Modelling the impact of vaccination and sexual behaviour adaptations on mpox cases in the USA during the 2022 outbreak.

BACKGROUND: The 2022 mpox outbreak has infected over 30 000 people in the USA, with cases declining since mid-August. Infections were commonly associated with sexual contact between men. Interventions to mitigate the outbreak included vaccination and a reduction in sexual partnerships. Understanding the contributions of these interventions to decreasing cases can inform future public health efforts. METHODS: We fit a dynamic network transmission model to mpox cases reported by Washington DC through 10 January 2023. This model incorporated both vaccine administration data and reported reductions in sexual partner acquisition by gay, bisexual or other men who have sex with men (MSM). The model output consisted of daily cases over time with or without vaccination and/or behavioural adaptation. RESULTS: We found that initial declines in cases were likely caused by behavioural adaptations. One year into the outbreak, vaccination and behavioural adaptation together prevented an estimated 84% (IQR 67% to 91%) of cases. Vaccination alone averted 79% (IQR 64% to 88%) of cases and behavioural adaptation alone averted 25% (IQR 10% to 42%) of cases. We further found that in the absence of vaccination, behavioural adaptation would have reduced the number of cases, but would have prolonged the outbreak. CONCLUSIONS: We found that initial declines in cases were likely caused by behavioural adaptation, but vaccination averted more cases overall and was key to hastening outbreak conclusion. Overall, this indicates that outreach to encourage individuals to protect themselves from infection was vital in the early stages of the mpox outbreak, but that combination with a robust vaccination programme hastened outbreak conclusion.

Low Self-Perceived Need for PrEP and Behavioral Indications of MSM Who Recently Refused Daily PrEP: A Mixed Methods Study in Three U.S. Cities.

Pre-exposure prophylaxis (PrEP) reduces sexual risk for HIV transmission by 99% when used appropriately, but remains underutilized among gay, bisexual, and other men who have sex with men (MSM). In this mixed-method study, we describe reasons for PrEP refusal associated with low self-perceived need for PrEP among MSM who recently declined daily oral PrEP when offered by a provider. Data are from a quantitative behavioral survey of MSM (N = 93) living in Atlanta, Chicago, and Raleigh-Durham, who also either responded to an in-depth interview (n = 51) or participated in one of 12 focus groups (n = 42). Themes of low self-perceived need for PrEP were: low self-perceived risk for HIV acquisition (33% of respondents); confidence in remaining HIV-negative (35%); using condoms (81%); limiting number of partners and choosing partners carefully (48%); asking partners about their HIV status before having sex (45%); engaging in safer sexual positions or oral sex (28%); being in a monogamous relationship or exclusivity with one partner (26%); and regular HIV testing (18%). Low self-perceived risk for HIV acquisition and high confidence in other prevention strategies were important factors related to low self-perceived need in MSM refusing daily oral PrEP when offered. Providers should continue to discuss the benefits of PrEP as a safe and highly effective option for HIV prevention.

RESUMEN: La profilaxis pre-exposición (PrEP) reduce el riesgo de transmisión sexual por el VIH en un 99% cuando se utiliza apropiadamente, pero sigue siendo subutilizada entre hombres gais, bisexuales y otros hombres que tienen sexo con hombres (HSH). En este estudio de método mixto, describimos los motivos del rechazo de la PrEP asociados a la baja necesidad autopercibida de la PrEP entre los HSH que recientemente rechazaron la PrEP oral diaria, cuando fue ofrecida por un proveedor de salud. Los datos provienen de una encuesta cuantitativa de comportamiento de los HSH (N = 93) que viven en Atlanta, Chicago y Raleigh-Durham, quienes también respondieron a una entrevista en profundidad (n = 51) o participaron en uno de los 12 grupos focales (n = 42). Los temas de baja necesidad autopercibida del uso de la PrEP fueron: el bajo riesgo auto percibido de contraer el VIH (33% de los encuestados); la confianza en seguir siendo VIH negativo (35%); utilizar condones (81%); limitar el número de parejas sexuales y elegir las parejas cuidadosamente (48%); preguntar a sus parejas sobre su estado de VIH antes de tener relaciones sexuales (45%); participar en posiciones sexuales más seguras o sexo oral (28%); estar en relación monógama o de exclusividad con una sola pareja (26%); y hacerse pruebas del VIH regularmente (18%). El bajo riesgo autopercibido de contraer el VIH y la alta confianza en otras estrategias de prevención fueron factores importantes relacionados con la baja necesidad autopercibida en los HSH que rechazaron la PrEP oral diaria cuando se les ofreció. Los proveedores de salud deben continuar el diálogo sobre los beneficios de la PrEP como una opción segura y altamente eficaz para la prevención del VIH.

Reducing Vaccination Disparities During a National Emergency Response: The US Mpox Vaccine Equity Pilot Program.

CONTEXT: In response to the first reported mpox cases in May 2022, the US government implemented plans to bring testing, treatment, and vaccines to communities disproportionately affected by mpox-including the population of men who have sex with men (MSM) and Black/African American and Hispanic/Latino men, 2 subpopulations experiencing vaccination disparities. We describe the development and implementation of the US Mpox Vaccine Equity Pilot Program (MVEPP), characteristics of completed vaccination projects, and challenges that occurred. We also discuss opportunities for reducing vaccination disparities in future outbreaks. PROGRAM: To address reported vaccination disparities, the US government launched MVEPP in 2 phases. Phase 1 centered around public events attended by large numbers of gay, bisexual, and other MSM, such as Pride festivals. Phase 2 asked health departments to propose mpox vaccination projects specifically aimed at reducing or eliminating racial/ethnic and other demographic disparities in mpox vaccination. IMPLEMENTATION: MVEPP received 35 vaccination project proposals. We analyzed data from 22 completed projects that resulted in 25 675 doses of JYNNEOS administered. We note 3 innovative strategies that were implemented in several projects: direct collaboration with organizations providing services to MSM and transgender women; implementation of MVEPP projects in unique nonclinical community settings and at venues frequented by MSM and transgender women; and offering an array of services as part of mpox vaccination projects, rather than offering only mpox vaccination. EVALUATION: MVEPP highlighted the importance of recognizing and working to eliminate racial/ethnic and other disparities in access to medical countermeasures during a public health emergency. Jurisdictions developed and implemented innovative strategies to bring mpox vaccination and related services to communities disproportionately affected by mpox-including MSM and the subpopulations of Black/African American and Hispanic/Latino MSM. Lessons learned from MVEPP may inform efforts to reduce disparities during future public health responses.

Progress Toward Equitable Mpox Vaccination Coverage: A Shortfall Analysis - United States, May 2022-April 2023.

More than 30,000 monkeypox (mpox) cases were reported in the United States during the 2022 multinational outbreak; cases disproportionately affected gay, bisexual, and other men who have sex with men (MSM). Substantial racial and ethnic disparities in incidence were also reported (1). The national mpox vaccination strategy* emphasizes that efforts to administer the JYNNEOS mpox vaccine should be focused among the populations at elevated risk for exposure to mpox (2). During May 2022-April 2023, a total of 748,329 first JYNNEOS vaccine doses (of the two recommended) were administered in the United States.† During the initial months of the outbreak, lower vaccination coverage rates among racial and ethnic minority groups were reported (1,3); however, after implementation of initiatives developed to expand access to mpox vaccination,§ coverage among racial and ethnic minority groups increased (1,4). A shortfall analysis was conducted to examine whether the increase in mpox vaccination coverage was equitable across all racial and ethnic groups (5). Shortfall was defined as the percentage of the vaccine-eligible population that did not receive the vaccine (i.e., 100% minus the percentage of the eligible population that did receive a first dose). Monthly mpox vaccination shortfalls were calculated and were stratified by race and ethnicity; monthly percent reductions in shortfall were also calculated compared with the preceding month's shortfall (6). The mpox vaccination shortfall decreased among all racial and ethnic groups during May 2022-April 2023; however, based on analysis of vaccine administration data with race and ethnicity reported, 66.0% of vaccine-eligible persons remained unvaccinated at the end of this period. The shortfall was largest among non-Hispanic Black or African American (Black) (77.9%) and non-Hispanic American Indian or Alaska Native (AI/AN) (74.5%) persons, followed by non-Hispanic White (White) (66.6%) and Hispanic or Latino (Hispanic) (63.0%) persons, and was lowest among non-Hispanic Asian (Asian) (38.5%) and non-Hispanic Native Hawaiian and other Pacific Islander (NH/OPI) (43.7%) persons. The largest percentage decreases in the shortfall were achieved during August (17.7%) and September (8.5%). However, during these months, smaller percentage decreases were achieved among Black persons (12.2% and 4.9%, respectively), highlighting the need for a focus on equity for the entirety of a public health response. Achieving equitable progress in JYNNEOS vaccination coverage will require substantial decreases in shortfalls among Black and AI/AN persons.

The CDC Domestic Mpox Response - United States, 2022-2023.

Monkeypox (mpox) is a serious viral zoonosis endemic in west and central Africa. An unprecedented global outbreak was first detected in May 2022. CDC activated its emergency outbreak response on May 23, 2022, and the outbreak was declared a Public Health Emergency of International Concern on July 23, 2022, by the World Health Organization (WHO),* and a U.S. Public Health Emergency on August 4, 2022, by the U.S. Department of Health and Human Services.† A U.S. government response was initiated, and CDC coordinated activities with the White House, the U.S. Department of Health and Human Services, and many other federal, state, and local partners. CDC quickly adapted surveillance systems, diagnostic tests, vaccines, therapeutics, grants, and communication systems originally developed for U.S. smallpox preparedness and other infectious diseases to fit the unique needs of the outbreak. In 1 year, more than 30,000 U.S. mpox cases were reported, more than 140,000 specimens were tested, >1.2 million doses of vaccine were administered, and more than 6,900 patients were treated with tecovirimat, an antiviral medication with activity against orthopoxviruses such as Variola virus and Monkeypox virus. Non-Hispanic Black (Black) and Hispanic or Latino (Hispanic) persons represented 33% and 31% of mpox cases, respectively; 87% of 42 fatal cases occurred in Black persons. Sexual contact among gay, bisexual, and other men who have sex with men (MSM) was rapidly identified as the primary risk for infection, resulting in profound changes in our scientific understanding of mpox clinical presentation, pathogenesis, and transmission dynamics. This report provides an overview of the first year of the response to the U.S. mpox outbreak by CDC, reviews lessons learned to improve response and future readiness, and previews continued mpox response and prevention activities as local viral transmission continues in multiple U.S. jurisdictions (Figure).

Abandonment of Human Immunodeficiency Virus Preexposure Prophylaxis Prescriptions at Retail Pharmacies-United States, 2019.

We analyzed a national pharmacy database to estimate the annual number of persons who abandoned preexposure prophylaxis (PrEP) prescriptions and assessed associated factors. About 9% of persons prescribed PrEP abandoned prescriptions in 2019; abandonment was associated with sex, age, insurance type, black race/ethnicity, and drug copayment amount.

Clusters of Rapid HIV Transmission Among Gay, Bisexual, and Other Men Who Have Sex with Men - United States, 2018-2021.

Gay, bisexual, and other men who have sex with men (MSM) accounted for 68% of new HIV diagnoses in the United States in 2020* (1). Despite advances in treatment and prevention, HIV transmission among MSM continues, in part because of stigma and barriers to accessing prevention and treatment services (2). HIV cluster detection and response, a core strategy of the Ending the HIV Epidemic in the United States initiative,† is an important tool for early identification and response to rapid HIV transmission, including among MSM. To better understand rapid HIV transmission among this population, CDC characterized large HIV molecular clusters detected using analysis of HIV-1 nucleotide sequence data from the National HIV Surveillance System (NHSS).§ Among 38 such clusters first detected during 2018-2019 that had grown to include more than 25 persons by December 2021, 29 occurred primarily among MSM. Clusters primarily among MSM occurred in all geographic regions, and 97% involved multiple states. Clusters were heterogeneous in age, gender identity, and race and ethnicity and had rapid growth rates (median = nine persons added per year). The overall transmission rate at cluster detection was 22 transmission events per 100 person-years, more than six times that of previously estimated national transmission rates (3). Most clusters of rapid HIV transmission occur among MSM. Swift response to reach diverse persons and communities with early, tailored, and focused interventions is essential to reducing HIV transmission (4).

HIV Services and Outcomes During the COVID-19 Pandemic - United States, 2019-2021.

Increasing HIV testing, preexposure prophylaxis (PrEP), and antiretroviral therapy (ART) are pillars of the federal Ending the HIV Epidemic in the U.S. (EHE) initiative, with a goal of decreasing new HIV infections by 90% by 2030.* In response to the COVID-19 pandemic, a national emergency was declared in the United States on March 13, 2020, resulting in the closure of nonessential businesses and most nonemergency health care venues; stay-at-home orders also limited movement within communities (1). As unemployment increased during the pandemic (2), many persons lost employer-sponsored health insurance (3). HIV testing and PrEP prescriptions declined early in the COVID-19 pandemic (4-6); however, the full impact of the pandemic on use of HIV prevention and care services and HIV outcomes is not known. To assess changes in these measures during 2019-2021, quarterly data from two large U.S. commercial laboratories, the IQVIA Real World Data - Longitudinal Prescription Database (IQVIA),† and the National HIV Surveillance System (NHSS)§ were analyzed. During quarter 1 (Q1)¶ 2020, a total of 2,471,614 HIV tests were performed, 190,955 persons were prescribed PrEP, and 8,438 persons received a diagnosis of HIV infection. Decreases were observed during quarter 2 (Q2), with 1,682,578 HIV tests performed (32% decrease), 179,280 persons prescribed PrEP (6% decrease), and 6,228 persons receiving an HIV diagnosis (26% decrease). Partial rebounds were observed during quarter 3 (Q3), with 2,325,554 HIV tests performed, 184,320 persons prescribed PrEP, and 7,905 persons receiving an HIV diagnosis. The proportion of persons linked to HIV care, the number who were prescribed ART, and proportion with a suppressed viral load test (<200 copies of HIV RNA per mL) among those tested were stable during the study period. During public health emergencies, delivery of HIV services outside of traditional clinical settings or that use nonclinical delivery models are needed to facilitate access to HIV testing, ART, and PrEP, as well as to support adherence to ART and PrEP medications.

Epidemiologic and Clinical Features of Mpox in Transgender and Gender-Diverse Adults - United States, May-November 2022.

As of November 9, 2022, a total of 28,730 cases of monkeypox (mpox) had been reported in the United States,* primarily among adult cisgender men reporting recent male-to-male sexual contact (1). Transgender and gender-diverse persons, who constitute an estimated 0.5% of the U.S. adult population,† face unique health disparities and barriers to care (2-4). However, data on the epidemiologic and clinical features of Monkeypox virus infections in this population are limited (5). CDC analyzed U.S. case surveillance data on mpox cases in transgender and gender-diverse adults reported during May 17-November 4, 2022. During this period, 466 mpox cases in transgender and gender-diverse adults were reported, accounting for 1.7% of reported cases among adults. Most were in transgender women (43.1%) or gender-diverse persons (42.1%); 14.8% were in transgender men. Among 374 (80.3%) mpox cases in transgender and gender-diverse adults with information available on sexual or close intimate contact, 276 (73.8%) reported sexual or close intimate contact with a cisgender male partner during the 3 weeks preceding symptom onset. During the ongoing outbreak, transgender and gender-diverse persons have been disproportionately affected by mpox. Members of this population frequently reported recent sexual or close intimate contact with cisgender men, who might be in sexual networks experiencing the highest incidence of mpox. These findings highlight the importance of tailoring public health prevention and outreach efforts to transgender and gender-diverse communities and could guide strategies to reduce mpox transmission.

Improving HIV medical care engagement by attending to status disclosure and social support.

Expeditious linkage and consistent engagement in medical care is important for people with HIV's (PWH) health. One theory on fostering linkage and engagement involves HIV status disclosure to mobilize social support. To assess disclosure and social support's association with linkage and engagement, we conducted a qualitative study sampling black and Latino men who have sex with men (MSM of color) in the U.S. Participants' narratives presented mixed results. For instance, several participants who reported delaying, inconsistent access, or detachment from care also reported disclosing for support purposes, yet sporadic engagement suggests that their disclosure or any subsequent social support have not assisted. The findings contribute to the literature that questions disclosure and social support's influence on care engagement, especially when decontextualized from circumstances and intentions. Our findings suggest the mechanics of disclosure and social support require planned implementation if intending to affect outcomes, especially among MSM of color. From the findings, we explore steps that may bolster interventions seeking to anchor medical care engagement.

Access to HIV, Viral Hepatitis, and Substance Use Disorder Treatment/Overdose Prevention Services: A Qualitative Analysis of Syringe Service Programs (SSPs) Serving Rural PWID.

BACKGROUND: Syringe service programs (SSP) increasingly serve rural areas of the United States, yet little is known about access and perceived need for their services. Objectives: This paper presents the HIV and viral hepatitis prevention, testing, and treatment, and, substance use disorder treatment and overdose prevention services offered at three SSPs and which services their clients accessed. Across the three SSPs, 45 clients (people who inject drugs [PWID]), 11 staff, and five stakeholders were interviewed. Results: Most clients (n = 34) reported accessing SSP services weekly and primarily for sterile syringes and injection-related supplies. All clients reported testing for HIV at least once, though concern for acquiring or transmitting HIV was divided between some or no concern. Most clients (n = 43) reported testing for hepatitis C virus (HCV). Concern for acquiring or transmitting HCV was also mixed. Vaccination for hepatitis A and/or B teetered around half (HAV: n = 23) to a third (HBV: n = 15). Most clients (n = 43) knew where to access the overdose countering medication, Narcan. Feelings about substance use treatment options varied, yet most felt not enough were available. Of note, not all assessed services were offered by the sampled SSPs. Conclusions/Importance: The findings help us understand PWIDs' rationale regarding services accessed and preference for particular services. The need for some services was not perceived by those at risk for the illness the services addressed. Discussing risk and providing tailored education is important when providing SSP services to rural residing PWIDs.

Brief Report: Refusal of Daily Oral PrEP: Implementation Considerations and Reported Likelihood of Using Various HIV Prophylaxis Products in a Diverse Sample of MSM.

BACKGROUND: An important subgroup of gay, bisexual, and other men who have sex with men (MSM) with behavioral indications refuse daily oral pre-exposure prophylaxis (PrEP) when recommended by a provider. Emerging HIV prophylaxis products (eg, injectable, event-driven) offer more options to MSM who refuse daily PrEP. In this article, we assess reasons for refusal and likelihood to use various products among MSM who refused PrEP. METHODS: MSM who reported anal sex without condoms or PrEP and refused daily oral PrEP in the past 6 months were recruited through clinics, community venues, and online in Atlanta, Chicago, and Raleigh-Durham. Men were asked their main reason for recently refusing daily PrEP and likelihood of using various PrEP options in the future. Bivariate and multivariable regression models were used to estimate associations. RESULTS: MSM (n = 93; 70% Black, 48% age 18-29 years) reported their main reason for refusing daily PrEP were potential side effects (35%), a daily pill regimen (22%), and not having enough information (18%). Reported likelihood of using PrEP products was 58% for penile gel, 54% for event-driven oral, 52% for injectable, and 50% for daily PrEP. MSM who reported daily regimen as the main reason for refusing PrEP had greater odds of likelihood to use an injectable [adjusted odds ratio (AOR) = 5.21, 95% confidence interval (CI): 1.32 to 20.52]. Younger men (18-29 vs 30+ years) had greater odds of likelihood to use condoms (AOR = 3.40, 95% CI: 1.15 to 10.04) and daily PrEP (AOR = 2.76, 95% CI: 1.06 to 7.16); there were no product preference differences by race. CONCLUSION: Most men who refused daily PrEP indicated likelihood of using some form of PrEP in the future.

Mapping Nurse Practitioners' Scope of Practice Laws: A Resource for Evaluating Pre-Exposure Prophylaxis Prescriptions.

Context: Reducing the number of new HIV infections will require addressing barriers to HIV pre-exposure prophylaxis (PrEP) access and uptake. Nurse practitioners (NPs) may help increase PrEP access and uptake. State scope of practice laws determines NPs' ability to work independently and their authority to prescribe PrEP, a legend nonscheduled medication. Methods: This analysis applied legal epidemiology methods to analyze the laws of the 50 states and the District of Columbia that govern NPs' scope of practice as they may apply to prescribing legend nonscheduled medications. These laws were extracted from Westlaw Next between April and June 2019. Results: As of June 8, 2019, 17 states had laws that allowed NPs to both practice independently and prescribe legend nonscheduled drugs without restriction. Conclusion: The role that state scope of practice laws plays in potentially limiting NPs' ability to prescribe PrEP should be considered. Increasing PrEP access and uptake is essential in reaching national HIV prevention goals. This analysis can inform further studies and polices on barriers to PrEP access and uptake.

Restricting Access: A Secondary Analysis of Scope of Practice Laws and Pre-exposure Prophylaxis Prescribing in the United States, 2017.

ABSTRACT: To assess advanced practitioners' scope of practice laws (i.e., legal authority providers can prescribe regulated medications) as potential barriers to HIV pre-exposure prophylaxis (PrEP), we conducted an analysis using IQVIA Real World Data in association with scope of practice law classifications supplied by the American Association of Nurse Practitioners and scopeofpracticepolicy.org. Nurse practitioners in states that allowed independent scope of practice were 1.4 times more likely to have prescribed PrEP compared with nurse practitioners in states where their prescribing authority is determined by a supervising medical doctor (MD). Physician assistants in states where the law or a state board defined their prescribing authority were more than twice as likely to prescribe PrEP compared with those in states where a supervising MD oversaw prescribing rights. Our findings suggest that restricting scope of prescribing practice by requiring MD oversight limits PrEP access and poses a barrier to scaling up PrEP.

HIV Testing Program Activities and Challenges in Four U.S. Urban Areas.

The national "Ending the HIV Epidemic: A Plan for America" supports expanded testing in jurisdictions and groups with disproportionate HIV burden. Public health planners benefit from learning HIV testing service (HTS) strengths, challenges, and innovations. We conducted semistructured interviews with 120 HTS staff from local health departments, community-based organizations, and community members in Houston, Texas; Miami, Florida; New Orleans, Louisiana; and Washington, DC. We coded interview transcripts using qualitative methods to identify themes. Program strengths include HIV testing integration with other client services; prioritized testing and tailored incentives; multiple advertising methods; and partnerships among HTS providers. Challenges include stigma, fear, and disparities; funding requirements that create competition between providers; and service accessibility, unnecessary repeat testing, and insufficient innovation. The four jurisdictions addressed some, but not all, of these challenges. Cross-jurisdictional collaboration, together with state and federal partners plus program data may help identify additional strategies for strengthening HTS.

Expansion of Preexposure Prophylaxis Capacity in Response to an HIV Outbreak Among People Who Inject Drugs-Cabell County, West Virginia, 2019.

From January 1, 2018, through October 9, 2019, 82 HIV diagnoses occurred among people who inject drugs (PWID) in Cabell County, West Virginia. Increasing the use of HIV preexposure prophylaxis (PrEP) among PWID was one of the goals of a joint federal, state, and local response to this HIV outbreak. Through partnerships with the local health department, a federally qualified health center, and an academic medical system, we integrated PrEP into medication-assisted treatment, syringe services program, and primary health care settings. During the initial PrEP implementation period (April 18-May 17, 2019), 110 health care providers and administrators received PrEP training, the number of clinics offering PrEP increased from 2 to 15, and PrEP referrals were integrated with partner services, outreach, and testing activities. The number of people on PrEP increased from 15 in the 6 months before PrEP expansion to 127 in the 6 months after PrEP implementation. Lessons learned included the importance of implementing PrEP within existing health care services, integrating PrEP with other HIV prevention response activities, adapting training and material to fit the local context, and customizing care to meet the needs of PWID. The delivery of PrEP to PWID is challenging but complements other HIV prevention interventions. The expansion of PrEP in response to this HIV outbreak in Cabell County provides a framework for expanding PrEP in other outbreak and non-outbreak settings.

Syringe Services Programs' Role in Ending the HIV Epidemic in the U.S.: Why We Cannot Do It Without Them.

Diagnoses of HIV among people who inject drugs have increased in the U.S. during 2014-2018 for the first time in 2 decades, and multiple HIV outbreaks have been detected among people who inject drugs since 2015. These epidemiologic trends pose a significant concern for achieving goals of the federal initiative for Ending the HIV Epidemic in the U.S. Syringe services programs are cost effective, safe, and highly effective in reducing HIV transmission and are an essential component of a comprehensive, integrated approach to addressing these concerns. Yet, geographic coverage of these programs remains limited in the U.S., and many jurisdictions continue to have laws and policies that limit or disallow syringe services programs. An in-depth literature review was conducted on the role of syringe services programs in the Ending the HIV Epidemic initiative. Empirical and model-based evidence consistently shows that syringe services programs have the highest impact in HIV prevention when combined with access to medications for substance use disorder and antiretroviral therapy. Their effectiveness is further maximized when they provide services without restrictions and include proven and innovative strategies to expand access to harm-reduction and clinical services (e.g., peer outreach, telehealth). Increasing geographic and service coverage of syringe services programs requires strong and sustainable policy, funding, and community support and will need to address new challenges related to the COVID-19 pandemic. Syringe services programs have a key role in all 4 Ending the HIV Epidemic initiative strategies-Prevent, Diagnose, Treat, and Respond-and thus are instrumental to its success in preventing disease and saving lives.