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Despite recent HIV outbreaks among people who inject drugs (PWID) in nonurban US settings, syringe service programs (SSP) are often inaccessible in these communities. Furthermore, pre-exposure prophylaxis (PrEP) awareness and coverage for PWID is limited. We aimed to model the impact of PrEP on HIV transmission among PWID in a rural setting.Using a calibrated agent-based model, we simulated HIV transmission in an adult population (n = 14,573 agents) in Scott County, Indiana between 2015 and 2024.We modeled PrEP eligibility according to CDC guidelines for PWID. PrEP coverage increased by 15% points in the range 10%-70%. Two counterfactual scenarios were modeled: Unrestricted access for PWID and PrEP for SSP attendees . We calculated the number of new HIV infections and number of person-years on PrEP per averted infection.In the status quo scenario, 153 (95% Simulation Interval: 85, 259) new HIV infections occurred among PWID over 10 years. Compared with the status quo, 40% PrEP coverage resulted in 25% fewer HIV infections in the Unrestricted access for PWID scenario and 10% fewer HIV infections in the PrEP for SSP attendees scenario. The PYPAI was 21 and 43 in the Unrestricted access for PWID and PrEP for SSP attendees scenarios, respectively.Our modeling suggests that PrEP provides substantial benefit to PWID in rural US communities, with fewer restrictions on access providing the greatest effect. Control of HIV outbreaks will require expansion of public health interventions that meet the needs of all individuals.

We developed an agent-based model using a trial emulation approach to quantify effect measure modification of spillover effects of pre-exposure prophylaxis (PrEP) for HIV among men who have sex with men (MSM) in the Atlanta-Sandy Springs-Roswell metropolitan area, Georgia. PrEP may impact not only the individual prescribed, but also their partners and beyond, known as spillover. We simulated a two-stage randomised trial with eligible components (≥3 agents with ≥1 HIV+ agent) first randomised to intervention or control (no PrEP). Within intervention components, agents were randomised to PrEP with coverage of 70%, providing insight into a high PrEP coverage strategy. We evaluated effect modification by component-level characteristics and estimated spillover effects on HIV incidence using an extension of randomisation-based estimators. We observed an attenuation of the spillover effect when agents were in components with a higher prevalence of either drug use or bridging potential (if an agent acts as a mediator between ≥2 connected groups of agents). The estimated spillover effects were larger in magnitude among components with either higher HIV prevalence or greater density (number of existing partnerships compared to all possible partnerships). Consideration of effect modification is important when evaluating the spillover of PrEP among MSM.

Introduction: We evaluated racial/ethnic differences in the receipt of naloxone distributed by opioid overdose prevention programs (OOPPs) in New York City (NYC). Methods: We used naloxone recipient racial/ethnic data collected by OOPPs from April 2018 to March 2019. We aggregated quarterly neighborhood-specific rates of naloxone receipt and other covariates to 42 NYC neighborhoods. We used a multilevel negative binomial regression model to assess the relationship between neighborhood-specific naloxone receipt rates and race/ethnicity. Race/ethnicity was stratified into four mutually exclusive groups: Latino, non-Latino Black, non-Latino White and non-Latino Other. We also conducted racial/ethnic-specific geospatial analyses to assess whether there was within-group geographic variation in naloxone receipt rates for each racial/ethnic group. Results: Non-Latino Black residents had the highest median quarterly naloxone receipt rate of 41.8 per 100,000 residents, followed by Latino residents (22.0 per 100,000), non-Latino White (13.6 per 100,000) and non-Latino Other residents (13.3 per 100,000). In our multivariable analysis, compared with non-Latino White residents, non-Latino Black residents had a significantly higher receipt rate and non-Latino Other residents had a significantly lower receipt rate. In the geospatial analyses, both Latino and non-Latino Black residents had the most within-group geographic variation in naloxone receipt rates compared to non-Latino White and Other residents. Conclusions: This study found significant racial/ethnic differences in naloxone receipt from NYC OOPPs. We observed substantial variation in naloxone receipt for non-Latino Black and Latino residents across neighborhoods, indicating relatively poorer access in some neighborhoods and opportunities for new approaches to address geographic and structural barriers in these locations.

Background: People who inject drugs (PWID) are at elevated risk for HIV infection; however, syringe services programs (SSPs) are effective in curtailing HIV transmission. Despite their effectiveness, SSPs in many settings are hampered by social and political opposition. We aimed to estimate the impact of closure and temporary interruption of SSP service provision on the HIV epidemic among PWID in a rural US setting. Methods: Using an agent-based model calibrated to observed surveillance data, we simulated HIV risk behaviors and transmission in adult populations who inject and do not inject drugs in Scott County, Indiana, a rural American setting that experienced a devastating HIV outbreak in 2015. We projected HIV incidence and prevalence between 2020 and 2025 for scenarios with permanent closure, delayed closure (one additional renewal for 24 months before closure), and temporary closure (representing the impact of the COVID-19 pandemic) of an SSP in comparison to SSP maintenance. Findings: With sustained SSP operation, we projected an incidence rate of 0.16 per 100 person-years among the overall population (95% simulation interval: 0.08-0.29). Permanently closing the SSP would cause an average of 62 more HIV infections and a 52.0% increase in the incidence rate during 2021 to 2025, resulting in a higher prevalence of 59.0% [48.3%-68.4%] (22.0% increase) among PWID by 2025. A delayed closure (from 2023 to 2025) would increase the five-year incidence rate by 33.2%. A temporary closure (lasting 12 months) would cause 12 (32.8%) more infections during 2020 to 2021. Interpretation: Our analysis suggests that temporary interruption and permanent closure of existing SSPs operating in rural US settings may lead to “rebound” HIV outbreaks among PWID. To maintain control of the HIV epidemic, it will be necessary to sustain existing or implement new SSPs in combination with other prevention interventions. Funding Statement: This work was supported by the National Institutes of Health (grant number DP2DA040236 to B.D.L.M and grant number R25MH083620 to W.C.G.) Declaration of Interests: The authors have no conflicts of interest to declare.

Background Understanding the sources of HIV transmission provides a basis for prioritizing HIV prevention resources in specific geographic regions and populations. This study estimated the number, proportion, and rate of HIV transmissions attributable to individuals along the HIV care continuum, within different HIV transmission risk groups in six US cities. Methods We used a dynamic, compartmental HIV transmission model that draws on racial/ethnic- and risk-behavior-specific linkage to HIV care and use of HIV prevention services from local, state and national surveillance sources. We estimated the rate and number of HIV transmissions attributable to individuals in the stage of acute undiagnosed HIV, non-acute undiagnosed HIV, HIV diagnosed but antiretroviral therapy (ART) naive, off ART, and on ART, stratified by HIV transmission group for the 2019 calendar year. Results Individuals with undiagnosed non-acute HIV infection accounted for the highest proportion of total transmissions in every city, ranging from 36.8% [26.7%-44.9%] in New York City to 64.9% [47.0%-71.6%] in Baltimore. Individuals who had discontinued ART contributed to the second highest percentage of total infections in four of six cities. Individuals with acute HIV had the highest transmission rate per 100 person years, ranging from 76.4 [58.9-135.9] in Miami to 160.2 [85.7-302.8] in Baltimore. Conclusion These findings underline the importance of both early diagnosis and improved ART retention for ending the HIV epidemic in the US. Differences in the sources of transmission across cities indicate that localized priority-setting to effectively address diverse microepidemics at different stages of epidemic control is necessary.

Study objective Emergency departments (ED) are critical touchpoints for encounters among patients with opioid use disorder (OUD), but implementation of ED initiated treatment and harm reduction programs has lagged. We describe national patient, visit and hospital-level characteristics of ED OUD visits and characterize EDs with high rates of OUD visits in order to inform policies to optimize ED OUD care. Methods We conducted a descriptive, cross-sectional study with the 2017 Nationwide Emergency Department Sample (NEDS) from the Healthcare Cost and Utilization Project, using diagnostic and mechanism of injury codes from ICD-10 to identify OUD related visits. NEDS weights were applied to generate national estimates. We evaluated ED visit and clinical characteristics of all OUD encounters. We categorized hospitals into quartiles by rate of visits for OUD per 1000 ED visits and described the visit, clinical, and hospital characteristics across the four quartiles. Results In 2017, the weighted national estimate for OUD visits was 1,507,550. Overdoses accounted for 295,954. (19.6%) of visits. OUD visit rates were over 8× times higher among EDs in the highest quartile of OUD visit rate (22.9 per 1000 total ED visits) compared with EDs in the lowest quartile of OUD visit rate (2.7 per 1000 ED visits). Over three fifths (64.2%) of all OUD visits nationwide were seen by the hospitals in the highest quartile of OUD visit rate. These hospitals were predominantly in metropolitan areas (86.2%), over half were teaching hospitals (51.7%), and less than a quarter (23.3%) were Level 1 or Level 2 trauma centers. Conclusion Targeting initial efforts of OUD care programs to high OUD visit rate EDs could improve care for a large portion of OUD patients utilizing emergency care.

STUDY OBJECTIVE Emergency department (ED)-based naloxone distribution and peer-based behavioral counseling have been shown to be feasible, but little is known about utilization maintenance over time and clinician, patient, and visit level factors influencing implementation. METHODS We conducted a retrospective cohort study of an ED overdose prevention program providing take-home naloxone, behavioral counseling, and treatment linkage for patients treated for an opioid overdose at two Rhode Island EDs from 2017 to 2020: one tertiary referral center and a community hospital. Utilizing a Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we evaluated program reach, adoption, implementation modifiers, and maintenance using logistic and Poisson regression. RESULTS Seven hundred forty two patients were discharged after an opioid overdose, comprising 966 visits (median: 32 visits per month; interquartile range: 29, 41). At least one intervention was provided at most (86%, 826/966) visits. Take-home naloxone was provided at 69% of visits (637/919). Over half (51%, 495/966) received behavioral counseling and treatment referral (65%, 609/932). Almost all attending physicians provided take-home naloxone (97%, 105/108), behavioral counseling (95%, 103/108), or treatment referral (95%, 103/108) at least once. Most residents and advanced practice practitioners (APPs) provided take home naloxone (78% residents; 72% APPs), behavioral counseling (76% residents; 67% APPs), and treatment referral (80% residents; 81% APPs) at least once. Most clinicians provided these services for over half of the opioid overdose patients they cared for. Patients were twice as likely to receive behavioral counseling when treated by an attending in combination with a resident and/or APP (adjusted odds ratio: 2.29; 95% confidence interval, 1.68, 3.12) compared to an attending alone. There was no depreciation in use over time. CONCLUSIONS ED naloxone distribution, behavioral counseling, and referral to treatment can be successfully integrated into usual emergency care and maintained over time with high reach and adoption. Further work is needed to identify low-cost implementation strategies to improve services use and dissemination across clinical settings.

Background Tools are needed to aid clinicians in estimating their patients' risk of transitioning to long-term opioid use and to inform prescribing decisions. Objective The objective of this study was to develop and validate a model that predicts previously opioid-naive patients' risk of transitioning to long-term use. Research design This was a statewide population-based prognostic study. Subjects Opioid-naive (no prescriptions in previous 2 y) patients aged 12 years old and above who received a pill-form opioid analgesic in 2016-2018 and whose prescriptions were registered in the California Prescription Drug Monitoring Program (PDMP). Measures A multiple logistic regression approach was used to construct a prediction model with long-term (ie, >90 d) opioid use as the outcome. Models were developed using 2016-2017 data and validated using 2018 data. Discrimination (c-statistic), calibration (calibration slope, intercept, and visual inspection of calibration plots), and clinical utility (decision curve analysis) were evaluated to assess performance. Results Development and validation cohorts included 7,175,885 and 2,788,837 opioid-naive patients with outcome rates of 5.0% and 4.7%, respectively. The model showed high discrimination (c-statistic: 0.904 for development, 0.913 for validation), was well-calibrated after intercept adjustment (intercept, -0.006; 95% confidence interval, -0.016 to 0.004; slope, 1.049; 95% confidence interval, 1.045-1.053), and had a net benefit over a wide range of probability thresholds. Conclusions A model for the transition from opioid-naive status to long-term use had high discrimination and was well-calibrated. Given its high predictive performance, this model shows promise for future integration into PDMPs to aid clinicians in formulating opioid prescribing decisions at the point of care.

An estimated one in five adolescents exhibit self-injurious behavior (SIB), which poses serious public health concerns. The present analysis aims to describe the prevalence and correlates of lifetime SIB among first-time offending court-involved nonincarcerated youth. Baseline data from 412 youth enrolled in Epidemiological Project Involving Children in the Court (EPICC), a longitudinal cohort study, were analyzed to identify the prevalence and correlates of lifetime SIB. Almost a quarter (22.4%) of youth self-reported lifetime SIB. Participants who were female, bisexual, and those with more severe post-traumatic stress symptoms had higher prevalence odds of lifetime SIB. These findings suggest the importance of screening for SIB among youth and may provide guidance in the development of interventions designed to improve health outcomes of adolescents who come into first contact with the juvenile justice system.

Concomitant with expanded legalization, cannabis is increasingly used to treat chronic pain among persons with HIV (PWH), despite equivocal benefit in research limited by small sample sizes and short duration of follow-up. To address these limitations, among a sample of PWH with pain interference enrolled in the Veterans Aging Cohort Study, we performed a target trial emulation study to compare the impact of four cannabis use strategies on pain interference. Among those receiving long-term opioid therapy (LTOT), we also explored impact of these strategies on ≥ 25% LTOT dose reduction. Among the analytic sample (N = 1284), the majority were men with a mean age of 50. Approximately 31% used cannabis and 12% received LTOT at baseline. Adjusting for demographic and clinical factors, cannabis use in any of 4 longitudinal patterns was not associated with resolved pain interference over 12- to 24-month follow-up. Among 153 participants receiving LTOT at baseline, cannabis use at both baseline and follow-up was negatively associated with LTOT dose reduction compared to no use at both baseline and follow-up. These findings support other observational studies finding no association between cannabis use and improved chronic pain or LTOT reduction among PWH.

Objective Justice-involved youth report high rates of adverse childhood experiences (ACEs; abuse, neglect, household dysfunction) and are at high risk for elevated behavioral health needs (i.e., substance use, psychiatric symptoms). Research with broad samples of adolescents shows ACEs predict behavioral health outcomes, yet most research on the impact of ACEs among justice-involved youth focuses on recidivism. The present study addresses this gap by examining the prospective association between ACEs and psychiatric symptoms, substance use, and substance-related problems (i.e., consequences of use) among first-time justice-involved youth. Method First-time justice-involved youth (n = 271; 54.3% male; M age = 14.5 years; 43.5% Latinx; non-Latinx: 34.2% White, 8.6% Black, 7.1% Other, 6.7% Multiracial) and their caregivers were assessed at youth's first court contact and 4- and 12-month follow-ups. Youth and caregivers reported youth's exposure to ACEs through a series of instruments at baseline and 4-months (e.g., Childhood Trauma Questionnaire Short-Form; Traumatic Life Events Inventory). Primary outcomes included youth alcohol and cannabis use (Adolescent Risk Behavior Assessment), consequences of use (Brief Young Adult Alcohol Consequences Questionnaire; Brief Marijuana Consequences Scale), and psychiatric symptoms (Behavior Assessment System for Children; National Stressful Events Survey PTSD Short Scale). Results Youth were exposed to three ACEs, on average, prior to first justice contact (M = 3). Exposure to more ACEs, particularly abuse, predicted substance use and psychiatric outcomes. Gender differences emerged for cannabis use and internalizing symptoms. Conclusions Implications for trauma-responsive juvenile justice reform are discussed, including screening for ACEs and their sequelae at first court contact and considering the role of masculine norms. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

This objective of this review is to describe the scope of the literature on the access to and use of nonpharmacologic therapies to manage chronic pain among people with disabilities and older adults.Clinical guidelines recommend nonpharmacologic interventions as first-line therapy for chronic pain management. The importance of nonpharmacologic management is magnified in populations with a high pain burden and multiple chronic conditions, such as people living with a disability and/or older adults, many of whom are enrolled in Medicare. Understanding the utilization of nonpharmacologic therapies for pain is critical to guide effective pain management delivery and policy.This scoping review will consider studies of Medicare beneficiaries and Medicare-eligible individuals who have chronic pain. Noninvasive and nonpharmacologic treatments for pain identified in clinical guidelines will be included. We will exclude studies exclusively focused on acute pain, cancer pain, palliative care and hospice settings, cannabis-based treatment, and pharmacologic therapies. Studies conducted outside the United States will be excluded.The proposed scoping review will be conducted in accordance with JBI methodology. The search strategy has been developed in consultation with a public health librarian and will be carried out in MEDLINE, CINAHL, and SocINDEX, Web of Science, and the Cochrane Library. The search will be limited to results published in English since January 1, 1990. Two independent reviewers will screen all titles and abstracts and then full-text articles. Data will be extracted and summarized in diagrammatic, tabular, and narrative formats.Open Science Framework ( https://osf.io/h7bwc/ ).

Suicidal thoughts and behaviors among juvenile justice populations are elevated. However, the characteristics of justice-involved youth who consider and attempt suicide are not well understood. This study examined suicidal ideation and attempt with first-time, preadjudicated diverted youth, and the relationship with commonly associated risk factors. The sample included 135 youth (50% male, Mage = 14.48) that provided complete responses to self-reported lifetime suicidal ideation and attempt items. Analyses examined relationships between suicidal ideation/attempt and mental health, child welfare involvement, delinquency, self-cutting, and substance use. First time, preadjudicated diverted youth reported high rates of lifetime suicidal ideation (27%) and attempt (17%). Suicidal ideation and attempt were associated with sexually minoritized status and self-cutting, while child welfare involvement was only associated with suicidal ideation. This high-risk population would benefit from refined suicide screening and prevention services not always available to justice-involved youth living in the community.

Among veterans in care reporting opioid use, we investigated the association between ceasing opioid use on subsequent reduction in report of other substance use and improvements in pain, anxiety, and depression.Using Veterans Aging Cohort Study survey data collected between 2003 and 2012, we emulated a hypothetical randomized trial (target trial) of ceasing self-reported use of prescription opioids and/or heroin, and outcomes including unhealthy alcohol use, smoking, cannabis use, cocaine use, pain, and anxiety and depressive symptoms. Among those with baseline opioid use, we compared participants who stopped reporting opioid use at the first follow-up (approximately 1 year after baseline) with those who did not. We fit logistic regression models to estimate associations with change in each outcome at the second follow-up (approximately 2 years after baseline) among participants with that condition at baseline. We examined two sets of adjusted models that varied temporality assumptions.Among 2473 participants reporting opioid use, 872 did not report use, 606 reported use, and 995 were missing data on use at the first follow-up. Ceasing opioid use was associated with no longer reporting cannabis (adjusted odds ratio [AOR]=1.82, 95% confidence interval [CI] 1.10, 3.03) and cocaine use (AOR=1.93, 95% CI 1.16, 3.20), and improvements in pain (AOR=1.53, 95% CI 1.05, 2.24) and anxiety (AOR=1.56, 95% CI 1.01, 2.41) symptoms.Cessation of opioid misuse may be associated with subsequent cessation of other substances and reduction in pain and anxiety symptoms, which supports efforts to screen and provide evidence-based intervention where appropriate.

BACKGROUND: Limiting the incidence of opioid-naïve patients who transition to long-term opioid use (i.e., continual use for > 90 days) is a key strategy for reducing opioid-related harms. OBJECTIVE: To identify variables constructed from data routinely collected by prescription drug monitoring programs that are associated with opioid-naïve patients’ likelihood of transitioning to long-term use after an initial opioid prescription. DESIGN: Statewide cohort study using prescription drug monitoring program data PARTICIPANTS: All opioid-naïve patients in California (no opioid prescriptions within the prior 2 years) age ≥ 12 years prescribed an initial oral opioid analgesic from 2010 to 2017. METHODS AND MAIN MEASURES: Multiple logistic regression models using variables constructed from prescription drug monitoring program data through the day of each patient’s initial opioid prescription, and, alternatively, data available up to 30 and 60 days after the initial prescription were constructed to identify probability of transition to long-term use. Model fit was determined by the area under the receiver operating characteristic curve (C-statistic). KEY RESULTS: Among 30,569,125 episodes of patients receiving new opioid prescriptions, 1,809,750 (5.9%) resulted in long-term use. Variables with the highest adjusted odds ratios included concurrent benzodiazepine use, ≥ 2 unique prescribers, and receipt of non-pill, non-liquid formulations. C-statistics for the day 0, day 30, and day 60 models were 0.81, 0.88, and 0.94, respectively. Models assessing opioid dose using the number of pills prescribed had greater discriminative capacity than those using milligram morphine equivalents. CONCLUSIONS: Data routinely collected by prescription drug monitoring programs can be used to identify patients who are likely to develop long-term use. Guidelines for new opioid prescriptions based on pill counts may be simpler and more clinically useful than guidelines based on days’ supply or milligram morphine equivalents. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06555-x.

Agent-based models are a key tool for investigating the emergent properties of population health settings, such as infectious disease transmission, where the exposure often violates the key “no interference” assumption of traditional causal inference under the potential outcomes framework. Agent-based models and other simulation-based modeling approaches have generally been viewed as a separate knowledge-generating paradigm from the potential outcomes framework, but this can lead to confusion about how to interpret the results of these models in real-world settings. By explicitly incorporating the target trial framework into the development of an agent-based or other simulation model, we can clarify the causal parameters of interest, as well as make explicit the assumptions required for valid causal effect estimation within or between populations. In this paper, we describe the use of the target trial framework for designing agent-based models when the goal is estimation of causal effects in the presence of interference, or spillover.

Scant research has examined the influence of overdoses occurring in social networks (i.e., knowing someone who has overdosed) on individual overdose risk. We sought to characterize drug use behaviors of individuals following the overdose of someone in their social network.We conducted semi-structured interviews with 25 people who use drugs and knew someone who overdosed in the prior 90 days. All interviews were conducted in person in Rhode Island from July to October 2021. Data were stratified by drug use behaviors following the overdose of a network member (i.e., risk behaviors, protective behaviors, no change; selected a priori) and analyzed using a thematic analysis variation to identify salient themes.We identified variation in the effect of knowing someone who overdosed on subsequent drug use behaviors and emotional affect. Several participants described increasing their drug use or using more types of drugs than usual to manage feelings of bereavement and trauma, and a subset of these participants described increased drug use with suicidal intention and increased suicidal ideations following the overdose event. Other participants described reducing their drug use and engaging in protective behaviors in response to heightened perceived overdose risk, protection motivation (i.e., increased motivation to protect oneself), and concern for others. Additionally, some participants reported no change in drug use behaviors, and these participants described already engaging in harm reduction practices, feeling desensitized due to frequent or repeated exposure to overdose, and ambivalence about living.Findings suggest a need for enhanced investment in network-based overdose prevention interventions, as well as more robust integration of bereavement support and mental health services in settings that serve people who use drugs. The findings also suggest a need for future research to identify mediators of the effect of overdose occurring in social networks on individual overdose risk.

Background: Prior evidence suggests that plasma HIV viral load is elevated during periods of crack cocaine use independent of antiretroviral therapy (ART) exposure. We sought to evaluate the effect of crack cocaine use frequency on HIV disease severity among HIV-positive people who use unregulated drugs (PWUD). Methods: We analyzed data from the ACCESS study, an open prospective cohort of HIV-positive PWUD including comprehensive HIV clinical monitoring in a setting with no-cost healthcare, including ART. Multivariable generalized linear mixed-effects models were used to estimate the independent effect of time-updated crack cocaine use frequency on HIV disease severity, adjusting for ART exposure and relevant confounders. HIV disease severity was measured using the Veterans Aging Cohort Study (VACS) Index, which is a validated prognostic index. Findings: Between 2005 and 2018, 806 individuals were recruited and contributed 8,537 observations. At baseline, the frequencies of crack cocaine use in the previous 180 days were: none (187, 23%), less than weekly (150, 19%), weekly (229, 28%), and daily or greater (240, 30%). In multivariable models adjusted for ART exposure and other confounders, daily or greater frequency of crack cocaine use was significantly associated with higher VACS Index scores (β = 0.9, 95% confidence interval: 0.2, 1.6) as compared to none. Interpretation: Daily or greater frequency of crack cocaine use may exacerbate HIV disease severity among HIV-positive PWUD. Although the observed effect was small, it was also independent of ART exposure. As this finding has been supported by previous evidence, the observed difference may reflect an underlying biological mechanism or other factors linked with crack cocaine use although further investigation is warranted. Funding Information: US National Institutes of Health. Declaration of Interests: We declare no competing interests. Ethics Approval Statement: The ACCESS study was approved by the University of British Columbia/Providence Healthcare Research Ethics Board.

Objective We aimed to determine the effectiveness of various pre-exposure prophylaxis (PrEP) prescription strategies for African American women impacted by mass incarceration within an urban setting. Design An agent-based model was utilized to evaluate prevention strategies in an efficient, ethical manner. By defining agents, their characteristics, and relationships, we assessed population-level effects of PrEP on HIV incidence. Methods We tested hypothetical PrEP prescription strategies within a simulation representing the African American population of Philadelphia, Pennsylvania. Four strategies were evaluated: PrEP for women meeting CDC indicators regarding partner characteristics, PrEP for women with a recently incarcerated male partner, PrEP for women with a recently released male partner, and couples-based PrEP at time of release. Interventions occurred alongside scale-up of HAART. We evaluated reductions in HIV transmissions, the number of persons on PrEP needed to avert one HIV transmission (NNT), and the resulting proportions of people on PrEP. Results Scenarios prescribing PrEP based on criminal justice system involvement reduced HIV transmissions. The NNT ranged from 147 (couples-based scenario) to 300 (recently released scenario). The percentage of the female population covered by PrEP at any one time ranged from 0.14% (couples-based) to 10.8% (CDC-based). CDC-guideline scenarios were consistently less efficient compared to the justice-involved interventions. Conclusions Expanding PrEP for African American women and their male partners affected by incarceration should be considered in national HIV prevention goals and correctional facilities leveraged as intervention sites. Partner characteristics in the current CDC indications may be more effective and efficient if guidelines considered criminal justice involvement.

Background Persons who inject drugs (PWID) are at a disproportionately high risk of HIV infection. We aimed to determine the highest-valued combination implementation strategies to reduce the burden of HIV among PWID in 6 US cities. Methods Using a dynamic HIV transmission model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City, and Seattle, we assessed the value of implementing combinations of evidence-based interventions at optimistic (drawn from best available evidence) or ideal (90% coverage) scale-up. We estimated reduction in HIV incidence among PWID, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) for each city (10-year implementation; 20-year horizon; 2018 $ US). Results Combinations that maximized health benefits contained between 6 (Atlanta and Seattle) and 12 (Miami) interventions with ICER values ranging from $94 069/QALY in Los Angeles to $146 256/QALY in Miami. These strategies reduced HIV incidence by 8.1% (credible interval [CI], 2.8%–13.2%) in Seattle and 54.4% (CI, 37.6%–73.9%) in Miami. Incidence reduction reached 16.1%–75.5% at ideal scale. Conclusions Evidence-based interventions targeted to PWID can deliver considerable value; however, ending the HIV epidemic among PWID will require innovative implementation strategies and supporting programs to reduce social and structural barriers to care.

Introduction Special populations, including veterans, pregnant and postpartum women, and adolescents, benefit from opioid use disorder treatment tailored to their specific needs, but access to such services is poorly described. This study identifies the availability of opioid use disorder treatment facilities that use medications and have special programming and contextualizes facilities amid counties’ opioid-related overdose mortality. Methods Data were compiled on 15,945 U.S. treatment facilities using medications for opioid use disorder listed in the Behavioral Health Services Treatment Locator in 2018. Facilities with programs tailored to special populations (veterans, pregnant and postpartum women, and adolescents) were identified and geocoded. Counties with such facilities were characterized. Cold spots (county clusters with poor treatment availability) were identified using Getis–Ord Gi* statistics. Data were extracted in October 2018 and analyzed from October 2018 to May 2019. Results Of all 3,142 U.S. counties, 1,889 (60.1%) had opioid use disorder treatment facilities. Facilities with tailored programs for veterans, pregnant and postpartum women, and adolescents were located in 701 (22.3%), 918 (29.2%), and 1,062 (33.8%) of the counties, respectively. Specific medications provided for opioid use disorder varied, with only a minority of facilities offering methadone (among facilities with tailored programs for veterans, 6.0%; pregnant and postpartum women, 13.2%; adolescents, 1.3%). Many counties reporting opioid-related overdose deaths lacked programs for special populations (veterans, 72.6%; pregnant and postpartum women, 54.8%; adolescents, 30.6%). Cold spots were located throughout the Midwest, U.S. Southeast, and portions of Texas. Conclusions Facilities using medications for opioid use disorder with tailored programs for veterans, pregnant and postpartum women, and adolescents are limited. There is a need for improved access to evidence-based programs that address the unique treatment needs of special populations.

We estimated human immunodeficiency virus incidence and incidence rate ratios (IRRs) for black and Hispanic vs white populations in 6 cities in the United States (2020–2030). Large reductions in incidence are possible, but without elimination of disparities in healthcare access, we found that wide disparities persisted for black compared with white populations in particular (lowest IRR, 1.69 [95% credible interval, 1.19–2.30]).

Background It is unknown what levels of preexposure prophylaxis (PrEP) use are needed to reduce racial disparities in HIV incidence among men who have sex with men (MSM). Using an agent-based model, we quantified the impact of achieving PrEP coverage targets grounded in equity on racial disparities in HIV incidence among MSM in an urban setting in the Southeastern United States. Methods An agent-based model was adapted to simulate HIV transmission in a network of Black/African American and White MSM aged 18-39 years in the Atlanta-Sandy Springs-Roswell metropolitan area over 10 years (2015-2024). Scenarios simulated coverage levels consistent with targets based on the ratio of the number of individuals using PrEP to the number of individuals newly diagnosed in a calendar year (i.e., the 'PrEP-to-need ratio'), ranging from 1 to 10. Incidence rate ratios and differences were calculated as measures of disparities. Results Without PrEP, the model predicted a rate ratio of 3.82 and a rate difference of 4.50 comparing HIV incidence in Black/African American and White MSM, respectively. Decreases in the rate ratio of at least 50% and in the rate difference of at least 75% were observed in all scenarios in which the PrEP-to-need ratio among Black/African American MSM was 10, regardless of the value among White MSM. Conclusion Significant increases in PrEP use are needed among Black/African American MSM to reduce racial disparities in HIV incidence. PrEP expansion must be coupled with structural interventions to address vulnerability to HIV infection among Black/African American MSM.

BACKGROUND: No prior studies have characterized long-term patterns of opioid use regardless of source or reason for use among patients with HIV (PWH). We sought to identify trajectories of self-reported opioid use and their correlates among a national sample of PWH engaged in care. SETTING: Veterans Aging Cohort Study, a prospective cohort including PWH receiving care at eight US Veterans Health Administration (VA) sites. METHODS: Between 2002 and 2018, we assessed past year opioid use frequency based on self-reported “prescription painkillers” and/or heroin use at baseline and follow-up. We used group-based trajectory models to identify opioid use trajectories and multinomial logistic regression to determine baseline factors independently associated with escalating opioid use compared to stable, infrequent use. RESULTS: Among 3,702 PWH, we identified four opioid use trajectories: 1) no lifetime use (25%); 2) stable, infrequent use (58%); 3) escalating use (7%); and 4) de-escalating use 11%). In bivariate analysis, anxiety; pain interference; prescribed opioids, benzodiazepines and gabapentinoids; and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. In multivariable analysis, illness severity, pain interference, receipt of prescribed benzodiazepine medications and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. CONCLUSION: Among PWH engaged in VA care, one in 15 reported escalating opioid use. Future research is needed to understand the impact of psychoactive medications and marijuana use on opioid use and whether enhanced uptake of evidence-based treatment of pain and psychiatric symptoms can prevent escalating use among PWH.

Background As the burden of opioid use disorder (OUD) increases in the United States, manifold federal and state initiatives have sought to increase access to treatment for OUD, which includes behavioral and pharmaceutical treatment modalities. Although the evidence base for outpatient treatment for OUD—including medications for opioid use disorder—is substantial, few studies have examined the risk factors for fatality during treatment for OUD. Methods Treatment Episode Data Set-Discharges (TEDS-D) data were used to evaluate correlates of death during outpatient treatment for OUD in 2016. To determine the correlates of mortality during an outpatient treatment for OUD, we constructed a pooled logistic regression model, stratified by use of medication for opioid use disorder (MOUD), to control for the duration of time in treatment and to identify the independent characteristics that may lead to differences in the odds of mortality during treatment. Findings 1861 (0.8%) of 235,745 outpatient treatment episodes for OUD included in our analysis resulted in fatality. Many factors correlated with death during treatment were similar for individuals who did and did not receive MOUD. However, non-White race was only significantly associated with decreases in fatality in non-MOUD treatment episodes. Male sex and reported intravenous drug use at admission were associated with fatality only for treatment episodes that did not involve MOUD. Conclusions In this national study of outpatient treatment episodes for OUD, we found differences in age, sex, region, drug use history, treatment setting, and treatment history significantly affected the risk of death during treatment. As more people become engaged with treatment, facilities should work toward delivering optimal treatment for all patients regardless of personal characteristics.

Author(s): Krebs, Emanuel; Zang, Xiao; Enns, Benjamin; Min, Jeong E; Behrends, Czarina N; Del Rio, Carlos; Dombrowski, Julia C; Feaster, Daniel J; Gebo, Kelly A; Golden, Matthew; Marshall, Brandon DL; Metsch, Lisa R; Schackman, Bruce R; Shoptaw, Steven; Strathdee, Steffanie A; Nosyk, Bohdan; Localized Economic Modeling Study Group | Abstract: ObjectiveEffective interventions to reduce the public health burden of HIV/AIDS can vary in their ability to deliver value at different levels of scale and in different epidemiological contexts. Our objective was to determine the cost-effectiveness of HIV treatment and prevention interventions implemented at previously documented scales of delivery in six US cities with diverse HIV microepidemics.DesignDynamic HIV transmission model-based cost-effectiveness analysis.MethodsWe identified and estimated previously documented scale of delivery and costs for 16 evidence-based interventions from the US CDC's Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention. Using a model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City and Seattle, we estimated averted HIV infections, quality-adjusted life years (QALY) gained and incremental cost-effectiveness ratios (healthcare perspective; 3% discount rate, 2018$US), for each intervention and city (10-year implementation) compared with the status quo over a 20-year time horizon.ResultsIncreased HIV testing was cost-saving or cost-effective across cities. Targeted preexposure prophylaxis for high-risk MSM was cost-saving in Miami and cost-effective in Atlanta ($6123/QALY), Baltimore ($18 333/QALY) and Los Angeles ($86 117/QALY). Interventions designed to improve antiretroviral therapy initiation provided greater value than other treatment engagement interventions. No single intervention was projected to reduce HIV incidence by more than 10.1% in any city.ConclusionCombination implementation strategies should be tailored to local epidemiological contexts to provide the most value. Complementary strategies addressing factors hindering access to HIV care will be necessary to meet targets for HIV elimination in the United States.

Background Male sex workers (MSWs) are at increased risk of HIV infection in the United States. Research is limited on sexual and drug use network characteristics of MSWs. Setting Community-based organization and health center in 2 US Northeast cities. Methods One hundred MSWs completed a behavioral assessment and sexual and drug network inventory. Using dyadic analyses, we assessed whether network characteristics, including sex worker-male client age, race, and HIV status homophily and risk multiplexity (ie, overlap in drug-use and sex networks), were associated with condom use. Results MSW participants' mean age was 33.6. Two-thirds identified as Black or Latino, 12% identified as heterosexual, and 90% reported recent drug use. Participants reported an average of 5.3 male clients in the past month (SD = 3.4), and having anal sex with 74% of these clients, at a rate of 2.2 times per month (SD = 4.6). Participants reported inconsistent condom use during anal sex with 53% of clients. In multivariable models, inconsistent condom use was more common in relationships with presumed HIV status homophily [odds ratio (OR): 1.25; 95% confidence interval (CI): 1.07 to 1.46] and sexual and drug network multiplexity (OR: 1.19; 95% CI: 1.09 to 1.30); and less common within relationships where the client is older than the MSW participant (OR: 0.83; 95% CI: 0.74 to 0.93). Number of multiplex relationships was positively associated with number of condomless anal sex acts with male clients (incidence rate ratio: 1.35; 95% CI: 1.19 to 1.54). Conclusions Network characteristics may contribute to disproportionate HIV risk among MSWs. Modeling studies should include network characteristics when simulating HIV transmission, and future HIV interventions should address the role of networks.

Introduction Infrequent use of and poor retention on evidence-based medications for alcohol use disorder (MAUD) represent a treatment gap, particularly among people living with HIV (PLWH). We examined predictors of MAUD initiation and retention across HIV status. Methods From Veterans Aging Cohort Study (VACS) data, we identified new alcohol use disorder (AUD) diagnoses from 1998 to 2015 among 163,339 individuals (50,826 PLWH and 112,573 uninfected, matched by age, sex, and facility). MAUD initiation was defined as a prescription fill for naltrexone, acamprosate or disulfiram within 30 days of a new diagnosis. Among those who initiated, retention was defined as filling medication for ≥80% of days over the following six months. We used multivariable logistic regression to assess patient- and facility-level predictors of AUD medication initiation across HIV status. Results Among 10,603 PLWH and 24,424 uninfected individuals with at least one AUD episode, 359 (1.0%) initiated MAUD and 49 (0.14%) were retained. The prevalence of initiation was lower among PLWH than those without HIV (adjusted odds ratio [AOR] 0.66, 95% confidence interval [CI] 0.51–0.85). Older age (for PLWH: AOR 0.78, 95% CI 0.61–0.99; for uninfected: AOR 0.70, 95% CI 0.61–0.80) and black race (for PLWH: AOR 0.63, 95% CI 0.0.49–0.1.00; for uninfected: AOR 0.63, 95% CI 0.48–0.83), were associated with decreased odds of initiation for both groups. The low frequency of retention precluded multivariable analyses for retention. Conclusions For PLWH and uninfected individuals, targeted implementation strategies to expand MAUD are needed, particularly for specific subpopulations (e.g. black PLWH).

BACKGROUND:Prescription drug monitoring programs (PDMP), by reducing access to prescribed opioids (POs), may contribute to a policy environment in which some people with opioid dependence are at increased risk for transitioning from POs to heroin/other illegal opioids. This study examines how PDMP adoption and changes in the characteristics of PDMPs over time contribute to changes in fatal heroin poisoning in counties within states from 2002 to 2016. METHODS:Latent transition analysis to classify PDMPs into latent classes (Cooperative, Proactive, and Weak) for each state and year, across three intervals (1999-2004, 2005-2009, 2010-2016). We examined the association between probability of PDMP latent class membership and the rate of county-level heroin poisoning death. RESULTS:After adjustment for potential county-level confounders and co-occurring policy changes, adoption of a PDMP was significantly associated with increased heroin poisoning rates (22% increase by third year post-adoption). Findings varied by PDMP type. From 2010-2016, states with Cooperative PDMPs (those more likely to share data with other states, to require more frequent reporting, and include more drug schedules) had 19% higher heroin poisoning rates than states with Weak PDMPs (adjusted rate ratio [ARR]=1.19; 95% CI=1.14, 1.25). States with Proactive PDMPs (those more likely to report outlying prescribing and dispensing and provide broader access to law enforcement) had 6% lower heroin poisoning rates than states with No/Weak PDMPs (ARR=0.94; 95% CI=0.90, 0.98). CONCLUSION:There is a consistent, positive association between state PDMP adoption and heroin poisoning mortality. However, this varies by PDMP type, with Proactive PDMPs associated with a small reduction in heroin poisoning deaths. This raises questions about the potential for PDMPs to support efforts to decrease heroin overdose risk, particularly by using proactive alerts to identify patients in need of treatment for opioid use disorder. Future research on mechanisms explaining the reduction in heroin poisonings after enactment of Proactive PDMPs is merited.

Background and aims Opioid-related overdose death rates continue to rise in the United States, especially in racial/ethnic minority communities. Our objective was to determine if US municipalities with high percentages of non-white residents have equitable access to the overdose antidote naloxone distributed by community-based organizations. Methods We used community-based naloxone data from the Massachusetts Department of Public Health and the Rhode Island Non-Pharmacy Naloxone Distribution program for 2016-2018. We obtained publicly available opioid-related overdose death data from Massachusetts and the Office of the State Medical Examiners in Rhode Island. We defined the naloxone coverage ratio as the number of community-based naloxone kits received by a resident in a municipality divided by the number of opioid-related overdose deaths among residents, updated annually. We used a Poisson regression with generalized estimating equations to analyze the relationship between the municipal racial/ethnic composition and naloxone coverage ratio. To account for the potential nonlinear relationship between naloxone coverage ratio and race/ethnicity, we created B-splines for the percentage of non-white residents; and for a secondary analysis examining the percentage of African American/Black and Hispanic residents. The models were adjusted for the percentage of residents in poverty, urbanicity, state, and population size. Results Between 2016-2018, the annual naloxone coverage ratios range was 0-135. There was no difference in naloxone coverage ratios among municipalities with varying percentages of non-white residents in our multivariable analysis. In the secondary analysis, municipalities with higher percentages of African American/Black residents had higher naloxone coverage ratios, independent of other factors. Naloxone coverage did not differ by percentage of Hispanic residents. Conclusions There appear to be no municipal-level racial/ethnic inequities in naloxone distribution in Rhode Island and Massachusetts, USA.

Racial/ethnic minorities have experienced disproportionate opioid-related overdose death rates in recent years. In this context, we examined inequities in community-based naloxone access across racial/ethnic groups in Massachusetts.We used data from: the Massachusetts Department of Public Health on community-based overdose education and naloxone distribution (OEND) programs; the Massachusetts Office of the Chief Medical Examiner on opioid-related overdose deaths, and; the United States Census American Community Survey for regional demographic/socioeconomic details to estimate community populations by race/ethnicity and racial segregation between African American/Black and white residents. Race/ethnicity groups included in the analysis were African American/Black (non-Hispanic), Hispanic, white (non-Hispanic), and "other" (non-Hispanic). We evaluated racial/ethnic differences in naloxone distribution across regions in Massachusetts and neighborhoods in Boston descriptively and spatially, plotting the race/ethnicity-specific number of kits per opioid-related overdose death per jurisdiction. Lastly, we constructed generalized estimating equations models with a negative binomial distribution to compare the race/ethnicity-specific naloxone distribution rate by OEND programs.From 2016-2019, the median annual rate of naloxone kits received from OEND programs in Massachusetts per racial/ethnicity group ranged between 160 and 447 per 100,000. In a multivariable analysis, we found that the naloxone distribution rates for racial/ethnic minorities were lower than the rate for white residents. We also found naloxone was more likely to be distributed in racially segregated communities than non-segregated communities.We identified racial/ethnic inequities in naloxone receipt by individuals in Massachusetts. Additional resources focused on designing and implementing OEND programs for racial/ethnic minorities are warranted to ensure equitable access to naloxone.

BACKGROUND AND AIMS: In light of the accelerating drug overdose epidemic in North America, new strategies are needed to identify communities most at risk to prioritize geographically the existing public health resources (e.g. street outreach, naloxone distribution efforts). We aimed to develop PROVIDENT (Preventing Overdose using Information and Data from the Environment), a machine learning-based forecasting tool to predict future overdose deaths at the census block group (i.e. neighbourhood) level. DESIGN: Randomized, population-based, community intervention trial. SETTING: Rhode Island, USA. PARTICIPANTS: All people who reside in Rhode Island during the study period may contribute data to either the model or the trial outcomes. INTERVENTION: Each of the state’s 39 municipalities will be randomized to the intervention (PROVIDENT) or comparator condition. An interactive, web-based tool will be developed to visualize the PROVIDENT model predictions. Municipalities assigned to the treatment arm will receive neighbourhood risk predictions from the PROVIDENT model, and state agencies and community-based organizations will direct resources to neighbourhoods identified as high risk. Municipalities assigned to the control arm will continue to receive surveillance information and overdose prevention resources, but they will not receive neighbourhood risk predictions. MEASUREMENTS: The primary outcome is the municipal-level rate of fatal and non-fatal drug overdoses. Fatal overdoses will be defined as unintentional drug-related death; non-fatal overdoses will be defined as an emergency department visit for a suspected overdose reported through the state’s syndromic surveillance system. Intervention efficacy will be assessed using Poisson or negative binomial regression to estimate incidence rate ratios comparing fatal and non-fatal overdose rates in treatment vs. control municipalities. COMMENTS: The findings will inform the utility of predictive modelling as a tool to improve public health decision-making and inform resource allocation to communities that should be prioritized for prevention, treatment, recovery and overdose rescue services.

The COVID-19 pandemic has greatly exacerbated the United States' overdose crisis. However, the overlapping impacts of COVID-19 and the overdose crisis have not been experienced equally, with unstably housed people who use drugs (PWUD) disproportionately impacted. Amid these changes, there is a need to understand how risk is experienced and managed among unstably housed PWUD to address health and social needs more effectively.This project draws on ethnographic research conducted from June 2020 to April 2021 in Rhode Island. Data include 39 in-depth interviews with unstably housed PWUD and approximately 50 h of ethnographic fieldwork conducted alongside street-based outreach workers.COVID-19 risks were primarily contextualized in relation to participants' prior experiences of overdose events and adverse health outcomes. However, participants had varying levels of risk tolerance that were managed in ways that allowed them to reassert control and agency within the uncertainty of overlapping public health crises. Given participants' level of structural vulnerabilities, COVID-19 risk was managed alongside meeting their basic needs to survive.Findings demonstrate how COVID-related public health measures (e.g., stay-at-home orders, service closures) reinforced participants' structural vulnerabilities in ways that increased their risk of health and social harms. Implementing and scaling up programs that meet the basic needs of individuals, including permanent housing, social supports, and overdose prevention interventions (e.g., supervised consumption sites) is critically needed to address intersecting risks faced by unstably housed PWUD.

Context Supervised injection facilities are harm reduction interventions that allow people who inject drugs to use previously obtained substances under the supervision of health professionals. Although currently considered illegal under U.S. federal law, several U.S. cities are considering implementing supervised injection facilities anyway as a response to the escalating overdose crisis. The objective of this review is to determine the effectiveness of supervised injection facilities, compared with that of control conditions, for harm reduction and community outcomes. Evidence Acquisition Studies were identified from 2 sources: a high-quality, broader review examining supervised injection facility–induced benefits and harms (from database inception to January 2014) and an updated search using the same search strategy (January 2014‒September 2019). Systematic review methods developed by the Guide to Community Preventive Services were used (screening and analysis, September 2019‒December 2020). Evidence Synthesis A total of 22 studies were included in this review: 16 focused on 1 supervised injection facility in Vancouver, Canada. Quantitative synthesis was not conducted given inconsistent outcome measurement across the studies. Supervised injection facilities in the included studies (n=number of studies per outcome category) were mostly associated with significant reductions in opioid overdose morbidity and mortality (n=5), significant improvements in injection behaviors and harm reduction (n=7), significant improvements in access to addiction treatment programs (n=7), and no increase or reductions in crime and public nuisance (n=7). Conclusions For people who inject drugs, supervised injection facilities may reduce the risk of overdose morbidity and mortality and improve access to care while not increasing crime or public nuisance to the surrounding community.

Summary Background In the USA, Black and Hispanic or Latinx individuals continue to be disproportionately affected by HIV. Applying a distributional cost-effectiveness framework, we estimated the cost-effectiveness and epidemiological impact of two combination implementation approaches to identify the approach that best meets the dual objectives of improving population health and reducing racial or ethnic health disparities. Methods We adapted a dynamic, compartmental HIV transmission model to characterise HIV micro-epidemics in six US cities: Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle. We considered combinations of 16 evidence-based interventions to diagnose, treat, and prevent HIV transmission according to previously documented levels of scale-up. We then identified optimal combination strategies for each city, with the distribution of each intervention implemented according to existing service levels (proportional services approach) and the racial or ethnic distribution of new diagnoses (between Black, Hispanic or Latinx, and White or other ethnicity individuals; equity approach). We estimated total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios of strategies implemented from 2020 to 2030 (health-care perspective; 20-year time horizon; 3% annual discount rate). We estimated three measures of health inequality (between-group variance, index of disparity, Theil index), incidence rate ratios, and rate differences for the selected strategies under each approach. Findings In all cities, optimal combination strategies under the equity approach generated more QALYs than those with proportional services, ranging from a 3·1% increase (95% credible interval [CrI] 1·4–5·3) in New York to more than double (101·9% [75·4–134·6]) in Atlanta. Compared with proportional services, the equity approach delivered lower costs over 20 years in all cities except Los Angeles; cost reductions ranged from $22·9 million (95% CrI 5·3–55·7 million) in Seattle to $579·8 million (255·4–940·5 million) in Atlanta. The equity approach also reduced incidence disparities and health inequality measures in all cities except Los Angeles. Interpretation Equity-focused HIV combination implementation strategies that reduce disparities for Black and Hispanic or Latinx individuals can significantly improve population health, reduce costs, and drive progress towards Ending the HIV Epidemic goals in the USA. Funding National Institute on Drug Abuse.