Since 2010, Kazakhstan has experienced an increase in HIV transmission. Men and transgender/gender-expansive people who have sex with men (MSM and TSM) carry a disproportionate HIV burden. Building on Paine et al. (2021), which linked HIV testing to stigma, internalized homophobia, and sexual- and gender-expansive (SGE) community connectedness—this brief report examined biologically confirmed HIV and other sexually transmitted infections (STIs). SGE connectedness was significantly associated with HIV infection, while HIV stigma and internalized homophobia were significantly associated with STIs. Interventions reducing stigma and strengthening SGE community ties may curb HIV and STI transmission among MSM and TSM in Kazakhstan.

HIV transmission in Kazakhstan has increased among men who have sex with men (MSM) and transgender and nonbinary people who have sex with men (TSM), driven by low HIV testing rates. PRIDE in HIV Care is an intervention designed to have a community-level effect of increasing HIV testing among MSM and TSM in Kazakhstan. The intervention was tested using a stepped-wedge, cluster-randomized controlled trial across three cities in Kazakhstan: Almaty, Astana, and Shymkent. The order of intervention implementation by city was randomly set to occur in 6-month increments. The PRIDE in HIV Care intervention is a theory-driven “crowdsourcing and peer-actuated network intervention” designed to amplify community members’ successes and resilience via “influencers” who can strengthen and impart benefit to their networks and community. We collected serial cross-sectional data where MSM and TSM (N = 629) among the study cities completed one assessment between 21 August 2018, and 30 March 2022. The primary outcome was whether they had received an HIV test in the prior six months. There was a statistically significant increase in odds of recent HIV testing for every additional month the intervention was implemented in a respondent’s city (AOR = 1.08, 95

AIM:We evaluated whether community-level naloxone distribution, medication for opioid use disorder treatment and retention and incident high-risk opioid prescribing rates were associated with opioid overdose death rates. DESIGN:Observational cohort conducted using 2019 to 2023 community-level data as an exploratory analysis of the HEALing (Helping to End Addiction Long-term®) Communities Study (HCS). Exposures included: (1) community-level naloxone distribution, past 12-months, categorized as ≤1000 units per 100 000 population vs. 1001-3000 units per 100 000 population vs. >3000 units per 100 000 population; (2) individuals treated with buprenorphine per 100 000 adult population in the current quarter; (3) individuals retained on buprenorphine for ≥ 180 days per 100 000 adult population in the current quarter; and (4) incident high-risk opioid prescribing per 100 000 adult population in the current quarter. SETTING AND PARTICIPANTS:Population-based study of 67 communities with 8.2 million adults in Kentucky, Massachusetts, New York and Ohio, USA, with required annual opioid overdose death rates of > 25 per 100 000 adult population and at least 30% rural. Across the 67 communities participating in the HCS, the adult population was 31% 18-34 years, 31% 35-54 years, 38% 55 years and over, 52% female, 73% non-Hispanic White, 15% non-Hispanic Black and 7.4% Hispanic. MEASUREMENTS:Quarterly community-level opioid overdose death rates from 2020 through 2023. FINDINGS:The 2019 annual rates were 40.4 opioid overdose deaths, 1287 naloxone rescue units distributed, 977.7 people received buprenorphine treatment, 546.3 people retained for more than 180 days on buprenorphine and 1266.7 high-risk opioid prescribing incidents per 100 000 population. In models adjusted for state, community age, sex, race/ethnicity, rurality, HCS intervention group assignment, 2019 rates of opioid overdose death, naloxone distribution, buprenorphine and high-risk opioid prescribing, and the ratio of opioid overdose deaths involving fentanyl, an increase in 100 people treated with buprenorphine per 100 000 population was associated with a decrease of 0.92 [95% confidence interval (CI) = -1.30 to -0.55] in the quarterly opioid overdose death rate, while an increase of 100 people retained on buprenorphine for more than 180 days per 100 000 population was associated with a decrease of 1.3 (95% CI = -1.8 to -0. 76). There were no statistically significant associations between naloxone distribution or incident high-risk opioid prescribing with change in quarterly opioid overdose death rates. CONCLUSIONS:In this exploratory analysis, increases in both buprenorphine treatment and retention were statistically significantly associated with decreases in opioid overdose death rates, after adjusting for baseline rates of buprenorphine treatment and retention.

Despite efforts to end the HIV epidemic, new transmissions among Black women in the U.S.’ Deep South remain disproportionately high. This study examined condomless sex experiences and PrEP non-engagement among Black women in community supervision programs (e.g., diversion, probation, parole) in Alabama. As part of Project E-WORTH South, we used a phenomenological approach and conducted 16 semi-structured interviews to explore factors influencing condom use and PrEP engagement. Participants (n = 16) were selected through criteria-based sampling: Black or African American individuals, female at birth, aged 18 years or older, English-speaking, and current community supervision involvement. Interview transcripts were double-coded using a phenomenological coding technique to identify general themes. The codes were then grouped into themes and subthemes. Analysis revealed four distinct forms of agency that participants employ in sexual health decision-making, mapped along two dimensions: structural constraints/coercion and HIV prevention knowledge/resources. Despite 37.5

This study examines associations between male- and female-perpetrated psychological, physical, and sexual intimate partner violence and child protective services involvement among Black women under community supervision in New York City ( N = 247). Up to 72.1% of women experienced lifetime intimate partner violence (IPV) and 55.9% child protective services (CPS) involvement as parents. Women had significantly higher odds of CPS involvement if they experienced sexual IPV by male partners, multiple forms of IPV by male partners, or multiple forms of IPV by any partner (ORs: 1.8; 95% CIs: 1.1, 3.0; p < .05). Adjusted models lacked significance, suggesting further research and service needs.

Community coalitions are a common implementation strategy for addressing public health challenges, such as the opioid epidemic. There remains a lack of understanding of the factors that support implementation effectiveness for community coalitions. This study leverages the HEALing Communities Study (HCS) which tested the Communities That HEAL (CTH) approach to supporting community coalitions to increase delivery of opioid overdose and naloxone distribution (OEND) and medication for opioid use disorder (MOUD) through facilitation, data-driven decision making, and a communications campaign. Using a parallel convergent, nested serial case study with a positive deviance design, we selected high performing waitlist control communities participating in the HCS for further examination. Performance was defined based on average ranking across a set of implementation measures; the top performing urban and rural community within each of the four HCS sites was then selected for in-depth case study. For selected sites, we conducted thematic analysis of qualitative interviews with coalition members (n = 41) conducted at the end of the implementation phase. Analysis was aligned with the PRISM/ RE-AIM framework. Despite achieving top performance, these communities still faced persistent and varied challenges related to OUD service delivery and access. However, community assets and policy changes provide a foundation for improvement. Implementation success was supported by representative coalition membership, high engagement, and alignment with coalition goals. Coalition members were highly collaborative and shared a vision for their community. Implementation success was also supported by coalition buy-in to the CTH process. Structured data connectivity and sharing facilitated effective strategy selection, while multi-channel communications campaigns increased awareness and uptake of OUD and MOUD services. No differences were observed across urban and rural communities. Implementation success reflects the synergy among external context, coalition strength, and intervention processes. Community coalition–based strategies benefit from ensuring representative membership and shared goals to build buy-in, while also leveraging data infrastructure and communication campaigns to promote effective implementation of EBPs. NCT04111939.

People under community supervision who use drugs face elevated HIV risk. This randomized controlled trial used a mixed-methods approach to examine PrEP acceptance among community-supervised men who use drugs and their female partners. The study evaluated PrEP willingness among participants (N = 394) randomized to either PACT (5-session couples’ HIV intervention) or control (1-session HIV counseling). Qualitative interviews with 20 couples (n = 40) explored PrEP attitudes. The PACT group showed significantly higher intentions to use condoms with PrEP compared to controls (64

Addressing the opioid overdose crisis requires developing contextually specific strategies promoting the adoption of evidence-based practices (EBPs) to prevent and treat opioid use disorder (OUD), including overdose education and naloxone distribution (OEND) and medications for OUD (MOUD). To effectively reach the groups most affected by the opioid crisis, EBP strategies must be adjusted to fit the culture and contexts of different communities. The HEALing Communities Study engaged coalitions in 67 communities across four states to select and implement EBP strategies to reduce opioid overdose mortality. Coalitions were encouraged to culturally adapt EBP strategies for “special populations,” which were defined as groups that are highly impacted by OUD and face unique challenges in accessing prevention and treatment services. EBP strategies, and any efforts to culturally adapt them, were documented in coalition action plans. We collected quantitative and qualitative details from coalitions’ action plans. Following the first wave of the intervention (January 2020 – June 2022), we utilized the DATA (Describe, Analyze, Theorize, and ACT) model to evaluate the HEALing Communities Study approach to reaching special populations and identify areas for improvement. Finally, we identified variations across states in how cultural adaptation was interpreted and implemented. We provide strategies to improve how cultural adaption strategies are developed, documented, implemented, and monitored in future studies. Coalitions selected and implemented a variety of culturally tailored EBP strategies. However, complete understanding of the nature and effectiveness of cultural adaptation was limited by varying interpretations of what counts as cultural adaptation, inconsistent use of reporting guidance across research sites, and lack of data on the reach of each EBP strategy. Examples of cultural adaptation that successfully reached special populations included locating EBP strategies near each other to reduce transportation barriers, funding community-based organizations to help unhoused individuals meet basic needs, and hiring a bilingual and bicultural workforce to support prevention and treatment for OUD. Future studies should improve reporting of intersectional identities, measure EBP strategies’ reach, utilize real-world evidence of successful implementation strategies for cultural adaptation, and incorporate qualitative methods to contextualize cultural adaptation at local levels. We call on funders, researchers, evaluators, and implementers to invest in training and technical assistance, robust documentation and monitoring protocols, and thoughtful community engagement to support cultural adaptation of EBP strategies to reduce overdose for the most vulnerable populations. Trial registration: ClinicalTrials.gov Identifier: NCT04111939. Date of registration 10/01/2019.

BackgroundCentral Asia, and Kazakhstan in particular, is virtually absent from global transgender (trans) Human Immunodeficiency Virus (HIV) research, despite evidence of disproportionate barriers to care. This absence erases local realities, weakens the evidence base, and renders communities invisible in policy. While global studies highlight trans people's heightened vulnerability to HIV and sexually transmitted infections (STIs) due to stigma, limited access, and scarce affirming services, little epidemiological data from Central Asia exists. This study addresses that absence by examining both known and newly detected infection prevalence among trans participants in Kazakhstan, underscoring the need to center trans health in the pursuit of collective trans liberation.AimsGenerate the first empirical data on HIV risk, prevention engagement, and structural determinants among trans people in Kazakhstan, situating findings within regional and global commitments to leaving no one behind in health.MethodsAnalysis of HIV and STI prevalence among 68 trans participants in Almaty, Astana, and Shymkent (2018-2022), drawing on behavioral and biological data from a National Institute on Drug Abuse-funded prevention trial for substance-using cisgender (cis) and trans gay and bisexual men who have sex with men.ResultsMost participants (69%) had tested for HIV at least once, 32% in the past six months; however, 37% did not know their current status. Fourteen (21%) were confirmed HIV-positive, 79% previously unaware. Nearly half tested positive for at least one STI, with 10% for multiple.DiscussionFindings reveal high HIV and STI burdens and critical gaps between self-reported awareness and confirmed diagnoses. Testing rates fall below UNAIDS 95-95-95 targets, highlighting the urgent need for expanded testing, research, and community-led interventions. Making these realities visible is essential for improving health in Kazakhstan and advancing collective trans liberation worldwide; without centering trans experiences, the global struggle for trans health and rights remains incomplete and the principle of leaving no one behind unfulfilled.

Opioid-related overdose is the leading cause of mortality among individuals recently released from incarceration in the U.S. Naloxone is an FDA-approved opioid antagonist medication designed to rapidly reverse opioid overdose. Despite evidence of its acceptability and effectiveness at reducing the risk of opioid overdose death after release from incarceration, only an estimated 25

Introduction:The goal was to evaluate how changes in coalition capacity and leadership were related to adoption and reach of overdose education and naloxone distribution in communities participating in the HEALing Communities Study. Study Design:This was a multisite, cluster randomized waitlist-controlled trial; only analysis of Wave 1 data was performed. Setting/Participants:Longitudinal analysis of cross-sectional surveys completed by coalition members from 33 communities in 4 states based on data collected from January 2021 to June 2022. Intervention:Study coalitions (n=33) received the Communities That HEAL intervention to support expansion of evidence-based practices, including overdose education and naloxone distribution, to curtail opioid-related fatalities. Main Outcomes:Coalition capacity and leadership were measured at the midpoint and end of the intervention using validated scales averaged at the community level. Community adoption and reach of overdose education and naloxone distribution were assessed as changes in the rate of community partners implementing overdose education and naloxone distribution strategies and naloxone units distributed from midpoint to the end of the intervention. Negative binomial and linear models, adjusted for baseline characteristics, were conducted in 2024. Results:Increases in general coalition capacity, adjusted for changes in overdose education and naloxone distribution-specific coalition capacity, were significantly associated with higher rates of community partners engaged in overdose education and naloxone distribution implementation. There was a 56% increase over time in community partners engaged in overdose education and naloxone distribution implementation per unit increase in general capacity scores among coalitions receiving Communities That HEAL. Changes in coalition leadership and capacity did not significantly correlate with changes in naloxone being distributed. Conclusions:Strengthening general coalition capacity is vital for increasing community partner engagement to expand adoption of overdose education and naloxone distribution. Findings support ongoing investment in coalition capabilities to enhance the effectiveness of public health interventions seeking to reduce opioid-related fatalities. Efforts to strengthen general capacities of coalitions, such as data-informed decision making and collective goalsetting, may accelerate implementation and scaling of evidence-based practices such as overdose education and naloxone distribution.

BACKGROUND:We describe the Community Advisory Board (CAB) development and costing processes employed by The Helping to End Addiction Long-term (HEALing) Communities Study, Massachusetts (HCS-MA). The actual process and costs associated with establishing a CAB representative of people who use drugs have not been published. METHODS:A participatory process was used to identify and recruit CAB members. Health economics costing strategies were used to develop an understanding of the economic costs associated with developing the CAB. RESULTS:A statewide CAB composed of 23 persons was created. The 6-month total costs, including personnel costs (both study staff and CAB members) and administrative costs (e.g., meeting costs) were $49,615. CONCLUSION:Results indicate intentional outreach can leverage existing community ties to develop CABs that are representative of communities but necessitate a focus on equitable resource allocation.

Introduction:The opioid epidemic in the USA presents a multifaceted challenge regulated by a patchwork of federal, state and local policies. In some communities, cross-sector coalitions navigate this complex policy environment to address the epidemic. However, limited research has explored these public health-oriented community coalitions and their interactions with the policy landscape. This study explores how cross-sector public health-oriented community coalition members perceive and navigate the multidimensional policy landscapes to address the opioid epidemic. Methods:Using data from 304 semistructured HEALing Communities Study coalition member interviews conducted April-June 2021 in 67 communities in Kentucky, New York, Massachusetts and Ohio, we inductively analysed participants' discussions of opioid-related policies to characterise themes and subthemes. Results:We describe two themes where coalitions and policy intersect: policy landscape barriers and navigation and mitigation strategies to address policy barriers. Participants revealed community misunderstandings and lack of knowledge of opioid-related policies. Furthermore, participants shared how these policies often hindered coalitions' initiatives to address substance use. Nevertheless, community coalitions functioned despite these policy challenges through knowledge sharing, innovation and policy advocacy. Conclusions:Cross-sector public health-oriented community coalitions serve a vital role in navigating the complexities of the multidimensional policy landscape regulating substance use services. Insights from these findings may encourage policy-makers to support community coalitions in pursuing solutions to the opioid crisis and other public health crises. Trial registration number:NCT04111939.

Introduction:Prescription opioids can contribute to risk for opioid use disorder and overdoses. Improving prescription opioid safety is a critical component in reducing opioid risks. This report aims to determine whether communities randomized to the Communities That HEAL (CTH) intervention have significantly different rates of prescription opioid safety measures. Study Design:A multisite, 2-arm, community-level, cluster randomized, unblinded, wait-list controlled comparison trial designed to assess the effectiveness of the CTH intervention in reducing opioid-related overdose deaths among community residents 18 years of age or older (adults). Setting/Participants:Sixty-seven (67) communities in Kentucky, Massachusetts, New York, and Ohio. Participants were communities in this study. Intervention:The Communities That Heal intervention consists of multiple dimensions: a coalition-driven community engagement process to select and support implementation of evidence-based practices; the Opioid-overdose Reduction Continuum of Care Approach, a compendium of evidence-based practices and technical assistance resources organized under overdose education and naloxone distribution, medication for opioid use disorder, and prescription opioid safety menus; and communication campaigns intended to reduce opioid use disorder stigma and raise awareness and demand for naloxone and medication for opioid use disorder. Main Outcomes and Measures:The main outcome was the number of adults with new incident high-risk opioid prescribing episodes after at least a 45-day washout. Other outcomes included the number of opioid-naïve adults with new opioid prescriptions limited to a 7-day supply, number of adults who received opioid prescriptions from multiple prescribers or pharmacies, and number of locations providing drug take-back services. Outcomes were assessed from July 2021 to June 2022. Results:There was no statistically significant difference in the adjusted rates for new incident high-risk opioid prescribing per 100,000 adults during the comparison period between intervention (1,094.48; 95% CI=1,063.15; 1,126.74) and wait-list control communities (1,121.90; 95% CI=1,079.62; 1,165.84). The adjusted relative rate comparing intervention to wait-list control communities was 0.98 (95% CI=0.93, 1.02; p-value=0.296). Similarly, there were no statistically significant differences between intervention and wait-list control communities for the other outcomes. Conclusions:Although no statistically significant differences were found in prescription opioid safety measures between study arms, improvement in these measures during the comparison period for both study arms suggested that there may have events outside the trial, such as published revised Center for Disease Control and Prevention clinical practice guidelines for prescribing opioids, that may have impacted study outcomes.

Background:When examining the relationship between intimate partner violence (IPV) and substance use, most studies have focused exclusively on individual-level correlates without considering cross-partner associations. Given the bidirectional nature of IPV within intimate relationships, a dyadic (couple) approach may assist in gaining a more precise understanding of the complex interrelationships between IPV, substance use, and overdose risks among couples. Methods:We employed the Actor-Partner Interdependence Model (APIM) using baseline data from a randomized controlled trial to examine how perpetration and experience of IPV in the past three months may be associated with substance use and non-fatal overdose risks among men in community supervision programs in New York City and their intimate partners (N=412 participants; 212 male and 196 female). The actor and partner effects were estimated using a multilevel logistic regression model with membership of a couple as a random effect for partner dependency, adjusting for key demographic factors. Findings:Over one-third of the participants (n=157, 38.1%) reported experiencing IPV and perpetrating IPV (n=149, 36.2%). Female participants who had been in the ER due to drugs or alcohol were more likely to report experiencing IPV (OR=2.62, 95% CI=1.02-6.88, p=0.046) and perpetrating IPV (OR=2.41, 95% CI=1.02-5.73, p=0.046) than those who had not been in the ER. Male participants who had been in the ER due to drugs or alcohol were also more likely to report perpetrating IPV (OR=3.07, 95% CI=1.31-7.16, p=0.010). Male participants who had experienced overdose were more likely to report perpetrating IPV than those who had not (OR=2.90, 95% CI=1.20, 7.01, p=0.018). No partner effects of overdose risks were significantly associated with participants' reports of IPV. Implications for D&I Research:Our findings suggest a complex relationship between IPV and substance use behaviors, with primarily actor effects, but no significant partner effects. Understanding these relationships is important for developing integrated interventions that address both IPV and substance use risks among tice-involved populations. Such approaches may help address racial health inequities in drug overdose rates among non-Hispanic Black and Latinx populations, who are disproportionately impacted by the criminal legal system due to racialized drug laws and policing.

BACKGROUND:The HEALing Communities Study (HCS) was conducted across four states with the goal of decreasing opioid-related overdose deaths by increasing community-level adoption of evidence-based practices (EBPs). Providing communities with training, technical assistance, and resources to aid them in addressing opioid overdoses was central to the Communities That HEAL (CTH) intervention. The intervention included 1) community engagement (CE) to facilitate data-driven EBP selection and implementation, 2) a menu of EBPs to implement, and 3) communication campaigns. METHODS:We performed an economic cost analysis for the 33 communities implementing CTH over a 30-month intervention period in Kentucky, Massachusetts, New York, and Ohio. Cost data were obtained from community members, consultants, and research faculty and staff. This study focuses on the communities' perspective and reports costs paid directly with HCS funds and the opportunity costs of community members' time and other unreimbursed resources. We report average costs across communities and for each component of the CTH. RESULTS:The average cost per community of CE was $1030,405, EBPs was $668,030, and communication campaigns was $235,915. The total community cost of CE was $34,003,373, of EBP implementation was $22,044,987, of communications campaign was $7785,182. CONCLUSIONS:Our study provides insight into the scope and value of resources incurred to implement community-based interventions to reduce opioid overdose deaths across four states.

INTRODUCTION:The HEALing (Helping to End Addiction Long-Term®) Communities Study (HCS) aimed to reduce opioid-involved overdose deaths across four states (Kentucky, Massachusetts, New York, and Ohio) via community-engaged implementation of three evidence-based practices (EBPs): (1) opioid overdose education and naloxone distribution, (2) medication for opioid use disorder expansion/linkage/retention, and (3) safer opioid prescribing and dispensing practices. A policy workgroup (PWG) was convened and developed a procedure to identify and address policies potentially impacting EBP implementation. METHODS:A five-step method was developed to identify, track, and respond to relevant policies at three of the research sites (Kentucky, Massachusetts, and New York) in collaboration with community partners and stakeholders. Policies possibly impacting EBPs were reported, reviewed, and documented, including any actions taken to address the policy issue. Policies were discussed with local, state, and federal level stakeholders in attempts to resolve barriers, clarify misunderstandings, and disseminate facilitators. RESULTS:A total of 87 (Kentucky = 37; Massachusetts = 19; New York = 31) policies were identified and addressed; 42 were identified as barriers, 24 as facilitators, and 21 as misunderstandings. PWG efforts resolved over 73 % (n = 31) of policy barriers, clarified 90 % (n = 19) of policy misunderstandings, and disseminated 100 % (n = 24) of policy facilitators. CONCLUSIONS:A community-driven approach in policy surveillance identified, addressed, and disseminated several different types of policy issues that could impact implementation of EBPs for opioid-involved overdose prevention. Many policy barriers persisted during the HCS study, which may have adversely affected study outcomes.