Faculty Bibliography

Stigma in healthcare settings is a critical barrier to HIV prevention and treatment among people who inject drugs (PWID). While previous tools have measured anticipated stigma, few account for the intersectional and provider-specific experiences of PWID-particularly from syringe service programs (SSPs). We developed and validated the Substance Use Anticipated Provider Stigma Scale (SU-APSS), a multidimensional instrument assessing anticipated stigma from four provider types: healthcare workers, substance use treatment staff, pharmacists, and SSP personnel. Data were drawn from a cross-sectional survey of 264 PWID who were 18 or older, HIV-negative, had injected drugs and used opioids within the past 30 days, and showed visible signs of recent injection. We conducted confirmatory factor analysis (CFA) on responses from 218 participants to evaluate structural validity and used Cronbach's alpha to assess internal consistency. The CFA supported a four-factor structure with strong model fit indices (CFI = 0.97, RMSEA = 0.09 [0.07, 0.11], SRMR = 0.04). All items significantly loaded onto their respective factors (loadings: 0.62-1.06). Internal consistency was high across all subscales (α = 0.85-0.96) and for the overall scale (α = 0.87). Attribution analysis revealed drug use, physical appearance, and income level as the most common perceived reasons for anticipated stigma. The SU-APSS offers a practical tool for identifying provider-specific stigma, informing stigma-reduction interventions, and evaluating implementation strategies to improve HIV prevention and care engagement among PWID.

BACKGROUND/UNASSIGNED:Despite the growing relevance of rural areas in the overdose crisis, research on rural people who inject drugs and their experiences with law enforcement remains limited. This research examines how rural policing and stigma uniquely shape the lives of people who inject drugs. METHODS/UNASSIGNED:Forty-one semi-structured qualitative interviews were conducted with people who inject drugs in southern Illinois. For this analysis, we focused on participants who mentioned police in response to the question, "Have you ever been treated differently because you used drugs?" RESULTS/UNASSIGNED:We identified three interrelated manifestations of stigma in rural people who inject drugs' interactions with police-verbal degradation and discrediting, unwarranted searches, and dehumanization-that align with Earnshaw's (2020) model distinguishing between stigma components (stereotypes, prejudice, discrimination) and health impact pathways. CONCLUSION/UNASSIGNED:This study emphasizes the impact of stigma on people who use drugs, particularly in their interactions with law enforcement.

HIV continues to disproportionately affect key populations in Malaysia, compared to the general population. Lessons learned from decades of research and programmatic experience suggest that HIV activism can be a driver for change. We pilot-tested a tele-training platform, Project ECHO^® for Stigma Reduction (PE-SR), in a randomised controlled trial from July 2022 to March 2023, alongside two comparator groups, i.e., Project ECHO^®-Standard (PE-S) and the conventional HIV training program for clinicians, HIV Connect (HC). We randomised 78 primary care physicians and general practitioners across Malaysia into the three study arms (n = 26 each). We evaluated changes in HIV activist identity and commitment, and orientation towards day-to-day HIV activism and structural HIV activism. Repeated measure analysis of covariance (ANCOVA), controlling for age, years of practice, and contact with key populations as covariates, compared changes in HIV activism constructs across time and groups. The randomised controlled trial yielded mixed results. We observed statistically significant changes in HIV activist identity and commitment, as well as changes in orientation towards structural activism in all groups. We also found statistically significant mean differences between PE-S and HC in terms of HIV activist identity and commitment, and between PE-SR and HC in terms of orientation towards structural activism. Results suggest that stigma reduction tools embedded in a tele-training platform had a preliminary impact on HIV activism and could be scaled up and tailored to train clinician-activists.Trial Registration NCT05597787.

BACKGROUND/UNASSIGNED: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/UNASSIGNED: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/UNASSIGNED: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/UNASSIGNED: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.

BACKGROUND:Community Network-Driven COVID-19 Testing and Vaccination of Vulnerable Populations in the Central United States (C3) evaluates the use of Social Network Strategy (SNS) with educational messaging to improve COVID-19 testing and vaccination among people most impacted by the pandemic. METHODS:We enrolled individuals with low-income who identify as Hispanic/Latino or a history of criminal legal involvement (CLI) through social network referral and randomized participants 1:1 to SNS vs. SNS plus messaging (SNS+), which included a self-affirmation activity and educational video. We assessed for COVID-19 testing and, among baseline unvaccinated participants, vaccination at 21 days, and used mixed effects logistic regression to examine outcomes. RESULTS:Of 1328 participants (SNS+: 667, SNS: 661), 46.6% identified as Black/African American, 33.4% as Hispanic/Latino, and 43.8% reported history of CLI. Majority (66.3%) reported testing and, of unvaccinated participants, 11.9% reported vaccination at follow-up. There were no differences in testing (aOR 0.89, 95% CI 0.71, 1.11, P = .49) or vaccination (aOR 1.46, 95% CI 0.78, 2.76, P = .30) among participants who received SNS+ compared to SNS after adjusting for recruitment wave and clustering within sites and referral chains. CONCLUSIONS:Social network referral successfully engaged communities disproportionately impacted by COVID-19 in testing and vaccination. Compared to SNS alone, adding educational messaging did not increase testing or vaccination. Additional work is needed to implement SNS to increase vaccination rates among vulnerable populations.

The social determinants of health (SDOH) framework has proven useful for research and practice in addressing the social causes of many health outcomes. However, its limitations may restrict its value as the world undergoes rapid ecological and social change. We argue that SDOH does not adequately incorporate rapidly changing or "far upstream" social processes (particularly social movements), the dialectics of social conflict and creative social innovation, or bidirectional causation. Ecosocial theory addresses some of these issues, yet dialectical frameworks offer additional insights during periods of rapid social change and disruption. The implications for research methods and practice are discussed. (Am J Public Health. Published online ahead of print September 18, 2025:e1-e9. https://doi.org/10.2105/AJPH.2025.308239).

The ongoing opioid crisis underscores the urgent need to understand and address stigma toward individuals with opioid use disorder (OUD). Applying message framing theory, this study examines how different segments of the public conceptualize OUD. Through in-depth interviews with 26 U.S. adults, segmented by their OUD experiences (personal, family/friend, or none) and stigma scores (high or low), we explored the underlying reasons for stigmatizing attitudes toward individuals with OUD. Our analysis revealed three key themes that differentiate perspectives between participants with higher and lower stigma scores: varying views on personal responsibility versus societal causes, the impact of non-addictive personal opioid use experiences on perceptions of addiction, and the role of perceived proximity to the epidemic in shaping attitudes. Participants with higher stigma scores predominantly viewed OUD as a matter of personal choice, while those with lower stigma scores emphasized systemic factors and medical models. Personal experiences with non-addictive opioid use tended to reinforce rather than challenge existing frames, with participants with higher stigma scores interpreting such experiences through a personal responsibility lens. Our findings suggest that effective anti-stigma messaging will likely need to start within audience members' preferred frames before gradually introducing alternative perspectives, particularly for audiences with higher OUD stigma scores who strongly resist medical or societal responsibility frames. This study advances message framing theory by detailing how different audience segments frame and interpret OUD, offering insights for developing more effective communication strategies that can bridge opposing viewpoints while maintaining scientific accuracy.

BACKGROUND/UNASSIGNED:Limited literature exists on how concurrent substance use and difficulty meeting basic needs impact recent psychiatric treatment among people who inject drugs (PWID) with diagnosed mental health disorders in the U.S. This study assessed the prevalence of taking current psychiatric medication treatment, and its association with concurrent substance use and subsistence difficulty. METHOD/UNASSIGNED:Baseline data from a prospective cohort study in Los Angeles, CA and Denver, CO between April 2021 and November 2022 were analyzed. Modified Poisson regression assessed the association between demographics, concurrent substance use, subsistence difficulty, and recent psychiatric medication treatment. RESULTS/UNASSIGNED:Out of 429 PWID, 287 (66.9%) who reported a history of diagnosed mental health disorders were included. Among them, 86.8% of participants were unhoused or unstably housed, and 22.6% reported taking prescribed psychiatric medications in the past three months. Factors positively associated with current psychiatric medication treatment included older age (40-59: adjusted prevalence ratio [aPR] = 1.84, 95%CI: 1.15, 2.94); 60-76: aPR = 2.22, 95%CI: 1.21, 4.06; vs. 20-39 years old), non-medical prescription opioid use (aPR = 1.57, 95%CI: 1.06, 2.35), and recent overdose (aPR = 2.16, 95%CI: 1.45, 3.22). Conversely, being unhoused or unstably housed (aPR = 0.51, 95%CI: 0.29, 0.89) and high subsistence difficulty (aPR = 0.41, 95%CI: 0.21, 0.81) were less likely to take prescribed psychiatric medications. CONCLUSION/UNASSIGNED:A significant gap exists in psychiatric medication treatment among PWID with diagnosed mental health disorders. Integrated treatment programs addressing essential needs, such as food and clothing, alongside overdose prevention and mental health care, are urgently needed, particularly for those struggling with substance use and housing instability.

There is an urgent need to ensure the opioid overdose reversal agent naloxone is available to protect youth given the increasing rates of overdose among this population. Through a public-academic partnership, overdose education and naloxone distribution training were provided to nonmedical public school staff in New York City. School staff were invited to a 90-minute in-person training. Consented participants took a pre- and post-survey to assess their overdose knowledge, confidence, and substance use stigma. A majority of respondents had never received training on how to identify an opioid overdose (70.7%) or how to administer naloxone (73.5%). Participants' overdose knowledge, including recognition of the signs of an overdose, response actions, and confidence to respond, significantly increased pre- to post-training. Participants' stigmatization of drug use significantly decreased following the training. Naloxone access and opioid overdose response training for nonmedical school staff is an acceptable and effective solution to expand overdose response. The significant reduction in participants' stigmatization of drug use suggests overdose education and naloxone training that address stigma may help prevent unnecessary mortality among youth.

INTRODUCTION/BACKGROUND: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.