Using an intersectionality lens to explore barriers and enablers to hepatitis C point-of-care testing: a qualitative study among people who inject drugs and service providers.

BACKGROUND: Hepatitis C virus (HCV) infection is a significant global health burden, particularly among people who inject drugs. Rapid point-of-care HCV testing has emerged as a promising approach to improve HCV detection and linkage to care in harm reduction organizations such as needle and syringe programs. The objective of this study was to use an intersectionality lens to explore the barriers and enablers to point-of-care HCV testing in a needle and syringe program. METHODS: A qualitative study was conducted using semi-structured interviews with clients (people who inject drugs) and service providers in a large community organization focused on the prevention of sexually transmitted and blood borne infections and harm reduction in Montreal, Canada. An intersectionality lens was used alongside the Theoretical Domains Framework to guide the formulation of research questions as well as data collection, analysis, and interpretation. RESULTS: We interviewed 27 participants (15 clients, 12 providers). For clients, four themes emerged: (1) understanding and perceptions of HCV testing, (2) the role of an accessible and inclusive environment, (3) the interplay of emotions and motivations in decision-making, and (4) the impact of intersectional stigma related to HCV, behaviors, and identities. For providers, five themes emerged: (1) knowledge, skills, and confidence for HCV testing, (2) professional roles and their intersection with identity and lived experience, (3) resources and integration of services, (4) social and emotional factors, and (5) behavioral regulation and incentives for HCV testing. Intersectional stigma amplified access, emotional and informational barriers to HCV care for clients. In contrast, identity and lived experience acted as powerful enablers for providers in the provision of HCV care. CONCLUSION: The application of an intersectionality lens provides a nuanced understanding of multilevel barriers and enablers to point-of-care HCV testing. Findings underscore the need for tailored strategies that address stigma, improve provider roles and communication, and foster an inclusive environment for equitable HCV care. Using an intersectionality lens in implementation research can offer valuable insights, guiding the design of equity-focused implementation strategies.

Examining the social and behavioral dynamics of substance use in a longitudinal network study in rural Appalachia.

BACKGROUND: Prior studies have shown that individuals and their peers often have similar substance use behaviors, but the mechanisms driving these similarities - particularly in rural settings, are not well understood. The primary objectives of this analysis are to (1) identify factors that contribute to relationship turnover and maintenance within a rural network of persons who use drugs (PWUD), (2) determine whether assimilation and/or homophily shape participants use of injection drugs, heroin, and stimulants (methamphetamine and cocaine), and (3) assess the extent that these mechanisms influence networks ties and/or behaviors and whether these effects vary across time. METHODS: Sociometric network data were collected from a cohort of PWUD in rural Eastern Kentucky at baseline (2008-2010) and at four follow-up visits conducted approximately semiannually. Stochastic actor-oriented models (SAOMS) were used to model network structure and participant behaviors as jointly dependent variables and to identify characteristics associated with the maintenance, dissolution, and formation of network ties and changes in drug use behaviors. RESULTS: Findings suggest (1) greater network stability over time for reciprocal and transitive relationships, (2) both homophily and assimilation played a greater role in shaping injection drug use (IDU) initiation and cessation than they did in shaping heroin and stimulant use, and (3) the importance of these mechanisms appeared consistent over time. CONCLUSION: Given the stability of particular network structures and evidence of both homophily and assimilation with respect to drug-use behaviors, interventions that leverage social networks could be used to motivate health-promoting behaviors.

Structural and social changes due to the COVID-19 pandemic and their impact on engagement in substance use disorder treatment services: a qualitative study among people with a recent history of injection drug use in Baltimore, Maryland.

BACKGROUND: Substance use disorder treatment and recovery support services are critical for achieving and maintaining recovery. There are limited data on how structural and social changes due to the COVID-19 pandemic impacted individual-level experiences with substance use disorder treatment-related services among community-based samples of people who inject drugs. METHODS: People with a recent history of injection drug use who were enrolled in the community-based AIDS Linked to the IntraVenous Experience study in Baltimore, Maryland participated in a one-time, semi-structured interview between July 2021 and February 2022 about their experiences living through the COVID-19 pandemic (n = 28). An iterative inductive coding process was used to identify themes describing how structural and social changes due to the COVID-19 pandemic affected participants' experiences with substance use disorder treatment-related services. RESULTS: The median age of participants was 54 years (range = 24-73); 10 (36%) participants were female, 16 (57%) were non-Hispanic Black, and 8 (29%) were living with HIV. We identified several structural and social changes due the pandemic that acted as barriers and facilitators to individual-level engagement in treatment with medications for opioid use disorder (MOUD) and recovery support services (e.g., support group meetings). New take-home methadone flexibility policies temporarily facilitated engagement in MOUD treatment, but other pre-existing rigid policies and practices (e.g., zero-tolerance) were counteracting barriers. Changes in the illicit drug market were both a facilitator and barrier to MOUD treatment. Decreased availability and pandemic-related adaptations to in-person services were a barrier to recovery support services. While telehealth expansion facilitated engagement in recovery support group meetings for some participants, other participants faced digital and technological barriers. These changes in service provision also led to diminished perceived quality of both virtual and in-person recovery support group meetings. However, a facilitator of recovery support was increased accessibility of individual service providers (e.g., counselors and Sponsors). CONCLUSIONS: Structural and social changes across several socioecological levels created new barriers and facilitators of individual-level engagement in substance use disorder treatment-related services. Multilevel interventions are needed to improve access to and engagement in high-quality substance use disorder treatment and recovery support services among people who inject drugs.

Stigma, and factors associated with experiencing stigma, while visiting health-care services among samples of people who use illegal drugs in Australia.

INTRODUCTION: People who inject drugs experience stigma across multiple settings, including when accessing health-care services, however, comparatively little is known about experiences of stigma towards other groups of people who use illegal drugs. This paper examines experience of, and factors associated with, stigma among two samples of people who use illegal drugs when visiting both specialist alcohol and other drug (AOD) and general health-care services. METHODS: Australians who regularly (i.e., ≥monthly) inject drugs (n = 879; illicit drug reporting system [IDRS]) or use ecstasy and/or other illegal stimulants (n = 700; ecstasy and related drugs reporting system [EDRS]) were surveyed between April and July 2022 about past 6-month experience of stigma in the above services. Multi-variable regression analyses were performed to determine the socio-demographic, drug use and health factors associated with stigma. RESULTS: Experiences of stigma in general health-care services were more common among IDRS (40%) than EDRS (24%; p < 0.001) participants, however, experiences were comparable in specialist AOD health-care settings (22% and 20%, respectively; p = 0.687). Gender identity and experiencing high psychological distress were associated with experiencing stigma across both samples. Past-year overdose was associated with experiencing stigma among the IDRS sample, while unstable housing and incomplete high school education were associated with experiencing stigma in the EDRS sample. DISCUSSION AND CONCLUSIONS: Experiences of stigma when accessing health-care services are relatively common across different populations of people who use illegal drugs. Our findings highlight the multiple and intersecting dimensions of stigma and provide further support for recent calls for a universal precautions approach to stigma in health care.

Disparities in HIV Testing and PrEP Awareness for Black Women who Inject Drugs in San Francisco, California.

HIV disproportionately affects Black/African Americans (AA), while PrEP is under-utilized by Black/AA, women, and people who inject drugs (PWID). In San Francisco, California's National HIV Behavioral Surveillance among PWID in 2022, Black/AA women were the least likely to be tested for HIV among all groups by sex and race/ethnicity and the least likely to be aware of PrEP among women. Yet, Black/AA women were no less likely to see a healthcare provider in the last year. Data suggest that providers' failure to discuss and address HIV risk with Black/AA female PWID is a major barrier to accessing effective care and prevention. El VIH afecta de manera desproporcionada a Black/afroamericanos (AA), mientras que la PrEP está infrautilizada por los Black/AA, las mujeres y las personas que se inyectan drogas (PWID). En la National HIV Behavioral Surveillance de PWID de San Francisco, California en 2022, las mujeres Black/AA eran las que menos probabilidades tenían de someterse a la prueba del VIH entre todos los grupos por sexo y raza/etnia y las que menos probabilidades tenían de conocer la PrEP entre las mujeres. Sin embargo, las mujeres Black/AA no tenían menos probabilidades de acudir a un profesional sanitario en el último año. Los datos sugieren que el hecho de que los proveedores no hablen ni aborden el riesgo de VIH con las PWID de raza Black/AA es un obstáculo importante para acceder a una atención y prevención eficaces.

Were Needles Everywhere?: Differing Views on Syringe Waste and Disposal Associated With Needs-Based Syringe Services Programs Among Community Partners and Persons Who Inject Drugs.

BACKGROUND: Community concerns surrounding syringe waste are a common barrier to syringe services program (SSP) implementation. In Kanawha County, West Virginia, community opposition to SSPs resulted in the closure of needs-based SSPs prior to and during an HIV outbreak among persons who inject drugs (PWID). This qualitative analysis examines views of PWID and community partners on syringe waste and disposal associated with needs-based SSPs. METHODS: Qualitative interviews with 26 PWID and 45 community partners (medical and social service providers, law enforcement personnel, policymakers, and religious leaders) were conducted. Interviews were recorded, transcribed, and coded. Code summaries described participants' views on syringe waste and disposal and needs-based SSPs. RESULTS: Community partners and PWID who favored needs-based SSPs reported that needs-based SSPs had not affected or reduced syringe waste. Conversely, community partners who favored one-to-one exchange models and/or barcoded syringes described needs-based SSPs increasing syringe waste. Community partners often cited pervasive community beliefs that SSPs increased syringe waste, risk of needlesticks, drug use, and crime. Community partners were unsure how to address syringe waste concerns and emphasized that contradictory views on syringe waste posed barriers to discussing and implementing SSPs. CONCLUSIONS: Participants' views on whether syringe waste was associated with needs-based SSPs often aligned with their support or opposition for needs-based SSPs. These differing views resulted in challenges finding common ground to discuss SSP operations amid an HIV outbreak among PWID. SSPs might consider addressing syringe waste concerns by expanding syringe disposal efforts and implementing community engagement and stigma reduction activities.

Decreasing Stigma Toward People Who Inject Drugs: Harm Reduction Training for First-Year Medical Students.

PROBLEM: Stigma in health care toward people who inject drugs (PWID) is a well-described, significant barrier to quality care, resulting in poor health outcomes. Harm reduction offers a person-centered counter-framework for minimizing harm for people who use drugs. Despite the evidence in support of harm reduction, medical students typically receive minimal training on harm reduction and the care of PWID. APPROACH: To fill this gap, medical students at the University of California, Los Angeles organized around the principles of harm reduction to improve the medical school curriculum related to PWID. Students screened lectures for stigmatizing language and collaborated with faculty to improve lecture materials. They partnered with a community organizer and hosted a mandatory 1-hour lecture and 30-minute discussion introducing the principles of harm reduction within an overdose prevention, recognition, and response training for first-year medical students during medical school orientation in August 2022. An anonymous online pretest and posttest survey, assessing student attitudes toward PWID, was used to evaluate the effects of the training. OUTCOMES: A total of 156 students completed the pretest survey, and 107 students completed the pretest and posttest survey (68.5% response rate). The overall posttest mean stigma score was 1.8 (standard deviation [SD] = 0.5) and was significantly lower than the pretest mean of 2.1 (SD = 0.7; P < .0001), indicating a reduction in stigma among medical student attitudes after the course. There was statistically significant improvement in attitudes for 7 of 13 component measures. NEXT STEPS: This analysis demonstrated that the mandatory class has the capacity to improve medical student attitudes toward PWID. The authors plan to further evaluate the program's effectiveness through measuring and reporting outcomes for future student cohorts. The authors are working with curriculum directors to further incorporate harm reduction principles into other lectures and problem-based learning exercises.

Differences in stigma reduction related to injection drug use between people expressing conservative, moderate and progressive values following an online intervention.

INTRODUCTION: Contact interventions have shown short-term effectiveness in reducing stigmatising attitudes and behaviours of the public towards marginalised population groups, including people who inject drugs. We theorised that the effectiveness of an intervention differs according to peoples' underlying social values and undertook a study to test this. METHODS: We recruited participants from the Australian public by social media and measured their attitudes, desire to maintain personal distance, and support for structural stigma towards people who inject drugs before and after a brief online video intervention (n = 314). We divided participants into tertile groups according to their responses to a conservatism scale and compared group differences in post-intervention stigma scores (n = 242-244), controlling for pre-intervention scores and demographic variables. RESULTS: Adjusting for baseline levels, the post-intervention scores in all measures showed significant improvement but scores of the moderate group were consistently most improved. Stigmatising attitudes in the moderate group were significantly reduced when compared with the conservative and progressive groups. However, reductions in desire for personal distance and support for structural stigma did not significantly differ by conservatism group. DISCUSSION AND CONCLUSIONS: A brief online contact intervention showed immediate effectiveness in reducing stigma towards people who inject drugs. As people with moderate values were found to be more amenable to changing their perspectives, audience social values may need consideration when designing and evaluating stigma interventions. More research is needed to understand how to influence people with more conservative values, and how to increase public support for policies and practices that reduce stigma.

Experiences of stigma and subsequent reduced access to health care among women who inject drugs.

INTRODUCTION: Research into stigma and injecting drug use has typically involved predominantly male participants, with limited research about the unique experience of women who inject drugs. METHODS: This study used survey methods to assess reduced access to health care due to stigma among a sample of women who inject drugs. Women (n = 232) completed a survey as part of a broader national study of people who inject drugs. RESULTS: Only 46 (19.9%) women reported that they had not experienced any injecting drug use-related stigma in the past year and most commonly noted 'sometimes' experiencing injecting-related stigma (36.8%) with more than 75% of women reporting that health workers had treated them negatively because of their injecting drug use. Most women undertook strategies to prevent experiencing stigma, such as not disclosing drug use to a health worker (81.3%), not attending follow-up appointments (76.7%) and delaying accessing health care (76.8%). Women with lower levels of personal wellbeing, who had experienced poorer treatment by health workers, had engaged in greater past month injecting, were employed and identified as lesbian, gay, bisexual, transgender or queer (LGBTQ) reported more reduced access to health care. DISCUSSION AND CONCLUSIONS: Stigma has concerning health care implications for women who inject drugs and this research highlights the importance of understanding the impact of stigma in impeding health care access. Public health interventions should focus on addressing the systemic factors that reduce health care access for women who inject and take account of the impact of stigma in diminishing the quality and accessibility of health care for this group.

Understanding healthcare engagement for people who inject drugs.

People who inject drugs (PWID) are at an increased risk of multimorbid mental health and chronic diseases, which are frequently underdiagnosed and under-treated due to systemic barriers and ongoing substance use. Healthcare engagement is essential to address these conditions and prevent excess morbidity and mortality. The goal of this study was to understand how PWID engage in care for their chronic health conditions and substance use treatment given the known historic and pervasive barriers. We conducted 24 semistructured qualitative interviews informed by the Behavioral Model for Vulnerable Populations between July-September 2019. Participants were sampled across a range of comorbidities, including co-occurring mental health disorders. Thematic analysis was conducted to explore experiences of healthcare engagement for multimorbid chronic diseases, mental health, and treatment for substance use disorder. Mean age for participants was 58 years; 63% reported male sex and 83% reported Black race. Interviews yielded themes regarding healthcare access and wraparound services, positive patient-provider relationships, service integration for substance use treatment and mental health, healthcare needs alignment, medication of opioid use disorder stigma, and acceptance of healthcare. Taken together, participants described how these themes enabled healthcare engagement. Engagement in care is crucial to support health and recovery. Clinical implications include the importance of strengthening patient-provider relationships, encouraging integration of medical and mental health services, and counseling on substance use treatment options in a non- stigmatizing manner. Additionally, policy to reimburse wrap-around support for substance use recovery can improve care engagement and outcomes related to chronic diseases, mental health, and substance use among PWID. No Patient or Public Contribution: While we acknowledge and thank ALIVE participants for their time for data collection and sharing their perspectives, no ALIVE participants, other people who use drugs, and service users were involved in data collection, analysis or interpretation of data, or in preparation of the manuscript.

Evaluation of a person-centred, nurse-led model of care delivering hepatitis C testing and treatment in priority settings: a mixed-methods evaluation of the Tasmanian Eliminate Hepatitis C Australia Outreach Project, 2020-2022.

INTRODUCTION: Australia has experienced sustained reductions in hepatitis C testing and treatment and may miss its 2030 elimination targets. Addressing gaps in community-based hepatitis C prescribing in priority settings that did not have, or did not prioritise, hepatitis C testing and treatment care pathways is critical. METHODS: The Tasmanian Eliminate Hepatitis C Australia Outreach Project delivered a nurse-led outreach model of care servicing hepatitis C priority populations in the community through the Tasmanian Statewide Sexual Health Service, supported by the Eliminating Hepatitis C Australia partnership. Settings included alcohol and other drug services, needle and syringe programs and mental health services. The project provided clients with clinical care across the hepatitis C cascade of care, including testing, treatment, and post-treatment support and hepatitis C education for staff. RESULTS: Between July 2020 and July 2022, a total of 43 sites were visited by one Clinical Nurse Consultant. There was a total of 695 interactions with clients across 219 days of service delivery by the Clinical Nurse Consultant. A total of 383 clients were tested for hepatitis C (antibody, RNA, or both). A total of 75 clients were diagnosed with hepatitis C RNA, of which 95% (71/75) commenced treatment, 83% (62/75) completed treatment and 52% (39/75) received a negative hepatitis C RNA test at least 12 weeks after treatment completion. CONCLUSIONS: Providing outreach hepatitis C services in community-based services was effective in engaging people living with and at-risk of hepatitis C, in education, testing, and care. Nurse-led, person-centred care was critical to the success of the project. Our evaluation underscores the importance of employing a partnership approach when delivering hepatitis C models of care in community settings, and incorporating workforce education and capacity-building activities when working with non-specialist healthcare professionals.

A qualitative study of professionals' perspectives on the ethics of medically-delivered safer injection education for people who inject drugs.

BACKGROUND: In this qualitative analysis we aimed to explore addiction physicians' perspectives on safer injection education for people who inject drugs, especially: (1) on possible means of introducing safer injection education in the medical environment, (2) on the compatibility of safer injection education with each physician's core values and goals, and (3) on possible reasons for the ethical dilemma in safer injection education. METHODS: We conducted semi-structured interviews with eleven physicians practicing addiction medicine in France in clinical and harm reduction settings. RESULTS: All participants were in favor of educational interventions for people who inject drugs. Nonetheless, these interventions varied from simple advice to injection supervision and they were seen as less acceptable when they concerned the practical and material aspects of injection. Some participants found that physicians practicing in clinical settings, where patients consult mostly to stop their drug use, should not practice safer injection education. On the contrary, other participants claimed that safer injection education was essential in all settings and was not a choice but rather a duty for addiction physicians. The ethical dilemma of such intervention when delivered by medical staff was viewed as a complex phenomenon, related to the representations of intravenous drug use and to societal expectations from physicians. CONCLUSION: Physicians' views on safer injection education for people who inject drugs reveal an emotionally charged subject related to the structural organization of addiction management in France. Such education is marked by an arduous history of harm reduction policies in France. IRB REGISTRATION: #00011928.

Design, implementation and preliminary results of a type-2 hybrid cluster-randomized trial of integrating screening and treatment for major depressive disorder into specialty clinics providing opioid agonist therapies in Ukraine.

INTRODUCTION: Ukraine has a high prevalence of co-occurring disorders (COD), defined as having both substance use (SUD) and psychiatric disorders. Major depressive disorder (MDD) is the most prevalent psychiatric disorder among people with SUD. People with COD experience poor health outcomes, and international agencies propose integrated COD care. In Ukraine, treatment for SUD is delivered in specialized substance use clinics, without providing any other medical services for comorbidities, including MDD. Here we present the protocol, along the with the preliminary results of the MEDIUM project, including observations over the first 6 months. METHODS: A cluster-randomized type-2 hybrid trial was conducted to integrate MDD treatment into specialty clinics providing opioid agonist therapies (OAT) in Ukraine. Twelve clinics in four regions underwent randomization to control (N = 1) vs experimental arms (N = 2) in each region. Clinicians at experimental sites received tele-education through modified project ECHO using a facilitated screening, evaluation, and treatment algorithm of depression, with or without financial incentives. Service-, patient- and provider-level data were collected for the analysis every 6 months for 24 months. PRELIMINARY RESULTS: For service delivery outcomes, 4421 patients enrolled on OAT across all sites were assessed for MDD for screening (76.7%), evaluation with diagnosis (43.5%) and treatment (30.7%) for MDD; 13.8% continued treatment at least for 6 months. For patient-level outcomes, 1345 patients and 54 providers participated in serial surveys every six months. CONCLUSION: This study will be the first to explore integrated COD care in Ukraine and generate evidence on effective service integration and delivery strategies for people with COD receiving treatment at substance use clinics with broader implications for Eastern Europe and Central Asia region.

The impacts of COVID-19 on structural inequities faced by people living with HIV who inject drugs: A qualitative study in St. Petersburg, Russia.

BACKGROUND: People who inject drugs (PWID) living with HIV may be disproportionately impacted by pandemic restrictions. This study qualitatively explored the impacts of the SARS-CoV-2 pandemic on PWID with HIV in St. Petersburg, Russia. METHODS: In March and April 2021, we conducted remote, semi-structured interviews with PWID with HIV, health care providers, and harm reductionists. RESULTS: We interviewed 25 PWID with HIV (aged 28-56 years, 46% female) and 11 providers. The pandemic exacerbated economic and psychological challenges experienced by PWID with HIV. Simultaneously, barriers to HIV care access, ART prescription refill and dispensing and police violence, which hindered the health and safety of PWID with HIV, were themselves hindered from normal operations by the pandemic, significantly reducing these burdens. CONCLUSION: Pandemic responses should account for the unique vulnerabilities of PWID with HIV to avoid worsening the structural violence they already experience. Wherever the pandemic decreased structural barriers, such as institutional, administrative, and bureaucratic challenges and state violence enacted by police and other elements of the criminal justice system, such changes should be protected.

Preliminary Efficacy of a Theory-Informed Intervention to Increase COVID-19 Testing Uptake Among People Who Inject Drugs in San Diego County: Findings From a Pilot Randomized Controlled Trial.

BACKGROUND: People who inject drugs (PWID) have low rates of COVID-19 testing yet are vulnerable to severe disease. In partnership with a mobile syringe service program (SSP) in San Diego County, CA, we developed the evidence-, community-, and Social Cognitive Theory-informed "LinkUP" intervention (tailored education, motivational interviewing, problem-solving, and planning) to increase COVID-19 testing uptake among PWID. PURPOSE: To assess preliminary efficacy of LinkUP in increasing PWID COVID-19 testing in a pilot randomized controlled trial (RCT). METHODS: We referred participants (PWID, ≥18 years old, San Diego County residents who had not recently undergone voluntary COVID-19 testing) to mobile SSP sites that had been randomized (by week) to offer the active LinkUP intervention or didactic attention-control conditions delivered by trained peer counselors. Following either condition, counselors offered on-site rapid COVID-19 antigen testing. Analyses estimated preliminary intervention efficacy and explored potential moderation. RESULTS: Among 150 participants, median age was 40.5 years, 33.3% identified as Hispanic/Latinx, 64.7% were male, 73.3% were experiencing homelessness, and 44.7% had prior mandatory COVID-19 testing. The LinkUP intervention was significantly associated with higher COVID-19 testing uptake (p < .0001). Homelessness moderated intervention effects; LinkUP increased COVID-19 testing uptake more among participants experiencing homelessness (adjusted risk ratio [aRR]: 1.80; 95% CI: 1.56-2.09; p < .0001) than those not experiencing homelessness (aRR: 1.20; 95% CI: 1.01-1.43; p = .04). CONCLUSIONS: Findings from this pilot RCT support the preliminary efficacy of the "LinkUP" intervention to increase COVID-19 testing among PWID and underscore the importance of academic-community partnerships and prevention service delivery through SSPs and other community-based organizations serving vulnerable populations.

People who inject drugs (PWID) are vulnerable to severe COVID-19 disease yet have low rates of COVID-19 testing. We partnered with a syringe service program (SSP) in San Diego County, CA, to develop "LinkUP," an evidence- and community-informed intervention. Specifically, LinkUP used tailored education, motivational interviewing, and problem-solving and planning strategies to increase COVID-19 testing uptake among PWID. This study was a pilot randomized controlled trial (RCT) designed to assess the preliminary efficacy of LinkUP in increasing PWID COVID-19 testing. We referred participants (PWID, ≥18 years old, San Diego residents without recent voluntary COVID-19 testing) to mobile SSP sites that had been randomized (by week). Trained peer counselors then offered LinkUP or an educational control condition lasting the same length (~30 minutes). After either condition, counselors offered on-site rapid COVID-19 antigen testing. Among 150 participants, our analyses found that the LinkUP intervention was associated with higher COVID-19 testing uptake, especially for participants experiencing homelessness. In summary, our findings from this pilot RCT support the preliminary efficacy of the "LinkUP" intervention in increasing COVID-19 testing among PWID. This study also underscores the importance of academic-community partnerships and prevention service delivery through SSPs and other community-based organizations serving vulnerable populations.

Practising care in a pandemic: Accounting for everyday life during COVID-19 among people who inject drugs.

From the outset of the COVID-19 pandemic, fears have been raised worldwide regarding the unique challenges facing socially marginalised people such as those who inject drugs. This article draws on in-depth interviews conducted during the first year of the pandemic with people who inject drugs living in urban and regional Australia. Perhaps the most surprising finding to emerge was the number of participants who reported minimal disruption to their everyday lives, even improved wellbeing in some instances. Attempting to make sense of this unanticipated finding, our analysis draws on the concept of 'care', not as a moral disposition or normative code but as something emergent, contingent and realised in practice. Working with Foucault's ethics and recent feminist insights on the politics of care from the field of Science and Technology Studies, we explore how care was enacted in the everyday lives of our participants. We examine how participants' daily routines became objects of care and changed practice in response to the pandemic; how their ongoing engagement with harm reduction services afforded not only clinical support but vital forms of social and affective connection; and how for some, care was realised through an ethos and practice of constrained sociality and solitude.

Evaluating the Mediating Role of Recall of Intervention Knowledge in the Relationship Between a Peer-Driven Intervention and HIV Risk Behaviors Among People Who Inject Drugs.

Peer-driven interventions can be effective in reducing HIV injection risk behaviors among people who inject drugs (PWID). We employed a causal mediation framework to examine the mediating role of recall of intervention knowledge in the relationship between a peer-driven intervention and subsequent self-reported HIV injection-related risk behavior among PWID in the HIV Prevention Trials Network (HPTN) 037 study. For each intervention network, the index participant received training at baseline to become a peer educator, while non-index participants and all participants in the control networks received only HIV testing and counseling; recall of intervention knowledge was measured at the 6-month visit for each participant, and each participant was followed to ascertain HIV injection-related risk behaviors at the 12-month visit. We used inverse probability weighting to fit marginal structural models to estimate the total effect (TE) and controlled direct effect (CDE) of the intervention on the outcome. The proportion eliminated (PE) by intervening to remove mediation by the recall of intervention knowledge was computed. There were 385 participants (47% in intervention networks) included in the analysis. The TE and CDE risk ratios for the intervention were 0.47 [95% confidence interval (CI): 0.28, 0.78] and 0.73 (95% CI: 0.26, 2.06) and the PE was 49%. Compared to participants in the control networks, the peer-driven intervention reduced the risk of HIV injection-related risk behavior by 53%. The mediating role of recall of intervention knowledge accounted for less than 50% of the total effect of the intervention, suggesting that other potential causal pathways between the intervention and the outcome, such as motivation and skill, self-efficacy, social norms and behavior modeling, should be considered in future studies.

A qualitative analysis of rural syringe service program fidelity in Appalachian Kentucky: Staff and participant perspectives.

PURPOSE: As drug-related epidemics have expanded from cities to rural areas, syringe service programs (SSPs) and other harm reduction programs have been slow to follow. The recent implementation of SSPs in rural areas demands attention to program fidelity based on core components of SSP success. METHODS: Semistructured interviews conducted with clients and staff at 5 SSPs in 5 counties within 2 Central Appalachian health districts. Interviews covered fidelity of SSP implementation to 6 core components: (1) meet needs for harm reduction supplies; (2) education and counseling for sexual, injection, and overdose risks; (3) cooperation between SSPs and local law enforcement; (4) provide other health and social services; (5) ensure low threshold access to services; and (6) promote dignity, the impact of poor fidelity on vulnerability to drug-related harms, and the risk environment's influence on program fidelity. We applied thematic methods to analyze the data. FINDINGS: Rural SSPs were mostly faithful to the 6 core components. Deviations from core components can be attributed to certain characteristics of the local rural risk environment outlined in the risk environment model, including geographic remoteness, lack of resources and underdeveloped infrastructure, and stigma against people who inject drugs (PWID) CONCLUSIONS: As drug-related epidemics continue to expand outside cities, scaling up SSPs to serve rural PWID is essential. Future research should explore whether the risk environment features identified also influence SSP fidelity in other rural areas and develop and test strategies to strengthen core components in these vulnerable areas.

Correlates of Intersectional HIV and Substance Use Stigma Affecting People with HIV and Substance Use in St. Petersburg, Russia.

People with HIV (PWH) who inject drugs often experience coexisting HIV- and substance use-related stigma manifestations. We assessed correlates of HIV stigma (Berger HIV stigma scale), substance use stigma (Substance Abuse Self-stigma scale) and intersectional HIV and substance use stigma in a cohort of PWH with a lifetime history of drug use in St. Petersburg, Russia. Intersectional stigma was defined as having a score greater than the median for both forms of stigma. Of the 208 participants, 56 (27%) had intersectional stigma. Depressive symptoms and alcohol dependence were significantly associated with a higher HIV and substance stigma score, but not with intersectional stigma. Individual and community interventions to reduce the impact of HIV stigma and substance use stigma affecting PWH who inject drugs should consider assessing and addressing mental health and unhealthy substance use. Further work with longitudinal data is needed to understand mechanisms leading to intersectional stigma.

RESUMEN: Las personas infectadas por el VIH que se inyectan drogas a menudo experimentan manifestaciones de estigma relacionadas con el uso de sustancias y el propio VIH. En este estudio evaluamos los correlatos de estigma asociado al VIH (escala de estigma asociado al VIH de Berger), el estigma asociado al uso de sustancias ("Substance Abuse Self-stigma Scale") y el estigma interseccional del VIH y el uso de sustancias en una cohorte de personas infectadas por el VIH con antecedente de uso de drogas en San Petersburgo, Rusia. El estigma interseccional se definió como una puntuación superior a la mediana para ambas formas de estigma. De los 208 participantes, 56 (27%) tenían estigma interseccional. Los síntomas depresivos y la dependencia del alcohol se asociaron significativamente con una puntuación más alta de estigma relacionado con el VIH y las sustancias, pero no con el estigma interseccional. Las intervenciones individuales y comunitarias para reducir el impacto del estigma asociado al VIH y al uso de sustancias que afectan a las personas con VIH que se inyectan drogas deben tener en cuenta la salud mental y el uso nocivo de sustancias. Se necesitan estudios con datos longitudinales para comprender mejor los mecanismos que conducen al estigma interseccional.