Integrated care van delivery of evidence-based services for people who inject drugs: A cluster-randomized trial.

BACKGROUND AND AIMS: People who inject drugs (PWID) are at risk for adverse outcomes across multiple dimensions. While evidence-based interventions are available, services are often fragmented and difficult to access. We measured the effectiveness of an integrated care van (ICV) that offered services for PWID. DESIGN, SETTING AND PARTICIPANTS: This was a cluster-randomized trial, which took place in Baltimore, MD, USA. Prior to randomization, we used a research van to recruit PWID cohorts from 12 Baltimore neighborhoods (sites), currently served by the city's mobile needle exchange program. INTERVENTION AND COMPARATOR: We randomized sites to receive weekly visits from the ICV (n = 6) or to usual services (n = 6) for 14 months. The ICV offered case management; buprenorphine/naloxone; screening for HIV, hepatitis C virus and sexually transmitted infections; HIV pre-exposure prophylaxis; and wound care. MEASUREMENTS: The primary outcome was a composite harm mitigation score that captured access to evidence-based services, risk behaviors and adverse health events (range = 0-15, with higher numbers indicating worse status). We evaluated effectiveness by comparing changes in the composite score at 7 months versus baseline in the two study arms. FINDINGS: We enrolled 720 cohort participants across the study sites (60 per site) between June 2018 and August 2019: 38.3% women, 72.6% black and 85.1% urine drug test positive for fentanyl. Over a median of 10.4 months, the ICV provided services to 734 unique clients (who may or may not have been cohort participants) across the six intervention sites, including HIV/hepatitis C virus testing in 577 (78.6%) and buprenorphine/naloxone initiation in 540 (74%). However, only 52 (7.2%) of cohort participants received services on the ICV. The average composite score decreased at 7 months relative to baseline, with no significant difference in the change between ICV and usual services (difference in differences: -0.31; 95% confidence interval: -0.70, 0.08; P = 0.13). CONCLUSIONS: This cluster-randomized trial in Baltimore, MD, USA, found no evidence that weekly neighborhood visits from a mobile health van providing injection-drug-focused services improved access to services and outcomes among people who injected drugs in the neighborhood, relative to usual services. The van successfully served large numbers of clients but unexpectedly low use of the van by cohort participants limited the ability to detect meaningful differences.

Expectations of preventative benefits and risk behaviors in a randomized trial evaluating oral HIV preexposure prophylaxis candidates.

When participants enrolled in an HIV prevention trial hold a preventive misconception (PM) - expectations that experimental interventions will confer protection from HIV infection - they may engage in behaviors that increase their risk of acquiring HIV. This can raise ethical concerns about whether those enrolled in the trial understand the nature of participation and their safety. Consequently, we systematically evaluated the prevalence of PM and its association with risk behaviors in a trial examining three candidate regimens for oral HIV pre-exposure prophylaxis in which all participants received at least one antiretroviral agent. Overall, trial participants exhibited relatively high preventive expectations that may be associated with an increase in risk behaviors among men who have sex with men. In addition, we identified substantial site variability in PM that necessitates future research to uncover its source. This will allow appropriate measures to be taken to mitigate PM and help ensure that participants have an accurate understanding of the potential risks and benefits of trial participation throughout the course of a trial.

High PrEP uptake, adherence, persistence and effectiveness outcomes among young Thai men and transgender women who sell sex in Bangkok and Pattaya, Thailand: findings from the open-label combination HIV prevention effectiveness (COPE) study.

Background: Daily oral pre-exposure prophylaxis (PrEP) is effective in preventing HIV infection, but no study has evaluated combination prevention interventions with PrEP for transgender women (TGW) and men who have sex with men (MSM) who sell sex. Methods: The Combination Prevention Effectiveness (COPE) study was a community-based, non-randomized implementation study in Bangkok and Pattaya, Thailand. Participants were HIV-negative MSM and TGW aged 18-26 years who reported exchanging sex with men in the prior 12 months and who met 2014 U.S. Public Health Service PrEP eligibility criteria. The intervention included quarterly HIV testing, semiannual testing for sexually transmitted infections, provision of condoms with lubricant, and the opportunity to initiate or end daily oral PrEP use at any time during study participation. Participants taking PrEP received monthly adherence counseling and short message service reminders. The primary outcome was HIV incidence rate ratio (IRR) on PrEP vs. not on PrEP. Secondary outcomes were PrEP initiation, PrEP use at 12 months, and PrEP adherence. Findings: From October 2017 to August 2019, 846 participants were enrolled: 531 (62.8%) immediately initiated PrEP; 104 (12.3%) subsequently initiated PrEP, and 211 (24.9%) never initiated PrEP. Among those initiating PrEP within 30 days of enrollment; 85.9% were on PrEP at the 12-months. When taking PrEP, participants reported adherent PrEP use at 94.2% of quarterly assessments. Ten HIV seroconversions occurred without PrEP use (incidence rate [IR] = 3.42 per 100 person-years [PY]; 95% CI = 1.64-6.30), while zero cases occurred with PrEP use (IR = 0.0 per 100PY; 95% CI = 0.0-0.62), with IRR = 0.0 (95% CI = 0.0-0.22; p < 0.001). Interpretation: Young Thai MSM and TGW who exchange sex can have high PrEP uptake, persistence and adherence, and low HIV incidence when offered in supportive community-based settings. Funding: U.S. National Institute of Allergy and Infectious Diseases; Centers for Disease Control and Prevention.

The changing epidemiology of opioid overdose in Baltimore, Maryland, 2012-2017: insights from emergency medical services.

INTRODUCTION: An estimated 100,306 people died from an overdose from May 2020 to April 2021. Emergency Medical Services (EMS) are often the first responder to opioid overdose, and EMS encounter records can provide granular epidemiologic data on opioid overdose. This study describes the demographic, temporal, and geographic epidemiology of suspected opioid overdose in Baltimore City using data from Baltimore City Fire Department EMS encounters with the administration of the opioid antagonist naloxone. METHOD: The present analyses used patient encounter data from 2012 to 2017 from the Baltimore City Fire Department, the city's primary provider of EMS services. The analytic sample included patient encounters within the city that involved naloxone administration to patients 15 years of age or older (n = 20,592). Negative binomial regression was used to calculate the incidence rates based on demographic characteristics, year, and census tract. Choropleth maps were used to show the geographic distribution of overdose incidence across census tracts in 2013, 2015, and 2017. RESULTS: From 2012 to 2017, the annual number of EMS encounters with naloxone administrations approximately doubled every 2 years, and the temporal pattern of naloxone administration was similar to the pattern of fatal opioid-related overdoses. For most census tracts, incidence rates significantly increased over time. Population-based incidence of naloxone administration varied significantly by socio-demographic characteristics. Males, non-whites, and those 25-69 years of age had the highest incidence rates. CONCLUSION: The incidence of naloxone administration increased dramatically over the study period. Despite significant cross-sectional variation in incidence across demographically and geographically defined groups, there were significant proportional increases in incidence rates, consistent with fatal overdose rates over the period. This study demonstrated the value of EMS data for understanding the local epidemiology of opioid-related overdose. Key MessagesPatterns of EMS encounters with naloxone administration appear to be an excellent proxy for patterns of opioid-related overdoses based on the consistency of fatal overdose rates over time.EMS plays a central role in preventing fatal opioid-related overdoses through the administration of naloxone, provision of other emergency services, and transportation to medical facilities.EMS encounters with naloxone administration could also be used to evaluate the impact of overdose prevention interventions and public health services.

Exploring the impact of the COVID-19 pandemic on syringe services programs in rural Kentucky.

BACKGROUND: The coronavirus pandemic (COVID-19) exacerbated risks for adverse health consequences among people who inject drugs by reducing access to sterile injection equipment, HIV testing, and syringe services programs (SSPs). Several decades of research demonstrate the public health benefits of SSP implementation; however, existing evidence primarily reflects studies conducted in metropolitan areas and before the COVID-19 pandemic. OBJECTIVES: We aim to explore how the COVID-19 pandemic affected SSP operations in rural Kentucky counties. METHODS: In late 2020, we conducted eighteen in-depth, semi-structured interviews with persons (10 women, 8 men) involved in SSP implementation in rural Kentucky counties. The interview guide broadly explored the barriers and facilitators to SSP implementation in rural communities; participants were also asked to describe how COVID-19 affected SSP operations. RESULTS: Participants emphasized the need to continue providing SSP-related services throughout the pandemic. COVID-19 mitigation strategies (e.g., masking, social distancing, pre-packing sterile injection equipment) limited relationship building between staff and clients and, more broadly, the pandemic adversely affected overall program expansion, momentum building, and coalition building. However, participants offered multiple examples of innovative solutions to the myriad of obstacles the pandemic presented. CONCLUSION: The COVID-19 pandemic impacted SSP operations throughout rural Kentucky. Despite challenges, participants reported that providing SSP services remained paramount. Diverse adaptative strategies were employed to ensure continuation of essential SSP services, demonstrating the commitment and ingenuity of program staff. Given that SSPs are essential for preventing adverse injection drug use-associated health consequences, further resources should be invested in SSP operations to ensure service delivery is not negatively affected by co-occurring crises.

Transactional sex, HIV and health among young cisgender men and transgender women who have sex with men in Thailand.

PURPOSE: To examine how recent sex work is identified and the HIV risk factors and service needs among Thai cisgender men who have sex with men (MSM) and transgender women (TGW) who exchange sex. METHODS: MSM and TGW in Bangkok and Pattaya who exchanged sex in the last year (n = 890) were recruited through social media, outreach, and word-of-mouth. Recent sex exchange was based on the primary question, "In the last 30 days, have you sold or traded sex"; secondary questions (regarding income source and client encounters) were also investigated. RESULTS: Overall, 436 (48%) participants engaged in sex work in the last 30 days; among those, 270 (62%) reported exchanging sex by the primary question, and 160 (37%) based on secondary questions only. Recent sex exchange was associated with gonorrhea, syphilis, discussing PrEP with others, and using condoms, alcohol, methamphetamine, amyl nitrate, and Viagra. Exchanging sex based on secondary questions only was associated with being in a relationship, social media recruitment, less recent anal intercourse, and not discussing PrEP. CONCLUSIONS: Thai MSM and TGW who exchange sex need regular access to HIV/STI prevention, testing, and treatment services, and multiple approaches to assessing sex work will help identify and serve this diverse and dynamic population.

Diverse contexts and social factors among young cisgender men and transgender women who sell or trade sex in Bangkok and Pattaya, Thailand: formative research for a PrEP program implementation study.

HIV incidence is high and persistent among cisgender men who have sex with men (MSM) and transgender women (TGW) who have sex with men, particularly among those who sell or trade sex. In preparation for an open-label combination HIV pre-exposure prophylaxis (PrEP) program for these groups, we conducted formative research to explore the context of sex work/trade and factors that affect implementation of PrEP interventions. This study analyzed interviews with 20 young (aged 18-26 years) MSM and TGW who sell/trade sex and three sex work venue managers in Bangkok and Pattaya, Thailand. Participants described diverse contexts of sex work/trade, including in multiple informal and formal sex venues. Several participants reported mobility across provinces and out of the country, which led to intermittent sex work/trade. TGW sex workers reported challenges with access and cost of femininizing hormones and limited employment opportunities. Factors that could facilitate or challenge PrEP program implementation included HIV stigma, the role of venue management in sexual health practice, lack of PrEP knowledge, lower perceived HIV risk, and interest in personal health and wellbeing. Program implementers must consider myriad factors to successfully implement PrEP among young MSM and TGW engaged in sex work or trade in Thailand.

Applications of research evidence during processes to acquire approvals for syringe services program implementation in rural counties in Kentucky.

INTRODUCTION: Despite decades of empirical research in the US and internationally documenting the benefits of implementing syringe services programs (SSPs), their implementation may be controversial in many jurisdictions. Better understanding how research evidence is applied during SSP implementation processes may enable the public health workforce to advocate for program scale up. This study explores applications of research evidence during processes to acquire approvals for SSP implementation in rural counties in Kentucky. METHODS: In-depth interviews were conducted among eighteen stakeholders (e.g. health department directors, SSP operators) involved in SSP implementation in rural Kentucky counties. Stakeholders were asked to describe the contexts surrounding SSP implementation processes. Interviews were transcribed and analysed for applications of research evidence. Research evidence-related quotes were subsequently categorised based on the typologies for applications of research evidence developed by Weiss et al. (instrumental, conceptual, and symbolic) and a fourth category for instances when research evidence was not used. RESULTS: Instrumental applications of research evidence occurred at the intrapersonal and interpersonal levels to dispel concerns about SSPs and formed the basis for implementation support. SSP proponents used research evidence in a conceptual manner to address underlying attitudes and beliefs that were not evidence-based. Participants reported symbolic research evidence applications to justify pre-existing attitudes and beliefs about meeting the public health needs of people who inject drugs. Lastly, in some instances, research evidence was met with scepticism and an unwillingness to consider its merits. CONCLUSION: Applications of research evidence during SSP implementation approval processes in rural Kentucky counties were heterogeneous in nature. Better understanding the diversity of ways in which research evidence may be employed during SSP implementation processes may support efforts to improve the public health of people who inject drugs.Key messagesApplications of research evidence during SSP implementation approval processes in rural Kentucky counties were heterogeneous in nature.Instrumental applications of research evidence occurred at the intrapersonal and interpersonal levels to dispel concerns about SSPs and formed the basis for implementation support.SSP proponents used research evidence in a conceptual manner to address underlying attitudes and beliefs that were not evidence-based.

Food access among people who inject drugs in West Virginia.

BACKGROUND: The substance use epidemic in the United States continues to drive high levels of morbidity and mortality, particularly among people who inject drugs (PWID). Poor access to food often co-occurs with drug use and contributes to associated sequelae, such as risks for HIV and diabetes. The objective of this study was to examine factors associated with adequate food access among PWID in a rural Appalachian community. METHODS: Cross-sectional surveys were used to collect data among PWID aged 18 and older in Cabell County, West Virginia. Frequency of hunger and sociodemographic, structural and drug use characteristics were measured. Adequate food access was defined as reporting 'never' going to bed hungry at night in the past six months. Pearson's χ2 and t-tests and multivariable logistic regression were used to identify factors associated with food access. RESULTS: Only 71 individuals (17%) reported never going to bed hungry at night in the past six months. Adjusted odds of having adequate food access were higher among PWID who completed high school (aOR 2.94; P = 0.010) and usually used drugs alone (aOR 1.97; P = 0.025), and lower among PWID who were female (aOR 0.51; P = 0.037), experienced homelessness (aOR 0.23, P < 0.001), were recently arrested (aOR 0.50 P = 0.047), and engaged in receptive sharing of injection equipment (aOR 0.52, P = 0.035). CONCLUSIONS: We found extremely low food access in a population of PWID in Appalachia who are vulnerable to overdose and infectious disease transmission. Integrated interventions promoting food access are needed to improve the public health and wellbeing of people who inject drugs in Appalachia.

Alcohol outlets, drug paraphernalia sales, and neighborhood drug overdose.

BACKGROUND: Alcohol outlets have been associated with various forms of injury and may contribute to neighborhood disparities in drug overdose. Few studies have examined the associations between alcohol outlets and drug overdose. This study investigated whether alcohol outlets were associated with the neighborhood drug overdose rate and whether the sale of drug paraphernalia contributes to this association. METHODS: A cross-sectional ecological spatial analysis was conducted within census block groups in Baltimore City (n = 653). Outcomes were counts of EMS calls for any drug overdose in 2015 (n = 3,856). Exposures of interest were counts of alcohol outlets licensed for off-premise and on-premise consumption and the proportion of off-premise outlets selling drug paraphernalia (e.g., blunt wrappers, baggies, pipes). Negative binomial regression was used to assess the relationship between outlet count and overdose rate, and if paraphernalia sales altered this relationship, controlling for other neighborhood factors. Spatial autocorrelation was assessed and regression inference adjusted accordingly. RESULTS: Each additional off-premise alcohol outlet was associated with a 16.6% increase in the neighborhood overdose rate (IRR=1.17, 95%CI=(1.11, 1.23)), adjusted for other neighborhood variables. On-premise alcohol outlets were not significantly associated with overdose rate when adjusting for off-premise alcohol outlets (IRR=1.01, 95% CI=(0.97, 1.06)). The proportion of off-premise outlets that sold drug paraphernalia was negatively associated with overdose rate (IRR=0.55, 95% CI=(0.41, 0.74)) and did not alter the relationship between off-premise outlets and overdose. CONCLUSION: This study provides preliminary public health evidence for informing policy decisions about alcohol outlet licensing and zoning. Alcohol outlets could be potential community partners for harm reduction strategies such as health communication in identifying overdose symptoms or Good Samaritan Laws.

Syringe Coverage Among People Who Inject Drugs in West Virginia, USA.

Ensuring people who inject drugs (PWID) have ≥ 100% sterile syringe coverage (i.e., persons have access to a sterile syringe for all injections) is optimal for HIV prevention. Existing syringe coverage literature is informative, yet little work has examined syringe coverage among PWID in rural communities. Using data from a 2018 PWID population estimation study conducted in a rural county in West Virginia, we used logistic regression to identify correlates of adequate sterile syringe coverage (at least 100%). A minority (37%) of PWID reported having adequate syringe coverage. Factors inversely associated with adequate syringe coverage included having recently (past 6 months): engaged in transactional sex work, shared syringes, and injected fentanyl. Having exclusively acquired syringes from a syringe services program was associated with increased odds of adequate syringe coverage. Rural PWID may benefit from tailored interventions designed to increase sterile syringe access.

Engagement in drug treatment following nonfatal overdose among people who inject drugs in Appalachia.

BACKGROUND: Immediately after experiencing a non-fatal overdose, many people who inject drugs (PWID) engage in harm-minimizing behavior change, including engagement in drug treatment. To inform the implementation of tailored interventions designed to facilitate drug treatment engagement in rural communities, we sought to identify correlates of starting any form of drug treatment after their most recent overdose among PWID who reside in a rural county in West Virginia. METHODS: Data are from a PWID population estimation study in Cabell County, West Virginia. We used multivariable logistic regression to identify independent sociodemographic and substance use-related correlates of any form of drug treatment engagement after an overdose among 179 PWID who had overdosed in the past 6 months. RESULTS: One-third of our sample (33.0%) started any form of drug treatment in the 30 days following their most recent overdose. Factors associated with engaging in drug treatment included: recent buprenorphine or Suboxone injection (aOR: 2.39, 95% CI: 1.15, 4.96), someone calling 911 after their most recent overdose (aOR: 3.29, 95% CI: 1.63, 6.65), and older age (aOR per year of age: 0.95, 95% CI: 0.91, 0.99). CONCLUSIONS: Our results suggest that contact with emergency personnel after an overdose may represent an important opportunity to link PWID to drug treatment. The implementation of response teams trained in linking PWID to the services they require and helping persons navigate treatment systems maybe be a valuable intervention to reduce the harms of the opioid overdose crisis.

Prevalence and correlates of receptive syringe-sharing among people who inject drugs in rural Appalachia.

BACKGROUND AND AIMS: Syringe-sharing significantly increases the risk of HIV and viral hepatitis acquisition among people who inject drugs (PWID). Clearer understanding of the correlates of receptive syringe-sharing (RSS) is a critical step in preventing bloodborne infectious disease transmission among PWID in rural communities throughout the United States. This study aimed to measure the prevalence and correlates of RSS among PWID in a rural county in Appalachia. DESIGN: Observational, cross-sectional sample from a capture-recapture parent study. SETTING: Cabell County, West Virginia (WV), USA, June-July 2018. PARTICIPANTS: The sample was restricted to people who reported injecting drugs in the past 6 months (n = 420). A total of 180 participants (43%) reported recent (past 6 months) RSS. Participants reported high levels of homelessness (56.0%), food insecurity (64.8%) and unemployment (66.0%). MEASUREMENTS: The main outcome was recent re-use of syringes that participants knew someone else had used before them. Key explanatory variables of interest, selected from the risk environment framework, included: unemployment, arrest and receipt of sterile syringes from a syringe services program (SSP). Logistic regression was used to determine correlates of recent RSS. FINDINGS: PWID reporting recent RSS also reported higher prevalence of homelessness, food insecurity and unemployment than their non-RSS-engaging counterparts. In adjusted analyses, correlates of RSS included: engagement in transactional sex work [adjusted odds ratio (aOR) = 2.27, 95% confidence interval (CI) = 1.26-4.09], unemployment (aOR = 1.67, 95% CI = 1.03-1.72), number of drug types injected (aOR = 1.33, 95% CI = 1.15-1.53) and injection in a public location (aOR = 2.59, 95% CI = 1.64-4.08). Having accessed sterile syringes at an SSP was protective against RSS (aOR = 0.57, 95% CI = 0.35-0.92). CONCLUSION: The prevalence of receptive syringe-sharing among people who inject drugs in a rural US county appears to be high and comparable to urban-based populations. Receptive syringe-sharing among people who inject drugs in a rural setting appears to be associated with several structural and substance use factors, including unemployment and engaging in public injection drug use. Having recently acquired sterile syringes at a syringe services program appears to be protective against receptive syringe sharing.

Knowledge of Good Samaritan Laws and Beliefs About Arrests Among Persons Who Inject Drugs a Year After Policy Change in Baltimore, Maryland.

OBJECTIVES: Delivering and receiving prompt medical care during an overdose are imperative to ensure survival. Good Samaritan laws encourage people to call 911 during an overdose by providing immunity from selected drug arrests (eg, low-level possession). However, it is unclear whether persons who inject drugs (PWID) are aware of and understand these laws and their implications. We examined awareness among PWID of the 2015 Good Samaritan law in Maryland and their beliefs about whether they could be arrested for calling 911 or having an overdose. METHODS: We surveyed 298 PWID in Baltimore, Maryland. We estimated the proportion who knew what the Good Samaritan law addressed and who believed they could be arrested for calling 911 or overdosing. We used a multivariate model to assess the association between harm-reduction services and knowledge of the Good Samaritan law or beliefs about getting arrested for calling 911 or overdosing. RESULTS: Of PWID, 56 of 298 (18.8%) knew what the Good Samaritan law addressed, 43 of 267 (16.1%) believed they could be arrested for calling 911, and 32 of 272 (11.8%) believed they could be arrested for having an overdose. After adjusting for demographic characteristics, accessing the syringe services program was associated with accurate knowledge and the belief that PWID could be arrested for calling 911; however, training in overdose reversal was not associated. CONCLUSIONS: Most PWID were unaware of the Good Samaritan law; this lack of awareness is a barrier to preventing overdose deaths. Educating PWID about Good Samaritan laws is essential, and such education should include police to ensure that law enforcement is congruent with Good Samaritan laws and does not perpetuate mistrust between police and PWID.

Factors associated with chronic pain and non-medical opioid use among people who inject drugs.

INTRODUCTION: Despite rising morbidity and mortality from the opioid epidemic and other addictions, people who inject drugs (PWID) remain understudied regarding pain outcomes. Data among PWID regarding chronic pain and drug use, including non-medical use of opioids, is largely unknown. We examined the prevalence of chronic pain and drug use for pain in this population. METHODS: Standardized surveys captured self-report of demographics, chronic pain, and non-prescription drug use in 203 PWID in an urban syringe services program between April and November 2016. Chronic pain was defined as self-report of chronic pain diagnosis or persistent pains over the past 6 months. RESULTS: Overall, 47% (95% CI, 40%-54%) of PWID reported chronic pain, while 35% (95% CI, 29%-42%) reported non-prescription drug use of any type for pain. Among those with chronic pain, drug use to treat pain was commonly reported (76%; 95% CI, 66%-83%). Non-medical opioid use did not differ among PWID with or without chronic pain or drug use for pain. A multivariable logistic regression model showed chronic pain was more likely among non-Hispanic whites and those with arthritis, older age, and homelessness. CONCLUSIONS: Chronic pain serves as an important factor in the persistence of drug use in more than one-third of PWID in this sample. The high prevalence of chronic pain with drug use for pain suggests that proper pain management is likely to be an essential component of preventing or regressing injection drug use in PWID, with data needed on effective interventions for this population.

Patterns of polysubstance use and overdose among people who inject drugs in Baltimore, Maryland: A latent class analysis.

BACKGROUND: Opioid-related overdose rates continue to climb. However, little research has examined the reach of overdose education and naloxone trainings among people who inject drugs (PWID). Understanding gaps in coverage is essential to improving the public health response to the ongoing crisis. METHODS: We surveyed 298 PWID in Baltimore City, MD. We conducted a latent class analysis of drug use indicators and tested for differences by class in past month overdose, having received overdose training, and currently having naloxone. RESULTS: Three classes emerged: cocaine/heroin injection (40.2%), heroin only injection (32.2%), and multi-drug/multi-route use (27.6%). The prevalence of past month overdose differed marginally by class (p = 0.06), with the multi-drug/multi-route use class having the highest prevalence (22.5%) and the heroin only class having the lowest (4.6%). The prevalence of previous overdose training differed significantly by class (p = 0.02), with the heroin/cocaine class (76.5%) having more training than the other two classes. Training was least common amongst the multi-drug/multi-route class (60.3%), though not statistically different from the heroin only class (63.0%). Classes did not differ significantly in current naloxone possession, although the multi-drug/multi-route class exhibited the lowest prevalence of naloxone possession (37.2%). CONCLUSIONS: People who inject multiple substances are at high risk for overdose and are also the least likely to receive overdose trainings. The current service landscape does not adequately reach individuals with high levels of structural vulnerability and high levels of drug use and homelessness. Actively including this subgroup into harm reduction efforts are essential for preventing overdose fatalities.

PrEP awareness, eligibility, and interest among people who inject drugs in Baltimore, Maryland.

BACKGROUND: Limited research has examined pre-exposure prophylaxis (PrEP) interest among people who inject drugs (PWID). To date, few studies have examined the relationship between PrEP eligibility and PrEP interest among PWID. METHODS: Data were from an anonymous, cross-sectional survey of Baltimore Syringe Services Program (SSP) clients and non-client peers, restricted to HIV-uninfected participants (N = 265). Participants were classified as PrEP eligible/ineligible based on injection related criteria outlined in the CDC's PrEP guidelines. Participants were asked if they were previously aware of PrEP, would be interested in taking PrEP, and the ease of taking PrEP daily. Participants self-reported their sociodemographic characteristics, health diagnoses, and recent drug use, overdose, and drug treatment history. We estimated bivariate and multivariate logistic regression models to test for significant predictors of interest in PrEP. RESULTS: One-quarter of PWID had previously heard of PrEP and 63% of the sample was interested in taking PrEP. Only two respondents were currently taking PrEP. The majority (89%) thought taking PrEP every day would be easy. In the presence of other variables, PrEP interest was associated with PrEP eligibility (adjusted odds ratio [aOR] = 2.46; 95% Confidence Interval [CI]:1.34,4.50) and the number of medical diagnoses (aOR = 1.16; 95% CI:1.01,1.33) CONCLUSIONS: Most PWID were unaware of PrEP but interested in taking it. PWID who were eligible for PrEP are more likely to be interested in taking it. Having co-morbid conditions was an important correlate of PrEP interest. These results underscore the importance of providers across the healthcare sector engaging PWID in discussions about PrEP.

Cost and Threshold Analysis of the FinishIt Campaign to Prevent Youth Smoking in the United States.

In 2014, Truth Initiative launched the national FinishIt campaign to prevent smoking initiation among youth and young adults. The significant changes in the communications landscape requires further analysis to determine resource requirements for public education campaigns relative to their impact. This analysis estimates the cost of the FinishIt campaign based on data from expenditure records and uses published estimates of the lifetime treatment costs and quality-adjusted life years associated with smoking. The total cost of the FinishIt campaign for 2014⁻2016 was $162 million. Under assumptions associated with the pessimistic base-case (no medical care costs saved through prevention), 917 smoking careers would need to be averted for the campaign to be cost-effective. Assuming smoking leads to increased medical care costs, 7186 smoking careers would need to be averted for the campaign to be cost-saving. Given these thresholds (917 and 7186) and the estimate of the impact of the previous truth campaign, the investments in the Truth Initiative's FinishIt campaign are likely warranted for preventing smoking careers among youth and young adults.

Fentanyl-contaminated drugs and non-fatal overdose among people who inject drugs in Baltimore, MD.

BACKGROUND: The opioid crisis remains a major public health issue in the US and beyond. Despite rapid rises in fentanyl-related mortality nationally, little is known about the role of fentanyl in the occurrence of non-fatal overdose among people who use drugs. We examined the prevalence of non-fatal overdose and perceived fentanyl exposure among syringe services program (SSP) clients and modeled the correlates of non-fatal overdose. METHODS: Data were drawn from a cross-sectional survey of 203 SSP clients in Baltimore, MD recruited in 2016. Logistic regression models were used to identify the correlates of experiencing non-fatal overdose in the past 12 months. RESULTS: The majority (65%) was male, 52% were black, 41% were white, and 37% were homeless. Almost all (97%) used heroin, 64% injected heroin with cocaine (i.e., speedball), and many used other types of drugs. Half (53%) perceived fentanyl presence in their drugs either half, most or all of the time. Lifetime and past 12 month prevalence of non-fatal overdose were 58 and 31%, respectively. Independent correlates of non-fatal overdose in the past 12 months were perceiving fentanyl in drugs more than half the time (aOR = 2.79; 95% CI = 1.00-4.68), speedball injection (aOR = 2.80, 95% CI = 1.26-6.23), non-prescription buprenorphine use (aOR = 6.37; 95% CI = 2.86-14.17), and homelessness (aOR = 3.07; 95% CI = 1.28-7.39). CONCLUSIONS: These data demonstrate that SSP clients are at high-risk of overdose, some of which is likely attributable to fentanyl exposure. Addressing the rising fentanyl epidemic will require comprehensive and innovative strategies that attend to drug use patterns and structural factors such as homelessness.

Relationship Between Weekly Patterns of Caloric Intake and Reported Weight Loss Outcomes: Retrospective Cohort Study.

BACKGROUND: Although millions of overweight and obese adults use mobile phone apps for weight loss, little is known about the predictors of success. OBJECTIVE: The objective of this study was to understand the relationship between weight loss outcomes and weekly patterns of caloric intake among overweight and obese adults using a mobile phone app for weight loss. METHODS: We examined the relationship between weekly patterns of caloric intake and weight loss outcomes among adults who began using a weight loss app in January 2016 and continued consistent use for at least 5 months (N=7007). Unadjusted and adjusted linear regression analyses were used to evaluate the predictors of percentage of bodyweight lost for women and men separately, including age, body mass index category, weight loss plan, and difference in daily calories consumed on weekend days (Saturday and Sunday) versus Monday. RESULTS: In adjusted linear regression, percentage of bodyweight lost was significantly associated with age (for women), body mass index (for men), weight loss plan, and differences in daily caloric intake on Mondays versus weekend days. Compared with women consuming at least 500 calories more on weekend days than on Mondays, those who consumed 50 to 250 calories more on weekend days or those with balanced consumption (±50 calories) lost 1.64% more and 1.82% more bodyweight, respectively. Women consuming 250 to 500 calories or more than 500 calories more on Mondays than on weekend days lost 1.35% more and 3.58% more bodyweight, respectively. Compared with men consuming at least 500 calories more on weekend days than on Mondays, those consuming 250 to 500 calories or more than 500 calories more on Mondays than on weekend days lost 2.27% and 3.42% less bodyweight, respectively. CONCLUSIONS: Consistent caloric intake on weekend days and Mondays or consuming slightly fewer calories per day on Mondays versus weekend days was associated with more successful weight loss. TRIAL REGISTRATION: ClinicalTrials.gov NCT03136692; https://clinicaltrials.gov/ct2/show/NCT03136692 (Archived by WebCite at http://www.webcitation.org/6y9JvHya4).