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\"Diagnosed with cystic fibrosis at the age of three, Mallory Smith grew into a determined, talented young woman who inspired others even as she raged against her illness. Despite the daily challenges of endless medical treatments and a deep understanding that she'd never lead a normal life, Mallory was determined to 'live happy,' a mantra she followed until her death\"-- Provided by publisher.

In a 2019 AMR threat assessment, the US Centers for Disease Control and Prevention reported 18% fewer deaths due to AMR since 2013, but increases in several severe multidrug-resistant bacterial infections, including a 315% increase in erythromycin-resistant group A Streptococcus, a 124% increase in drug-resistant Neisseria gonorrhoeae, and a 50% increase in extended-spectrum β-lactamase-producing Enterobacteriaceae.3 A 2019 report from the US Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria endorsed most priorities from the 2015 national action plan and proposed new targets for 2020–25.10 The US approach to AMR has been mixed and, looking ahead, needs to move beyond priority setting to concrete action. The recommendations of the UN Interagency Coordination Group on AMR provide a roadmap by taking a One Health approach to intervene on AMR at the interface between humans, animals, and the environment.5 The US Federal Government could accelerate progress on its AMR national action plan in several ways: first, by permanently ceasing use of medically important antibiotics in agribusiness; second, by supporting antibiotic stewardship programmes; third, by encouraging the development of new antibiotics through bipartisan initiatives such as the Developing an Innovative Strategy for Antimicrobial Resistant Microorganisms (DISARM) Act,10,13 which some legislators have proposed as part of a COVID-19 relief bill, as well as the Pioneering Antimicrobial Subscriptions to End Up Surging Resistance (PASTEUR) Act, which incorporates an antibiotic subscription programme similar to that in the UK; and, finally, by simultaneously investing in innovation to identify and evaluate other anti-infectives. [...]to accelerate and sustain progress against AMR, the USA should support the multilateral global architecture needed to confront AMR, including WHO, the UN Food and Agriculture Organization, and the World Organisation for Animal Health.

Forced migration is occurring at unprecedented levels. Forced migrants may be at risk for substance use for reasons including coping with traumatic experiences, co-morbid mental health disorders, acculturation challenges and social and economic inequality. This paper aimed to systematically review the literature examining substance use among forced migrants, and identify priority areas for intervention and future research. Seven medical, allied health and social science databases were searched from inception to September 2015 in accordance with PRISMA guidelines to identify original peer-reviewed articles describing any findings relating to alcohol and/or illicit drug use among refugees, internally displaced people (IDPs), asylum seekers, people displaced by disasters and deportees. A descriptive synthesis of evidence from quantitative studies was conducted, focusing primarily on studies which used validated measures of substance use. Synthesis of evidence from qualitative studies focused on identifying prominent themes relating to the contexts and consequences of substance use. Critical Appraisal Skills Programme (CASP) checklists were used to assess methodological quality of included studies. Forty-four quantitative (82% cross-sectional), 16 qualitative and three mixed-methods studies were included. Ten studies were rated as high methodological quality (16%), 39 as moderate quality (62%) and 14 as low quality (22%). The majority of research was conducted among refugees, IDPs and asylum seekers (n = 55, 87%), predominantly in high-income settings. The highest-quality prevalence estimates of hazardous/harmful alcohol use ranged from 17%-36% in camp settings and 4%-7% in community settings. Few studies collected validated measures of illicit drug use. Seven studies compared substance use among forced migrants to other migrant or native-born samples. Among eight studies which conducted multivariable analysis, male sex, trauma exposure and symptoms of mental illness were commonly identified correlates of substance use. Our understanding of substance use among forced migrants remains limited, particularly regarding persons displaced due to disasters, development and deportation. Despite a growing body of work among refugee-background populations, few studies include refugees in low and middle-income countries, where over 80% of the global refugee population resides. Findings suggest a need to integrate substance use prevention and treatment into services offered to forced migrants, particularly in camp settings. Efforts to develop and evaluate interventions to reduce substance use and related harms are needed.

An HIV outbreak in rural Indiana provides a cautionary tale. An aggressive, multipronged strategy is needed to prevent similar outbreaks, and it requires permanently lifting the ban on using federal funds to support needle-exchange programs. Many observers were surprised when Indiana Governor Mike Pence issued an executive order on March 26, 2015, declaring a public health emergency after a rapidly escalating outbreak of human immunodeficiency virus (HIV) was identified in Scott County, a rural region on the Kentucky border. 1 Others, however, had seen it coming. Over the years, a growing number of young people in Scott County — like those in surrounding counties and states — had begun abusing opiates such as oxymorphone, an opioid analgesic prescribed by local medical providers, until a more tamper-resistant formulation and policy reform began limiting its abuse. Facing the . . .

People who inject drugs may be at elevated SARS-CoV-2 risk due to their living conditions and/or exposures when seeking or using drugs. No study to date has reported upon risk factors for SARS-CoV-2 infection among people who inject drugs. Between October, 2020 and June, 2021, participants aged ≥18 years from San Diego, California, USA and Tijuana, Baja California, Mexico who injected drugs within the last month underwent interviews and testing for SARS-CoV-2 RNA and antibodies. Binomial regressions identified correlates of SARS-CoV-2 seropositivity. Of 386 participants, SARS-CoV-2 seroprevalence was 36.3% (95% CI: 31.5%-41.1%); 92.1% had detectable IgM antibodies. Only 37.5% had previously been tested. Seroprevalence did not differ by country of residence. None tested RNA-positive. Most (89.5%) reported engaging in ≥1 protective behavior [e.g., facemasks (73.5%), social distancing (46.5%), or increasing handwashing/sanitizers (22.8%)]. In a multivariate model controlling for sex, older age, and Hispanic/Latinx/Mexican ethnicity were independently associated with SARS-CoV-2 seropositivity, as was engaging in sex work (AdjRR: 1.63; 95% CI: 1.18-2.27) and having been incarcerated in the past six months (AdjRR: 1.49; 95% CI: 0.97-2.27). Comorbidities and substance using behaviors were not associated with SARS-CoV-2 seropositivity. In this community-based study of people who inject drugs in the San Diego-Tijuana border region, over one third were SARS-CoV-2 seropositive, exceeding estimates from the general population in either city. We found no evidence that substance use behaviors were associated with an elevated risk of SARS-CoV-2 infection, but observed that circumstances in the risk environment, notably sex work and incarceration, were independently associated with higher SARS-CoV-2 seroprevalence. Our findings suggest that a binational policy response to COVID-19 mitigation is warranted beyond the closure of the U.S.-Mexico border. Furthermore, decriminalizing sex work and drug use could reduce the burden of COVID-19 among people who inject drugs.

Female sex workers (FSWs) bear a disproportionately large burden of HIV infection worldwide. Despite decades of research and programme activity, the epidemiology of HIV and the role that structural determinants have in mitigating or potentiating HIV epidemics and access to care for FSWs is poorly understood. We reviewed available published data for HIV prevalence and incidence, condom use, and structural determinants among this group. Only 87 (43%) of 204 unique studies reviewed explicitly examined structural determinants of HIV. Most studies were from Asia, with few from areas with a heavy burden of HIV such as sub-Saharan Africa, Russia, and eastern Europe. To further explore the potential effect of structural determinants on the course of epidemics, we used a deterministic transmission model to simulate potential HIV infections averted through structural changes in regions with concentrated and generalised epidemics, and high HIV prevalence among FSWs. This modelling suggested that elimination of sexual violence alone could avert 17% of HIV infections in Kenya (95% uncertainty interval [UI] 1–31) and 20% in Canada (95% UI 3–39) through its immediate and sustained effect on non-condom use) among FSWs and their clients in the next decade. In Kenya, scaling up of access to antiretroviral therapy among FSWs and their clients to meet WHO eligibility of a CD4 cell count of less than 500 cells per μL could avert 34% (95% UI 25–42) of infections and even modest coverage of sex worker-led outreach could avert 20% (95% UI 8–36) of infections in the next decade. Decriminalisation of sex work would have the greatest effect on the course of HIV epidemics across all settings, averting 33–46% of HIV infections in the next decade. Multipronged structural and community-led interventions are crucial to increase access to prevention and treatment and to promote human rights for FSWs worldwide.

Following a global wave of end-demand criminalization of sex work, the Protection of Communities and Exploited Persons Act (PCEPA) was implemented in Canada, which has implications for the health and safety of sex workers. This study aimed to evaluate the impact of the PCEPA on sex workers' access to health, violence, and sex worker-led services. Longitudinal data were drawn from a community-based cohort of ~900 cis and trans women sex workers in Vancouver, Canada. Multivariable logistic regression examined the independent effect of the post-PCEPA period (2015-2017) versus the pre-PCEPA period (2010-2013) on time-updated measures of sex workers' access to health, violence supports, and sex worker/community-led services. The PCEPA was independently correlated with reduced odds of having access to health services when needed (AOR 0.59; 95%CI: 0.45-0.78) and community-led services (AOR 0.77; 95%CI: 0.62-0.95). Among sex workers who experienced physical violence/sexual violence or trauma, there was no significant difference in access to counseling supports post-PCEPA (AOR 1.24; 95%CI: 0.93-1.64). Sex workers experienced significantly reduced access to critical health and sex worker/community-led services following implementation of the new laws. Findings suggest end-demand laws may exacerbate and reproduce harms of previous criminalized approaches to sex work in Canada. This study is one of the first globally to evaluate the impact of end-demand approaches to sex work. There is a critical evidence-based need to move away from criminalization of sex work worldwide to ensure full labor and human rights for sex workers. Findings warn against adopting end-demand approaches in other cities or jurisdictions.

The opioid epidemic is one of the greatest public health problems that the USA faces. Opioid overdose death rates have increased steadily for more than a decade and doubled in 2013–17, as the highly potent synthetic opioid fentanyl entered the drug supply. Demographics of new HIV diagnoses among people who inject drugs are also changing, with more new HIV diagnoses occurring among White people, young people (aged 13–34 years), and people who reside outside large central metropolitan areas. Racial differences also exist in syringe sharing, which decreased among Black people and Hispanic people but remained unchanged among White people in 2005–15. Recent HIV outbreaks have occurred in rural areas of the USA, as well as among marginalised people in urban areas with robust HIV prevention and treatment services (eg, Seattle, WA). Multiple evidence-based interventions can effectively treat opioid use disorder and prevent HIV acquisition. However, considerable barriers exist precluding delivery of these solutions to many people who inject drugs. If the USA is serious about HIV prevention among this group, stigma must be eliminated, discriminatory policies must change, and comprehensive health care must be accessible to all. Finally, root causes of the opioid epidemic such as hopelessness need to be identified and addressed.

About the Authors: Alexander C. Tsai * E-mail: actsai@partners.org Affiliations Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America, Harvard Medical School, Boston, Massachusetts, United States of America, Mbarara University of Science and Technology, Mbarara, Uganda ORCID logo http://orcid.org/0000-0001-6397-7917 Margarita Alegría Affiliations Harvard Medical School, Boston, Massachusetts, United States of America, Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America ORCID logo http://orcid.org/0000-0003-2241-707X Steffanie A. Strathdee Affiliation: Division of Infectious Diseases and Global Public Health, University of California at San Diego School of Medicine, San Diego, California, United States of America ORCID logo http://orcid.org/0000-0002-7724-691X Citation: Tsai AC, Alegría M, Strathdee SA (2019) Addressing the context and consequences of substance use, misuse, and dependence: A global imperative. [...]although opioid prescribing patterns undoubtedly played a significant role in how opioid use disorders came to be so highly prevalent [27–29] and asymmetrically distributed in the US [30–32], a public health response that focuses solely on prescribing behavior is likely to be ineffective in reducing the number of fatal and nonfatal opioid overdoses. [...]called treatment cascade models have been used to identify gaps in the access and treatment continuum for a wide range of health conditions, including HIV treatment [43], prevention of mother-to-child transmission of HIV [44], depression [45], and, most recently, opioid use disorders [46]. [...]for people with opioid use disorders who either cannot or do not choose to achieve sustained remission, alternative approaches might be considered to reduce the harms associated with ongoing use.