The impact of the 2014 military conflict in the east of Ukraine and the Autonomous Republic of the Crimea among patients receiving opioid agonist therapies.

BACKGROUND: Opioid agonist therapies (OAT) for people with opioid use disorders (OUD) have been available in Ukraine since 2004. This study assessed the effect of 2014 Russian invasion of Ukraine on OAT re-enrollment and retention in conflict areas. METHODS: We analyzed the Ukraine national registry of OAT patients containing 1868 people with OUD receiving OAT as of January 2014 in conflict areas (Donetsk, Luhansk, and the Autonomous Republic [AR] of the Crimea). We developed logistic regression models to assess the correlates of re-enrollment of OAT patients in government-controlled areas (GCA) from conflict areas and retention on OAT at 12 months after re-enrollment. RESULTS: Overall, 377 (20.2 %) patients were re-enrolled at an OAT site in a GCA from confict areas, of whom 182 (48.3 %) were retained on OAT through 2021. Correlates of re-enrollment were residing in Donetsk (adjusted odds ratios (aOR) = 7.06; 95 % CI: 4.97-10.20) or Luhansk (aOR = 6.20; 95 % CI: 4.38-8.93) vs. AR Crimea; age 18-34 (aOR = 2.03; 95 % CI: 1.07-3.96) or 35-44 (aOR = 2.09; 95 % CI: 1.24-3.71) vs. ≥55 years, and being on optimal (aOR = 1.78; 95 % CI: 1.33-2.39) or high OAT dosing (aOR = 2.76; 95 % CI: 1.93-3.96) vs. low dosing. Correlates of retention were drug use experience 15-19 years (aOR = 3.69; 95 % CI: 1.47-9.49) vs. <14 years of drug use; take-home (aOR = 3.42; 95 % CI: 1.99-5.96) vs. daily on-site dosing, and optimal (aOR = 2.19; 95 % CI:1.05-4.72) vs. low OAT dosing. CONCLUSION: Our study showed that one-fifth of patients were re-enrolled at sites in GCA areas, less than half of re-enrolled patients were retained. Disruption of OAT has implications for drug-, HIV-, and HCV-related morbidity and mortality. FUNDING: AM was funded by NIH-funded grant D43TW010562; DCO was funded by the NIDA-funded Center for Drug Use and HIV|HCV Research (P30DA011041).

The effectiveness of malaria camps as part of the malaria control program in Odisha, India.

Durgama Anchalare Malaria Nirakaran (DAMaN) is a multi-component malaria intervention for hard-to-reach villages in Odisha, India. The main component, malaria camps (MCs), consists of mass screening, treatment, education, and intensified vector control. We evaluated MC effectiveness using a quasi-experimental cluster-assigned stepped-wedge study with a pretest-posttest control group in 15 villages: six immediate (Arm A), six delayed (Arm B), and three previous interventions (Arm C). The primary outcome was PCR + Plasmodium infection prevalence. The time (i.e., baseline vs. follow-up 3) x study arm interaction term shows that there were statistically significant lower odds of PCR + Plasmodium infection in Arm A (AOR = 0.36, 95% CI = 0.17, 0.74) but not Arm C as compared to Arm B at the third follow-up. The cost per person ranged between US$3-8, the cost per tested US$4-9, and the cost per treated US$82-1,614, per camp round. These results suggest that the DAMaN intervention is a promising and financially feasible approach for malaria control.

Creation and Validation of a New Socio-built Environment Index Measure of Opioid Overdose Risk for Use in Both Non-urban and Urban Settings.

A great deal of literature has examined features of the physical built environment as predictors of opioid overdose and other substance use-related outcomes. Other literature suggests that social characteristics of settings are important predictors of substance use outcomes. However, there is a dearth of literature simultaneously measuring both physical and social characteristics of settings in an effort to better predict opioid overdose. There is also a dearth of literature examining built environment as a predictor of overdose in non-urban settings. The present study presents a novel socio-built environment index measure of opioid overdose risk comprised of indicators measuring both social and physical characteristics of settings - and developed for use in both urban and non-urban settings - and assesses its validity among 565 urban, suburban, and rural New Jersey municipalities. We found that this novel measure had good convergent validity, based on significant positive associations with a social vulnerability index and crime rates, and significant negative associations with a municipal revitalization index and high school graduation rates. The index measure had good discriminant validity, based on lack of association with three different racial isolation indices. Finally, our index measure had good health outcome-based criterion validity, based on significant positive associations with recent overdose mortality. There were no major differences between rural, suburban, and urban municipalities in validity analysis findings. This promising new socio-built environment risk index measure could improve ability to target and allocate resources to settings with the greatest risk, in order to improve their impact on overdose outcomes.

I Don't Believe a Person Has to Die When Trying to Get High: Overdose Prevention and Response Strategies in Rural Illinois.

BACKGROUND: Overdose is a leading cause of morbidity and mortality among people who inject drugs. Illicitly manufactured fentanyl is now a major driver of opioid overdose deaths. METHODS: Semi-structured interviews were conducted with 23 participants (19 persons who inject drugs and 4 service providers) from rural southern Illinois. Data were analyzed using constant comparison and theoretical sampling methods. RESULTS: Participants were concerned about the growing presence of fentanyl in both opioids and stimulants, and many disclosed overdose experiences. Strategies participants reported using to lower overdose risk included purchasing drugs from trusted sellers and modifying drug use practices by partially injecting and/or changing the route of transmission. Approximately half of persons who inject drugs sampled had heard of fentanyl test strips, however fentanyl test strip use was low. To reverse overdoses, participants reported using cold water baths. Use of naloxone to reverse overdose was low. Barriers to naloxone access and use included fear of arrest and opioid withdrawal. CONCLUSIONS: People who inject drugs understood fentanyl to be a potential contaminant in their drug supply and actively engaged in harm reduction techniques to try to prevent overdose. Interventions to increase harm reduction education and information about and access to fentanyl test strips and naloxone would be beneficial.

How the rural risk environment underpins hepatitis C risk: Qualitative findings from rural southern Illinois, United States.

BACKGROUND: Hepatitis C virus (HCV) infection has increased among persons who inject drugs (PWID) in the United States with disproportionate burden in rural areas. We use the Risk Environment framework to explore potential economic, physical, social, and political determinants of hepatitis C in rural southern Illinois. METHODS: Nineteen in-depth semi-structured interviews were conducted with PWID from August 2019 through February 2020 (i.e., pre-COVID-19 pandemic) and four with key informants who professionally worked with PWID. Interviews were recorded, professionally transcribed, and coded using qualitative software. We followed a grounded theory approach for coding and analyses. RESULTS: We identify economic, physical, policy, and social factors that may influence HCV transmission risk and serve as barriers to HCV care. Economic instability and lack of economic opportunities, a lack of physically available HCV prevention and treatment services, structural stigma such as policies that criminalize drug use, and social stigma emerged in interviews as potential risks for transmission and barriers to care. CONCLUSION: The rural risk environment framework acknowledges the importance of community and structural factors that influence HCV infection and other disease transmission and care. We find that larger structural factors produce vulnerabilities and reduce access to resources, which negatively impact hepatitis C disease outcomes.

The effectiveness of malaria camps as part of the malaria control program in Odisha, India.

Durgama Anchalare Malaria Nirakaran (DAMaN) is a multi-component malaria intervention for hard-to-reach villages in Odisha, India. The main component, Malaria Camps (MCs), consists of mass screening, treatment, education, and intensified vector control. We evaluated MC effectiveness using a quasi-experimental cluster-assigned stepped-wedge study with a pretest-posttest control group in 15 villages: six immediate (Arm A), six delayed (Arm B), and three previous interventions (Arm C). The primary outcome was PCR+ Plasmodium infection prevalence. Across all arms, the odds of PCR+ malaria were 54% lower at the third follow-up compared to baseline. A time (i.e., visit) x study arm interaction revealed significantly lower odds of PCR+ malaria in Arm A versus B at the third follow-up. The cost per person ranged between US$3-8, the cost per tested US$4-7, and the cost per treated US$82-1,614, per camp round. These results suggest that the DAMaN intervention is a promising, financially feasible approach for malaria control.

Predictors of Anal High-Risk HPV Infection Across Time in a Cohort of Young Adult Sexual Minority Men and Transgender Women in New York City, 2015-2020.

Cisgender sexual minority men (SMM) and transgender women are disproportionately vulnerable to HPV-related anal cancer, but little is known about longitudinal predictors of high-risk human papillomavirus (hrHPV) infection in this population. As such, this analysis aims to identify factors associated with incident anal hrHPV infection in a diverse cohort of young SMM and transgender women. This study of HPV infection, nested within a larger cohort study, took place between October 2015 and January 2020. Participants completed a brief computer survey assessing HPV symptomatology, risk, and prevention alongside multi-site testing, in addition to biannual cohort study assessments. In the analytic sample of 137 participants, 31.6% tested positive for an anal hrHPV infection, with 27.0% and 29.9% testing positive for incident anal hrHPV infections at Visits 2 and 3, respectively. When adjusting for time between study visits, participants had significantly greater odds of incident anal hrHPV at Visit 2 if they had a concurrent HSV infection (AOR = 5.08 [1.43, 18.00]). At Visit 3, participants had significantly greater odds of incident anal hrHPV infection if they reported a greater number of sex partners in the previous month (AOR = 1.25 [1.03, 1.51]). Prevalence of cancer-causing HPV at baseline was high and many participants tested positive for additional types of anal hrHPV at subsequent visits. Risk for newly detected anal hrHPV infection was significantly associated with biological and behavioral factors. Our findings strongly indicate a need for programs to increase uptake of HPV vaccination and provide HPV-related health education for sexual and gender minorities.

Conceptualizing the Socio-Built Environment: An Expanded Theoretical Framework to Promote a Better Understanding of Risk for Nonmedical Opioid Overdose Outcomes in Urban and Non-Urban Settings.

Nonmedical opioid (NMO) use has been linked to significant increases in rates of NMO morbidity and mortality in non-urban areas. While there has been a great deal of empirical evidence suggesting that physical features of built environments represent strong predictors of drug use and mental health outcomes in urban settings, there is a dearth of research assessing the physical, built environment features of non-urban settings in order to predict risk for NMO overdose outcomes. Likewise, there is strong extant literature suggesting that social characteristics of environments also predict NMO overdoses and other NMO use outcomes, but limited research that considers the combined effects of both physical and social characteristics of environments on NMO outcomes. As a result, important gaps in the scientific literature currently limit our understanding of how both physical and social features of environments shape risk for NMO overdose in rural and suburban settings and therefore limit our ability to intervene effectively. In order to foster a more holistic understanding of environmental features predicting the emerging epidemic of NMO overdose, this article presents a novel, expanded theoretical framework that conceptualizes "socio-built environments" as comprised of (a) environmental characteristics that are applicable to both non-urban and urban settings and (b) not only traditional features of environments as conceptualized by the extant built environment framework, but also social features of environments. This novel framework can help improve our ability to identify settings at highest risk for high rates of NMO overdose, in order to improve resource allocation, targeting, and implementation for interventions such as opioid treatment services, mental health services, and care and harm reduction services for people who use drugs.

Presence of Content Appealing to Youth on Cannabis-Infused Edibles Packaging.

BACKGROUND: There is a lack of consistent regulation of cannabis edibles packaging to restrict youth-appealing content in the United States. OBJECTIVE: To describe content appealing to youth on U.S. cannabis-infused edibles packaging. METHODS: We analyzed 256 photos of cannabis-infused edibles packaging collected from U.S. adults from 25 states, District of Columbia, and Puerto Rico between May 2020 to August 2021. We coded the presence of product knockoffs, human and non-human creatures, images indicating flavor, text indicating flavor, and the number of colors. We compared these codes across states' legalization status (medical and non-medical cannabis, medical cannabis only, or limited cannabis legalization). RESULTS: Overall, 15% of packages resembled product knockoffs, 23% contained human/non-human creatures, 35% contained flavor images, 91% contained flavor text, and median number of colors was 5 (range from 1 to 10+). Packages purchased in states with medical and non-medical cannabis, medical cannabis only, or limited cannabis legalization differed significantly on product knockoffs (11%, 26%, 38%, p = 0.007), human/non-human creatures (19%, 33%, 63%, p = 0.002), flavor text (93%, 81%, 100%, p = 0.046), and number of colors (median of 5, 5, and 10, p = 0.022). CONCLUSIONS: Existing laws have not adequately limited content appealing to youth on U.S. cannabis-infused edibles packaging. Robust and consistent regulations in the U.S. are needed to ensure that the packaging of such products does not contain content that appeal to youth and lead to initiation or inadvertent ingestion.

Structural and community changes during COVID-19 and their effects on overdose precursors among rural people who use drugs: a mixed-methods analysis.

BACKGROUND: Drug overdose rates in the United States have been steadily increasing, particularly in rural areas. The COVID-19 pandemic and associated mitigation strategies may have increased overdose risk for people who use drugs by impacting social, community, and structural factors. METHODS: The study included a quantitative survey focused on COVID-19 administered to 50 people who use drugs and semi-structured qualitative interviews with 17 people who use drugs, 12 of whom also participated in the quantitative survey. Descriptive statistics were run for the quantitative data. Qualitative coding was line-by-line then grouped thematically. Quantitative and qualitative data were integrated during analysis. RESULTS: Findings demonstrate how COVID-19 disruptions at the structural and community level affected outcomes related to mental health and drug use at the individual level. Themes that emerged from the qualitative interviews were (1) lack of employment opportunities, (2) food and housing insecurity, (3) community stigma impacting health service use, (4) mental health strains, and (5) drug market disruptions. Structural and community changes increased anxiety, depression, and loneliness on the individual level, as well as changes in drug use patterns, all of which are likely to increase overdose risk. CONCLUSION: The COVID-19 pandemic, and mitigation strategies aimed at curbing infection, disrupted communities and lives of people who use drugs. These disruptions altered individual drug use and mental health outcomes, which could increase risk for overdose. We recommend addressing structural and community factors, including developing multi-level interventions, to combat overdose. Trial registration Clinicaltrails.gov: NCT04427202. Registered June 11, 2020: https://clinicaltrials.gov/ct2/show/NCT04427202?term=pho+mai&draw=2&rank=3.

Copycat and lookalike edible cannabis product packaging in the United States.

BACKGROUND: Recent media reports have highlighted copycat/lookalike cannabis edibles as a public health concern. No empirical papers have described this phenomenon. METHODS: From May 2020-August 2021, we collected photos of cannabis products via an online survey of cannabis users and through personal contacts. Copycat/lookalike products are defined as those that use the same or similar brand name, logo, and/or imagery as an existing commercial non-cannabis counterpart (CNCC). We assessed each package for similarities with its CNCC with respect to brand name, product name, font, color, flavors, and brand/promotional characters. We examined cannabis content indicators including: THC content per package and serving, cannabis leaf symbol, product warnings, cannabis terms, cannabis motifs, activation time, and guidance on edible use. RESULTS: We collected photos of 731 cannabis products; 267 (36%) were edibles of which 22 (8%) represented 13 unique copycat/lookalike products. Eight used exact brand/product names as existing CNCCs, and five used similar names. Packages copied or imitated a mean of 3.9 of six features and indicated cannabis content with a mean of 4.1 of eight features. Thirteen packages indicated a mean THC content of 459 mg/package. Four reported THC dose per serving, with a mean dose of 47.5 mg. CONCLUSIONS: Our content analysis highlights three key concerns. First, copycat/lookalike edibles subtly indicate cannabis content while using high fidelity replication or imitation of their CNCC. Second, THC content is high and there were multiple 10 mg THC doses in the equivalent of 1 serving of a CNCC. Third, these products may be attractive to children.

PrEP Care Continuum Engagement Among Persons Who Inject Drugs: Rural and Urban Differences in Stigma and Social Infrastructure.

Pre-exposure prophylaxis (PrEP) is a medication that prevents HIV acquisition, yet PrEP uptake has been low among people who inject drugs. Stigma has been identified as a fundamental driver of population health and may be a significant barrier to PrEP care engagement among PWID. However, there has been limited research on how stigma operates in rural and urban settings in relation to PrEP. Using in-depth semi-structured qualitative interviews (n = 57) we explore PrEP continuum engagement among people actively injecting drugs in rural and urban settings. Urban participants had more awareness and knowledge. Willingness to use PrEP was similar in both settings. However, no participant was currently using PrEP. Stigmas against drug use, HIV, and sexualities were identified as barriers to PrEP uptake, particularly in the rural setting. Syringe service programs in the urban setting were highlighted as a welcoming space where PWID could socialize and therefore mitigate stigma and foster information sharing.

Racial and ethnic disparities in "stop-and-frisk" experience among young sexual minority men in New York City.

Although racial/ethnic disparities in police contact are well documented, less is known about other dimensions of inequity in policing. Sexual minority groups may face disproportionate police contact. We used data from the P18 Cohort Study (Version 2), a study conducted to measure determinants of inequity in STI/HIV risk among young sexual minority men (YSMM) in New York City, to measure across-time trends, racial/ethnic disparities, and correlates of self-reported stop-and-frisk experience over the cohort follow-up (2014-2019). Over the study period, 43% reported stop-and-frisk with higher levels reported among Black (47%) and Hispanic/Latinx (45%) than White (38%) participants. Stop-and-frisk levels declined over follow-up for each racial/ethnic group. The per capita rates among P18 participants calculated based on self-reported stop-and-frisk were much higher than rates calculated based on New York City Police Department official counts. We stratified respondents' ZIP codes of residence into tertiles of per capita stop rates and observed pronounced disparities in Black versus White stop-and-frisk rates, particularly in neighborhoods with low or moderate levels of stop-and-frisk activity. YSMM facing the greatest economic vulnerability and mental disorder symptoms were most likely to report stop-and-frisk. Among White respondents levels of past year stop-and-frisk were markedly higher among those who reported past 30 day marijuana use (41%) versus those reporting no use (17%) while among Black and Hispanic/Latinx respondents stop-and-frisk levels were comparable among those reporting marijuana use (38%) versus those reporting no use (31%). These findings suggest inequity in policing is observed not only among racial/ethnic but also sexual minority groups and that racial/ethnic YSMM, who are at the intersection of multiple minority statuses, face disproportionate risk. Because the most socially vulnerable experience disproportionate stop-and-frisk risk, we need to reach YSMM with community resources to promote health and wellbeing as an alternative to targeting this group with stressful and stigmatizing police exposure.

How urban and rural built environments influence the health attitudes and behaviors of people who use drugs.

Research suggests that the built environment is associated with drug use. However, there is limited scholarship focusing on specific features of the built environment that influence drug use behaviors, experiences, and patterns and how risk factors for drug use are placed in distinctive urban and rural settings. Applying Neely and Samura's conceptual theory that describes space as contested, fluid and historical, interactional and relational, and defined by inequality and difference, we assessed data from semi-structured qualitative interviews conducted between 2019 and 2020 with consumers at syringe exchange programs (SEPs) in an urban location (New York City) and a rural location (southern Illinois). We aimed to contextualize how drug use manifests in each space. In total, 65 individuals, including 59 people who use drugs (PWUD) and six professionals who worked with PWUD, were interviewed. Findings illustrate that, in both the urban and rural setting, the built environment regulates the drug use milieu by mediating social reproduction, namely the degree of agency PWUD exert to acquire and use drugs where they desire. Processes of "stigma zoning," defined as socio-spatial policing of boundaries of behavior deemed undesirable or deviant, impacted PWUD's socio-geographic mobility, social conditions, and resource access, and modulated PWUD's broader capacity and self-efficacy. Similar patterns of drug use, according to social and economic inequities chiefly related to housing instability, were further observed in both settings.

The effectiveness of malaria camps as part of the Durgama Anchalare Malaria Nirakaran (DAMaN) program in Odisha, India: study protocol for a cluster-assigned quasi-experimental study.

The Indian state of Odisha has a longstanding battle with forest malaria. Many remote and rural villages have poor access to health care, a problem that is exacerbated during the rainy season when malaria transmission is at its peak. Approximately 62% of the rural population consists of tribal groups who are among the communities most negatively impacted by malaria. To address the persistently high rates of malaria in these remote regions, the Odisha State Malaria Control Program introduced 'malaria camps' in 2017 where teams of health workers visit villages to educate the population, enhance vector control methods, and perform village-wide screening and treatment. Malaria rates declined statewide, particularly in forested areas, following the introduction of the malaria camps, but the impact of the intervention is yet to be externally evaluated. This study protocol describes a cluster-assigned quasi-experimental stepped-wedge study with a pretest-posttest control group design that evaluates if malaria camps reduce the prevalence of malaria, compared to control villages which receive the usual malaria control interventions (e.g. IRS, ITNs), as detected by PCR.

Acceptability and Effectiveness of Hepatitis C Care at Syringe Service Programs for People Who Inject Drugs in New York City.

Introduction/Objectives: The incidence of hepatitis C (HCV) infection is rising among people who inject drugs (PWID). Even in the context of known HCV prevention and treatment strategies, some PWID remain unengaged in HCV care. This study aimed to identify and characterize experiences and perceptions of PWID regarding the acceptability and effectiveness of HCV testing and treatment at a local syringe service program (SSP). Methods: A total of 36 PWID participated in semi-structured interviews at an SSP in New York City. Interviews were audio-recorded, transcribed, and coded by three coders, following a constructivist grounded theory approach. Relevant themes were identified as they emerged from the data. Results: Interviews with PWID revealed three themes related to the impact of SSPs on HCV care: (1) non-stigmatizing SSP environments, (2) the role of SSPs in improving HCV knowledge, and (3) acceptability of SSPs as sites for HCV care among PWID. Discussion: This paper contributes to the ongoing understanding that SSPs provide a well-accepted source of HCV services for PWID. Participants believed that SSPs are accessible and effective sites for HCV care, and suggested that stigma among PWID continues to affect receipt of HCV care in traditional settings. Conclusions: Understanding attitudes and beliefs of PWID regarding the effectiveness of SSPs as sites for HCV care is crucial for the development of focused strategies to reduce HCV transmission, and to ultimately achieve HCV elimination. Given this, further research is warranted investigating how best to improve HCV care at harm reduction sites such as SSPs.

The Opioid/Overdose Crisis as a Dialectics of Pain, Despair, and One-Sided Struggle.

The opioid/overdose crisis in the United States and Canada has claimed hundreds of thousands of lives and has become a major field for research and interventions. It has embroiled pharmaceutical companies in lawsuits and possible bankruptcy filings. Effective interventions and policies toward this and future drug-related outbreaks may be improved by understanding the sociostructural roots of this outbreak. Much of the literature on roots of the opioid/overdose outbreak focuses on (1) the actions of pharmaceutical companies in inappropriately promoting the use of prescription opioids; (2) "deaths of despair" based on the deindustrialization of much of rural and urban Canada and the United States, and on the related marginalization and demoralization of those facing lifetimes of joblessness or precarious employment in poorly paid, often dangerous work; and (3) increase in occupationally-induced pain and injuries in the population. All three of these roots of the crisis-pharmaceutical misconduct and unethical marketing practices, despair based on deindustrialization and increased occupational pain-can be traced back, in part, to what has been called the "one-sided class war" that became prominent in the 1970s, became institutionalized as neo-liberalism in and since the 1980s, and may now be beginning to be challenged. We describe this one-sided class war, and how processes it sparked enabled pharmaceutical corporations in their misconduct, nurtured individualistic ideologies that fed into despair and drug use, weakened institutions that created social support in communities, and reduced barriers against injuries and other occupational pain at workplaces by reducing unionization, weakening surviving unions, and weakening the enforcement of rules about workplace safety and health. We then briefly discuss the implications of this analysis for programs and policies to mitigate or reverse the opioid/overdose outbreak.

"They look at us like junkies": influences of drug use stigma on the healthcare engagement of people who inject drugs in New York City.

BACKGROUND: People who inject drugs (PWID) are a medically and socially vulnerable population with a high incidence of overdose, mental illness, and infections like HIV and hepatitis C. Existing literature describes social and economic correlations to increased health risk, including stigma. Injection drug use stigma has been identified as a major contributor to healthcare disparities for PWID. However, data on this topic, particularly in terms of the interface between enacted, anticipated, and internalized stigma, is still limited. To fill this gap, we examined perspectives from PWID whose stigmatizing experiences impacted their views of the healthcare system and syringe service programs (SSPs) and influenced their decisions regarding future medical care. METHODS: Semi-structured interviews conducted with 32 self-identified PWID in New York City. Interviews were audio recorded and transcribed. Interview transcripts were coded using a grounded theory approach by three trained coders and key themes were identified as they emerged. RESULTS: A total of 25 participants (78.1%) reported at least one instance of stigma related to healthcare system engagement. Twenty-three participants (71.9%) reported some form of enacted stigma with healthcare, 19 participants (59.4%) described anticipated stigma with healthcare, and 20 participants (62.5%) reported positive experiences at SSPs. Participants attributed healthcare stigma to their drug injection use status and overwhelmingly felt distrustful of, and frustrated with, medical providers and other healthcare staff at hospitals and local clinics. PWID did not report internalized stigma, in part due to the availability of non-stigmatizing medical care at SSPs. CONCLUSIONS: Stigmatizing experiences of PWID in formal healthcare settings contributed to negative attitudes toward seeking healthcare in the future. Many participants describe SSPs as accessible sites to receive high-quality medical care, which may curb the manifestation of internalized stigma derived from negative experiences in the broader healthcare system. Our findings align with those reported in the literature and reveal the potentially important role of SSPs. With the goal of limiting stigmatizing interactions and their consequences on PWID health, we recommend that future research include explorations of mechanisms by which PWID make decisions in stigmatizing healthcare settings, as well as improving medical care availability at SSPs.

The role of access to integrated services at opioid agonist treatment sites in reaching 90-90-90 cascade in people who inject drugs in Ukraine: Country-level data.

INTRODUCTION: Opioid agonist treatment (OAT) is an effective means to prevent HIV transmission. Ukraine started integrating HIV services into OAT sites to improve people who inject drugs' (PWID) access to treatment. METHODS: Data from the national registry of OAT patients (n = 9,983) were analyzed. These data are collected from all 179 OAT sites countrywide. For the cascade, HIV-positive OAT patients (n = 4,084) were stratified into two categories: OAT alone (received OAT at one site and antiretroviral therapy (ART) at different location, n = 1,789) and integrated care (received OAT and ART at one location, n = 2,295) for comparison. RESULTS: Most HIV-positive OAT patients in Ukraine are male (85.6 %) and the mean age is 40.3 years old. The mean length of injecting before OAT is 17.2 years and the mean length on OAT is 4.2 years. All HIV-positive OAT clients are aware of their HIV status. The proportion of HIV-positive clients receiving ART was higher at integrated care sites compared to OAT alone sites (84.2 vs. 73.1 %, p- = 0.012); distribution of viral suppression among those receiving ART across the strata were 79.4 and 59.2 % for 'integrated care sites' vs. 'OAT only sites' respectively (p < 0.001). CONCLUSIONS: This analysis clearly demonstrates much better progress towards the 90-90-90 goals among those OAT patients who receive integrated care services (both OAT and ART) at one site at each stage of the HIV care cascade as compared to receiving OAT and ART at different sites. There is an urgent need to further expand the integration of OAT and HIV services in Ukraine.