The epidemiology of violence and posttraumatic stress disorder among street-based female sex workers in Baltimore, Maryland

Background: Female sex workers (FSW) experience high levels of sexual and physical violence, posttraumatic stress disorder (PTSD) symptoms and substance use. Despite these health risks, FSW are virtually absent in the mental health literature. This dissertation examined the role of numerous dimensions of violence and substance use on PTSD symptoms using data from an observational cohort study of street-based FSW. Methods: Street-based FSW were enrolled into The Sex workers And Police Promoting Health In Risky Environments (SAPPHIRE) cohort, an observational prospective cohort in Baltimore, Maryland. Recruitment occurred between April 2016 and January 2017 and utilized targeted sampling methods. Data from participants who completed the PTSD Checklist for DSM-5 (PCL-5) at baseline (N=230; Aims 1 & 2) and six-month follow-up (N=130; Aim 3) were included in the analyses. Several statistical methods were used to achieve the aims including Confirmatory Factor Analysis, Poisson regression, Linear regression, and Multinomial Regression. Results: Among 230 FSW, mean age was 36 years, and mostly Non-Hispanic White (66%), followed by Non-Hispanic Black (23%) and Hispanic/Other (11%); half (51%) did not complete high school, 62% were homeless, and 86% were daily heroin/cocaine users. Most (81%) had a history of sexual/physical violence at baseline. Over half (56%) met symptom criteria for DSM-5 PTSD and 28% were subsyndromic. Factor analysis supported a 4-factor DSM-5 model of PTSD. Exposure to ≥2 violence types held a dose-response relationship with each PTSD symptom cluster (p<0.01). Sexual and physical revictimization at baseline was high at 15% and 38% respectively. While all four types of violence were independently associated with PTSD severity (childhood sexual: β=14.43, 95% CI: 9.56, 19.31; adulthood sexual: β=14.04, 95% CI: 5.02, 23.06; childhood physical: β=12.35, 95% CI: 0.26-24.44; adulthood physical: β=11.02, 95% CI: 1.74-20.29), revictimization interactions were not observed (p>0.2). Cumulative violence had a non-linear dose-response relationship with PTSD severity (p<0.05). Binge drinking was also independently associated with higher PTSD severity in both multivariate models (p<0.05). Recent polyvictimization was common (68%) among those exposed to violence over follow-up. Cumulative violence at baseline predicted both high stable PTSD (relative risk ratio[RR]=2.51, 95% CI: 1.61-3.90) and high-to-low PTSD (RR=1.67, 95% CI: 1.01-2.74). Recent polyvictimization and reductions in drug use as effect modifiers did not reach statistical significance. Conclusions: Findings from this dissertation highlight that street-based FSW have a complex set of health needs and experience high levels of violence over the life course. Trauma-informed interventions will need to concurrently address PTSD symptoms, ongoing violence from multiple sources, and comorbidities including active drug and alcohol use. Interventions addressing violence against FSW must be non-stigmatizing and sensitive to the realities and needs of this structurally vulnerable population in order to be successful. Engaging police and the criminal justice system will likely be required in order to make a sustainable impact

Interpersonal Violence and Contraceptive Method Use by Women Sex Workers

Objective More than one-half of women sex workers (sex workers) in the United States experience interpersonal violence, defined as physical or sexual violence, by sexual partners, including clients or intimate partners. Women experiencing interpersonal violence by intimate partners often choose hidden, woman-controlled contraception (e.g., intrauterine devices, pills, or sterilization) because fear of violence can impede condom negotiation. Yet, little is known about how interpersonal violence relates to contraception among sex workers who may have different sexual partner perpetrators (clients and intimate partners). The purpose of this study was to examine associations between interpersonal violence perpetrated by clients or intimate partners and contraceptive use. Study Design Data are from an observational, prospective cohort of sex workers, aged 18 to 49 in Baltimore, Maryland (N = 218). Bivariate and multivariable logistic regression were used to assess associations between lifetime interpersonal violence and past 3-month contraceptive use. The outcome was any woman-controlled contraceptive use versus partner-controlled or no contraception. Results Nearly all sex workers (96.5%) reported contraceptive use, with most using male condoms (69%), nearly one-half using woman-controlled methods (43%), and 25% using dual methods (e.g., condoms and a woman-controlled method). Lifetime experiences of interpersonal violence by clients (58%) and intimate partners (52%) were prevalent. Sex workers who experienced interpersonal violence by intimate partners had over twice the odds of woman-controlled contraceptive use (adjusted odds ratio, 2.48; 95% confidence interval, 1.36–4.54). Conclusions Findings highlight the importance of relationship context in the associations between interpersonal violence and use of woman-controlled contraceptive methods among sex workers, because only violence experiences by intimate partners were associated with increased odds of woman-controlled contraceptive method use

Harm Reduction and Common Sense

In 2022, over 100,000 people in the US died of drug overdose, with the majority of these deaths occurring without a bystander present. People who use drugs alone are at high risk for fatal overdoses. Sensors designed to alert responders to a potential overdose detect the reduction of micro-movements (e.g., respiratory distress) in single-occupancy bathrooms. Naloxone and harm reduction practices are commonsense implementations to reduce overdose deaths in our community.  Since January 2023, we conducted 70 structured surveys to organizations in overdose hotspots across eight townships in Rhode Island. Sites surveyed were categorized into food service, gas/service stations, housing facilities, medical facilities, and retail establishments. Survey questions assessed overdose detection technologies feasibility, and acceptability, and perceived effectiveness of responding to overdoses as well as harm reduction practices and naloxone. Only 38.5% reported having naloxone present on site, of which 66.6% was inaccessible to non-staff members (e.g., patients, patrons). 50% of respondents indicated having no staff members trained in naloxone administration with 21.4% and 21.4% reporting some or all of their staff were trained, respectively. 67.6% reported having no standardized procedures in place to respond to an overdose on site outside of naloxone. 74.3% indicated being comfortable with installing the sensors, with 68.6% of respondents agreed that sensors could be effective at preventing overdose death at their site. The implementation of harm reduction practices in our community can be greatly beneficial in reducing fatalities and damage from overdose. Facilitating naloxone training and distribution, and overdose response at our university can also be incredibly impactful in helping raise awareness for this issue, regardless of substance use relevance. Further support is needed to fund and facilitate installing them in public locations where public drug use may go unnoticed

Fentanyl-contaminated drugs and non-fatal overdose among people who inject drugs in Baltimore, MD

Abstract Background The opioid crisis remains a major public health issue in the US and beyond. Despite rapid rises in fentanyl-related mortality nationally, little is known about the role of fentanyl in the occurrence of non-fatal overdose among people who use drugs. We examined the prevalence of non-fatal overdose and perceived fentanyl exposure among syringe services program (SSP) clients and modeled the correlates of non-fatal overdose. Methods Data were drawn from a cross-sectional survey of 203 SSP clients in Baltimore, MD recruited in 2016. Logistic regression models were used to identify the correlates of experiencing non-fatal overdose in the past 12 months. Results The majority (65%) was male, 52% were black, 41% were white, and 37% were homeless. Almost all (97%) used heroin, 64% injected heroin with cocaine (i.e., speedball), and many used other types of drugs. Half (53%) perceived fentanyl presence in their drugs either half, most or all of the time. Lifetime and past 12 month prevalence of non-fatal overdose were 58 and 31%, respectively. Independent correlates of non-fatal overdose in the past 12 months were perceiving fentanyl in drugs more than half the time (aOR = 2.79; 95% CI = 1.00–4.68), speedball injection (aOR = 2.80, 95% CI = 1.26–6.23), non-prescription buprenorphine use (aOR = 6.37; 95% CI = 2.86–14.17), and homelessness (aOR = 3.07; 95% CI = 1.28–7.39). Conclusions These data demonstrate that SSP clients are at high-risk of overdose, some of which is likely attributable to fentanyl exposure. Addressing the rising fentanyl epidemic will require comprehensive and innovative strategies that attend to drug use patterns and structural factors such as homelessness

Opioid-related overdose mortality in the era of fentanyl: Monitoring a shifting epidemic by person, place, and time

BackgroundWith the emergence of illicit fentanyl, fentanyl-involved overdose rates increased from 2013 to 2017 in the United States (US). We describe US trends in opioid-related overdose mortality rates by race, age, urbanicity, and opioid type before and after the emergence of fentanyl.MethodsUsing the Centers for Disease Control and Prevention's WONDER database, we estimated crude and age-standardized opioid-related overdose mortality rates at the intersections of race (non-Hispanic [NH] Black and white), age (&lt;55 and ≥55 years), sex (male and female) and urbanicity (urban and rural residence) from 2005 to 2017. We compare relative changes in mortality from 2013 to 17, and describe changes in the contributions of fentanyl, heroin, and other opioids to opioid-related overdose mortality.ResultsFrom 2013 to 2017, the overall opioid overdose mortality rate was consistently higher in NH white Americans, however, the rate increase was greater among NH Black (174 %) compared to NH white (85 %) Americans. The steepest increases occurred in the overdose rates between 2013 and 2017 among younger (aged &lt;55 years) urban NH Black Americans (178 % increase). Among older (≥55 years) adults, only urban NH Black Americans had an increase in overdose-related mortality rate (87 % increase). Urban NH Black Americans also experienced the greatest increase in the percent of fentanyl-involved deaths (65 % in younger, 61 % in older).ConclusionsIn the era of increased availability of illicitly manufactured fentanyl (2013-2017), there has been a disproportionate increase in opioid-related overdose deaths among urban NH Black Americans. Interventions for urban NH Black Americans are urgently needed to halt the increase in overdose deaths

A Novel Capacity-Strengthening Intervention for Frontline Harm Reduction Workers to Support Pre-exposure Prophylaxis Awareness-Building and Promotion Among People Who Use Drugs: Formative Research and Intervention Development

BackgroundHIV prevalence among people who use drugs (PWUD) in Baltimore, Maryland, is higher than among the general population. Pre-exposure prophylaxis (PrEP) is a widely available medication that prevents HIV transmission, yet its usefulness is low among PWUD in Baltimore City and the United States. Community-level interventions to promote PrEP uptake and adherence among PWUD are limited. ObjectiveWe describe the development of a capacity-strengthening intervention designed for frontline harm reduction workers (FHRWs) to support PrEP awareness-building and promotion among PWUD. MethodsOur study was implemented in 2 phases in Baltimore City, Maryland. The formative phase focused on a qualitative exploration of the PrEP implementation environment, as well as facilitators and barriers to PrEP willingness and uptake, among cisgender women who use drugs. This work, as well as the existing literature, theory, and feedback from our community partners, informed the intervention development phase, which used an academic-community partnership model. The intervention involved a 1-time, 2-hour training with FHRWs aimed at increasing general PrEP knowledge and developing self-efficacy promoting PrEP in practice (eg, facilitating PrEP dialogues with clients, supporting client advancement along a model of PrEP readiness, and referring clients to PrEP services). In a separate paper, we describe the conduct and results of a mixed methods evaluation to assess changes in PrEP-related knowledge, attitudes, self-efficacy, and promotion practices among FHRWs participating in the training. ResultsThe pilot was developed from October to December 2021 and implemented from December 2021 through April 2022. We leveraged existing relationships with community-based harm reduction organizations to recruit FHRWs into the intervention. A total of 39 FHRWs from 4 community-based organizations participated in the training across 4 sessions (1 in-person, 2 online synchronous, and 1 online asynchronous). FHRW training attendees represented a diverse range of work cadres, including peer workers, case managers, and organizational administrators. ConclusionsThis intervention could prevent the HIV burden among PWUD by leveraging the relationships that FHRWs have with PWUD and by supporting advancement along the PrEP continuum. Given suboptimal PrEP uptake among PWUD and the limited number of interventions designed to address this gap, our intervention offers an innovative approach to a burgeoning public health problem. If effective, our intervention has the potential to be further developed and scaled up to increase PrEP awareness and uptake among PWUD worldwide

“Make yourself un-NIMBY-able”: stakeholder perspectives on strategies to mobilize public and political support for overdose prevention centers in the United States of America

Abstract Background Overdose prevention centers (OPCs), also known as supervised injection facilities and safe consumption sites, are evidenced-based interventions for preventing overdose deaths and drug-related morbidities. The pathways to legalizing OPCs in the USA have confronted multiple social, political, and legal obstacles. We conducted a multi-site, qualitative study to explore heterogeneities in these pathways in four jurisdictions, as well as to understand stakeholder perspectives on valuable strategies for galvanizing political and public support for OPCs. Methods From July 2022 to February 2023, we conducted 17 semi-structured, in-depth interviews with OPC policymakers, service providers, advocates, and researchers from California, New York City, Philadelphia, and Rhode Island, where efforts have been undertaken to authorize OPCs. Using inductive thematic analysis, we identified and compared contextually relevant, salient approaches for increasing support for OPCs. Results Participants described several strategies clustering around five distinct domains: (1) embedding OPC advocacy into broader overdose prevention coalitions to shape policy dialogs; (2) building rapport with a plurality of powerbrokers (e.g., lawmakers, health departments, law enforcement) who could amplify the impact of OPC advocacy; (3) emphasizing specific benefits of OPCs to different audiences in different contexts; (4) leveraging relationships with frontline workers (e.g., emergency medicine and substance use treatment providers) to challenge OPC opposition, including ‘NIMBY-ism,’ and misinformation; and (5) prioritizing transparency in OPC decision-making to foster public trust. Conclusion While tailored to the specific socio-political context of each locality, multiple OPC advocacy strategies have been deployed to cultivate support for OPCs in the USA. Advocacy strategies that are multi-pronged, leverage partnerships with stakeholders at multiple levels, and tailor communications to different audiences and settings could yield the greatest impact in increasing support for, and diffusing opposition to, future OPC implementation

Interrogating perceived relevance and feasibility of HIV pre-exposure prophylaxis: A novel model of PrEP acceptability among cisgender women who inject drugs

Introduction: Uptake of daily oral HIV pre-exposure prophylaxis (PrEP) remains low among cisgender women who inject drugs (WWID) in the U.S., who experience elevated sexual- and injection-mediated HIV exposure risks. While anticipated barriers to PrEP uptake have been explored, further work is needed to situate PrEP acceptability (i.e., PrEP interest and willingness) within the context of WWID’s lives and the HIV risk environment. Methods: We conducted semi-structured, in-depth interviews (N = 27) with cisgender WWID in Baltimore, Maryland, between April–September 2021. Interviews explored women’s daily survival needs, substance use practices, healthcare experiences, HIV risk perception, and PrEP perspectives. Thematic analysis revealed complex dimensions of WWID’s health perspectives and HIV risk conceptualization, from which a Psychosocial Model of PrEP Acceptability and a novel construct of ‘perceived PrEP relevance’ were developed using a grounded theory approach. Results: In our Psychosocial Model of PrEP Acceptability, anticipated PrEP feasibility and perceived PrEP relevance shape women’s interest in and willingness to initiate PrEP. Attending to PrEP-related healthcare tasks (e.g., medical appointments, bloodwork) and managing a daily medication regimen were anticipated as feasible but would likely be de-prioritized relative to women’s competing substance-related and survival needs. Women’s perceptions of both their locus of HIV risk and sufficiency of existing HIV prevention practices determined their perceived PrEP relevance. PrEP was least relevant for women perceiving their prevention practices as sufficient to mitigate self-controlled HIV risk and most relevant for women perceiving their prevention practices as insufficient to mitigate environmentally shaped HIV risk. Conclusions: Our models demonstrate how PrEP acceptability is influenced by WWID’s lived experiences and complex risk conceptualization. Effective multilevel interventions to enhance PrEP engagement should support women’s competing needs, affirm women’s existing prevention strategies, and address the harms of the HIV risk environment

Disruptions to naloxone training among lay and occupational responders in Maryland during the emergence of COVID-19: Early impacts, recovery, and lessons learned

Background: Opioid overdose death rates increased during the COVID-19 pandemic. Disruptions in community-based naloxone trainings could have reduced the likelihood of overdose reversal and increased the chances of a fatal overdose. We investigated changes in the number of people trained in naloxone administration and distribution in Maryland before, during, and after COVID-related stay-at-home orders. Methods: Data on naloxone training are from the Maryland Department of Health. We used interrupted time series models to estimate changes in average monthly number of people trained: [1] pre-interruption (4/2019–3/2020), [2] 1-month post-interruption (4/2020–5/2020), and [3] 12-month post-interruption (4/2020–3/2021). Trainees were classified as lay (e.g., people who use drugs) or occupational (e.g., law enforcement officers and harm reduction workers) responders. Results: There were 101,332 trainees; 54.1% lay, 21.5% occupational, and 23.4% unknown responder status. We observed a decrease in the average monthly number of trainees in the pre-interruption period (-235, p<0.001), a larger decrease of 93.2% during the 1-month post-interruption (-846, p = 0.013), and an increase during the 12-month post-interruption (+217, p<0.001). There was a significant decrease among occupational responders 1-month post-interruption, and a significant increase among lay responders in the 12-month post-interruption period. Conclusions: Findings suggest a marked decrease in naloxone trainees immediately after stay-at-home order, followed by a moderate rebound in the 12-months after stay-at-home order. The decrease in occupational responders trained may have limited access to naloxone, but would likely have been offset by increases in number of lay responders trained. Strengthening lay and occupational responder connections could maintain naloxone distribution during public health crises

Sex Workers as Mothers: Correlates of Engagement in Sex Work to Support Children

Background Globally, most female sex workers (FSWs) are mothers but are rarely considered as such in public health and social service programs and research. We aimed to quantitatively describe FSWs who are mothers and to examine correlates of current engagement in sex work to support children among a cohort of FSWs in Baltimore, Maryland, United States (U.S.). Methods The study utilized baseline survey and HIV/STI testing data from the Sex workers And Police Promoting Health In Risky Environments (SAPPHIRE) study of women engaged in street-based sex work in Baltimore, Maryland. Variable selection and interpretation were guided by Connell’s theory of Gender and Power. We used bivariate and multivariate logistic regression analyses to examine correlates of engagement in sex work to support children among FSW mothers. Results Our sample included 214 FSWs with children, of whom 27% reported supporting children as a reason for the current engagement in sex work. Median age was 36 years, and mean number of children was 2.88. A total of 20.6% were currently living with any of their minor aged children, and this was significantly more common among mothers engaged in sex work to support children (57.9% vs. 7%; p \u3c 0.001). A total of 38.7% had ever lost legal custody of children, which was significantly less common among those supporting children through sex work (26.8% vs. 42.9%; p = 0.033). In multivariate analyses, the following were independently associated with engaging in sex work to support children: African-American versus white race (aOR = 2.62; 95% CI 1.18–5.82; p = 0.018), less housing instability (aOR = 0.42; 95% CI 0.20–0.89; p = 0.024), initiating sex work at age \u3c 23 (aOR = 2.59; 95% CI 1.23–5.46; p = 0.012), less frequent intoxication during sex with clients (aOR = 0.31; 95% CI 0.14–0.67; p = 0.003), and reporting mental health as most important health concern (aOR = 2.37; 95% CI:1.09–5.17; p = 0.029). Conclusions FSW mothers who report engagement in sex work to support children are distinct from their counterparts in key areas related to HIV and other health outcomes. Neglecting to account for this important social role may lead to missed opportunities to meaningfully promote physical and mental health and to engage women on their own terms. Future research and interventions should seek to address FSWs as whole social beings and center their experiences and needs as mothers