Background: Online communities such as Reddit can reveal critical information needs (CINs) among people who discuss opioid use for chronic or acute pain under conditions of stigma and uncertainty. Methods: We used a mixed-method design to analyze 3428 unique Reddit posts from 1 January to 31 December 2022. Sentence-BERT embeddings and K-means clustering identified eight dominant themes, followed by qualitative analysis of a random subsample of 400 posts. Results: The most prevalent theme was seeking alternatives to opioids for pain relief (28.00%), followed by medications for chronic pain (19.84%) and kratom use experiences (14.64%). Qualitative findings showed recurrent concerns about addiction, stigma in clinical encounters, withdrawal, treatment access, and peer-to-peer discussion of kratom, tianeptine, cannabis, and other substitute substances. Conclusions: The study suggests an unmet need for accessible, nonstigmatizing, and clinically grounded information on pain management, tapering, and lower-risk alternatives to opioid use. These results have implications for addiction prevention, harm reduction, and patient-facing communication strategies for clinical practice and community health.

In February 2026, two travel-associated cases of measles were reported to the Wisconsin Department of Health Services (WDHS). Public health investigations for each case included wastewater (sewage) surveillance for wild-type measles, which was first implemented by the WDHS Wastewater Monitoring Program in June 2025. The virus from one case, caused by measles genotype D8, was detected by a wastewater surveillance assay before the case was identified by local health authorities, leading to public health notifications and action. Measles virus from the second case, caused by measles genotype B3, was not detected by the assay. Additional analysis of the measles wastewater assay, which is among the most widely used assays in the United States, revealed that the assay was not able to detect an internationally circulating variant of the measles B3 genotype. Two alternative assays confirmed that measles virus was present and detectable in the wastewater. The assay developers designed and released a modified assay that incorporated an additional probe that could detect the B3 variant. These cases demonstrate the potential benefit of wastewater surveillance in detecting wild-type measles virus from a single case, while also highlighting the importance of regularly monitoring wastewater assays with respect to available genomic data. These activities should be supported by up-to-date libraries of publicly available whole-genome sequencing data.

Marburg Virus Disease (MVD) outbreaks have mortality rates up to 90% and disproportionately affect healthcare workers (HCWs). Although no treatments are approved, remdesivir, an antiviral drug that inhibits RNA-dependent RNA polymerase, was shown to protect against MVD in animal models. This study aims to evaluate the safety, clinical, and laboratory outcomes among HCWs who received a 3-day course of remdesivir following suspected MVD exposure during the 2024 outbreak in Rwanda.Table 1Characteristics of HCWs exposed to MVD during the 2024 Rwanda outbreakTable 2Description of MVD exposure and clinical outcomes and NPS antibody results Between September 27 and October 30, 2024, intravenous remdesivir (200 mg on Day 1, 100 mg on Days 2-3) was offered as post-exposure prophylaxis (PEP) to HCW who had worked at least one shift in MVD-affected units.Liver function tests (LFTs) and symptom assessments were performed pre- and post-remdesivir infusion. In March 2025, eligible HCWs were surveyed about post-treatment symptoms and provided blood samples for Marburg virus-specific antibody testing.CT values and incubation periods from MVD-positive individuals without PEP (Rwanda Biomedical Center) were compared to MVD-positive PEP participants in this study. Analyses used STATA v28.Table 3.Remdesivir Possible side effects, MVD severity and antibody testing among participants who received remdesivir only (N=194)Graph 1.Box plot of CT values and incubation Period among Remdesivir use status By July 14, 2025, 380 HCWs were enrolled: 194 (51%) received PEP and 186 (49%) declined. Participant characteristics are shown in Table 1. Overall, 261 (68.7%) reported MVD testing; 20 (5.3%) were hospitalized with MVD-like symptoms, and 11 (3.2%) tested positive. MVD exposure risks are presented in Table 2.15 HCWs (4%) developed MVD-specific antibodies. Table 3 summarizes self-reported complications and MVD severity. A significant difference in incubation period was observed between PEP recipients (median: 11 vs. 8 days; P = 0.0014).Seroprevalence was higher in the PEP group (5.6%) than in the non-PEP group (2.2%). CT values were similar (median: 26.29 vs. 25.38; P = 0.41), with less variation in the PEP group (Graph 1). LFTs showed no notable changes pre- and post-remdesivir. Remdesivir appears safe as post-exposure prophylaxis (PEP) for HCWs during MVD outbreaks.findings suggest that remdesivir may lead to a clinically and statistically significant extension of the incubation period, as well as a modest reduction in viral load at the time of diagnosis. However, controlled clinical trials are needed to confirm its preventive efficacy. All Authors: No reported disclosures

OBJECTIVES:More than 3.7 million individuals are currently under community correctional supervision (eg, probation, parole) in the United States, and approximately 46% of them use illicit substances. Although high rates of substance use and the need for high-quality treatment for this population have been acknowledged, additional research is needed to characterize treatment needs among this population, especially those residing in rural or underserved communities. METHODS:Data were drawn from the Rural Opioid Initiative, a study focused on substance use in rural communities across 10 states in the United States. Our analyses examined past 6-month substance use disorder (SUD) treatment receipt among 978 participants under community supervision in the past 6 months. RESULTS:More than 55 percent had engaged in some type of treatment for substance use in the past 6 months; among those, nearly half (46%) had enrolled in inpatient or residential treatment. The odds of receiving treatment were greater among women than men (odds ratio [OR] 1.49, 95% confidence interval [CI] [1.15-1.94]), those with health insurance coverage (OR 3.10, 95% CI: [2.24-4.31]) and those with access to transportation (OR 1.54, 95% CI: [1.08-2.20]). Treatment receipt was lower among participants who used methamphetamine/amphetamine as their primary drug of choice compared with other substances. CONCLUSIONS:Initiatives to increase SUD treatment engagement among rural people who use drugs under community correctional supervision should address gaps in insurance coverage, transportation access, and treatment modalities that target stimulant use disorders. Gender-specific needs should also be considered when creating substance use interventions for this population.

PURPOSE:Naloxone administration by laypersons is proven to reduce opioid overdose mortality. Despite legislative advances, people who use drugs (PWUD) in rural settings face unique barriers to naloxone possession. This study aims to examine naloxone possession and identify its correlates among a large, geographically diverse sample of people who either use opioids or inject drugs in rural areas. METHODS:We performed a cross-sectional analysis using Rural Opioid Initiative (ROI) data from rural counties of ten US states. Study sites administered a harmonized survey instrument of 3048 PWUD recruited from January 2018 to March 2020. The primary outcome was current naloxone possession. Potential correlates were identified through review of the literature. Data were collected on demographics, drug use behaviors, overdose experiences, access to care, and addiction treatment. Data were analyzed using descriptive statistics, bivariate associations, and multivariable prevalence ratios. FINDINGS:Among 3008 participants included in the analysis, 36.4% reported possessing naloxone. Naloxone possession was associated with younger age, illegal income sources, past 30-day opioid use, personal history of overdose, witnessing an overdose, knowing someone who died from an overdose, current injection drug use, and receiving syringes from syringe service programs (SSPs). No association was found between access to care and naloxone possession. CONCLUSIONS:Only 36% of high-risk rural PWUD possessed naloxone. Factors such as injection drug use, overdose history, and SSP access increased the likelihood of naloxone possession. These findings highlight the need for targeted naloxone distribution strategies in rural areas, considering the unique barriers faced by rural PWUD.

Background: Mobile health (mHealth) applications are positioned to provide information and support anywhere and anytime, though few focus on overdose-related harm reduction. We aimed to describe the use of an e-harm reduction smartphone application theoretically based on self-determination theory among people who inject drugs. Methods: We enrolled 60 clients from 3 syringe services programs in Wisconsin in a single-arm, pre-post pilot study between December 2022 and June 2023. Eligible participants used opioids and injected drugs within the past week. Participants received a smartphone, unlimited data plan, and e-harm reduction focused mHealth application based on the self-determination theory principles of autonomy, competence, and relatedness. The app was used to deliver a 12-week overdose risk reduction intervention. Every week, participants self-selected 1 of 11 available overdose-focused harm reduction goals and received tailored education, resources, and support from study staff through the smartphone application. We evaluated the use of app features, intervention adherence, and described the most commonly selected overdose risk reduction goals. Results: Of available app features, participants most often used private messaging (median, interquartile range [IQR] days used: 28 [18-53]), viewed a motivational “thought of the day” (median [IQR] days used: 24 [15-47]), and interacted with discussion boards (median [IQR] days used: 12 [5-24]). Of 12 available weekly goal-setting intervention activities, participants completed a median of 9 (IQR: 4-11). Of 448 completed goal-setting activities, reducing drug injection and reducing drug use were the most commonly selected goals (chosen N = 86 [19.2%] and N = 81 [18.1%] times, respectively) followed by quitting use (N = 69 times, 15.4%), and reducing solitary drug use (N = 54 times, 12.1%). Conclusion: An e-harm reduction mHealth application was used by participants for overdose risk reduction goal setting, messaging, and viewing motivational content. Future studies will evaluate benefits of engaging with e-harm reduction mHealth applications for overdose prevention intervention relative to a control group.

Objective: Using an innovative data sharing model, we assessed the impacts of the COVID-19 pandemic on the health of people who inject drugs (PWID). Design: The PWID Data Collaborative was established in 2021 to promote data sharing across PWID studies in North America. Contributing studies submitted aggregate data on 23 standardized indicators during four time periods: prepandemic (March 2019 to February 2020), early-pandemic (March 2020 to February 2021), mid-pandemic (March 2021 to February 2022), and late pandemic (March 2022 to February 2023). Methods: We present study-specific and meta-analyzed estimates for the percentage of PWID who took medications for opioid use disorder, received substance use treatment, shared syringes or injection equipment, had a mental health condition, had been incarcerated, or had experienced houselessness. To examine change over time across indicators, we fit a random effects meta-regression model to prevalence estimates using time as a moderator. Results: Thirteen studies contributed estimates to the Data Collaborative on these indicators, representing 6213 PWID interviews. We observed minimal change across prevalence of the six indicators between the prepandemic (March 2019 to February 2020) and three subsequent time periods, overall or within individual studies. Considerable heterogeneity was observed across study-specific and time-specific estimates. Conclusion: Limited pandemic-related change observed in indicators of PWID health is likely a result of policy and supportive service-related changes and may also reflect resilience among service providers and PWID themselves. The Data Collaborative is an unprecedented data sharing model with potential to greatly improve the quality and timeliness of data on the health of PWID.

BACKGROUND:Individuals with opioid use disorder living in rural areas face barriers to accessing medications for treatment (MOUD), including finding prescribing clinicians and difficulties with transportation. This study sought to describe self-reported barriers to MOUD access in rural areas and associations between desired MOUD type and barriers encountered or perceived. METHODS:We performed a cross-sectional study of Rural Opioid Initiative participants who ever used opioids and sought MOUD treatment, who were surveyed from 2018 to 2020 about access to MOUD. Multivariable logistic regressions explored the association between MOUD type and barriers while controlling for age, gender, race, and study site. RESULTS:Of 2906 participants who used opioids and sought MOUD, 826 (28.4 %) were unable to access MOUD. In logistic regression models, lack of transportation was a more common barrier for those seeking methadone versus sublingual buprenorphine (adjusted odds radio [aOR] 1.87, 95 % confidence interval (CI) 1.24-2.81). A long wait list was more common for those seeking injectable naltrexone than sublingual buprenorphine (aOR 1.68, 95 % CI 1.05-2.69). Lack of doctors or programs and affordability were more common for those seeking injectable versus sublingual buprenorphine (aOR 7.84, 95 % CI 4.87-12.63 and aOR 1.89, 95 % CI 1.26-2.83, respectively). CONCLUSIONS:Access barriers vary by MOUD type for rural individuals with OUD. Compared to sublingual buprenorphine, methadone access was hindered more by transportation difficulties, while injectable long-acting buprenorphine was hindered more by affordability and finding a doctor or program. These barriers highlight the need to de-regulate and expand locations for methadone access and prescribing, and to improve affordability and prescriber uptake of newer MOUDs, such as injectable buprenorphine.

Syringe services programs (SSPs) reduce the risk of overdose by distributing supplies like naloxone. SSPs also support clients in meeting their basic needs via referrals to organizations providing food, housing, and healthcare. This paper describes the Exploration of Novel Harm Reduction Approaches to Increase Client Engagement (ENHANCE) Project, a prospective cohort study developed in partnership with people who use drugs that aims to characterize the influence of longitudinal engagement in SSPs on overdose risk behaviors. The ENHANCE Project protocol was developed with a community leadership team of 16 people with living experience of drug use who were clients from four SSPs in Wisconsin that serve as study recruitment sites. The community leadership team met five times to conceptualize the study priorities, protocol, recruitment strategies, and measures. ENHANCE will enroll 400 people who use opioids and/or stimulants via recruitment of clients from study sites and peer referrals. Clients will report on primary outcomes (overdose experiences and risk behaviors) and other covariates (substance use history and behaviors, mental and physical health, satisfaction of basic needs, stigma, and others) over a 2-year follow-up period. At enrollment, clients select a self-generated identification code that is documented in all subsequent harm reduction services received from ten SSPs in Wisconsin. These data will be linked to study survey data using probabilistic methods and used for the primary exposure variable, frequency of using SSP services. ENHANCE will test the primary hypothesis that more frequently using SSP services is associated with reduced overdose risk behavior frequency. Preliminary results: Among the first 125 clients enrolled, 22.4

Hepatitis C virus (HCV) remains a significant public health concern in the United States particularly in rural communities where the opioid epidemic has accelerated transmission among people who use drugs (PWUD)/ Despite, this growing burden the genetic features and transmission patterns of HCV in these settings are poorly understood. This study analyzed 692 HCV antibody-positive specimens collected from rural communities in ten U.S. states. Using amplicon-based deep sequencing and the Global Hepatitis Outbreak and Surveillance Technology (GHOST) platform, transmission networks were reconstructed. Among sequenced individuals, 29.5% were linked within clusters. The structure of these clusters varied by region-from sparse networks in Ohio to dense, interconnected clusters in New England. Phylogenetic analysis revealed that some transmission networks persisted for over a decade, highlighting long-term, sustained transmission. Nearly half of all clusters involved individuals connected through social recruitment, suggesting peer-referral strategies can effectively identify transmission chains. Younger age was independently associated with clustering, while recruitment by an intimate partner showed a weaker link. These findings emphasize the importance of ongoing genomic surveillance and social network-informed strategies to detect emerging HCV clusters and guide targeted public health interventions in underserved rural communities.

Importance Identifying prescription needs of adults returning from prison can inform intervention design to mitigate high morbidity and mortality during reentry to the community. Objective To characterize the prevalence and factors associated with continuity of medication use for treatment of chronic illness among adults returning to the community from prison. Design, Setting, and Participants This retrospective cohort study linked administrative records and prescription claims from the Wisconsin Department of Corrections and the Medicaid program. The study included all adults (aged 18-64 years) released from a Wisconsin state correctional facility between April 1, 2015, and June 30, 2017, after incarceration of at least 31 days who enrolled in Medicaid within the month of release. Analyses were conducted between May 2022 and May 2024. Exposure Receipt of a prescription medication commonly used for treatment of certain chronic conditions during the last 3 months of incarceration. Main Outcomes and Measures The primary outcome was medication continuity, which was defined as having a prescription medication claim in the first 6 months after release that was within the same chronic condition therapeutic class as the medication received during the last 3 months of incarceration. Results This cohort study included 13 792 individual releases representing 12 960 individuals from the Wisconsin state prison system who immediately enrolled in Medicaid upon release. These individuals had a mean (SD) age of 35.5 (10.5) years; 89.5% were male. In terms of race, 38.5% of individuals were Black and 57.2% were White. For one-third of individual Medicaid-enrolled releases (4302 [31.2%]), the individual received a prescription medication for a chronic condition. Prescription continuity was observed for 51.7%, with variability across drug class ranging from less than 20.0% to 71.6%. Classes with the highest continuity (eg, thyroid agents) were also those that treated serious chronic conditions, although gaps between realized and clinically recommended care remained. Continuity varied by race, sex, and age. Individuals with continuity were more likely to have had an outpatient visit in the 6 months following release than those without continuity (93.9% vs 55.6%; P < .001) despite similar Medicaid enrollment. Conclusions and Relevance In this study, prescription continuity between prison release and the community was limited, even for drugs with high clinical need and relevance for population health and especially among individuals who did not receive outpatient care in the 6 months post incarceration. These findings suggest that effective transitional care interventions may need to include increased emphasis on connecting with clinicians.

Background:Active substance use, food or housing insecurity, and criminal legal system involvement can disrupt HIV care for people living with HIV and opioid use disorder (OUD). These social determinants of health are not routinely captured in clinical settings. Objective:We evaluated whether real-time reports of social and behavioral factors using a smartphone app could predict viral nonsuppression and missed care visits to inform future mobile health interventions. Methods:We enrolled 59 participants from the AIDS Linked to the Intravenous Experience (ALIVE) Study in Baltimore, Maryland, into a 12-month substudy between February 2017 and October 2018. Participants were eligible if they had OUD and had either a measured HIV RNA ≥1000 copies/mL or a ≥1-month lapse in antiretroviral therapy in the preceding 2 years. Participants received a smartphone and reported HIV medication adherence, drug use or injection, and several disruptive life events, including not having a place to sleep at night, skipping a meal due to lack of income, being stopped by police, being arrested, or experiencing violence on a weekly basis, through a survey on a mobile health app. We described weekly survey completion and investigated which factors were associated with viral nonsuppression (HIV RNA ≥200 copies/mL) or a missed care visit using logistic regression with generalized estimating equations adjusted for age, gender, smartphone comfort, and drug use. Results:Participants were predominantly male (36/59, 61%), Black (53/59, 90%), and had a median of 53 years old. At baseline, 16% (6/38) were virally unsuppressed. Participants completed an average of 23.3 (SD 16.3) total surveys and reported missing a dose of antiretroviral therapy, using or injecting drugs, or experiencing any disruptive life events on an average of 13.1 (SD 9.8) weekly surveys over 1 year. Reporting use of any drugs (adjusted odds ratio [aOR] 2.3, 95% CI 1.4-3.7), injecting drugs (aOR 2.3, 95% CI 1.3-3.9), and noncompletion of all surveys (aOR 1.6, 95% CI 1.1-2.2) were associated with missing a scheduled care visit over the subsequent 30 days. Missing ≥2 antiretroviral medication doses within 1 week was associated with HIV viral nonsuppression (aOR 3.7, 95% CI: 1.2-11.1) in the subsequent 30 days. Conclusions:Mobile health apps can capture risk factors that predict viral nonsuppression and missed care visits among people living with HIV who have OUD. Using mobile health tools to detect sociobehavioral factors that occur prior to treatment disengagement may facilitate early intervention by health care teams.

Background: The impact of changing drug use patterns on hepatitis C virus (HCV) and HIV incidence among people who inject drugs (PWID) in the US is understudied. Methods: An HCV and HIV transmission model was calibrated to urban and rural area data (San Diego, CA and Central/Northern Wisconsin). Fentanyl use among PWID was assumed to increase mortality and injecting-related risk of HIV and HCV based on San Diego data. We predicted HCV/HIV incidence with recent trends (in fentanyl use, transition from injecting to smoking drugs, opiate agonist treatment (OAT) and incarceration), and scenarios with no trend changes since 2020. We calculated the population attributable fraction of fentanyl on incidence, comparing to a no fentanyl counterfactual from 2015 to 2025. Results: High and increasing self-reported fentanyl use among PWID was observed in Central/Northern Wisconsin (20 % in 2018 to 45 % in 2021) and San Diego (51 % in 2021 to 66 % in 2023). Between 2015-2025, modeling suggests fentanyl use contributed to 18 % (95 %CI 9-25) and 34 % (95 %CI 26-45) of new HCV infections among PWID in Central/Northern Wisconsin and San Diego, respectively. Fentanyl contributed to 10 % (95 %CI 1-26) of HIV infections in San Diego; no HIV was observed among Central/Northern Wisconsin PWID. Fentanylassociated risk was mitigated by increased OAT, reduced incarceration (Wisconsin), and shifts from injecting to smoking drugs (San Diego). Conclusions: Fentanyl use increased HCV and/or HIV in an urban and rural area, suggesting expanded access to harm reduction, alongside interventions to reduce blood-borne virus transmission risk among PWID who use fentanyl are urgently needed.

Background: The United States’ (US) opioid overdose epidemic has evolved into a combined stimulant/opioid epidemic, a pattern driven in part by mitigating opioid overdose risk, variable substance availability, and personal preferences. This study aimed to investigate the association between self-reported substance preference (heroin or methamphetamine) and behavioral/health outcomes among individuals who used both heroin and methamphetamine in the rural US. Methods: The Rural Opioid Initiative is a consortium of 8 research cohorts from 10 states and 65 rural counties that recruited individuals reporting past 30-day injection of any substance or opioid substance use by any route from 1/2018 to 3/2020. Analyses were restricted to participants ⩾18 years, who self-reported either heroin or methamphetamine as their preferred substance and past 30-day use of both heroin and methamphetamine. We examined cross-sectional associations between preferred substance (heroin versus methamphetamine) and behavioral and health outcomes using random effects meta-analysis with adjusted regression models. Results: Among 1239 participants, 61% (n = 752) reported heroin as their preferred substance. Adjusting for age, sex, and race/ethnicity, methamphetamine preference was associated with lower prevalence ratios for current naloxone possession (adjusted prevalence ratio [aPR] = 0.68; 95% Confidence Interval [95% CI] = 0.59-0.78; P-value ⩽ .001), of ever being told they had the hepatitis C virus (HCV; aPR = 0.72; 95% CI: 0.61-0.85; P-value ⩽ .001) and a personal history of overdose (aPR = 0.81; 95% CI = 0.73-0.90; P-value ⩽ .001). Conclusion: In our study analyzing associations between preferred substance and various behavioral and health outcomes amongst people who use both heroin and methamphetamine, a majority of participants preferred heroin. Methamphetamine preference was associated with lower prevalence of naloxone possession, ever being told they had HCV, and prior history of an overdose. This study underscores the need for targeted harm reduction services for people who prefer methamphetamine in rural areas.

BACKGROUND:Benzodiazepines and opioids are among the most frequently misused psychoactive substances, but their patterns of co-use (polysubstance use) in rural areas are unclear. As resources to address substance use are disproportionally scarce in rural areas, a better understanding of this polysubstance use is critical to allocate and direct interventions. METHODS:The Rural Opioid Initiative comprises 8 research cohorts spanning 10 states and 65 rural counties. Participants were recruited from January 2018 to March 2020 and eligibility included past 30-day opioid use by any route or past 30-day injection of any substance. Analyses were restricted to participants reporting past 30-day opioid use and either benzodiazepine or stimulant use. We described bivariate cross-sectional associations between benzodiazepine+opioid use, compared with stimulant+opioid use, and substance use behaviors, health outcomes, injection drug use, addiction treatment, and criminal legal system involvement. RESULTS:Of the 1107 ROI participants that met inclusion criteria, 10% (n = 107) reported benzodiazepine+opioid use, and 90% (n = 1000) reported stimulant+opioid use. The benzodiazepine+opioid group, compared with the stimulant+opioid group, had a higher use of opioid pain medication (73% vs 55%), gabapentin (43% vs 23%), and clonidine (12% vs 4%) to get high and used these substances more frequently; they also reported more frequent heavy episodic drinking (6.1 days per 30 days, SD = 9.4 vs 4.1 days, SD 7.5). The benzodiazepine+opioid group reported a lower prevalence in the past 6 months of law enforcement stop-and-search incidents (29% vs 48%), arrests (11% vs 28%), probation (22% vs 34%), jail/prison (18% vs 41%), and fewer days in jail/prison (4.7, SD = 19.1 days vs 15.9, SD = 35.7 days). CONCLUSION:We found that benzodiazepines+opioids use was associated with more heavy episodic drinking and gabapentin use, and lower prevalence of criminal legal system involvement. These data suggest that individuals reporting benzodiazepines+opioids use have distinct behavioral patterns and outcomes that require targeted interventions for rural populations.

OBJECTIVES:Understanding COVID-19 vaccination behavior can guide public health efforts to increase vaccination acceptance and uptake. We examined COVID-19 vaccination intention among Wisconsin residents and assessed racial and ethnic disparities in vaccine uptake. METHODS:We assessed vaccination intention during COVID-19 testing registration in February 2021 and used the Wisconsin Immunization Registry to ascertain COVID-19 vaccination uptake by July 2022. We described differences in intention to get vaccinated and assessed the association between racial and ethnic identity and vaccination. We analyzed vaccination likelihood by using Cox proportional hazards models and presented adjusted hazard ratios (AHRs) with 95% CIs. RESULTS:Of 12 196 people, 9843 (80.7%) intended to be vaccinated against COVID-19. A higher proportion of non-Hispanic Black people (21.1%) than people in all other racial and ethnic groups did not intend to get vaccinated. Adjusting for vaccination intention, age group, sex, and neighborhood Area Deprivation Index, Hispanic people were 41% (AHR = 0.59; 95% CI, 0.54-0.64) less likely than non-Hispanic White people to get vaccinated. Compared with non-Hispanic White people, non-Hispanic Black people were 24% (AHR = 0.76; 95% CI, 0.68-0.84) less likely to get vaccinated and Asian people were 18% (AHR = 0.82; 95% CI, 0.75-0.90) less likely to get vaccinated. CONCLUSIONS:Racial and ethnic disparities in vaccination uptake persisted despite controlling for intention. Efforts to focus public health resources on increasing COVID-19 vaccination among racial and ethnic minority groups are important.

INTRODUCTION:People who use drugs (PWUD) are at risk of HIV infection, but the frequency and distribution of transmission-associated behaviors within rural communities is not well understood. Further, while interventions designed to more explicitly affirm individuals' sexual orientation and behaviors may be more effective, descriptions of behavior variability by orientation are lacking. We sought to describe how disease transmission behaviors and overdose risk vary by sexual orientation and activity among rural PWUD. METHODS:From 01/2018-03/2020, rural PWUD participating in the Rural Opioid Initiative were surveyed across 8 sites. Collected data included: demographics; experiences with drug use, overdose, and healthcare; stigma; gender identity; and sexual orientation and partners. Participants were categorized as: monosexual by orientation and behavior (Mono-only), monosexual by orientation but behaviorally bisexual (Mono/Bi), and bisexual by orientation (Bi+). Analyses included descriptive summaries, bivariate examination (chi-square), and logistic regression (relative risk [RR] and 95 % confidence interval [CI]). RESULTS:The 1455 participants were 84.8 % Mono-only, 3.2 % Mono/Bi, and 12.0 % Bi+. Compared to Mono-only men, Mono/Bi and Bi+ men had greater risk of transactional sex (RR = 9.71, CI = 6.66-14.2 and RR = 5.09, CI = 2.79-9.27, respectively) and sharing syringes for injection (RR = 1.58, CI = 1.06-2.35 and RR = 1.85, CI = 1.38-2.47). Compared to Mono-only women, Mono-Bi and Bi+ women had greater risk of transactional sex (RR = 4.47, CI = 2.68-7.47 and RR = 2.63, CI = 1.81-3.81); and Bi+ women had greater risk of sharing syringes for injection (RR = 1.49, CI = 1.23-1.81), sharing syringes to mix drugs (RR = 1.44, CI = 1.23-1.69), and experiencing an overdose (RR = 1.32, CI = 1.12-1.56). Bi+ men and women both more frequently reported selling sex as a source of income (versus Mono-only, both p < 0.050) and measures of perceived stigma (all p < 0.050). CONCLUSIONS:Rural PWUD who are bisexual by orientation or behavior are significantly more likely to engage in behaviors associated with infectious disease transmission and to experience stigma and drug overdose. Given the growing recognition of bisexuality as a distinct orientation that warrants individualized consideration, interventions that are specifically acknowledging and affirming to the circumstances of this group are needed.

Introduction: As expanded Medicaid coverage reduces financial barriers to receiving health care among formerly incarcerated adults, more information is needed to understand the factors that predict prompt use of health care after release among insured adults with a history of substance use. This study's aim was to estimate the associations between characteristics suggested by the Andersen behavioral model of health service use and measures of health care use during the immediate reentry period and in the presence of Medicaid coverage. Methods: In this retrospective cohort study, we linked individual-level data from multiple Wisconsin agencies. The sample included individuals aged 18-64 released from a Wisconsin State Correctional Facility between April 2014 and June 2017 to a community in the state who enrolled in Medicaid within one month of release and had a history of substance use. We grouped predictors of outpatient care into variable domains within the Andersen model: predisposing- individual socio-demographic characteristics; enabling characteristics including area-level socio-economic resources, area-level health care supply, and characteristics of the incarceration and release; and need-based- pre-release health conditions. We used a model selection algorithm to select a subset of variable domains and estimated the association between the variables in these domains and two outcomes: any outpatient visit within 30 days of release from a state correctional facility, and receipt of medication for opioid use disorder within 30 days of release. Results: The size and sign of many of the estimated associations differed for our two outcomes. Race was associated with both outcomes, Black individuals being 12.1 p.p. (95 % CI, 8.7-15.4, P < .001) less likely than White individuals to have an outpatient visit within 30 days of release and 1.3 p.p. (95 % CI, 0.48-2.1, P = .002) less likely to receive MOUD within 30 days of release. Chronic pre-release health conditions were positively associated with the likelihood of post-release health care use. Conclusions: Conditional on health insurance coverage, meaningful differences in post-incarceration outpatient care use still exist across adults leaving prison with a history of substance use. These findings can help guide the development of care transition interventions including the prioritization of subgroups that may warrant particular attention.