"Something Like That": Awareness and Acceptability of HIV PrEP and PEP Among Kenyan Adolescents.

BACKGROUND: Adolescents account for 15% of new HIV cases in Kenya. HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) are highly effective prevention tools, but uptake is low among adolescents, particularly in resource-limited settings. We assessed awareness and acceptability of PrEP and PEP among Kenyan adolescents. METHOD: Focus group discussions were conducted with 120 adolescent boys and girls ages 15 to 19 in Kisumu. Data were analyzed using the Framework Approach. RESULTS: Adolescent participants often had not heard of or could not differentiate between PrEP and PEP. They also confused these HIV prevention tools with emergency contraceptives. Taking a daily pill to prevent HIV was perceived as analogous to taking a pill to treat HIV. Boys were aware of and willing to consider using PrEP and PEP due to their dislike for using condoms. Adolescents identified insufficient information, cost, and uncomfortableness speaking with healthcare workers about their HIV prevention needs due to sexuality stigma as barriers to using PrEP and PEP. CONCLUSION: Low awareness and poor understanding of PrEP and PEP among adolescents reveal the need for increased education and sensitization about these HIV prevention options. Expanding access to sexual and reproductive health services that are tailored to the needs of adolescents and staffed with non-judgmental providers could help reduce sexuality stigma as a barrier to accessing care. New HIV prevention approaches such as long-acting injectables or implants, on-demand regimens, and multipurpose prevention technologies may encourage increased uptake of PrEP and PEP by adolescents.

"Entre Nosotras:" a qualitative study of a peer-led PrEP project for transgender latinas.

BACKGROUND: Uptake of HIV pre-exposure prophylaxis (PrEP) remains low among transgender people as compared to other subgroups, despite high rates of HIV acquisition. In California, Latinx people comprise 40% of the population and Latina transgender women experience some of the highest burden of HIV of any subgroup, indicating a critical need for appropriate services. With funding from the California HIV/AIDS Research Programs, this academic-community partnership developed, implemented, and evaluated a PrEP project that co-located HIV services with gender affirming care in a Federally Qualified Heath Center (FQHC). Trans and Latinx staff led intervention adaptation and activities. METHODS: This paper engages qualitative methods to describe how a PrEP demonstration project- Triunfo- successfully engaged Spanish-speaking transgender Latinas in services. We conducted 13 in-depth interviews with project participants and five interviews with providers and clinic staff. Interviews were conducted in Spanish or English. We conducted six months of ethnographic observation of intervention activities and recorded field notes. We conducted thematic analysis. RESULTS: Beneficial elements of the intervention centered around three intertwined themes: creating trusted space, providing comprehensive patient navigation, and offering social support "entre nosotras" ("between us women/girls"). The combination of these factors contributed to the intervention's success supporting participants to initiate and persist on PrEP, many of whom had previously never received healthcare. Participants shared past experiences with transphobia and concerns around discrimination in a healthcare setting. Developing trust proved foundational to making participants feel welcome and "en casa/ at home" in the healthcare setting, which began from the moment participants entered the clinic and continued throughout their interactions with staff and providers. A gender affirming, bilingual clinician and peer health educators (PHE) played a critical part in intervention development, participant recruitment, and patient navigation. CONCLUSIONS: Our research adds nuance to the existing literature on peer support services and navigation by profiling the multifaced roles that PHE served for participants. PHE proved instrumental to empowering participants to overcome structural and other barriers to healthcare, successfully engaging a group who previously avoided healthcare in clinical settings.

"We Don't Fear HIV. We Just Fear Walking around Pregnant.": A Qualitative Analysis of Adolescent Sexuality and Pregnancy Stigma in Informal Settlements in Kisumu, Kenya.

In Kenya, adolescent pregnancy rates are high, contraception utilization is low, and adolescent sexuality is stigmatized. We describe how perceptions of sexuality and pregnancy stigma influence decision-making among adolescents in the informal settlements of Kisumu. We used purposive sampling to recruit 120 adolescent boys and girls aged 15-19 for focus group discussions. A semistructured interview guide was used to elicit social norms and community attitudes about sexual and reproductive health. We analyzed the data using the Framework Approach. The social stigma of adolescent sexuality and the related fear of pregnancy as an unambiguous marker of sexual activity emerged as main themes. This stigma led adolescents to fear social retribution but did not lead to more frequent contraception use due to additional stigma. The intensity of this fear was most acutely expressed by girls, leading some to seek unsafe, sometimes fatal, abortions, and to contemplate suicide. Fear of pregnancy outweighed fear of contracting HIV that was viewed as both treatable and less stigmatized. Our findings illustrate how fear of pregnancy among these adolescents is driven primarily by fears that their community will discover that they are sexually active. Interventions are urgently needed to address adolescent sexual stigma and to prevent negative outcomes.

"I don't have to do this all by myself": Systems Navigation to Ensure Continuity of HIV Care for Persons Leaving Prison.

Ensuring continuity of and retention in care after release from prison is critical for optimizing health outcomes among people living with HIV. As part of a large federal initiative, we conducted qualitative interviews (n = 24) with individuals living with HIV and recently released from prison in four states to understand their experiences in different navigation interventions to improve access to HIV care post-release. Interventions were delivered only in prison, only in the community, or in both settings. While the interventions varied by design, overall, participants appreciated the breadth of support received from interventionists, including health system navigation, case management and social support. Even when individuals leaving prison were returning to clinics that they were familiar with, systems navigation supported continuity of care. Our findings elucidate why navigational support was instrumental, and underscore the value of a variety of types of navigation programs in facilitating continuity of care and reintegration post-prison.

"Closing the Loop" Developing State-Level Data Sharing Interventions to Promote Optimum Outcomes Along the HIV Continuum of Care.

This manuscript describes the experiences of three state departments of health (SDoH) that successfully launched data sharing interventions involving surveillance and/or patient data collected in clinics to improve care outcomes among people living with HIV. We examined 58 key informant interviews, gathered at two time points, to describe the development and implementation of data sharing interventions. We identified three common themes across states' experiences: creating standard practices, fostering interoperability, and negotiating the policy environment. Projects were successful when state teams adapted to changing circumstances and were committed to a consistent communication process. Once implemented, the interventions streamlined processes to promote linkage and retention in care among low-income populations living with HIV. Despite using routinely collected data, key informants emphasized the labor-intensive process to develop and sustain the interventions. Lessons learned from these three state experiences can help inform best practices for other SDoH that are considering launching similar interventions.

"I am still human and worth a life:" a qualitative study of the impacts of a community based, peer-led, treatment support model for young adults living with HIV in Zimbabwe.

Background: A persistent treatment gap remains between children and adults living with HIV. The Zvandiri program, developed by Africaid, is one of the few models of differentiated service delivery for children, adolescents, and youth that has been shown to improve outcomes along the HIV care continuum, employing Community Adolescent Treatment Supporters (CATS) to offer peer counseling and patient navigation. Our qualitative study provides an in-depth analysis of the feelings and experiences Zimbabwean youth had following an HIV diagnosis, and the ways that CATS facilitated linkage and retention in care. Methods: We conducted in-depth interviews in Shona with adolescents and young adults who were recently diagnosed with HIV in Zimbabwe. Interviews were audio-recorded, transcribed, and then translated to English. Interviews were coded in Dedoose using a structured a priori codebook. We wrote semi-structured summary memos for each interview. We co-conducted thematic analysis, guided by interpretive phenomenology with a team of Zimbabwean and American experienced qualitative researchers and community partners. We co-developed memos to elaborate and understand key themes across interviews. Results: Most of our interview participants recounted an immediate sense of loss upon testing HIV positive and a fear that "there was no hope for the future." CATS played a pivotal role for youth, providing emotional, educational, and logistical support to facilitate treatment initiation, adherence, and persistence in care. The CATS program supported youth through multiple approaches: group sessions, individual meetings, and via text or phone. While CATS offered counseling and comfort to participants, they emphasized the long-term importance of identifying at least one other person in participants' lives who could know their status and support them around HIV. Conclusion: Our findings delineate some of the key concerns that face youth after receiving an HIV diagnosis and the ways that a community-based adherence peer navigation program supported participants to navigate both their feelings and the health care system. Results can inform practice at community-based agencies that are implementing or considering peer youth navigation programs and garner support for policy to fund interventions for youth.

Designing Implementation Strategies for the Inclusion of Lesbian, Gay, Bisexual, Transgender, Intersex, Queer, and Allied and Key Populations' Content in Undergraduate Nursing Curricula in KwaZulu-Natal, South Africa: Protocol for a Multimethods Research Project.

BACKGROUND: Lesbian, gay, bisexual, transgender, intersex, queer, and allied (LGBTQIA+) individuals encounter challenges with access and engagement with health services. Studies have reported that LGBTQIA+ individuals experience stigma, discrimination, and health workers' microaggression when accessing health care. Compelling evidence suggests that the LGBTQIA+ community faces disproportionate rates of HIV infection, mental health disorders, substance abuse, and other noncommunicable diseases. The South African National Strategic Plan for HIV or AIDS, tuberculosis, and sexually transmitted infections, 2023-2028 recognizes the need for providing affirming LGBTQIA+ health care as part of the country's HIV or AIDS response strategy. However, current anecdotal evidence suggests paucity of LGBTQIA+ and key populations' health content in the undergraduate health science curricula in South Africa. Moreover, literature reveals a general lack of health worker training regarding the health needs of LGBTQIA+ persons and other key populations such as sex workers, people who inject drugs, and men who have sex with men. OBJECTIVE: This study aimed to describe the design of a project that aims at facilitating the inclusion of health content related to the LGBTQIA+ community and other key populations in the undergraduate nursing curricula of KwaZulu-Natal, South Africa. METHODS: A multimethods design encompassing collection of primary and secondary data using multiple qualitative designs and quantitative approaches will be used to generate evidence that will inform the co-design, testing, and scale-up of strategies to facilitate the inclusion of LGBTQIA+ and key populations content in the undergraduate nursing curricula in KwaZulu-Natal, South Africa. Data will be collected using a combination of convenience, purposive, and snowball sampling techniques from LGBTQIA+ persons; academic staff; undergraduate nursing students; and other key populations. Primary data will be collected through individual in-depth interviews, focus groups discussions, and surveys guided by semistructured and structured data collection tools. Data collection and analysis will be an iterative process guided by the respective research design to be adopted. The continuous quality improvement process to be adopted during data gathering and analysis will ensure contextual relevance and sustainability of the resultant co-designed strategies that are to be scaled up as part of the overarching objective of this study. RESULTS: The proposed study is designed in response to recent contextual empirical evidence highlighting the multiplicity of health challenges experienced by LGBTQIA+ individuals and key populations in relation to health service delivery and access to health care. The potential findings of the study may be appropriate for contributing to the education of nurses as one of the means to ameliorate these problems. Data collection is anticipated to commence in June 2024. CONCLUSIONS: This research has potential implications for nursing education in South Africa and worldwide as it addresses up-to-date problems in the nursing discipline as it pertains to undergraduate students' preparedness for addressing the unique needs and challenges of the LGBTQIA+ community and other key populations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/52250.

HIV Disclosure Practices to Family Among Mexican and Puerto Rican Sexual Minority Men with HIV in the Continental USA: Intersections of Sexual Orientation and HIV Stigma.

Disclosing a seropositive HIV status still is a complex process of assessing the risks, benefits, and potential personal and interpersonal outcomes associated with disclosure, such as stigma, rejection, or emotional support. We examined HIV disclosure practices to family and intersectional stigma related to HIV and sexual orientation among Latino sexual minority men (LSMM) of Mexican and Puerto Rican origin with HIV in the continental USA. Guided by Framework Analysis, we present data from 54 interviews with 33 LSMM participants in HIV care engagement interventions, and 21 project staff implementing the interventions. LSMM disclosed their HIV status to family seeking support. They applied stigma management techniques to manage the information communicated to family about their HIV status, including selective disclosure to some family members, conveying strategic information about the significance of having HIV, non-disclosure, or partial disclosure, silence and deceptions. LSMM HIV disclosure practices to family encompassed appraisals of intersectional stigma related to their sexual orientation and HIV, assessing the potential outcomes of disclosure, and the preservation of family ties.

Adapting and Implementing an Evidence-Based Reentry Intervention for Incarcerated Transgender Women: Lessons Learned.

Incarceration is a significant public health issue that disproportionately impacts transgender (trans) women, particularly those of color. The cycle of incarceration interacts with high levels of substance use, mental illness, and HIV to produce a high disease burden among trans women, but, to date, there are no published studies of trans-specific reentry support interventions. Informed by the Model of Gender Affirmation, we systematically adapted and pilot tested the evidence-based Project START intervention to create Girlfriends Connect (GC), a reentry support intervention for trans women incarcerated in a county jail. Qualitative interviews with trans women (10 prerelease and 6 postrelease) and community social service providers and jail staff (n = 7) who serve justice-involved transgender women, as well as input from a community advisory board, informed our adaptation. We then conducted a pilot randomized controlled trial (n = 14) and a service implementation project (n = 16) of GC to examine its feasibility and acceptability. Lessons learned include the importance of peer facilitators, facilitated referral to gender-affirming community resources, and obtaining programmatic buy-in from jail staff and administration. Results indicate that GC is feasible and acceptable, and holds promise in improving the health of transgender women reentering the community after a period of incarceration.

If, when and how to tell: a qualitative study of HIV disclosure among young women in Zimbabwe.

In the Shona culture of Zimbabwe, a high regard for childbearing contributes to strong pressures on women to have children. For young women living with HIV, consequently, disclosure of HIV status can be a central strategy to garner support for controlling fertility. This paper reports findings from qualitative interviews with 28 young women aged 16-20 living with HIV in urban Zimbabwe and discusses how these findings can contribute to better policies and programs for this population. Regardless of their current relationship status, interview participants described disclosure as a turning point in romantic partnerships, recounting stressful experiences with major ramifications such as abuse and abandonment on the one hand, and support and love on the other. All but one participant had been in a committed relationship, and most had disclosed to a previous or current partner, with about half of disclosure experiences resulting in adverse reactions. Findings suggest that sexual and reproductive health services must do more to help young women living with HIV negotiate the complexities of disclosure in the context of achieving desired fertility.

Health Care Experiences of Patients with Nonbinary Gender Identities.

Purpose: The primary purpose of this study was to characterize the health care experiences of diverse patients with nonbinary gender identities across a range of geographic locations. A secondary aim was to use the qualitative findings to inform recommendations for clinics and providers to create gender-affirming health care environments for nonbinary patients. Methods: We conducted 3 focus group discussions with 7-9 participants, for a total of 24 unique participants. To be eligible, participants were required to be 18 years of age or older, live in the United States, speak English, have the ability to access Zoom in a private room, have a nonbinary gender identity, and be able to attend one of three scheduled focus groups. Results: Participants reported frequent negative health care experiences, including misgendering, invalidation, and pathologization, even within clinics that signaled alliance with transgender communities. Participants described strategies they use to cope with negative experiences, including health care avoidance, identity concealment, and seeking out providers that are matched in terms of gender minority status and/or race. Conclusion: Recommendations for the provision of gender-affirming health care for nonbinary patients include nonbinary-inclusive intake forms and electronic health records, having providers be proactive in eliciting preferred names and pronouns, and requiring education for providers and staff at all levels on the provision of nonbinary-inclusive gender-affirming health care.

Seeking a "Sponyo": Insights Into Motivations and Risks Around Intergenerational Transactional Sex Among Adolescent Boys and Girls in Kenya.

PURPOSE: Intergenerational transactional sex (ITS) occurs in Sub-Saharan Africa within the context of widespread poverty and limited employment opportunities. We examined how adolescents describe these relationships, why their peers engage in ITS, and what repercussions adolescents shoulder as a result. METHODS: We conducted 14 focus group discussions with boys and girls (N = 120) aged 15-19 years in informal settlement communities in Kisumu, Kenya. We used a framework approach to guide data analysis. RESULTS: Adolescents referred to a relatively well-off older partner in ITS relationships as a "sponsor." Poverty proved the main driver of ITS. Boys and girls noted family and peer pressure to have a "better life" via sponsors who provided for three levels of need: urgent (e.g., food), critical (e.g., school fees), and material (e.g., clothes). Adolescents described multiple risks, including "no power" to negotiate condom use. Repercussions included dropping out of school because of community stigma, "abandonment" in the event of pregnancy, and unsafe abortions. CONCLUSIONS: Adolescents face the difficult choice between the need for money to contribute to their families' income and the discomfort and health risks of a sponsor relationship. The pressure to have a sponsor was higher among out-of-school adolescents and adolescent mothers because of heightened poverty and vulnerability. Structural interventions, such as eliminating school fees, could help reduce adolescents' perceived need to acquire sponsors. Our findings suggest a need to update guidelines for sexual and reproductive health counseling in schools and community settings to openly discuss why ITS is so commonplace and engage in risk reduction conversations with adolescents.

"Holidays Come, Sundays Come. It is Very Sad to be Alone": Transnational Practices and the Importance of Family for Mexican and Puerto Rican Latinxs Living with HIV in the Continental U.S.

Latinxs continue to be overrepresented in the U.S. HIV epidemic. We examined the transnational practices, family relationships, and realities of life of Mexicans and Puerto Ricans living with HIV in the continental U.S. We conducted qualitative interviews with 44 persons of Mexican and Puerto Rican origin participating in HIV care engagement interventions. Framework Analysis guided our data analysis. Among participants, a strong connection to the family was intertwined with transnational practices: communication, travel to their place of origin to maintain family ties, and material and/or emotional support. Separation from their family contributed to social isolation. Many participants lacked emotional support regarding living with HIV. Transnational practices and family relationships were intrinsic to the experiences of Mexicans and Puerto Ricans living with HIV in the continental U.S.; and may help understand the points of reference, health-seeking behaviors, and support sources that influence their health, well-being and engagement in HIV care.

"No Estas Solo": Navigation Programs Support Engagement in HIV Care for Mexicans and Puerto Ricans Living in the Continental U.S.

A range of social and structural barriers continue to impede timely diagnosis and consistent access to care for Latinos living with HIV in the U.S. Navigation programs have helped other populations overcome comparable barriers to care. This qualitative paper examined nine navigation programs that were culturally tailored for Mexicans or Puerto Ricans, using a transnational framework that situated clients in the context of lives that bridge the U.S. and their countries of origin. We completed in-depth semi-structured interviews with 48 clients and 27 intervention providers. A framework approach guided analysis. We identified two overarching themes: developing trusting and supportive relationships between navigators and clients and empowering clients to connect and stay in primary care, which summarized the impact of the interventions on participants' lives and the approaches used to increase their care engagement. Our findings highlight the importance of tailoring intervention strategies to the unique experiences of specific Latino populations.

From Theory to Application: A Description of Transnationalism in Culturally-Appropriate HIV Interventions of Outreach, Access, and Retention Among Latino/a Populations.

Interventions aiming to improve access to and retention in HIV care are optimized when they are tailored to clients' needs. This paper describes an initiative of interventions implemented by ten demonstration sites using a transnational framework to tailor services for Mexicans and Puerto Ricans living with HIV. Transnationalism describes how immigrants (and their children) exist in their "receiving" place (e.g., continental U.S.) while simultaneously maintaining connections to their country or place of origin (e.g., Mexico). We describe interventions in terms of the strategies used, the theory informing design and the tailoring, and the integration of transnationalism. We argue how applying the transnational framework may improve the quality and effectiveness of services in response to the initiative's overall goal, which is to produce innovative, robust, evidence-informed strategies that go beyond traditional tailoring approaches for HIV interventions with Latino/as populations.

Breastfeeding practices, beliefs, and social norms in low-resource communities in Mexico: Insights for how to improve future promotion strategies.

INTRODUCTION: Breastfeeding is recommended exclusively for the first 6 months after birth, with continued breastfeeding for at least 2 years. Yet prevalence of these recommendations is low globally, although it is an effective and cost-effective way to prevent serious infections and chronic illness. Previous studies have reported that social support greatly influences breastfeeding, but there is little evidence on perceived social norms in Mexico and how they affect actual behavior. OBJECTIVE: Our objective was to investigate breastfeeding intention, practices, attitudes, and beliefs, particularly normative, among low-resource communities in central and southern Mexico. METHODS: We performed a secondary analysis using the theory of planned behavior with cross-sectional data, which included semi-structured individual interviews with fathers (n 10), 8 focus groups with mothers (n 50), and 8 focus groups with women community leaders (n 44) with a total of 104 participants. Our data also included a quantitative survey among pregnant women and mothers (n 321). RESULTS: Women reported supplementing breast milk with water and teas soon after birth, as well as introducing small bites of solid food a few months after birth. Social norms appeared to support breastfeeding, but not exclusive breastfeeding or breastfeeding for periods longer than about a year. This may be partially explained by: a) behavioral beliefs that for the first 6 months breast milk alone is insufficient for the baby, and that water in addition to breast milk is necessary to hydrate an infant and b) normative beliefs related to the appropriateness of breastfeeding in public and as the child gets older. CONCLUSIONS: Future strategies should focus on positively influencing social norms to support recommended practices, and emphasize the specific reasons behind the recommendations. Future efforts should take a multi-pronged approach using a variety of influences, not only directed at healthcare providers but close family members, including fathers.

Scaling-up health information systems to improve HIV treatment: An assessment of initial patient monitoring systems in Mozambique.

INTRODUCTION: The rapid scale-up of HIV care and treatment in resource-limited countries requires concurrent, rapid development of health information systems to support quality service delivery. Mozambique, a country with an 11.5% prevalence of HIV, has developed nation-wide patient monitoring systems (PMS) with standardized reporting tools, utilized by all HIV treatment providers in paper or electronic form. Evaluation of the initial implementation of PMS can inform and strengthen future development as the country moves towards a harmonized, sustainable health information system. OBJECTIVE: This assessment was conducted in order to 1) characterize data collection and reporting processes and PMS resources available and 2) provide evidence-based recommendations for harmonization and sustainability of PMS. METHODS: This baseline assessment of PMS was conducted with eight non-governmental organizations that supported the Ministry of Health to provide 90% of HIV care and treatment in Mozambique. The study team conducted structured and semi-structured surveys at 18 health facilities located in all 11 provinces. Seventy-nine staff were interviewed. Deductive a priori analytic categories guided analysis. RESULTS: Health facilities have implemented paper and electronic monitoring systems with varying success. Where in use, robust electronic PMS facilitate facility-level reporting of required indicators; improve ability to identify patients lost to follow-up; and support facility and patient management. Challenges to implementation of monitoring systems include a lack of national guidelines and norms for patient level HIS, variable system implementation and functionality, and limited human and infrastructure resources to maximize system functionality and information use. CONCLUSIONS: This initial assessment supports the need for national guidelines to harmonize, expand, and strengthen HIV-related health information systems. Recommendations may benefit other countries with similar epidemiologic and resource-constrained environments seeking to improve PMS implementation.

Generating trust: Programmatic strategies to reach women who inject drugs with harm reduction services in Dar es Salaam, Tanzania.

BACKGROUND: Strong evidence supports the effectiveness of methadone-assisted therapy (MAT) to treat opioid dependence, reduce the risk of HIV transmission, and improve HIV related health outcomes among people who inject drugs (PWID). HIV prevalence reaches 71% in women who inject drugs (WWID) in Dar es Salaam, Tanzania; creating an urgent need for access to MAT. Despite the availability and potential benefits of treatment, few women have enrolled in services. This formative research sought to identify programmatic strategies to increase women's participation in outreach and their subsequent enrollment in MAT. METHODS: We conducted twenty-five, in-depth interviews with patients and their providers at a MAT clinic. Open-ended interviews explored enrollment experiences, with a focus on contextual barriers and facilitators unique to women. Ethnographic observations of harm reduction education at outreach sites and the MAT clinic enriched interview data. Trust/mistrust emerged as an overarching theme cross cutting patient and provider accounts of the connective process to enroll PWID in the methadone program. We explore trust and mistrust in relationship to the interrelated themes of family loss, social isolation, vehement discrimination and motivation for treatment. RESULTS: Narratives delineated both the generation of mistrust against PWID and the generation of mistrust in PWID against outsiders and medical institutions. In order to enroll PWID in treatment, community base organizations engaged outreach strategies to overcome mistrust and connect eligible patients to care, which varied in their success at recruiting women and men. Greater discrimination against WWID pushed them into hiding, away from outreach teams that focus on outdoor areas where men who inject drugs congregate. Building trust through multiple encounters and making a personal connection facilitated entry into care for women. Only PWID were eligible for MAT, due to resource constraints and the higher risk associated with injection drug use. Many women smoke heroin, yet still face high risk of HIV, resulting from low condom use during sex work to fund drug use. CONCLUSION: Expanding outreach times and locations, by women peers, could increase women's enrollment in treatment. Allowing women who smoke heroin to enter the program could prevent onward transmission via sex work and reduce the chance of progressing from the lower risk smoking or sniffing to injection drug use.