Background Although treatment for drug-use reduces HIV/HCV risk, little is known about its relationship with other sexually transmitted infections (STIs) among women who use drugs. We examined the prospective association between receipt of treatment for drug use and incident STIs, and whether associations differ across racial and ethnic groups among women who use drugs.Methods We conducted a secondary analysis of a 2010 longitudinal cohort among women participants who reported drug use at baseline (n = 826). Participants completed surveys and STI testing at baseline and 6 months. The primary exposure was baseline self-reported receipt of treatment for drug use in the prior 6 months. The outcome was incident chlamydia, gonorrhea, trichomoniasis, and/or syphilis at 6 months follow up. Modified Poisson regression with robust variance estimated race and ethnicity-specific risk ratios (RRs), adjusting for baseline sociodemographic, behavioral, and health factors.Results STI incidence was highest among Black women (22%), followed by Hispanic/Latina women and those of other racial/ethnic groups (14%), and lowest among White women (5%). In unadjusted analyses, treatment for drug-use was associated with higher STI incidence among White women (RR = 2.83; 95% CI: 0.97, 8.29) and women of other racial/ethnic groups (RR = 3.21; 95% CI: 1.21, 8.50). In adjusted models, associations attenuated among White and Hispanic/Latina women, while among women of other racial/ethnic groups, self-help treatment remained associated with elevated STI risk (adjusted RR = 3.03; 95% CI: 1.22, 8.96). No associations were observed among Black women.Conclusions Among Black women who use drugs, STI risk may be shaped by structural and network-level factors rather than individual-level treatment for drug use. Integrating STI screening and prevention services into drug-related care settings may address elevated STI vulnerability. Additional research should examine mechanisms underlying racial and ethnic differences and how to reach the diverse population of women who use drugs.

Rates of bacterial sexually transmitted infections (STIs) and substance use-related harms have risen sharply in the United States, yet little is known about whether drug treatment affects STI risk among people who use drugs. We analyzed prospective data from 2142 participants who reported illicit drug use at baseline in Project AWARE recruited from nine STI clinics nationwide. We examined associations between self-reported drug treatment in the past six months at baseline and biologically confirmed incident STI at six-month follow-up, overall and by gender, using inverse probability of treatment weighting to estimate average treatment effects (ATE) and average treatment effects among the treated (ATT). At baseline, 14% reported drug treatment. In unadjusted models, drug treatment was associated with higher STI risk (RR = 1.43, 95% CI: 1.09, 1.88), driven by laboratory-identified infections. After weighting, the ATE was attenuated (RR = 1.37, 95% CI: 0.91, 2.07) and the ATT was null. Gender-stratified analyses suggested elevated STI risk among women in unadjusted models, but weighted estimates were nonsignificant, although clinically diagnosed STIs were less common among women in drug treatment. Findings indicate complex, gender-specific relationships between drug treatment and STI risk and underscore the need for integrated, gender-responsive STI prevention within drug treatment settings.

Objectives : To evaluate associations between syringe services program (SSP) implementation and sexually transmitted and blood-borne infections (STBBIs) rates in Florida counties. Methods : A difference-in-difference analysis was conducted using surveillance data (2010–2023) to compare STBBIs rates, including bacterial STIs (i.e., chlamydia, gonorrhea, infectious syphilis), acute HCV, and HIV, pre- and post-SSP implementation in Florida counties with operational SSPs versus control counties without SSPs. Two-way fixed effects models were used to estimate average treatment effects and multiple sensitivity analyses explored the robustness of results. Results : SSP implementation was associated with significant reductions in HIV rates (-11 per 100,000, 95% confidence interval: -15.4, -6.7 in Miami-Dade County vs. control counties), and HCV rates appeared stable, while non-viral STI rates appeared to increase. Conclusions : SSPs appear effective in reducing HIV at the population level in Florida. The observed increase in STI rates may reflect improved detection facilitated by SSPs and linkage to other care. Findings support SSP expansion as a public health strategy and highlight the need for research on their broader population level impact.

While Connecticut has successfully slowed overdose death (ODD) rates, additional progress is necessary. We examined policies that allocate resources with maximal efficiency to reduce ODDs. We developed a mechanistic simulation of overdose policies, including medications for opioid use disorder (OUD) among people involved in the criminal justice system both during incarceration (MOUD-INC) and post-release in the community (MOUD-COM), and naloxone in the community (NLX) to determine how maximally scaling all permutations compared to current MOUD and NLX levels (i.e., status quo) would impact five-year cohort ODDs, discounted life-years (LYs), discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER). A simulated cohort of 2748 people with OUD incarcerated in Connecticut moved between settings and OUD statuses. Costs were assessed in 2021 US, employed health and public health sector perspective in base-case analyses and limited-societal perspective in sensitivity analyses, 3

Introduction:The dual epidemics of sexually transmitted infections (STIs) and unprescribed opioid use persist globally, including in the United States. This study addresses gaps in STI prevention and contraception among people who use unprescribed opioids in New York City (NYC), focusing on both men and women. Methods:We conducted a cross-sectional substudy from November 2021-August 2022 assessing sexual health with a one-time survey within a longitudinal cohort study among people who use unprescribed opioids in NYC that collected baseline data during 2019-2020. We measured sociodemographic characteristics, substance use history, sexual partnerships and STI prevention and contraception categorized as providing effective prevention versus none/ineffective. We estimated the prevalence of lack of effective STI prevention and contraception and potential correlates among males and females. Results:The analytic sample included 108 participants (54 % male, 46 % female) with a mean age of 46 years. No/ineffective STI prevention was most common among reproductive-age females (81 %) and lowest among males (67 %) and no/less effective contraception was reported by approximately 90 % of participants. No/ineffective STI prevention and contraception were differentially associated with factors such as sexual partnerships, substance use treatment, and healthcare utilization among males and females. Discussion:Findings highlight the need for improved provision of effective STI and pregnancy prevention methods for both men and women who use drugs. There is a critical need to expand access to sexual and reproductive health services for people who use drugs, including integrating these services into diverse healthcare and drug-service settings.

People with opioid use disorder (POUD) who are incarcerated are disproportionately impacted by the overdose crisis. We sought to identify overdose policies that allocate resources with maximal efficiency to reduce mortality among POUD in the New Jersey (NJ) Department of Corrections. We created a probabilistic state-transition model of a simulated cohort of POUD incarcerated in NJ to simulate maximizing medication for opioid use disorder (MOUD) during incarceration and/or post-release in the community and naloxone in the community. We estimated how maximizing each intervention individually and in combinations compared to current provision would impact five-year overdose deaths (ODDs), life-years (LYs), and quality-adjusted life-years (QALYs) among the simulated cohort, who moved between different modeled settings and opioid use statuses. Inputs were derived from literature reviews and expert opinion. Costs were in 2021 USD, employing a health sector perspective in base-case analyses and a limited societal perspective in sensitivity analyses, a 3

Background:In 2021, NYC implemented overdose prevention center (OPC) services at two existing syringe exchange programs, allowing people to use pre-obtained drugs on-site. Although OPCs in Canada, Western Europe, and Australia have demonstrated their feasibility and benefits towards reducing overdose risk and drug-related harm, there is less data on how people who use drugs (PWUD) conceptualize the benefits and any potential drawbacks of using OPCs. Methods:In June-August 2022, we conducted 26 semistructured interviews with people in New York City who used unprescribed opioids. Interviews lasted 30-60 min and were conducted remotely using Zoom and later transcribed by a professional service. Data were then coded, using AtlasTi, into meaningful categories using a thematic approach based on the aims of the study and existing literature. Results:Most participants had heard of OnPoint and reported a willingness to use it. They described the ability of OnPoint staff to reverse an overdose quickly and the presence of naloxone, oxygen, and other supplies as the primary benefits. Yet, many also noted that OPCs provide PWUD with a place to escape from the weather and/or avoid law enforcement. Participants also reported concerns about how far PWUD would be willing to travel or wait to use an OPC and for the autonomy of PWUD in the context of formal, sanctioned OPCs. Conclusions:Results suggest that many PWUD in NYC are well-informed about OnPoint and are willing to use OPCs. Yet, to fulfil their potential, OPCs must be located near to where PWUD live, and should be made as low-threshold as possible. However, since it is unlikely that OPCs will be expanded enough to meet the need and because some PWUD will never choose to use in sanctioned OPCs, expanding the reach of alternative strategies, such as Mobile Overdose Response Services, is recommended.

People who use drugs are at elevated sexual and reproductive health risk but experience barriers to services. Syringe services programs (SSP) are an important venue to provide integrated health services. Few studies have examined SSP use within intersecting gender, racial, and ethnic groups, including by injection drug use (IDU), and differences in sexual and reproductive health among these groups. Within a cohort study among people who use unprescribed opioids in New York City, we conducted a nested cross-sectional study from November 2021-August 2022 assessing sexual health with a survey (n = 120). The parent study measured baseline characteristics, and the cross-sectional study survey measured self-reported past-year SSP use and sexual and reproductive health. We estimated SSP use within gender, racial, and ethnic groups by IDU, and the prevalence of sexual and reproductive health outcomes by gender, race, ethnicity, and SSP use. Among men (n = 61) and women (n = 54), SSP use was disproportionately low among Black participants irrespective of IDU. Women reporting SSP use had a higher prevalence of multiple, new, sex trade, and/or casual sex partners, history of STI symptoms, and lack of effective STI prevention, although women who did not use SSP had non-negligible levels of risk with variation between racial and ethnic groups. Among men, sexual and reproductive health varied across racial and ethnic groups but not as clearly by SSP use. SSP offer opportunity to address elevated STI risk among people who use drugs but may miss certain intersecting gender, race, and ethnic groups.

Background Quitting smoking may lead to improvement in substance use, psychiatric symptoms, and pain, especially among high-risk populations who are more likely to experience comorbid conditions. However, causal inferences regarding smoking cessation and its subsequent benefits have been limited.Methods We emulated a hypothetical open-label randomized control trial of smoking cessation using longitudinal observational data of HIV-positive and HIV-negative US veterans from 2003-2015 in the Veterans Aging Cohort Study. We followed individuals from the first time they self-reported current cigarette smoking (baseline). We categorized participants as quitters or non-quitters at the first follow-up visit (approximately 1 year after baseline). Using inverse probability weighting to adjust for confounding and selection bias, we estimated odds ratios for improvement of co-occurring conditions (unhealthy alcohol use, cannabis use, illicit opioid use, cocaine use, depressive symptoms, anxiety symptoms, and pain symptoms) at second follow-up (approximately 2 years after baseline) for those who quit smoking compared to those who did not, among individuals who had the condition at baseline.Results Of 4,165 eligible individuals (i.e., current smokers at baseline), 419 reported no current smoking and 2,330 reported current smoking at the first follow-up. Adjusted odds ratios (95% confidence intervals) for associations between quitting smoking and improvement of each condition at second follow-up were: 2.10 (1.01, 4.35) for unhealthy alcohol use, 1.75 (1.00, 3.06) for cannabis use, 1.10 (0.58, 2.08) for illicit opioid use, and 2.25 (1.20, 4.24) for cocaine use, 0.78 (0.44, 1.38) for depressive symptoms, 0.93 (0.58, 1.49) for anxiety symptoms, and 1.31 (0.84, 2.06) for pain symptoms.Conclusions While a causal interpretation of our findings may not be warranted, we found evidence for decreased substance use among veterans who quit cigarette smoking but none for the resolution of psychiatric conditions or pain symptoms. Findings suggest the need for additional resources combined with smoking cessation to reduce psychiatric and pain symptoms for high-risk populations.

Black men and people belonging to sexual minority groups are disproportionately impacted by criminal legal involvement and sexually transmitted infections (STIs). Traumatic experiences are often associated with later criminal legal involvement, depression symptoms, sexual risk behavior, and STIs. Research on the joint influence of trauma and incarceration on STI risk among racial and/or sexual minority people is limited. This study tested the association between posttraumatic stress disorder (PTSD) symptoms and incarceration on sexual risk behavior and STI among Black sexual minority men (SMM), a population that may be at higher risk for contracting STIs. Using data from the HIV Prevention Trials Network 061 Study, a longitudinal study of adult Black SMM in six U.S. cities (N = 855), we tested associations between past 6-month incarceration and subsequent sexual risk behavior, STI, and depression symptoms, for those with and without preincarceration PTSD symptoms. PTSD symptoms were elevated among participants who reported Hispanic ethnicity, having sex with both men and women, and previous incarceration. Although there were no significant differences between recent incarceration and sexual risk for those with and without PTSD, incarceration was linked to some sexual risk behaviors regardless of PTSD symptoms. Among people with PTSD symptoms, there was a higher prevalence of sexual risk and depression symptoms, regardless of incarceration. These findings suggest a potentially compounding influence of PTSD symptoms and incarceration on sexual risk and infection among Black SMM.

Background: Research describes inequities in substance use treatment, but few studies focus specifically on racial and ethnic disparities in a range of aspects of substance use treatment among women with opioid use disorder (OUD).Objective: To examine whether substance use treatment (i.e. receipt, sources, barriers) differs by race and ethnicity among women with opioid use disorder (OUD) and to identify factors associated with treatment gap (i.e. needing treatment but not receiving it).Methods: We performed cross-sectional analyses using National Survey on Drug Use and Health 2015-2019 data, restricted to non-Hispanic Black, non-Hispanic White, and Hispanic women with past-year OUD (unweighted n = 1089). We estimated the prevalence of aspects of treatment among racial and ethnic groups, and used modified Poisson regression to estimate correlates of reported treatment gap.Results: Approximately 68% of White versus 87% of Black and 81% of Hispanic women with OUD had a treatment gap (p-value 0.0034). Commonly reported barriers to treatment included prioritization, affordability, and stigma. Older age was associated with lower prevalence of treatment gap among all women [prevalence ratio (PR) = 0.83, and 95% confidence interval (CI): 0.76, 0.92], while criminal legal involvement and healthcare coverage was associated with a lower prevalence of treatment gap among Hispanic and White women only (past year arrest: Hispanic women PR = 0.38, 95% CI: 0.17, 0.86; White women PR = 0.62, 95% CI: 0.47, 0.82).Conclusions: Receipt of treatment is low among women with OUD, especially Black and Hispanic women. Intersectional intervention approaches are needed to increase access and reduce inequities.

Background: People who use drugs (PWUD) often have elevated sexually transmitted infection (STI) risk and unmet healthcare needs. Self-directed STI specimen collection (i.e., individuals collect the specimen and mail to the laboratory) may be valuable in addressing STI testing barriers among PWUD. Methods: Within a cohort study among PWUD in New York City, we conducted a cross-sectional substudy from November 2021-August 2022 assessing sexual health with a one-time online survey (n = 120); participants could opt-in to receive a self-collection kit. Participants who opted-in were mailed a kit containing collection materials (males: urine cup, females: vaginal swab), pre-paid return label, instructions, and educational information. Specimens were sent to the laboratory and tested for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC). We measured the number of kits requested, delivered, mailed to the lab, and CT/GC positive; and examined differences in requesting a kit by sociodemographic and behavioral characteristics. Results: Sixty-three total kits were requested by 44 unique participants. Of the 63 requested, 41 were delivered; one kit was undeliverable at the provided address and the rest were not sent due to no address provided or being duplicate requests. Of the 41 kits delivered, three participants returned the kit to the lab; of those, one was positive for CT and GC. The greatest differences in those who did and did not request a kit were observed by age, sexual orientation, past-year sex trade and casual partnerships, and experiences of relationship violence. Conclusions: Self-directed specimen collection may be desirable for PWUD, but research is needed to understand barriers to this testing approach for this population.

BACKGROUND:People in Connecticut are now more likely to die of a drug-related overdose than a traffic accident. While Connecticut has had some success in slowing the rise in overdose death rates, substantial additional progress is necessary. METHODS:We developed, verified, and calibrated a mechanistic simulation of alternative overdose prevention policy options, including scaling up naloxone (NLX) distribution in the community and medications for opioid use disorder (OUD) among people who are incarcerated (MOUD-INC) and in the community (MOUD-COM) in a simulated cohort of people with OUD in Connecticut. We estimated how maximally scaling up each option individually and in combinations would impact 5-year overdose deaths, life-years, and quality-adjusted life-years. All costs were assessed in 2021 USD, employing a health sector perspective in base-case analyses and a societal perspective in sensitivity analyses, using a 3% discount rate and 5-year and lifetime time horizons. RESULTS:Maximally scaling NLX alone reduces overdose deaths 20% in the next 5 years at a favorable incremental cost-effectiveness ratio (ICER); if injectable rather than intranasal NLX was distributed, 240 additional overdose deaths could be prevented. Maximally scaling MOUD-COM and MOUD-INC alone reduce overdose deaths by 14% and 6% respectively at favorable ICERS. Considering all permutations of scaling up policies, scaling NLX and MOUD-COM together is the cost-effective choice, reducing overdose deaths 32% at ICER $19,000/QALY. In sensitivity analyses using a societal perspective, all policy options were cost saving and overdose deaths reduced 33% over 5 years while saving society $338,000 per capita over the simulated cohort lifetime. CONCLUSIONS:Maximally scaling access to naloxone and MOUD in the community can reduce 5-year overdose deaths by 32% among people with OUD in Connecticut under realistic budget scenarios. If societal cost savings due to increased productivity and reduced crime costs are considered, one-third of overdose deaths can be reduced by maximally scaling all three policy options, while saving money.

Introduction: Depressive symptoms are linked with pain, anxiety, and substance use. Research estimating whether a reduction in depressive symptoms is linked to subsequent reductions in pain and anxiety symptoms and substance use is limited. Methods: Using data from the Veterans Aging Cohort Study, a multisite observational study of U.S. veterans, the authors used a target trial emulation framework to compare individuals with elevated depressive symptoms (Patient Health Questionnaire-9 score >= 10) who experienced reductions in depressive symptoms (Patient Health Questionnaire-9 score < 10) with those whose symptoms persisted (Patient Health Questionnaire-9 score >= 10) at the next follow-up visit (on average, 1 year later). Using inverse probability of treatment weighting, the authors estimated ORs and 95% CIs for associations between depressive symptom reduction status and improvement on the following: anxiety symptoms, pain symptoms, unhealthy alcohol use, and use of tobacco, cannabis, cocaine, and/or illicit opioids. Results: Reductions in depressive symptoms were associated with reductions in pain symptoms (OR=1.43, 95% CI=1.01, 2.02), anxiety symptoms (OR=2.50, 95% CI=1.63, 3.83), and illicit opioid use (OR=2.07, 95% CI=1.13, 3.81). Depressive symptom reductions were not associated with reductions in unhealthy alcohol use (OR=0.85, 95% CI=0.48, 1.52) or use of tobacco (OR=1.49, 95% CI=0.89, 2.48), cannabis (OR=1.07, 95% CI=0.63, 1.83), or cocaine (OR=1.28, 95% CI=0.73, 2.24). Conclusions: Reducing depressive symptoms may potentially reduce pain and anxiety symptoms and illicit opioid use. Future work should determine whether reductions achieved through antidepressant medications, behavioral therapy, or other means have comparable impact. (c) 2024 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

BACKGROUND:Given the disproportionate rates of incarceration and lower life expectancy (LE) among Black sexual minority men (BSMM) and Black transgender women (BTW) with HIV, we modeled the impact of decarceration and screening for psychiatric conditions and substance use on LE of US BSMM/BTW with HIV. METHODS:We augmented a microsimulation model previously validated to predict LE and leading causes of death in the US with estimates from the HPTN 061 cohort and the Veteran's Aging Cohort Studies. We estimated independent associations among psychiatric and substance use disorders, to simulate the influence of treatment of one condition on improvement on others. We used this augmented simulation to estimate LE for BSMM/BTW with HIV with a history of incarceration under alternative policies of decarceration (ie, reducing the fraction exposed to incarceration), screening for psychiatric conditions and substance use, or both. RESULTS:Baseline LE was 61.3 years. Reducing incarceration by 25%, 33%, 50%, and 100% increased LE by 0.29, 0.31, 0.53, and 1.08 years, respectively, versus no reductions in incarceration. When reducing incarceration by 33% and implementing screening for alcohol, tobacco, substance use, and depression, in which a positive screen triggers diagnostic assessment for all psychiatric and substance use conditions and linkage to treatment, LE increased by 1.52 years compared with no screening or decarceration. DISCUSSION:LE among BSMM/BTW with HIV is short compared with other people with HIV. Reducing incarceration and improving screening and treatment of psychiatric conditions and substance use could substantially increase LE in this population.

Introduction Opioid withdrawal is a regular occurrence for many people who use illicit opioids (PWUIO) involving acute physical and psychological pain. Yet, there is very little data on the withdrawal experience of people in methadone maintenance treatment (MMT) and almost none from the patients' experience. Learning more about patients' withdrawal experiences can help to inform policies and practices that are better suited to address withdrawal and may improve patient satisfaction as well as uptake and retention. Methods This article is based on 29 semi-structured interviews with people who use illicit opioids who reported recent withdrawal experience. The study conducted interviews remotely via Zoom between April and August 2022 and later transcribed them professionally. The study team then coded data thematically using Atlas.ti, based on a combination of inductive and deductive coding strategies and informed by the literature and study aims. Results Participants described withdrawal as a significant issue that negatively impacts their treatment experience and increases the likelihood of treatment cessation. Their accounts of withdrawal were complex and often involved multiple factors; however, feeling underdosed and missing clinic dosing hours were seen as important vectors that led to their withdrawal experiences. Importantly, participants framed feeling underdosed and missing clinic dosing hours as institutional problems, resulting primarily from clinic policies, practices, and culture rather than from patients' decisions or individual behavior. Specifically, they cited restricted access to take-home doses, limited hours of operation, and a punitive focus on complete abstinence as factors that made withdrawal difficult to avoid. Conclusions Patients' accounts demonstrate a disconnect between providers' focus on promoting complete abstinence and patients, who were often using MMT for more pragmatic reasons that did not include complete abstinence from all drugs. These findings support growing calls for the integration of MMT into the mainstream healthcare system by making it available via prescription from office-based medical settings and dispensed through pharmacies.

Black sexual minority men and Black transgender women (BSMM/BTW) experience disproportionate levels of HIV/STI-related risk factors as well as police harassment (PH). PH is linked to psychiatric risk and could play a role in substance use, sexual risk behavior, and HIV/STI risk. We used data from the HIV Prevention Trials Network 061(HPTN 061) study to examine associations between PH and HIV/STI-related outcomes. Using PH exposure measured at baseline and 6-month study visits, we examined an ordinal exposure (PH reported at both visits, PH reported at either visit, versus PH reported at neither baseline nor 6 months) and a binary exposure of persistent PH reported at both visits (yes versus no). We estimate risk ratios (RR) for associations between PH and depression, use of alcohol and methamphetamine, multiple partnerships, condomless sex, and syphilis. Persistent PH (binary) was associated with a 20