Validation of dried blood spots for capturing hepatitis C virus diversity for genomic surveillance.

Dried blood spots (DBS) have emerged as a promising alternative to traditional venous blood for hepatitis C virus (HCV) testing. However, their capacity to accurately reflect the genetic diversity of HCV remains poorly understood. We employed deep sequencing and advanced phylogenetic analyses on paired plasma and DBS samples from two common subtypes to evaluate the suitability of DBS for genomic surveillance. Results demonstrated that DBS captured equivalent viral diversity compared to plasma with no phylogenetic discordance observed. The ability of DBS to accurately reflect the profile of viral genetic diversity suggests it may be a promising avenue for future surveillance efforts to curb HCV outbreaks.

Evaluation of respondent-driven sampling in seven studies of people who use drugs from rural populations: findings from the Rural Opioid Initiative.

BACKGROUND: Accurate prevalence estimates of drug use and its harms are important to characterize burden and develop interventions to reduce negative health outcomes and disparities. Lack of a sampling frame for marginalized/stigmatized populations, including persons who use drugs (PWUD) in rural settings, makes this challenging. Respondent-driven sampling (RDS) is frequently used to recruit PWUD. However, the validity of RDS-generated population-level prevalence estimates relies on assumptions that should be evaluated. METHODS: RDS was used to recruit PWUD across seven Rural Opioid Initiative studies between 2018-2020. To evaluate RDS assumptions, we computed recruitment homophily and design effects, generated convergence and bottleneck plots, and tested for recruitment and degree differences. We compared sample proportions with three RDS-adjusted estimators (two variations of RDS-I and RDS-II) for five variables of interest (past 30-day use of heroin, fentanyl, and methamphetamine; past 6-month homelessness; and being positive for hepatitis C virus (HCV) antibody) using linear regression with robust confidence intervals. We compared regression estimates for the associations between HCV positive antibody status and (a) heroin use, (b) fentanyl use, and (c) age using RDS-1 and RDS-II probability weights and no weights using logistic and modified Poisson regression and random-effects meta-analyses. RESULTS: Among 2,842 PWUD, median age was 34 years and 43% were female. Most participants (54%) reported opioids as their drug of choice, however regional differences were present (e.g., methamphetamine range: 4-52%). Many recruitment chains were not long enough to achieve sample equilibrium. Recruitment homophily was present for some variables. Differences with respect to recruitment and degree varied across studies. Prevalence estimates varied only slightly with different RDS weighting approaches, most confidence intervals overlapped. Variations in measures of association varied little based on weighting approach. CONCLUSIONS: RDS was a useful recruitment tool for PWUD in rural settings. However, several violations of key RDS assumptions were observed which slightly impacts estimation of proportion although not associations.

Overdose responses among rural people who use drugs: A multi-regional qualitative study.

BACKGROUND: Efforts to distribute naloxone have equipped more people with the ability to reverse opioid overdoses but people who use drugs are often reluctant to call 911 due to concerns for legal repercussions. Rural communities face unique challenges in reducing overdose deaths compared to urban communities, including limited access to harm reduction services as well as greater concerns about stigma and privacy. METHODS: The Rural Opioid Initiative was funded in 2017 to better understand the health-related harms associated with the opioid crisis in rural US communities and consists of eight studies spanning ten states and 65 counties. Each study conducted semi-structured qualitative interviews with people who use drugs to understand contextual factors influencing drug use and health behaviors. We analyzed qualitative data from seven studies with data available at the time of analysis to understand peer response to overdose. RESULTS: Of the 304 participants interviewed, 55% were men, 70% were white, 80% reported current injection drug use, and 60% reported methamphetamine use. Similar to what has been found in studies focused on urban settings, people who use drugs in rural communities use a range of strategies to reverse overdoses, including non-evidence-based approaches. Several reported that multiple doses of naloxone are needed to reverse overdose. Three themes emerged around the willingness to call 911, including (1) hesitancy to call 911 for fear of legal consequences, (2) negative perceptions or experiences with law enforcement officers, and (3) efforts to obtain medical intervention while avoiding identification/law enforcement involvement. CONCLUSION: People who use drugs employ multiple strategies to attempt overdose reversal, including non-evidence-based approaches. Greater education about the most effective and least harmful strategies is needed. Reluctance to call 911 is rooted in concerns about potential legal consequences as well as perceptions about law enforcement officers, which may be heightened in rural communities where people who use drugs are more easily identified by law enforcement. People who use drugs will go to great strides to connect their peers to needed medical services, suggesting that comprehensive interventions to reduce interactions with law enforcement officers and eliminate legal consequences for reporting overdoses are critical.

Examining the Awareness, Acceptability, and Adoption of Conventional and non-conventional Forms of Pre-Exposure Prophylaxis (PrEP) for HIV Prevention Among jail-involved Black Sexual Minority men (BSMM) and Black Transgender Women (BTW) in Two Diverse US Cities.

Black sexual minority men (BSMM) and Black transgender women (BTW) are disproportionately impacted by HIV and incarceration in the United States. In-depth interviews (N=34) and ongoing thematic analysis guided by the Exploration Phase of the Exploration, Preparation, Implementation, Sustainment framework were conducted to uncover key themes focused on the awareness, acceptability, and early adoption of conventional (i.e., daily oral pill) and non-conventional forms of PrEP (i.e., long-acting injectable, e-prescription for pick up post release) among jail-involved BSMM and BTW in Chicago, Illinois and Baton Rouge, Louisiana. The majority of participants were cisgender BSMM (88%) and were enrolled in Chicago (65%). There was greater awareness, availability, and adoption of conventional PrEP and non-conventional PrEP e-prescription for pick up post release among Chicago participants compared with Baton Rouge participants. Participants were largely receptive to all three forms of PrEP and stated a high need for HIV prevention in jails and immediately following release. PrEP stigma emerged as a major barrier to conventional daily PrEP adoption while incarcerated; potential misuse (e.g., pill selling) as a potential barrier to PrEP eprescription; and needle aversion and added clinic time as potential barriers to longacting injectable (LAI)-PrEP. Participants indicated that PrEP e-prescription could help support continuity of care post release and highlighted reduced stigma, convenience, and longer-term HIV protection as benefits for LAI-PrEP. Study findings provided context-specific information to inform the implementation of future PrEP interventions for jail-involved BSMM and BTW in two highly HIV-impacted jurisdictions.

Houselessness and syringe service program utilization among people who inject drugs in eight rural areas across the USA: a cross-sectional analysis.

BACKGROUND: Research conducted in urban areas has highlighted the impact of housing instability on people who inject drugs (PWID), revealing that it exacerbates vulnerability to drug-related harms and impedes syringe service program (SSP) use. However, few studies have explored the effects of houselessness on SSP use among rural PWID. This study examines the relationship between houselessness and SSP utilization among PWID in eight rural areas across 10 states. METHODS: PWID were recruited using respondent-driven sampling for a cross-sectional survey that queried self-reported drug use and SSP utilization in the prior 30 days, houselessness in the prior 6 months and sociodemographic characteristics. Using binomial logistic regression, we examined the relationship between experiencing houselessness and any SSP use. To assess the relationship between houselessness and the frequency of SSP use, we conducted multinomial logistic regression analyses among participants reporting any past 30-day SSP use. RESULTS: Among 2394 rural PWID, 56.5% had experienced houselessness in the prior 6 months, and 43.5% reported past 30-day SSP use. PWID who had experienced houselessness were more likely to report using an SSP compared to their housed counterparts (adjusted odds ratio [aOR] = 1.24 [95% confidence intervals [CI] 1.01, 1.52]). Among those who had used an SSP at least once (n = 972), those who experienced houselessness were just as likely to report SSP use two (aOR = 0.90 [95% CI 0.60, 1.36]) and three times (aOR = 1.18 [95% CI 0.77, 1.98]) compared to once. However, they were less likely to visit an SSP four or more times compared to once in the prior 30 days (aOR = 0.59 [95% CI 0.40, 0.85]). CONCLUSION: This study provides evidence that rural PWID who experience houselessness utilize SSPs at similar or higher rates as their housed counterparts. However, housing instability may pose barriers to more frequent SSP use. These findings are significant as people who experience houselessness are at increased risk for drug-related harms and encounter additional challenges when attempting to access SSPs.

Sociodemographic characteristics and HIV risk behaviors of native-born and displaced Syrian men and transgender women who have sex with men in Lebanon.

HIV rates among men and transgender women who have sex with men (MTWSM) in Lebanon are consistent with a concentrated epidemic. Geopolitical and social circumstances leave these communities vulnerable to HIV spread. To document this risk encountered by Lebanese native and displaced Syrian MTWSM, participants, recruited by respondent driven sampling beginning with Syrian seeds, completed a survey with questions covering sociodemographic, behavioral, medical, and stigma, followed by opt-out HIV testing. Analyses included descriptive statistics and linear regression to differentiate between native Lebanese and Syrians who migrated after the onset of the civil war to identify correlations among sociodemographic factors, stigma, and risk behavior as a function of country of birth. Experienced and internalized stigmas were higher in the Syrian born MTWSM and correlated with elements of HIV risk. Combatting the intersectional stigmas of Syrian MTWSM in Lebanon would be most beneficial in mitigating HIV risk for these individuals.

RESUMEN: Las tasas de VIH entre hombres y mujeres transgénero que tienen sexo con hombres (HMTSH) en el Líbano son consistentes con una epidemia concentrada. Las circunstancias geopolíticas y sociales dejan a estas comunidades vulnerables a la propagación del VIH. Para documentar este riesgo al que se enfrentan los HMTSH nativos libaneses y HMTSH sirios desplazados, los participantes, reclutados mediante un muestreo impulsado por los encuestados que comenzó con semillas sirias, completaron una encuesta con preguntas que cubrían aspectos sociodemográficos, conductuales, médicos y de estigma, seguidas de una prueba de VIH de exclusión voluntaria. Los análisis incluyeron estadísticas descriptivas y regresión lineal para diferenciar entre libaneses nativos y sirios que emigraron después del inicio de la guerra civil para identificar correlaciones entre factores sociodemográficos, estigma y comportamiento de riesgo como función del país de nacimiento. Los estigmas experimentados e internalizados fueron más altos en los HMTSH nacidos en Siria y se correlacionaron con elementos de riesgo de VIH. Combatir los estigmas interseccionales de los HMTSH sirios en el Líbano sería lo más beneficioso para mitigar el riesgo de VIH para estos individuos.

Hepatitis C Virus Transmission Clusters in Public Health and Correctional Settings, Wisconsin, USA, 2016-20171.

Ending the hepatitis C virus (HCV) epidemic requires stopping transmission among networks of persons who inject drugs. Identifying transmission networks by using genomic epidemiology may inform community responses that can quickly interrupt transmission. We retrospectively identified HCV RNA-positive specimens corresponding to 459 persons in settings that use the state laboratory, including correctional facilities and syringe services programs, in Wisconsin, USA, during 2016-2017. We conducted next-generation sequencing of HCV and analyzed it for phylogenetic linkage by using the Centers for Disease Control and Prevention Global Hepatitis Outbreak Surveillance Technology platform. Analysis showed that 126 persons were linked across 42 clusters. Phylogenetic clustering was higher in rural communities and associated with female sex and younger age among rural residents. These data highlight that HCV transmission could be reduced by expanding molecular-based surveillance strategies to rural communities affected by the opioid crisis.

Contribution of insulin resistance to the relationship between sugar-sweetened beverage intake and a constellation of cardiometabolic abnormalities in adolescents.

BACKGROUND: Insulin resistance (IR) is a pathophysiological construct that derives a series of metabolic disturbances that promote cardiometabolic dysfunction. This study evaluated mediating and modifying effects of homeostatic model assessment-based IR (HOMA-IR) on the association between sugar-sweetened beverage (SSB) consumption and a constellation of adolescent cardiometabolic abnormalities. METHODS: Comprehensive data on sociodemographics, diet, physical activity, and anthropometric and biochemical parameters for 1454 adolescents were obtained from a large-scale representative study for adolescent metabolic syndrome (MetS) conducted in Taiwan. The original (HOMA1-IR) and updated nonlinear (HOMA2-IR) HOMA-IR indicators were used as IR biomarkers. Principal component (PC) analysis was employed to create reduced groups of variables and risk scores for retained PCs. RESULTS: Higher SSB intake was associated with higher levels of HOMA1-IR and HOMA2-IR, and the two IR biomarkers were positively correlated with metabolic dysfunction clustering. Compared with SSB nondrinkers, adolescents who consumed >500 mL/day of hand-shaken high-fructose corn syrup beverages (HHB) had a 0.22 increase in the number of abnormal MetS components, and HOMA-IR mediation explained 33.9-37.9% of the effect. IR biomarkers accounted for 26.5-31.0% of the relationship between >500 mL/day of SSB consumption and bodyweight-enhanced PC scores. The effects of HOMA-IR indicators on all bodyweight-related factors were consistently intensified among >350 mL/day HHB drinkers (all Pinteraction < 0.05). CONCLUSIONS: Fructose-rich SSB intake correlates with a constellation of cardiometabolic abnormalities in adolescents, and this association may be partly mediated by HOMA-IR levels. The adverse effects of HOMA-IR on bodyweight-associated cardiometabolic risk factors depend on the type of SSB consumption, with enhanced risks observed in the intake of high amounts of HFCS-containing SSBs.

Age difference in the combined effect of soda drinks consumption and body adiposity on hyperuricaemia in US adults.

OBJECTIVE: To evaluate age-related differences in the independent/combined association of added sugar intake from soda and body adiposity with hyperuricaemia in gender-stratified US adults. DESIGN: Consumption of added sugar from soda was calculated from 24-h dietary interviews and categorised into none, regular and excessive consumption. Hyperuricaemia was defined as serum uric acid levels >417 mmol/l in men and >357 mmol/l in women. Multiple regression models with interaction terms and logistic models adjusted for covariates were conducted under survey-data modules. SETTING: National Health and Nutrition Examination Survey during 2007-2016. PARTICIPANTS: 15 338 adults without gout, failing kidneys, an estimated glomerular filtration rate < 30 or diabetes were selected. RESULTS: The age-stratified prevalence rate of hyperuricaemia was 18·8-20·4 % in males and 6·8-17·3 % in females. Hyperuricaemia prevalence of approximately 50 % was observed in young and middle age males who consumed excessive added sugar from soda. Excessive added sugar intake was observed to be associated with 1·5- to 2·0-fold and 2·0- to 2·3-fold increased risk of the probability of hyperuricaemia in young and middle age males and middle age females, respectively. Study participants, regardless of age or gender, who were obese and consumed excessive added sugar from soda had the highest risk of having hyperuricaemia. CONCLUSIONS: Our study revealed that the association between hyperuricaemia and consumption of excessive added sugar from soda may vary by age and gender. Obese adults who consumed excessive added sugar from soda had the highest risk of hyperuricaemia, a finding that was found across all age-specific groups for both genders.

Behind bars: the burden of being a woman in Brazilian prisons.

BACKGROUND: Brazil has the third largest prison population in the world. In 2016, the female prison population totaled 42,000, an increase of 656% over the population recorded in the early 2000s. The objective of this study was to describe the socialeconomic and reproductive health of women in Brazilian prisons, and the specific assistance received within the prison system. METHODS: This is a first of its kind national survey conducted in 15 female prisons in eight Brazilian states between 2014 and 2015. The sample consisted of 1327 women in closed or semi-open prison regimes. Data collection used Audio Computer-Assisted Self-Interviewing (ACASI). STATA v.15. Was use in analysis. The study was submitted to the Research Ethics Committee of the Federal University of Ceará, under CEP protocol No. 1,024,053. RESULTS: The population was overwhelmingly Black or Brown, poor and little educated. When women worked previously, they had worked as domestic servants and were the sole source of income for their families. Most were mothers, with 39% having children less than 10 years old, now in the care of others. Most were in jail for drug-related crimes. Prisons were crowded, with more than 2/3rds of the inmates sharing a cell with 6 or more inmates. Services were provide, but women had not had a cervical cancer screening within the past 3 years and breast cancer screening was not conducted. CONCLUSIONS: Overall, given their backround and prison conditions they are unlikely to change the circumstances that brought them to prison in the first place.

Gender Differences in HIV Risk Behaviors Among Persons Involved in the U.S. Criminal Justice System and Living with HIV or at Risk for HIV: A "Seek, Test, Treat, and Retain" Harmonization Consortium.

The U.S. female criminal justice (CJ) population is rapidly growing, yet large-scale studies exploring gender-specific HIV risk behaviors in the CJ population are lacking. This analysis uses baseline data on adults with a CJ history from eight U.S. studies in an NIH-funded "Seek, Test, Treat, Retain" harmonization consortium. Data were collected using a standardized HIV risk behavior assessment tool and pooled across studies to describe participants' characteristics and risk behaviors. Multilevel mixed-effects logistic regression models were used to test for gender-based behavior differences. Among 784 HIV-positive (21.4% female) and 5521 HIV-negative (8.5% female) participants, HIV-positive women had higher odds than HIV-positive men of engaging in condomless sexual intercourse (AOR 1.84 [1.16-2.95]) with potentially sero-discordant partners (AOR 2.40 [1.41-4.09]) and of sharing injection equipment (AOR 3.36 [1.31-8.63]). HIV risk reduction interventions targeting CJ-involved women with HIV are urgently needed as this population may represent an under-recognized potential source of HIV transmission.

Social-emotional aspects of male escorting: experiences of men working for an agency.

Social situations and emotional correlates associated with male sex work have not been well documented. Most of the research in this area focuses on sexual activity with little mention of other aspects of the job. Yet, research with female sex workers finds significant social and emotional components to sex work. The current study focused on how male sex workers (MSWs) perceived and adapted to the social-emotional aspects of their job. As part of a larger project examining MSWs working for a single escort agency, 40 men (M age, 22.3 years, 75 % Caucasian) located in the mid-Atlantic U.S. participated in semi-structured interviews. The agency owner was also interviewed. Participants reported a range of social and emotional factors regarding sex work and employed a variety of strategies to provide good customer service and adapt to negative experiences. For most, social support was inhibited due to fear of stigmatization that might result if participants disclosed sex work to significant others outside the agency. Instead, interactions within the agency provided core work-related social support for most MSWs. Emotional and relational tasks inherent to escort work grew easier with experience and negativity about the job declined. Our data suggested that socially connected individuals seemed to be more satisfied with sex work. Social and emotional requirements represented a significant but unanticipated component of male sex work to which escorts actively adapted. Escorting may be similar to other service occupations in terms of the social-emotional situations and skills involved.

A systematic review of universal campaigns targeting child physical abuse prevention.

The purpose of this review was to better understand the impact of universal campaign interventions with a media component aimed at preventing child physical abuse (CPA). The review included 17 studies featuring 15 campaigns conducted from 1989 to 2011 in five countries. Seven studies used experimental designs, but most were quasi-experimental. CPA incidence was assessed in only three studies and decreased significantly in two. Studies also found significant reductions in relevant outcomes such as dysfunctional parenting, child problem behaviors and parental anger as well as increases in parental self-efficacy and knowledge of concepts and actions relevant to preventing child abuse. The following risk factors were most frequently targeted in campaigns: lack of knowledge regarding positive parenting techniques, parental impulsivity, the stigma of asking for help, inadequate social support and inappropriate expectations for a child's developmental stage. The evidence base for universal campaigns designed to prevent CPA remains inconclusive due to the limited availability of rigorous evaluations; however, Triple-P is a notable exception. Given the potential for such interventions to shift population norms relevant to CPA and reduce rates of CPA, there is a need to further develop and rigorously evaluate such campaigns.

Cross-cultural comparison of successful aging definitions between Chinese and Hmong elders in the United States.

The purpose of the study was to elicit the definitions of successful aging according to Chinese and Hmong elders living in Milwaukee, WI. In-depth semi-structured interviews were conducted with 44 elders (Hmong n = 21 and Chinese n = 23). Findings show some similarities in the Chinese and Hmong elders' definitions though specific cultural differences exist. Chinese elders emphasized physical health and mobility, mental health, positive attitudes, shedding responsibilities, positive family relationships, financial stability, social engagement, religious faith, and accomplishments and volunteer work. Hmong elders emphasized physical health and mobility, mental health, harmonious relationships, positive family relationships, tangible family support, financial stability, social engagement, and religious faith. Cross-cultural comparisons of the findings highlight the cultural heterogeneity between these two subgroups. Implications for practice are discussed.

Experiences of stigma, mental health, and coping strategies in Lebanon among Lebanese and displaced Syrian men who have sex with men: A qualitative study.

BACKGROUND: In Lebanon, men who have sex with men (MSM) face high rates of stigma, discrimination, and violence. Minority stress, or the unique stressors related to anti-MSM stigma and discrimination, negatively impacts the mental health of MSM. These stressors are heightened for those with intersectional minority identities such as displaced Syrian MSM in Lebanon. METHODS: In this qualitative study conducted in 2020-21, part of a larger study focused on the mental and sexual health risks among MSM, we collected qualitative data from Lebanese and displaced Syrian MSM living in Lebanon and analyzed reports of their experiences with stigma, mental health, and coping strategies. We conducted semi-structured, in-depth interviews with 12 displaced Syrian MSM and 13 Lebanese MSM. RESULTS: Our findings highlight how MSM in Lebanon navigate stigma and the mental health risks that result. Common stressors among Lebanese and displaced Syrian MSM were related to finances, sexual orientation discrimination, and social isolation. Comparing the two groups, we found that stressors specific to displaced Syrian MSM were related to adverse childhood experiences, recent exposure to the Syrian war, displacement, and discrimination in Lebanon based on their intersectional identities as MSM and Syrians. For Lebanese participants, the most common stigma coping strategies were avoidance, drinking alcohol, using drugs, or having sex. As for displaced Syrian MSM, the most common stigma coping strategy was seeking the freely available mental health services offered to them through non-governmental organizations. CONCLUSION: Our findings suggest that increased targeted mental health and social support interventions, informed by the unique experiences of Lebanese and displaced Syrian MSM, are highly needed to improve the coping and mental health resources of all MSM in Lebanon.

Validation of Dried Blood Spots for Capturing Hepatitis C Virus Diversity for Genomic Surveillance.

Dried blood spots (DBS) have emerged as a promising alternative to traditional venous blood for HCV testing. However, their capacity to accurately reflect the genetic diversity of HCV remains poorly understood. We employed deep sequencing and advanced phylogenetic analyses on paired plasma and DBS samples to evaluate the suitability of DBS for genomic surveillance. Results demonstrated that DBS captured equivalent viral diversity compared to plasma with no phylogenetic discordance observed. The ability of DBS to accurately reflect the profile of viral genetic diversity suggests it may be a promising avenue for future surveillance efforts to curb HCV outbreaks.

Mediation of BMI on 25-Hydroxyvitamin D Levels in U.S. Adults with Sugar-Sweetened Beverages Consumption.

Body mass index (BMI) as well as sugar-sweetened beverages (SSB) has been suggested to independently decrease 25-hydroxyvitamin D (25(OH)D). However, the relationship between SSB, BMI, and 25(OH)D is uncertain. This study aimed to investigate the potential mediating role of BMI in the association between SSB intake and 25(OH)D. A total of 4505 representative U.S. adults aged above 20 years and without liver conditions were selected from the 2013-2014 NHANES. All analyses were performed under survey modules with appropriate sampling weights. The prevalence of 25(OH)D insufficiency and deficiency was 37.8% and 24.1% in U.S. adults, respectively. Compared with non-SSB consumers, an increased risk of vitamin D deficiency was found in either heavy SSB consumers or soda consumers, respectively (aOR = 2.10, 95% CI = 1.25-3.54 in heavy SSB consumers; aOR = 1.61, 95% CI = 1.06-2.44 in soda consumers). Around 21.3% of the total effect of sugar intake from SSB on decreased 25(OH)D was explained by BMI. In conclusion, high total sugar intake from SSB and BMI independently contribute to lower 25(OH)D, and BMI mediates the inverse association between total sugar intake from SSB intake and 25(OH)D. Furthermore, an increased risk of having vitamin D deficiency was found in the population who consumed higher levels of sugar from SSB or soda drinks.

"I would do anything but that": Attitudes towards sex work among rural people who use drugs.

BACKGROUND: Stigma towards people who use drugs and those who engage in sex work is well-documented, leading to consequences such as reduced access to health services and support, especially in rural milieus. Stigma reduction has been recognized as a priority in the opioid overdose crisis, but little attention has been paid to within-group attitudes and beliefs. This study aimed to explore how people who use drugs in rural counties across the United States appraise sex work by themselves or other community members. METHODS: Qualitative interview data came from the Rural Opioid Initiative (ROI), a project coordinated by research teams across 65 rural counties in 10 states. Interviews were individual and conducted from 2018 to 2020. All participants reported past 30-day opioid use and/or any injection drug use. A working group coded the data, then used an iterative inductive-deductive approach to organize data into themes of stigma among people who use drugs, focusing on stigma towards sex work. RESULTS: Across sites, 355 interviews were conducted. Mean participant age was 36, 55 % of participants were male, and 93 % were white. Participants expressed negative attitudes towards sex work as a function of its criminal-legal repercussions or framed sex work as morally transgressive. Many appraisals were gendered, with the behavior conveyed as being "easier" for women who were often described as "whores," with more neutral terms used to describe men. Some viewed sex work as an implicit "exchange" for drugs. Several participants noted a lack of agency as a feature leading to involvement in sex work, with partner power dynamics influencing an individual's behavior. Finally, a few participants acknowledged the circumstances under which they would newly engage in sex work. CONCLUSION: We identified several patterns by which people who use drugs evaluate community members who sell sex. These included gendered and morally-charged forms of stigma, which may represent barriers to community acceptance and support among this subgroup.

Variation in HIV Transmission Behaviors Among People Who Use Drugs in Rural US Communities.

Importance: People who use drugs (PWUD) continue to be at risk of HIV infection, but the frequency and distribution of transmission-associated behaviors within various rural communities is poorly understood. Objective: To examine the association of characteristics of rural PWUD with HIV transmission behaviors. Design, Setting, and Participants: In this cross-sectional study, surveys of PWUD in rural communities in 10 states (Illinois, Kentucky, New Hampshire, Massachusetts, North Carolina, Ohio, Oregon, Vermont, West Virginia, and Wisconsin) were collected January 2018 through March 2020 and analyzed August through December 2022. A chain-referral sampling strategy identified convenience sample seeds who referred others who used drugs. Rural PWUD who reported any past 30-day injection drug use or noninjection opioid use "to get high" were included. Exposures: Individual characteristics, including age, race, gender identity, sexual orientation, partnership status, drug of choice, and location, were collected. Main Outcomes and Measures: Past 30-day frequency of behaviors associated with HIV transmission, including drug injection, syringe sharing, opposite- and same-gender partners, transactional sex, and condomless sex, was assessed. Results: Of 3048 rural PWUD (mean [SD] age, 36.1 [10.3] years; 225 American Indian [7.4%], 96 Black [3.2%], and 2576 White [84.5%] among 3045 with responses; and 1737 men [57.0%] among 3046 with responses), most participants were heterosexual (1771 individuals [86.8%] among 2040 with responses) and single (1974 individuals [68.6%] among 2879 with responses). Opioids and stimulants were reported as drug of choice by 1636 individuals (53.9%) and 1258 individuals (41.5%), respectively, among 3033 individuals with responses. Most participants reported recent injection (2587 of 3046 individuals [84.9%] with responses) and condomless sex (1406 of 1757 individuals [80.0%] with responses), among whom 904 of 1391 individuals (65.0%) with responses indicated that it occurred with people who inject drugs. Syringe sharing (1016 of 2433 individuals [41.8%] with responses) and transactional sex (230 of 1799 individuals [12.8%] with responses) were reported less frequently. All characteristics and behaviors, except the number of men partners reported by women, varied significantly across locations (eg, mean [SD] age ranged from 34.5 [10.0] years in Wisconsin to 39.7 [11.0] years in Illinois; P < .001). In multivariable modeling, younger age (adjusted odds ratio [aOR] for ages 15-33 vs ≥34 years, 1.36; 95% CI, 1.08-1.72) and being single (aOR, 1.37; 95% CI, 1.08-1.74) were associated with recent injection; younger age (aOR, 1.49; 95% CI, 1.20-1.85) and bisexual orientation (aOR vs heterosexual orientation, 2.27; 95% CI, 1.60-3.23) with syringe sharing; gender identity as a woman (aOR vs gender identity as a man, 1.46; 95% CI, 1.01-2.12), bisexual orientation (aOR vs heterosexual orientation, 2.59; 95% CI, 1.67-4.03), and being single (aOR, 1.71; 95% CI, 1.15-2.55) with transactional sex; and bisexual orientation (aOR vs heterosexual orientation, 1.60; 95% CI, 1.04-2.46) and stimulants as the drug of choice (aOR vs opioids, 1.45; 95 CI, 1.09-1.93) with condomless sex with someone who injects drugs. Conclusions and Relevance: This study found that behaviors associated with HIV transmission were common and varied across communities. These findings suggest that interventions to reduce HIV risk among rural PWUD may need to be tailored to locally relevant factors.