Syringe services programs (SSPs) offer critical, evidence-based services for people who use drugs (PWUD), including infectious disease and overdose prevention. SSPs operate from harm reduction and health equity frameworks, prioritizing non-coercive care and client autonomy; these values foster engagement among a community often stigmatized or discriminated against in traditional healthcare settings. As SSPs increasingly expand their clinical service offerings, they may encounter tensions among their core values, internal or funder-driven pressures for service expansion, and partnerships with external healthcare systems. Accordingly, we undertook a qualitative study to understand how SSP staff uphold core values and practice recipient-centeredness, as defined by the Consolidated Framework for Implementation Research (CFIR), when engaging PWUD in health services within harm reduction settings. From May 2023 to February 2024, we conducted qualitative interviews with 41 representatives of 27 SSPs serving diverse U.S. jurisdictions. Guided by the CFIR, trained interviewers used semi-structured interview guides to explore SSPs’ health services delivery models. From interviews, recipient-centeredness emerged as a central theme, leading us to employ thematic and narrative analysis to further explore how SSPs defined and operationalized this construct in their programs’ health-related services. SSP staff consistently emphasized the centrality of core values guiding their services, particularly recipient-centeredness. SSPs operationalized recipient-centeredness through three primary facets: accessibility, consistency, and non-coerciveness. These facets informed direct service delivery and referral processes, enabling programs to build trust and meet clients’ complex needs. To uphold these facets, SSPs implemented low-barrier service access, mobile outreach, client-centered referrals, and predictable service schedules despite dynamic and sometimes unsupportive contexts. This study offers a specific operationalization of recipient-centeredness for the unique and understudied setting of SSPs, identifying accessibility, consistency, and non-coerciveness as key facets of this organizational culture. Understanding these facets yields actionable guidance for supporting SSPs in implementing values-driven public health and prevention programming. These findings may also be relevant for other harm reduction and low-barrier care settings seeking to preserve trust, dignity, autonomy, and effectiveness while delivering evidence-based services. NCT06025435

Background:For over a decade, drug overdose has been the leading cause of injury and accidental death in the United States. Most fatal overdoses involve opioids and occur during solitary drug use events when no one is available to initiate lifesaving responses (eg, naloxone). While there is a growing interest in devices providing early overdose detection and automated responses, little research has engaged end users in a device design process. Objective:This study aimed to describe user experience, perceived harms and benefits, and the acceptability of a shoulder-mounted wearable sensor among people who inject drugs who wore a device prototype for 7 days and to explore real-time responses that could be incorporated into a next-generation sensor. Methods:Individuals aged ≥18 years reporting past week injection drug use were recruited from a walk-in substance use disorder clinic in Camden, New Jersey. Participants completed a brief survey assessing sociodemographics and recent drug use and were assigned a sensor prototype that they were asked to wear near-continuously for 7 days. At endline, they completed semistructured interviews exploring acceptability, usability, and form and function preferences for next-generation devices with integrated automated response options. Structured field notes and transcripts were analyzed to identify key themes and design considerations. Results:Participants (n=23) had a median age of 41 years. Most were primarily non-Hispanic White (65%) males (61%), experiencing homelessness (57%) who reported daily injection drug use (74%) within 3 months and receipt of opioid use disorder medication within a month (74%). A total of 16 people completed an exit interview. They found the concept of a shoulder-mounted overdose detection device acceptable and unanimously endorsed the need for long-lasting discreet devices. They emphasized the importance of having multiple response options that wearers could tailor to their individual circumstances and preferences, noting some might prefer an automatic call to emergency services, while others might prefer to alert a peer. Participants expressed a preference for solutions that alert first responders over automated biomedical solutions, such as naloxone injection, because of concerns about device error (eg, false positives) leading to precipitated withdrawal. Conclusions:After wearing a shoulder-mounted prototype, this small group of participants found the idea acceptable and provided feedback to improve usability and design. Data suggest that a variety of devices with differing functions, sizes, and capacities will be needed to meet user needs and increase the likelihood of adoption once devices come to market.

With changing drug supplies and associated drug consumption behaviors, HIV transmission has increased among people who inject drugs in the United States. HIV testing and referrals to effective prevention and treatment services are critical for individual and population health, yet multilevel barriers limit access to HIV testing for this population, even within syringe services programs (SSPs). In this organizational-level interrupted time series randomized controlled trial, we will assess the effectiveness and cost-effectiveness of an implementation strategy, the Systems Analysis and Improvement Approach (SAIA), in optimizing HIV testing and referrals to appropriate clinical services among U.S. SSPs. From 01/12/2023 to 01/07/2025, we will recruit a diverse sample of 32 SSPs nationally that directly provide HIV testing to participants. SSPs will be randomized to the active implementation arm (i.e., SAIA-SSP-HIV) or an implementation-as-usual arm (n = 16 organizations per arm). SAIA-SSP-HIV is a flexible, data-driven implementation strategy designed to help optimize SSPs' delivery of HIV testing and referrals to appropriate clinical services for HIV prevention (e.g., pre-exposure prophylaxis) and treatment. In the active implementation arm, trained SAIA specialists will guide SSPs through three cyclical steps over 12 months: (1) process mapping to identify organization-specific needs, (2) cascade analysis and prioritization of areas for improvement, and (3) testing solutions through continuous quality improvement. In both arms, we will collect outcome data over 21 months (3-month lead-in period, 12-month implementation period, 6-month sustainment period). We will assess the initial and sustained effectiveness of SAIA and calculate its cost and cost-effectiveness. This trial presents a novel opportunity to test the effectiveness of an organization-level implementation strategy for optimizing the delivery of HIV screening and referrals in community settings that are frequented by an at-risk population. If successful, SAIA-SSP-HIV could be adapted for other infectious or chronic disease care cascades within SSPs. Trial registration: ClinicalTrials.gov: NCT06025435.

Long-acting injectable PrEP was approved for use in the US in 2021 but roll out has been slow, with few studies exploring uptake among cisgender women who inject drugs (WWID). We purposively recruited 25 WWID within 30-days of receiving a PrEP prescription from a low-barrier clinic co-located with a syringe services program to complete semi-structured interviews about PrEP product choice. We used an intersectional lens to compare decision-making between women choosing injectable PrEP versus oral PrEP and continued enrolling new participants until we reached thematic saturation (12/2022 to 2/2024). Participants represent a diverse sample of WWID (12 women of color) with median age 43 years. Daily injection drug use (72%) and ≥ 1 sex partner (64%) were common. Salient themes from interviews include: (1) PrEP provides women with a valued safety net and initiation is a form of self-preservation. (2) Co-located care, small incentives, and provider respect for WWID's medical autonomy helped participants navigate a multi-visit PrEP intake process. (3) Longer lasting HIV protection with less frequent dosing is preferrable to a shorter acting daily oral medication. When selecting a product, WWID evaluated its attributes against their medical history and personal circumstances like homelessness (64%). Most chose CAB-LA (72%) because it provides longer lasting protection which was a highly valued product attribute. Together, our findings underscore the critical importance of offering multiple PrEP options when implementing HIV prevention strategies that are patient-centered and responsive to the unique needs of WWID.

Background: Amidst population-level transitions from injecting to smoking unregulated drugs, US. syringe services programs (SSPs) are increasingly distributing safer smoking equipment. Methods: We conducted qualitative interviews with representatives of 27 geographically diverse U.S. SSPs from May 2023-March 2024. Guided by the Consolidated Framework for Implementation Research, we explored programs' experiences distributing safer smoking equipment, including staff perceptions on challenges to implementation and sustainment. Thematic analysis identified key findings. Results: We interviewed 41 SSP representatives, including leadership (63 %), frontline (22 %), and clinical and clinical support staff (15 %). Two critical incidents-fentanyl adulteration of unregulated drug supplies and the COVID-19 pandemic-drove the adoption of this intervention. Interviewees perceived that safer smoking equipment facilitated client engagement, expanded SSPs' reach into previously underserved communities, and promoted individual health by reducing the adverse consequences of injecting drugs. Barriers to implementation and sustainment included program staff and leadership concerns about limited evidence on the public health benefits of safer smoking equipment, stigma and negative local attitudes, funding restrictions, and cost (particularly for glass pipes). Strategies to support implementation included incrementally piloting safer smoking equipment, partnering with diverse funders, and adapting services to navigate resource constraints. Nevertheless, limited funding and legal support hindered broader adoption, reach and sustainability. Conclusions: Implementation of safer smoking equipment represents a critical evolution in harm reduction programming that may engage underserved communities in the range of evidence-based prevention services offered by SSPs. Flexible funding and supportive implementation climates are needed to support SSPs in providing this impactful service.

We conducted semi-structured interviews with 20 members who engaged in community-based effort to reverse overdoses using a smartphone-based app in an Eastern United States (U.S.) city. Drawing from feminist ethics of care, we identify how the caring practices of community members extend from administering a medical intervention to building trust and support between the care receivers and caregivers in the case of opioid overdose response. Contrary to the predominant patient-centered care paradigm, we emphasize community-centered care, which acknowledges the resistance of individuals and attends to reallocating caring responsibility and building relationships within the community. Our results highlight how trust intersects with social ecologies of care in the highly stigmatized context of opioid overdose and that trustful and less hierarchical relationships are critical sources of care for groups experiencing marginalization. We discuss applying harm reduction principles in designing health technologies for substance use disorders. We also discuss research and design opportunities for community-centered design for marginalized individuals and community caregivers.

For over a decade, drug overdose has been the leading cause of injury and accidental death in the United States. Most fatal overdoses involve opioids and occur during solitary drug use events when no one is available to initiate lifesaving responses (e.g., rescue breathing or naloxone).​ There is a growing interest in overdose detection technologies that detect and enable rapid, automated responses. However, little user experience research has been conducted to inform device design.​ This qualitative study explores user experience and key features driving device acceptability among people who inject drugs who wore a shoulder-mounted sensor for one week. We recruited individuals ≥18 years reporting past week injection drug use from a walk-in substance use disorder clinic. Participants were assigned a prototype sensor to wear on their upper arm for one week. At baseline, they completed a brief survey assessing socio-demographic and behavioral information. At exit, they completed semi-structured interviews that explored experiences and preferences for next-generation sensors. Structured field notes and transcripts were analyzed to identify perceived benefits and harms, and key design considerations important to improve the acceptability of the sensor prototype. Participants (n=23) were predominantly middle-aged (median age 41 years), non-Hispanic White (65%), and male (61%). The majority engaged in polysubstance use (57%) and reported an average of 5 daily injection events over the past three months. Of the participants, 70% returned an intact prototype and completed an exit interview. Overall, participants found wearable overdose detection and response devices acceptable, with perceived benefits outweighing potential harms. They unanimously supported the need for small, discreet devices that wouldn’t be noticeable to others. However, most participants emphasized that no single device could fully address end users’ needs, suggesting the importance of offering multiple, customizable response options. Concerns about false positives were also raised, as they could hinder adoption once devices are available on the market. Interviews with a small group of potential users show that wearable overdose technologies are generally well-received, especially when they are tailored to users’ preferences for design, functionality, and accuracy. Continuously refining the design with feedback from end users is key to creating a device that truly meets their needs and enhances their overall experience.

Contingency management (CM) is an effective intervention that provides financial incentives as positive reinforcement for reducing opioid or stimulant use. However, it has not been tested in populations of women who inject drugs (WWID) engaging in polysubstance use. We aimed to compare the feasibility of two CM protocols designed to encourage illicit stimulant and opioid abstinence among WWID participating in an ongoing HIV prevention trial. Participants completed a 3-month CM period during which they submitted thrice weekly urine toxicology screenings (UTOX). In the ‘abstinence from stimulants and opioids’ protocol, participants received a 5 USD incentive when metabolites of stimulants and opioids were not detected in urine. In the ‘partial-abstinence protocol’, they received a5 USD incentive when metabolites of stimulants or opioids were not detected, thus doubling the potential incentive obtained each visit. Women also received scaling bonuses after three consecutive negative UTOX (5-15 USD). We used descriptive statistics to summarize the total number of (1) UTOXs completed and (2) bonuses distributed. Rates of engagement per person per month were calculated (i.e., total number of completed UTOX/3 months*24 participants). Rates of engagement were compared by CM protocol period. Participants were primarily White women (67

The recent rise in HIV incidence among people who inject drugs in the United States highlights an urgent need to improve HIV testing, treatment linkage, and pre-exposure prophylaxis access in this group. Syringe services programs (SSPs) play a critical role by offering or linking clients to these services, yet little is known about how such care is delivered. Informed by the Consolidated Framework for Implementation Research, we conducted qualitative interviews with 41 representatives from 27 SSPs across the United States to characterize the current service delivery landscape, identify barriers to care, and explore modifiable implementation determinants. Rapid qualitative analysis revealed four primary HIV service delivery models: "one-stop shop" offering integrated, on-site HIV testing and follow-up care provided by the SSP; "test and refer" with integrated, on-site testing services followed by referrals to external partners for follow-up care; "co-located services" with SSPs relying on external partner organizations to provide HIV testing (and additional services) on-site; and "hand-off" involving referrals to off-site, external partners for HIV testing and follow-up care. SSPs faced varied implementation challenges, including staffing, funding, and space constraints; competing priorities; availability and accessibility of local partnerships; as well as SSP culture, which values participant autonomy (recipient-centeredness). These contextual factors influenced the feasibility and acceptability of HIV services and why SSPs adopted a particular service delivery model. To strengthen HIV prevention and care in SSPs, tailored implementation strategies are needed that account for programs' unique constraints and capacities.

Fifty-five of 62 women who inject drugs (WWID) selected long-acting cabotegravir (CAB-LA) over oral PrEP, and 51/55 received a first injection. More recent injection drug use and number of sexual partners were associated with selecting CAB-LA (P < .05). Findings provide preliminary evidence of a strong preference for longer-acting products among WWID.

BACKGROUND:Naloxone is critical for reversing opioid-related overdoses. However, there is a dearth of research examining how naloxone possession and carriage are impacted by time-varying individual and social determinants, and if this differed during the height of the COVID-related mitigation measures (e.g., shutdowns). METHODS:We utilized weekly ecological momentary assessments (EMA) to measure factors associated with naloxone possession and carriage among 40 people who use illicit opioids in New York City, for 24 months. Descriptive statistics were used to explore the frequency of weeks with consistent naloxone possession and carriage. Mixed effects binary and multivariable logistic regression was used to test for the impact of time-varying EMA- and baseline-level factors on each outcome. RESULTS:Approximately 70% of weekly EMAs were associated with consistent naloxone possession or carriage. In multivariable models, compared to during the height of the COVID-related shutdowns (March 12, 2020-May 19, 2021), the time before was associated with lower odds of consistent possession (Odds Ratio (OR) = 0.05, 95% Confidence Interval (CI) = 0.01-0.15) and consistent carriage (OR = 0.06, CI = 0.01-0.25). Additionally, being female (OR = 11.15, CI = 2.85-43.42), being White versus being Black or Hispanic/Latinx (OR = 8.05, CI = 1.96-33.06), and lifetime overdose (OR = 1.96, CI = 1.16-19.80) were associated with higher odds of consistent possession. Recent opioid injection (OR = 3.66, CI = 1.34-9.94), being female (OR = 7.91, CI = 3.91-8.23), and being White (OR = 5.77, CI = 1.35-24.55) were associated with higher odds of consistent carriage. Not wanting to be perceived as a drug user was reported in nearly one third (29.0%; 190/656) of EMAs where inconsistent possession was reported. CONCLUSIONS:Our findings paint a relatively positive picture of possession and carriage during COVID-related shutdowns, particularly among white and female participants, and highlight the importance of capturing time-varying factors to understand naloxone-related behavior. To curb growing disparities, outreach to equip Black and Hispanic/Latinx people with naloxone is needed as well as interventions to reduce stigma as a barrier to naloxone engagement.

Introduction Opioid overdose and blood-borne virus transmission are key health risks for people who inject drugs. Existing study methods that record data on injecting drug risks mostly rely on retrospective self-reporting that, while valid, are limited to being broad and subject to recall bias. The In-The-Moment-Expanded (ITM-Ex) study will evaluate the feasibility and acceptability of multiple novel data collection methods to capture in situ drug injecting data.Methods and analysis ITM-Ex will purposively recruit 50 participants from an existing longitudinal cohort (SuperMIX study) of people who inject drugs in Melbourne, Australia. Over a 4-week study period, participants will be asked to complete baseline/endline spirometry, continuously wear a heart rate monitoring device, complete short-form ecological momentary assessment (EMA) questionnaires for every injecting episode during the study period and return previously used needles/syringes for drug residue testing. These multiple data sources will be combined to conduct a comprehensive analysis of the physiological and risk characteristics of an estimated 800 individual injecting drug use episodes (if participants inject four times weekly). Finally, post-participation qualitative interviews will explore the acceptability of the data collection methods.Ethics and dissemination Ethics approval for ITM-Ex was obtained from Alfred Hospital Ethics Committee (project number 368/22). Results will be disseminated via national and international scientific and public health conferences and peer-reviewed journal publications.Results from ITM-Ex may demonstrate vastly more complete and accurate methods of capturing data on injecting drug use risk and support future development and evaluation of devices to monitor and intervene during drug overdose. Further, ITM-Ex may demonstrate innovative methodologies to support myriad future public health research studies.

ABSTRACTWe informed women who inject drugs about different pre-exposure prophylaxis (PrEP) formulations; they then ranked their preferences. Daily oral PrEP was most preferred, followed by injectable PrEP and vaginal rings/gels, especially among women of color. Multiple PrEP options should be discussed with women who inject drugs to increase uptake.

BACKGROUND:Smartphone-based emergency response apps are increasingly being used to identify and dispatch volunteer first responders (VFRs) to medical emergencies to provide faster first aid, which is associated with better prognoses. Volunteers' availability and willingness to respond are uncertain, leading in recent studies to response rates of 17% to 47%. Dispatch algorithms that select volunteers based on their estimated time of arrival (ETA) without considering the likelihood of response may be suboptimal due to a large percentage of alerts wasted on VFRs with shorter ETA but a low likelihood of response, resulting in delays until a volunteer who will actually respond can be dispatched.OBJECTIVE:This study aims to improve the decision-making process of human emergency medical services dispatchers and autonomous dispatch algorithms by presenting a novel approach for predicting whether a VFR will respond to or ignore a given alert.METHODS:We developed and compared 4 analytical models to predict VFRs' response behaviors based on emergency event characteristics, volunteers' demographic data and previous experience, and condition-specific parameters. We tested these 4 models using 4 different algorithms applied on actual demographic and response data from a 12-month study of 112 VFRs who received 993 alerts to respond to 188 opioid overdose emergencies. Model 4 used an additional dynamically updated synthetic dichotomous variable, frequent responder, which reflects the responder's previous behavior.RESULTS:The highest accuracy (260/329, 79.1%) of prediction that a VFR will ignore an alert was achieved by 2 models that used events data, VFRs' demographic data, and their previous response experience, with slightly better overall accuracy (248/329, 75.4%) for model 4, which used the frequent responder indicator. Another model that used events data and VFRs' previous experience but did not use demographic data provided a high-accuracy prediction (277/329, 84.2%) of ignored alerts but a low-accuracy prediction (153/329, 46.5%) of responded alerts. The accuracy of the model that used events data only was unacceptably low. The J48 decision tree algorithm provided the best accuracy.CONCLUSIONS:VFR dispatch has evolved in the last decades, thanks to technological advances and a better understanding of VFR management. The dispatch of substitute responders is a common approach in VFR systems. Predicting the response behavior of candidate responders in advance of dispatch can allow any VFR system to choose the best possible response candidates based not only on ETA but also on the probability of actual response. The integration of the probability to respond into the dispatch algorithm constitutes a new generation of individual dispatch, making this one of the first studies to harness the power of predictive analytics for VFR dispatch. Our findings can help VFR network administrators in their continual efforts to improve the response times of their networks and to save lives.

Abstract Background Despite increased availability of take-home naloxone, many people who use opioids do so in unprotected contexts, with no other person who might administer naloxone present, increasing the likelihood that an overdose will result in death. Thus, there is a social nature to being “protected” from overdose mortality, which highlights the importance of identifying background factors that promote access to protective social networks among people who use opioids. Methods We used respondent-driven sampling to recruit adults residing in New York City who reported recent (past 3-day) nonmedical opioid use (n = 575). Participants completed a baseline assessment that included past 30-day measures of substance use, overdose experiences, and number of “protected” opioid use events, defined as involving naloxone and the presence of another person who could administer it, as well as measures of network characteristics and social support. We used modified Poisson regression with robust variance to estimate unadjusted and adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs). Results 66% of participants had ever been trained to administer naloxone, 18% had used it in the past three months, and 32% had experienced a recent overdose (past 30 days). During recent opioid use events, 64% reported never having naloxone and a person to administer present. This was more common among those: aged ≥ 50 years (PR: 1.18 (CI 1.03, 1.34); who identified as non-Hispanic Black (PR: 1.27 (CI 1.05, 1.53); experienced higher levels of stigma consciousness (PR: 1.13 (CI 1.00, 1.28); and with small social networks (< 5 persons) (APR: 1.14 (CI 0.98, 1.31). Having a recent overdose experience was associated with severe opioid use disorder (PR: 2.45 (CI 1.49, 4.04), suicidality (PR: 1.72 (CI 1.19, 2.49), depression (PR: 1.54 (CI 1.20, 1.98) and positive urinalysis result for benzodiazepines (PR: 1.56 (CI 1.23, 1.96), but not with network size. Conclusions Results show considerable gaps in naloxone protection among people who use opioids, with more vulnerable and historically disadvantaged subpopulations less likely to be protected. Larger social networks of people who use opioids may be an important resource to curtail overdose mortality, but more effort is needed to harness the protective aspects of social networks.