances. Maintaining uninterrupted continuity of care among immigrants held in detention or deported to their home countries is challenging. In this Viewpoint, we identify periods of particular vulnerability for immigrants during deportation proceedings, from initial detention to deposition in their country of origin. We discuss the effect of enhanced immigration enforcement on the health and wellbeing of HIV-infected immigrants, and on public health. Finally, we also discuss recommendations for clinicians, immigration authorities, and public health institutions in the USA and in receiving countries.

Identifying Barriers to Access and Utilization of Preventive Health-Care Services by Young Adults in Vermont.

PURPOSE: The objective of this study was to examine barriers to accessing and utilizing routine preventive health-care checkups for Vermont young adults. METHODS: A population-based analysis was conducted using aggregated data from the 2011-2014 Behavioral Risk Factor Surveillance System (BRFSS) surveys of Vermont young adults aged 18-25 years (N = 1,329). Predictors analyzed as barriers were classified county of residence, health-care coverage, and annual household income level, as well as covariates, with the outcome of the length of time since the last routine checkup. RESULTS: A total of 81.1% of Vermont young adults reported having a routine checkup in the past 2 years. Health-care coverage was a predictor of undergoing routine checkups within the past 2 years, with 85.2% of insured respondents undergoing checkups compared with 56.3% of uninsured respondents (p < .001). Additionally, 81.9% of respondents from Vermont counties classified as mostly rural reported undergoing a checkup within the past 2 years (p < .05). A total of 80.8% of respondents from the middle level (p < .05) and 89.0% of respondents from the highest level (p < .001) of annual household incomes reported undergoing a checkup in the past 2 years. Finally, age (p < .001) and sex (p < .01) were shown to indicate receipt of routine preventive checkups more often. CONCLUSIONS: For Vermont young adults, health-care coverage, classified county of residence, and household income level were shown to be indicators of undergoing routine preventive health care more often. Further investigation is needed to examine how these barriers may impede preventive screenings, thereby contributing to the ongoing development of health-care guidelines and policies for young adults in rural settings.

Ultrasonographic assessment of joint pathology in type 2 diabetes and hyperuricemia: The Fremantle Diabetes Study Phase II.

AIMS: The prevalence and consequences (articular and extra-articular) of hyperuricemia in type 2 diabetes, especially when asymptomatic (ASH), are incompletely understood. The aim of this study was to use ultrasonography to assess pathology associated with monosodium urate deposition in the joints of well-characterized hyperuricemic patients with type 2 diabetes. METHODS: A subset of 101 participants (mean age 70.4 years, 59.8% males, median diabetes duration 14.6 years) with hyperuricemia (fasting serum uric acid ≥0.42 mmol/L) from the community-based observational Fremantle Diabetes Study Phase II were assessed by ultrasound for signs of intra-articular urate deposition and inflammation in 14 joints at increased risk of involvement in patients with gout. RESULTS: Most participants had evidence of crystal deposition comprising aggregates (59.4%), tophi (19.8%) or a double contour sign (27.7%), and 37% had a power Doppler signal indicative of inflammation in at least one joint. There was no difference between the prevalence of these abnormalities in those with ASH (n = 60) versus participants with a history of gout (n = 41; P ≥ 0.15). There was no association between a history of ischemic heart disease (reported by 17.8% of participants) and either any abnormality on joint ultrasound or inflammatory changes assessed by power Doppler (P ≥ 0.41). CONCLUSIONS: Joint inflammation and/or urate deposition were present in the majority of community-based patients with type 2 diabetes and hyperuricemia regardless of whether there was a history of gout. Given the potential consequences of chronic inflammation for joint damage and extra-articular complications such as cardiovascular disease, these data have potential clinical implications.

Community Savings Groups, Financial Security, and HIV Risk Among Female Sex Workers in Iringa, Tanzania.

This study assessed the association between community savings group participation and consistent condom use (CCU) among female sex workers (FSW) in Iringa, Tanzania. Using cross-sectional data from a survey of venue-based FSW (n = 496), logistic regression was used to examine the associations between financial indicators including community savings group participation and CCU. Over one-third (35%) of the women participated in a savings group. Multivariable regression results indicated that participating in a savings group was significantly associated with nearly two times greater odds of CCU with new clients in the last 30 days (aOR = 1.77, 95% CI 1.10-2.86). Exploratory mediation analysis indicated that the relationship between savings group participation and CCU was partially mediated by financial security, as measured by monthly income. Findings indicate that community savings groups may play an important role in reducing sexual risk behaviors of FSW and hold promise as part of comprehensive, community-led HIV prevention strategies among FSW.

History and Purpose of Postpartum Support International.

Postpartum Support International provides training for professionals and supports families who experience perinatal mood and anxiety disorders. The purpose of this article is to describe Postpartum Support International, which was founded in 1987 to increase awareness among public and professional communities about the emotional difficulties women experience during and after pregnancy. We recommend strategies with which health care professionals can support families, reduce stigma, and offer resources for treatment and support.

Cost-effectiveness of artemisinin-naphthoquine versus artemether-lumefantrine for the treatment of uncomplicated malaria in Papua New Guinean children.

BACKGROUND: A recent randomized trial showed that artemisinin-naphthoquine (AN) was non-inferior to artemether-lumefantrine (AL) for falciparum malaria and superior for vivax malaria in young Papua New Guinean children. The aim of this study was to compare the cost-effectiveness of these two regimens. METHODS: An incremental cost-effectiveness analysis was performed using data from 231 children with Plasmodium falciparum and/or Plasmodium vivax infections in an open-label, randomized, parallel-group trial. Recruited children were randomized 1:1 to receive once daily AN for 3 days with water or twice daily AL for 3 days given with fat. World Health Organisation (WHO) definitions were used to determine clinical/parasitological outcomes. The cost of transport between the home and clinic, plus direct health-care costs, served as a basis for determining each regimen's incremental cost per incremental treatment success relative to AL by Day 42 and its cost per life year saved. RESULTS: In the usual care setting, AN was more effective for the treatment of uncomplicated malaria in children aged 0.5-5.9 years. AL and AN were equally efficacious for the treatment of falciparum malaria, however AN had increased anti-malarial treatment costs per patient of $10.46, compared with AL. AN was the most effective regimen for treatment of vivax malaria, but had increased treatment costs of $14.83 per treatment success compared with AL. CONCLUSIONS: Whilst AN has superior overall efficacy for the treatment of uncomplicated malaria in PNG children, AL was the less costly regimen. An indicative extrapolation estimated the cost per life year saved by using AN instead of AL to treat uncomplicated malaria to be $12,165 for girls and $12,469 for boys (discounted), which means AN may not be cost-effective and affordable for PNG at current cost. However, AN may become acceptable should it become WHO prequalified and/or should donated/subsidized drug supply become available.

Client and Partner Violence Among Urban Female Exotic Dancers and Intentions for Seeking Support and Justice.

Urban female exotic dancers are thought to experience unique risk for violence and barriers to care, though limited research has focused on this aspect of urban sex industries. We characterize recent client-perpetrated and intimate partner violence (IPV) and their correlates, and describe women's intentions for violence-related help-seeking, among venue-based exotic dancers in a high-risk urban environment. We conducted a cross-sectional study with new female exotic dancers (n = 117) in Baltimore, MD. Over one third (36%) reported intimate partner violence (IPV), and 16% reported client physical or sexual violence, in the six months prior to the survey. Both forms of violence were correlated with arrest, sex trade, substance use, and childhood abuse. Violence-related help-seeking intentions were highest for club management. Intentions to seek help from police and violence-related support hotlines were lowest among those with recent experiences of violence. Recent violence, particularly from intimate partners, was pervasive in this sample of female exotic dancers, and enabled by substance use, criminal history, and sex trade. Preferences for help within venues, rather than the justice sector and publicly funded support services, indicate the need for systems reform to meet the needs of this high-risk group of women.