A systematic review of the effects of hepatitis B and C virus on the progression of liver fluke infection to liver cancer.

Hepatitis B and C virus, Opisthorchis viverrini and Clonorchis sinensis, are all individually known to put a person at increased risk for cholangiocarcinoma and hepatocellular carcinoma. This paper seeks to determine if there is any interaction between liver flukes and hepatitis virus infection that are known to put a person at an increased risk for cholangiocarcinoma and hepatocellular carcinoma collectively. This paper seeks to determine whether there is any publicly available articles in English that determine if having a hepatitis viral co-infection along with liver flukes would influence the risk of developing liver cancer. We followed PRISMA systematic review guidelines to conduct a literature review. Three manuscripts fit the search criteria. Two presented evidence in support of a synergistic relationship between liver fluke and viral hepatitis infection while the other found no relationship. One manuscript determined that the interaction between hepatitis B and C. sinensis did not have any significant risk of liver cancer. Studies found that HBV affected progression of co-infection to liver cancer but may have its own disease state worsened by presence of liver flukes. Only one paper was found that presented data on HCV, therefore no conclusion can be drawn due to the lack of evidence discovered. Of the studies, the conclusions and strength of the data were mixed. However, the stronger studies suggested a synergistic relationship between liver flukes and HBV to increase the risk of progressing to liver cancer.

A qualitative exploration of barriers and facilitators to drug treatment services among people who inject drugs in west Virginia.

BACKGROUND: The opioid overdose crisis in the USA has called for expanding access to evidence-based substance use treatment programs, yet many barriers limit the ability of people who inject drugs (PWID) to engage in these programs. Predominantly rural states have been disproportionately affected by the opioid overdose crisis while simultaneously facing diminished access to drug treatment services. The purpose of this study is to explore barriers and facilitators to engagement in drug treatment among PWID residing in a rural county in West Virginia. METHODS: From June to July 2018, in-depth interviews (n = 21) that explored drug treatment experiences among PWID were conducted in Cabell County, West Virginia. Participants were recruited from locations frequented by PWID such as local service providers and public parks. An iterative, modified constant comparison approach was used to code and synthesize interview data. RESULTS: Participants reported experiencing a variety of barriers to engaging in drug treatment, including low thresholds for dismissal, a lack of comprehensive support services, financial barriers, and inadequate management of withdrawal symptoms. However, participants also described several facilitators of treatment engagement and sustained recovery. These included the use of medications for opioid use disorder and supportive health care workers/program staff. CONCLUSIONS: Our findings suggest that a range of barriers exist that may limit the abilities of rural PWID to successfully access and remain engaged in drug treatment in West Virginia. Improving the public health of rural PWID populations will require expanding access to evidence-based drug treatment programs that are tailored to participants' individual needs.

Surveillance of carbapenem-resistant organisms using next-generation sequencing.

The genomic data generated from next-generation sequencing (NGS) provides nucleotide-level resolution of bacterial genomes which is critical for disease surveillance and the implementation of prevention strategies to interrupt the spread of antimicrobial resistance (AMR) bacteria. Infection with AMR bacteria, including Gram-negative Carbapenem-Resistant Organisms (CRO), may be acute and recurrent-once they have colonized a patient, they are notoriously difficult to eradicate. Through phylogenetic tools that assess the single nucleotide polymorphisms (SNPs) within a pathogen genome dataset, public health scientists can estimate the genetic identity between isolates. This information is used as an epidemiologic proxy of a putative outbreak. Pathogens with minimal to no differences in SNPs are likely to be the same strain attributable to a common source or transmission between cases. These genomic comparisons enhance public health response by prompting targeted intervention and infection control measures. This methodology overview demonstrates the utility of phenotypic and molecular assays, antimicrobial susceptibility testing (AST), NGS, publicly available genomics databases, and open-source bioinformatics pipelines for a tiered workflow to detect resistance genes and potential clusters of illness. These methods, when used in combination, facilitate a genomic surveillance workflow for detecting potential AMR bacterial outbreaks to inform epidemiologic investigations. Use of this workflow helps to target and focus epidemiologic resources to the cases with the highest likelihood of being related.

Overdose Experiences among People Who Inject Drugs in West Virginia: Personal Loss, Psychological Distress, Naloxone, and Fentanyl.

Background: As overdose remains a major public health concern in the United States, it is important to understand the experiences people who inject drugs (PWID) have with overdose. Past experiences during such emergencies are an important determinant of future behavior, including help seeking, which can be lifesaving. Methods: We explored experiences with overdose, using data from 21 in-depth interviews collected from PWID in a rural county in West Virginia (Cabell County). We used an iterative, modified constant comparison approach to synthesize resulting interview data. Results: Participants reported pervasive experiences with overdose, including through their own personal overdose experiences, witnessing others overdose, and losing loved ones to overdose fatalities. Experiencing emotional distress when witnessing an overdose was common among our participants. Many participants reported regularly carrying naloxone and using it to reverse overdoses. Multiple participants described believing the myth that people grow immune to naloxone over time. Concerns about the presence of fentanyl in drugs were also common, with many participants attributing their own and others' overdoses to fentanyl. Conclusions: Our findings have important implications for naloxone access and education, as well as policies and practices to encourage help seeking during overdose events among rural PWID. Participant concerns about fentanyl in the drug supply highlight the need for access to drug checking technologies.

Evaluating the impact of naloxone dispensation at public health vending machines in Clark County, Nevada.

INTRODUCTION: Implementing public health vending machines (PHVMs) is an evidence-based strategy for mitigating substance use-associated morbidity and mortality via the dispensation of essential supplies to people who use drugs, including overdose prevention resources. PHVMs have been implemented throughout the world; however, their implementation in the United States (US) is a recent phenomenon. In 2017, Trac-B Exchange (a syringe services program in Clark County, Nevada) installed three PHVMs. In 2019, naloxone dispensation was launched at PHVMs in Clark County. The purpose of this research is to examine the extent to which naloxone dispensation at PHVMs was associated with changes in opioid-involved overdose fatalities. METHODS: Monthly counts of opioid-involved overdose fatalities among Clark County residents that occurred from January 2015 to December 2020 were used to build an autoregressive integrated moving averages (ARIMA) model to measure the impact of naloxone dispensation at PHVMs. We forecasted the number of expected opioid-involved overdose fatalities had naloxone dispensation at PHVMs not occurred and compared to observed monthly counts. Interrupted time series analyses (ITSA) were used to evaluate the step (i.e. the immediate impact of naloxone dispensation at PHVMs on opioid-involved overdose fatalities) and slope change (i.e. changes in trend and directionality of monthly counts of opioid-involved overdose fatalities following naloxone dispensation at PHVMs). RESULTS: During the 12-months immediately following naloxone dispensation at PHVMs, our model forecasted 270 opioid-involved overdose fatalities, but death certificate data indicated only 229 occurred, suggesting an aversion of 41 deaths. ITSA identified a significant negative step change in opioid-involved overdose fatalities at the time naloxone dispensation at PHVMs was launched (B = -8.52, p = .0022) and a significant increasing slope change (B = 1.01, p<.0001). Forecasts that extended into the COVID-19 pandemic suggested worsening trends in overdose fatalities. CONCLUSION: Naloxone dispensation at PHVMs was associated with immediate reductions in opioid-involved overdose fatalities. Key MessagesNaloxone dispensation at PHVMs was associated with immediate reductions in opioid-involved overdose fatalities.Communities should consider implementing public health vending machines in efforts to prevent opioid-involved overdose fatalities.The COVID-19 pandemic worsened the overdose crisis.

Total and Chemoenzymatic Synthesis of Seongsanamide E.

The total and chemoenzymatic synthesis of the depsipeptide natural product seongsanamide E, 3, is described. The synthetic C-terminal N-acetylcysteamine thioester of linear natural product 1 was macrolactonized by the excised recombinant purified seongsanamide thioesterase (Sgd-TE) domain, generating 3. Sgd-TE also effects the ring opening of 3. Chemical synthesis provided 3 through a macrolactamization strategy. This work confirms the biosynthesis of 3 and demonstrates the power of Sgd-TE as a biocatalyst.

The Impact of Housing Insecurity on Access to Care and Services among People Who Use Drugs in Washington, DC.

People who use drugs are highly marginalized communities and are disproportionately affected by environmental changes-e.g., neighborhood gentrification-that affect housing availability and stability, particularly in urban locations. These changes could negatively affect individuals' access to and utilization of health care and social services, resulting in poorer health outcomes. This study examined the impact of gentrification and housing instability on drug users' access to harm reduction and other health services. Data were collected from 139 clients of a large harm reduction organization. Results showed that 67% of the participants were either unstably housed or homeless, and about one-third of participants indicated that their current housing situations negatively affected their access to primary care (33.9%), behavioral health services (36.7%) and basic services (38.3%). While homeless individuals were still able to access services generally, a greater percentage-compared to those unstably or stably housed-reported difficulty accessing care. As these data were collected prior to the COVID pandemic, it is likely that many of our participants faced greater struggles with housing insecurity and health care access issues due to shutdowns and increased need for social isolation and quarantine. More work is needed to address housing instability and homelessness among already marginalized populations.

Factors Associated with Likelihood of Initiating Others into Injection Drug Use Among People Who Inject Drugs in West Virginia.

People who inject drugs (PWID) play a critical role in injection-naïve individuals transitioning to injection drug use. We investigated factors associated with future likelihood of initiating injection-naïve individuals using multivariable logistic regression among 418 PWID in rural Appalachia (Cabell County, West Virginia). Less than 10% reported they were likely to initiate someone in the future. Acquiring syringes from a syringe services program was associated with decreased odds of being likely to initiate someone in the future (adjusted odds ratio [aOR] 0.46, 95% CI 0.23, 0.95), while having previously initiated someone into injection drug use was associated with increased odds (aOR 8.65, 95% CI 4.07, 18.41). Among our sample of PWID in Appalachia, a small proportion reported that they would be likely to initiate an injection-naïve individual in the future. Efforts to reduce injection initiation assistance should focus on this subpopulation of PWID who indicate a willingness to engage in this behavior.

Food access among people who inject drugs in West Virginia.

BACKGROUND: The substance use epidemic in the United States continues to drive high levels of morbidity and mortality, particularly among people who inject drugs (PWID). Poor access to food often co-occurs with drug use and contributes to associated sequelae, such as risks for HIV and diabetes. The objective of this study was to examine factors associated with adequate food access among PWID in a rural Appalachian community. METHODS: Cross-sectional surveys were used to collect data among PWID aged 18 and older in Cabell County, West Virginia. Frequency of hunger and sociodemographic, structural and drug use characteristics were measured. Adequate food access was defined as reporting 'never' going to bed hungry at night in the past six months. Pearson's χ2 and t-tests and multivariable logistic regression were used to identify factors associated with food access. RESULTS: Only 71 individuals (17%) reported never going to bed hungry at night in the past six months. Adjusted odds of having adequate food access were higher among PWID who completed high school (aOR 2.94; P = 0.010) and usually used drugs alone (aOR 1.97; P = 0.025), and lower among PWID who were female (aOR 0.51; P = 0.037), experienced homelessness (aOR 0.23, P < 0.001), were recently arrested (aOR 0.50 P = 0.047), and engaged in receptive sharing of injection equipment (aOR 0.52, P = 0.035). CONCLUSIONS: We found extremely low food access in a population of PWID in Appalachia who are vulnerable to overdose and infectious disease transmission. Integrated interventions promoting food access are needed to improve the public health and wellbeing of people who inject drugs in Appalachia.

Factors Associated with Sterile Syringe Acquisition among People Who Inject Drugs in West Virginia.

BACKGROUND: Syringe services programs (SSPs) are evidence-based interventions that provide essential overdose and infectious disease prevention resources to people who inject drugs (PWID). Little research has examined factors associated with sterile syringe acquisition at SSPs among rural PWID populations. OBJECTIVES: We aim to identify factors associated with PWID in a rural county in West Virginia having recently acquired sterile syringes at an SSP. METHODS: PWID (n = 420) completed a survey that included measures related to sociodemographics, structural vulnerabilities, and substance use. We used multivariable Poisson regression with robust variance estimation to examine independent associations with sterile syringe acquisition at an SSP. RESULTS: Sixty-five percent of our sample reported having recently acquired sterile syringes at an SSP. Factors associated with recent sterile syringes acquisition at an SSP included: being older (aPR [adjusted prevalence ratio]: 1.011, 95% CI: 1.003-1.019), single (aPR: 0.862, 95% CI: 0.755-0.984), experiencing food insecurity (aPR: 1.233, 95% CI: 1.062-1.431), recently injecting fentanyl (aPR: 1.178, 95% CI: 1.010-1.375) and prescription opioid pain relievers (aPR: 0.681, 95% CI: 0.551-0.842), and recent naloxone acquisition (aPR: 1.360; 95% CI: 1.178-1.569). Receptive syringe sharing was inversely associated with acquiring sterile syringes at an SSP (aPR: 0.852; 95% CI: 0.741-0.979). CONCLUSION: PWID accessing sterile syringes at an SSP was associated with several sociodemographic, structural, and substance use factors. Ensuring rural SSP operations are tailored to local PWID population-level needs is paramount to the prevention of infectious disease outbreaks and overdose fatalities.

Syringe Coverage Among People Who Inject Drugs in West Virginia, USA.

Ensuring people who inject drugs (PWID) have ≥ 100% sterile syringe coverage (i.e., persons have access to a sterile syringe for all injections) is optimal for HIV prevention. Existing syringe coverage literature is informative, yet little work has examined syringe coverage among PWID in rural communities. Using data from a 2018 PWID population estimation study conducted in a rural county in West Virginia, we used logistic regression to identify correlates of adequate sterile syringe coverage (at least 100%). A minority (37%) of PWID reported having adequate syringe coverage. Factors inversely associated with adequate syringe coverage included having recently (past 6 months): engaged in transactional sex work, shared syringes, and injected fentanyl. Having exclusively acquired syringes from a syringe services program was associated with increased odds of adequate syringe coverage. Rural PWID may benefit from tailored interventions designed to increase sterile syringe access.

Correlates of recent nonfatal overdose among people who inject drugs in West Virginia.

AIM: Experiencing a nonfatal overdose (NFOD) is a significant risk factor for a subsequent nonfatal or fatal overdose. Overdose mortality rates in rural Appalachian states are some of the highest in the USA, but little is known about correlates of overdose among rural populations of people who inject drugs (PWID). Our study aimed to identify correlates of experiencing a recent (past 6 months) NFOD among rural PWID in Cabell County, West Virginia. METHODS: Using data from a June-July 2018 cross-sectional survey that was designed to estimate the size and characteristics of the PWID population in Cabell County, West Virginia, we used log binomial regression to identify correlates (e.g., structural vulnerabilities and substance use) of NFOD in the past 6 months. RESULTS: The majority of our sample of 420 PWID were male (61.2%), White, non-Hispanic (83.6%), and reported recent heroin injection (81.0%). More than two-fifths (42.6%) experienced a recent NFOD. Independent correlates of NFOD included witnessing an overdose in the past 6 months (adjusted prevalence ratio [aPR] = 2.28; 95% CI 1.48-3.50), attempting to quit using drugs in the past 6 months (aPR = 1.54; 95% CI 1.11-2.14), and the number of drugs injected (aPR = 1.16; 95% CI 1.10-1.23) CONCLUSIONS: A large proportion of rural PWID in Appalachia reported having recently overdosed. The associations between witnessing an overdose, attempting to quit using drugs, and number of drugs injected with recent nonfatal overdose underscore the need for expanded access to overdose prevention resources that are tailored to the needs of this population. Expanding access to evidence-based overdose prevention strategies-such as take-home naloxone programs, treatment with methadone or buprenorphine, and harm reduction services-may decrease overdose morbidity and mortality among rural PWID in Appalachia.

Engagement in drug treatment following nonfatal overdose among people who inject drugs in Appalachia.

BACKGROUND: Immediately after experiencing a non-fatal overdose, many people who inject drugs (PWID) engage in harm-minimizing behavior change, including engagement in drug treatment. To inform the implementation of tailored interventions designed to facilitate drug treatment engagement in rural communities, we sought to identify correlates of starting any form of drug treatment after their most recent overdose among PWID who reside in a rural county in West Virginia. METHODS: Data are from a PWID population estimation study in Cabell County, West Virginia. We used multivariable logistic regression to identify independent sociodemographic and substance use-related correlates of any form of drug treatment engagement after an overdose among 179 PWID who had overdosed in the past 6 months. RESULTS: One-third of our sample (33.0%) started any form of drug treatment in the 30 days following their most recent overdose. Factors associated with engaging in drug treatment included: recent buprenorphine or Suboxone injection (aOR: 2.39, 95% CI: 1.15, 4.96), someone calling 911 after their most recent overdose (aOR: 3.29, 95% CI: 1.63, 6.65), and older age (aOR per year of age: 0.95, 95% CI: 0.91, 0.99). CONCLUSIONS: Our results suggest that contact with emergency personnel after an overdose may represent an important opportunity to link PWID to drug treatment. The implementation of response teams trained in linking PWID to the services they require and helping persons navigate treatment systems maybe be a valuable intervention to reduce the harms of the opioid overdose crisis.

Prevalence and correlates of receptive syringe-sharing among people who inject drugs in rural Appalachia.

BACKGROUND AND AIMS: Syringe-sharing significantly increases the risk of HIV and viral hepatitis acquisition among people who inject drugs (PWID). Clearer understanding of the correlates of receptive syringe-sharing (RSS) is a critical step in preventing bloodborne infectious disease transmission among PWID in rural communities throughout the United States. This study aimed to measure the prevalence and correlates of RSS among PWID in a rural county in Appalachia. DESIGN: Observational, cross-sectional sample from a capture-recapture parent study. SETTING: Cabell County, West Virginia (WV), USA, June-July 2018. PARTICIPANTS: The sample was restricted to people who reported injecting drugs in the past 6 months (n = 420). A total of 180 participants (43%) reported recent (past 6 months) RSS. Participants reported high levels of homelessness (56.0%), food insecurity (64.8%) and unemployment (66.0%). MEASUREMENTS: The main outcome was recent re-use of syringes that participants knew someone else had used before them. Key explanatory variables of interest, selected from the risk environment framework, included: unemployment, arrest and receipt of sterile syringes from a syringe services program (SSP). Logistic regression was used to determine correlates of recent RSS. FINDINGS: PWID reporting recent RSS also reported higher prevalence of homelessness, food insecurity and unemployment than their non-RSS-engaging counterparts. In adjusted analyses, correlates of RSS included: engagement in transactional sex work [adjusted odds ratio (aOR) = 2.27, 95% confidence interval (CI) = 1.26-4.09], unemployment (aOR = 1.67, 95% CI = 1.03-1.72), number of drug types injected (aOR = 1.33, 95% CI = 1.15-1.53) and injection in a public location (aOR = 2.59, 95% CI = 1.64-4.08). Having accessed sterile syringes at an SSP was protective against RSS (aOR = 0.57, 95% CI = 0.35-0.92). CONCLUSION: The prevalence of receptive syringe-sharing among people who inject drugs in a rural US county appears to be high and comparable to urban-based populations. Receptive syringe-sharing among people who inject drugs in a rural setting appears to be associated with several structural and substance use factors, including unemployment and engaging in public injection drug use. Having recently acquired sterile syringes at a syringe services program appears to be protective against receptive syringe sharing.

Awareness of and interest in oral pre-exposure prophylaxis (PrEP) for HIV prevention and interest in hypothetical forms of PrEP among people who inject drugs in rural West Virginia.

Injection drug use-associated HIV outbreaks have occurred in rural communities throughout the United States, which often have limited HIV prevention services for people who inject drugs (PWID). Pre-exposure prophylaxis (PrEP) is one tool that may help fill gaps in HIV prevention programing in rural settings. Oral PrEP has been approved for use, and new PrEP formulations are under development. Research is needed to better understand interest in oral and possible forthcoming PrEP formulations among PWID. We used survey data from 407 PWID in rural West Virginia. We asked if participants had heard of, taken, and were interested in taking PrEP, and about interest in several hypothetical forms of PrEP (arm injections, abdomen injections, implants, intravenous infusions). We estimated the prevalence of interest in each formulation and assessed correlates using Chi-squared tests. A minority had heard of oral PrEP (32.6%), and few had used it (3.7%). Many were interested in using oral PrEP (58.3%). Half were interested in arm injections (55.7%). Common correlates of interest across PrEP formulations were sexual minority status, comfort talking to a doctor about sex, sex work, and sharing injection equipment. Oral and injectable PrEP have the potential to fill HIV prevention gaps for rural PWID.

The Relationship Between Polysubstance Injection Drug Use, HIV Risk Behaviors, and Interest in Pre-Exposure Prophylaxis (PrEP) Among People Who Inject Drugs in Rural West Virginia.

OBJECTIVE: The opioid crisis has increased risks for injection drug use (IDU)-associated HIV outbreaks throughout the United States. Polysubstance use and syringe sharing are common among rural people who inject drugs (PWID). However, little is known about how polysubstance IDU affects engagement in HIV prevention efforts among non-urban PWID. This study assesses the associations between profiles of polysubstance injection, injection-related HIV risk, acquiring syringes from a syringe services program (SSP), HIV testing, and pre-exposure prophylaxis (PrEP) awareness and interest among PWID in rural Appalachia. METHOD: We used survey data from 392 respondents in Cabell County, West Virginia who had injected drugs in the past 6 months. We conducted a latent class analysis using seven measures of IDU and tested for associations with injection-related HIV risk, receiving syringes from an SSP, having been tested for HIV, and PrEP awareness and interest. RESULTS: We identified three classes of polysubstance IDU in our sample: polysubstance use, heroin and crystal methamphetamine use, and crystal methamphetamine and buprenorphine/suboxone use. The polysubstance use class had the highest injection-related HIV risk (81.8% at risk), high syringe acquisition at an SSP (67.7%), and highest rate of HIV testing (60.0%). PrEP awareness was low across the sample (30.0%), but most PWID expressed interest in using PrEP (57.7%). CONCLUSIONS: Patterns of polysubstance IDU have unique relationships with key HIV risk factors and protective behaviors. The expansion of harm reduction services in rural settings is warranted to prevent incident HIV infections.

Human Immunodeficiency Virus Testing Among People Who Inject Drugs in Rural West Virginia.

BACKGROUND: Limited research exists on factors associated with human immunodeficiency virus (HIV) testing among people who inject drugs (PWID) in rural America. The purpose of this research is to identify factors associated with rural PWID in Appalachia having not been tested for HIV in the past year. METHODS: Cross-sectional data (n = 408) from a 2018 PWID population estimation study in West Virginia were used to examine factors associated with PWID having not been tested for HIV in the past year. RESULTS: Most participants identified as male (61%), white, non-Hispanic (84%), and reported having recently injected heroin (81%) and/or crystal methamphetamine (71%). Most (64%) reported having been tested for HIV in the past year, 17% reported having been tested but not in the past year, and 19% reported never having been tested. In multivariable analysis, not having been in a drug treatment program in the past year was associated with PWID not having been tested for HIV in the past year (adjusted prevalence ratio, 1.430; 95% confidence interval, 1.080-1.894). CONCLUSIONS: Drug treatment programs may be important venues for rural PWID to access HIV testing; however, testing services should be offered at multiple venues as most PWID had not engaged in drug treatment in the past year.

PFKFB3-mediated glycolysis rescues myopathic outcomes in the ischemic limb.

Compromised muscle mitochondrial metabolism is a hallmark of peripheral arterial disease, especially in patients with the most severe clinical manifestation - critical limb ischemia (CLI). We asked whether inflexibility in metabolism is critical for the development of myopathy in ischemic limb muscles. Using Polg mtDNA mutator (D257A) mice, we reveal remarkable protection from hind limb ischemia (HLI) due to a unique and beneficial adaptive enhancement of glycolytic metabolism and elevated ischemic muscle PFKFB3. Similar to the relationship between mitochondria from CLI and claudicating patient muscles, BALB/c muscle mitochondria are uniquely dysfunctional after HLI onset as compared with the C57BL/6 (BL6) parental strain. AAV-mediated overexpression of PFKFB3 in BALB/c limb muscles improved muscle contractile function and limb blood flow following HLI. Enrichment analysis of RNA sequencing data on muscle from CLI patients revealed a unique deficit in the glucose metabolism Reactome. Muscles from these patients express lower PFKFB3 protein, and their muscle progenitor cells possess decreased glycolytic flux capacity in vitro. Here, we show supplementary glycolytic flux as sufficient to protect against ischemic myopathy in instances where reduced blood flow-related mitochondrial function is compromised preclinically. Additionally, our data reveal reduced glycolytic flux as a common characteristic of the failing CLI patient limb skeletal muscle.

Fentanyl Preference among People Who Inject Drugs in West Virginia.

Background: Overdose fatality rates in rural areas surpass those in urban areas with the state of West Virginia (WV) reporting the highest drug overdose death rate in 2017. There is a gap in understanding fentanyl preference among rural people who inject drugs (PWID). The aim of this study is to investigate factors associated with fentanyl preference among rural PWID in WV. Methods: This analysis uses data from a PWID population estimation study conducted in Cabell County, WV in June-July 2018. Factors associated with fentanyl preference were assessed using multivariable Poisson regression with a robust variance estimate. Results: Among PWID who reported having ever used fentanyl (n = 311), 43.4% reported preferring drugs containing fentanyl. Participants reported high levels of socioeconomic vulnerability, including homelessness (57.9%) and food insecurity (66.9%). Recent increases in drug use and injecting more than one drug in the past 6 months were reported by 27.0% and 84.2% of participants, respectively. In adjusted analyses, fentanyl preference was associated with being younger (PrR:0.98, 95% CI: 0.97-1.00), being female (PrR:1.45, 95% CI:1.14-1.83), being a Cabell county resident (PrR:0.60, 95% CI: 0.45-0.81), increased drug use in the past 6 months (PrR:1.28, 95% CI: 1.01-1.63), and injecting fentanyl in the past 6 months (PrR:1.89, 95% CI: 1.29-2.75). Conclusion: Fentanyl preference is highly prevalent among rural PWID in WV and associated with factors that may exacerbate overdose risks. There is an urgent need for increased access to tailored harm reduction services that address risks associated with fentanyl preference.

Perspectives on Fentanyl Test Strip Use among People Who Inject Drugs in Rural Appalachia.

Background: Fentanyl-associated overdose fatalities have increased dramatically throughout the United States. Fentanyl test strips (FTS) may be used by people who inject drugs (PWID) to lower overdose risks; however, virtually no research has been conducted to understand the perspectives of rural PWID in Appalachia on FTS utilization. Objectives: We aim to explore FTS awareness and potential use among PWID in two rural counties in West Virginia (WV). Methods: Semi-structured interviews with PWID (n = 48) in two rural counties in WV were conducted to explore FTS awareness, potential use, and possible behavioral changes following FTS utilization. Participants were recruited in areas where PWID congregate in each county. With participants' permission, interviews were audio recorded and transcribed verbatim. Transcripts were analyzed using an iterative, constant comparative approach. Results: Very few participants had heard of FTS prior to the interview. Upon learning about FTS, PWID who reported frequently injecting heroin expressed high willingness to use FTS. Participants explained that learning their drugs contained fentanyl may make them more likely to engage in overdose risk reduction behaviors, such as: using less, doing tester shots, and not using the drugs entirely. Conclusion: Among our sample of rural PWID in Appalachia, most were unaware of FTS but expressed high willingness to utilize the technology. Participants described how receiving a positive FTS result may lead them to engage in overdose risk reduction behaviors. Augmenting existing overdose prevention initiatives in rural Appalachia such that rural PWID have access to FTS may result in reductions in overdose fatalities.