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Patel EU, Grieb SM, Winiker AK, Ching J, Schluth CG, Mehta SH, Kirk GD, Genberg BL. Structural and social changes due to the COVID-19 pandemic and their impact on engagement in substance use disorder treatment services: a qualitative study among people with a recent history of injection drug use in Baltimore, Maryland. Harm Reduct J 2024; 21:91. [PMID: 38720307 PMCID: PMC11077846 DOI: 10.1186/s12954-024-01008-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 04/22/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Substance use disorder treatment and recovery support services are critical for achieving and maintaining recovery. There are limited data on how structural and social changes due to the COVID-19 pandemic impacted individual-level experiences with substance use disorder treatment-related services among community-based samples of people who inject drugs. METHODS People with a recent history of injection drug use who were enrolled in the community-based AIDS Linked to the IntraVenous Experience study in Baltimore, Maryland participated in a one-time, semi-structured interview between July 2021 and February 2022 about their experiences living through the COVID-19 pandemic (n = 28). An iterative inductive coding process was used to identify themes describing how structural and social changes due to the COVID-19 pandemic affected participants' experiences with substance use disorder treatment-related services. RESULTS The median age of participants was 54 years (range = 24-73); 10 (36%) participants were female, 16 (57%) were non-Hispanic Black, and 8 (29%) were living with HIV. We identified several structural and social changes due the pandemic that acted as barriers and facilitators to individual-level engagement in treatment with medications for opioid use disorder (MOUD) and recovery support services (e.g., support group meetings). New take-home methadone flexibility policies temporarily facilitated engagement in MOUD treatment, but other pre-existing rigid policies and practices (e.g., zero-tolerance) were counteracting barriers. Changes in the illicit drug market were both a facilitator and barrier to MOUD treatment. Decreased availability and pandemic-related adaptations to in-person services were a barrier to recovery support services. While telehealth expansion facilitated engagement in recovery support group meetings for some participants, other participants faced digital and technological barriers. These changes in service provision also led to diminished perceived quality of both virtual and in-person recovery support group meetings. However, a facilitator of recovery support was increased accessibility of individual service providers (e.g., counselors and Sponsors). CONCLUSIONS Structural and social changes across several socioecological levels created new barriers and facilitators of individual-level engagement in substance use disorder treatment-related services. Multilevel interventions are needed to improve access to and engagement in high-quality substance use disorder treatment and recovery support services among people who inject drugs.
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Affiliation(s)
- Eshan U Patel
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Suzanne M Grieb
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Abigail K Winiker
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jennifer Ching
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Catherine G Schluth
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Gregory D Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Becky L Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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Heidari O, Winiker A, Dangerfield DT, Wenzel J, Rodney T, Mehta S, Genberg B. Understanding healthcare engagement for people who inject drugs. Res Nurs Health 2024; 47:242-250. [PMID: 37982368 PMCID: PMC10961200 DOI: 10.1002/nur.22355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/28/2023] [Accepted: 11/03/2023] [Indexed: 11/21/2023]
Abstract
People who inject drugs (PWID) are at an increased risk of multimorbid mental health and chronic diseases, which are frequently underdiagnosed and under-treated due to systemic barriers and ongoing substance use. Healthcare engagement is essential to address these conditions and prevent excess morbidity and mortality. The goal of this study was to understand how PWID engage in care for their chronic health conditions and substance use treatment given the known historic and pervasive barriers. We conducted 24 semistructured qualitative interviews informed by the Behavioral Model for Vulnerable Populations between July-September 2019. Participants were sampled across a range of comorbidities, including co-occurring mental health disorders. Thematic analysis was conducted to explore experiences of healthcare engagement for multimorbid chronic diseases, mental health, and treatment for substance use disorder. Mean age for participants was 58 years; 63% reported male sex and 83% reported Black race. Interviews yielded themes regarding healthcare access and wraparound services, positive patient-provider relationships, service integration for substance use treatment and mental health, healthcare needs alignment, medication of opioid use disorder stigma, and acceptance of healthcare. Taken together, participants described how these themes enabled healthcare engagement. Engagement in care is crucial to support health and recovery. Clinical implications include the importance of strengthening patient-provider relationships, encouraging integration of medical and mental health services, and counseling on substance use treatment options in a non- stigmatizing manner. Additionally, policy to reimburse wrap-around support for substance use recovery can improve care engagement and outcomes related to chronic diseases, mental health, and substance use among PWID. No Patient or Public Contribution: While we acknowledge and thank ALIVE participants for their time for data collection and sharing their perspectives, no ALIVE participants, other people who use drugs, and service users were involved in data collection, analysis or interpretation of data, or in preparation of the manuscript.
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Affiliation(s)
- Omeid Heidari
- Department of Child, Family, and Population Health Nursing, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Abigail Winiker
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Derek T Dangerfield
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia, USA
| | - Jennifer Wenzel
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
- Sidney Kimmel Comprehensive Cancer Center, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tamar Rodney
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Shruti Mehta
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Becky Genberg
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Eschliman EL, Patel EU, Murray SM, German D, Kirk GD, Mehta SH, Kaufman MR, Genberg BL. Drug Use-Related Discrimination in Healthcare Settings and Subsequent Emergency Department Utilization in a Prospective Cohort Study of People With a History of Injection Drug Use. Subst Use Misuse 2024; 59:1210-1220. [PMID: 38519443 DOI: 10.1080/10826084.2024.2330906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Abstract
BACKGROUND People with a history of injection drug use face discrimination in healthcare settings that may impede their use of routine care, leading to greater reliance on the emergency department (ED) for addressing health concerns. The relationship between discrimination in healthcare settings and subsequent ED utilization has not been established in this population. METHODS This analysis used longitudinal data collected between January 2014 and March 2020 from participants of the ALIVE (AIDS Linked to the IntraVenous Experience) study, a community-based observational cohort study of people with a history of injection drug use in Baltimore, Maryland. Logistic regressions with generalized estimating equations were used to estimate associations between drug use-related discrimination in healthcare settings and subsequent ED utilization for the sample overall and six subgroups based on race, sex, and HIV status. RESULTS 1,342 participants contributed data from 7,289 semiannual study visits. Participants were predominately Black (82%), mostly male (66%), and 33% were living with HIV. Drug use-related discrimination in healthcare settings (reported at 6% of study visits) was positively associated with any subsequent ED use (OR = 1.40, 95% CI: 1.15-1.72). Positive associations persisted after adjusting for covariates, including past sixth-month ED use and drug use, among the overall sample (aOR = 1.28, 95% CI: 1.04-1.59) and among some subgroups. CONCLUSIONS Drug use-related discrimination in healthcare settings was associated with greater subsequent ED utilization in this sample. Further exploration of mechanisms driving this relationship may help improve care and optimize healthcare engagement for people with a history of injection drug use.
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Affiliation(s)
- Evan L Eschliman
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Eshan U Patel
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sarah M Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Danielle German
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Gregory D Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Michelle R Kaufman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Becky L Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Byrne CJ, Radley A, Fletcher E, Thain D, Stephens BP, Dillon JF. A multicomponent holistic care pathway for people who use drugs in Tayside, Scotland. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 120:104159. [PMID: 37574644 DOI: 10.1016/j.drugpo.2023.104159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND People Who Use Drugs (PWUD) are at high risk of non-fatal overdose and other drug-related harms. The United Kingdom drugs policy landscape makes it challenging to support those at risk. Tayside, in East Scotland, has a sizeable population at risk of drug-related harms. In 2021, the National Health Service implemented a care pathway for PWUD to provide multidimensional healthcare interventions. We aimed to quantify drug-related harms; assess wider health and well-being; and understand substance use trends and behaviours, among those engaged in the pathway. METHODS Existing community-embedded blood-borne virus pathways were adapted to provide multiple healthcare assessments over three visits. We undertook an observational cohort study to analyse uptake and outcomes for the initial cohort of PWUD engaged at appointment one. RESULTS From August 2021-September 2022, 150 PWUD engaged with the pathway. Median age was 39 (34-42) years, 108 (72%) were male, and 124 (83%) lived in deprived areas. Seventy (47%) had been disengaged from healthcare for over a year. Polysubstance use was reported by 124 (83%), 42 (28%) disclosed injecting daily, and 54 (36%) shared equipment. Fifty-four (36%) experienced recent non-fatal overdose, and there were six overdose fatalities (4.1 [1.5-9.0] per 100PY). The offer of take-home naloxone was accepted by 108 (72%). Fourteen (9%) were diagnosed with Hepatitis C and two (1%) with HIV. Renal, hepatological, and endocrine impairment were observed among 30 (20%), 23 (15%), and 11 (7%), people respectively. Ninety-six (65%) had high risk of clinical depression. Forty-eight (32%) declined Covid-19 vaccination. CONCLUSION The pathway engaged PWUD with high exposure to recent non-fatal overdose and other drug-related harms, alongside co-morbid health issues. Our results suggest multi-dimensional health assessments coupled with harm reduction in community settings, with appropriate linkage to care, are warranted for PWUD. Service commissioners should seek to integrate these assessments where possible.
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Affiliation(s)
- Christopher J Byrne
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, Scotland; Directorate of Public Health, Kings Cross Hospital, NHS Tayside, Dundee, Scotland.
| | - Andrew Radley
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, Scotland; Directorate of Public Health, Kings Cross Hospital, NHS Tayside, Dundee, Scotland
| | - Emma Fletcher
- Directorate of Public Health, Kings Cross Hospital, NHS Tayside, Dundee, Scotland
| | - Donna Thain
- Directorate of Public Health, Kings Cross Hospital, NHS Tayside, Dundee, Scotland
| | - Brian P Stephens
- Department of Gastroenterology, Ninewells Hospital and Medical School, NHS Tayside, Dundee, Scotland
| | - John F Dillon
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, Scotland; Department of Gastroenterology, Ninewells Hospital and Medical School, NHS Tayside, Dundee, Scotland
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Patel EU, Mehta SH, Genberg BL, Baker OR, Schluth CG, Astemborski J, Fernandez RE, Quinn TC, Kirk GD, Laeyendecker O. Prevalence and correlates of SARS-CoV-2 seropositivity among people who inject drugs in Baltimore, Maryland. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 8:100184. [PMID: 37637232 PMCID: PMC10450408 DOI: 10.1016/j.dadr.2023.100184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/29/2023]
Abstract
Background SARS-CoV-2 serosurveys can help characterize disparities in SARS-CoV-2 infection and identify gaps in population immunity. Data on SARS-CoV-2 seroprevalence among people who inject drugs (PWID) are limited. Methods We conducted a cross-sectional study between December 2020 and July 2022 among 561 participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study-a community-based cohort of current and former PWID in Baltimore, Maryland. Serum samples were assayed for infection-induced anti-nucleocapsid (anti-N) and infection and/or vaccination-induced anti-spike-1 (anti-S) SARS-CoV-2 IgG. We estimated adjusted prevalence ratios (aPR) via modified Poisson regression models. Results The median age was 59 years, 35% were female, 84% were non-Hispanic Black, and 16% reported recent injection drug use. Anti-N antibody prevalence was 26% and anti-S antibody prevalence was 63%. Anti-N and anti-S antibody prevalence increased over time. Being employed (aPR=1.53 [95%CI=1.11-2.11]) was associated with higher anti-N prevalence, while a cancer history (aPR=0.40 [95%CI=0.17-0.90]) was associated with lower anti-N prevalence. HIV infection was associated with higher anti-S prevalence (aPR=1.13 [95%CI=1.02-1.27]), while younger age and experiencing homelessness (aPR=0.78 [95%CI=0.60-0.99]) were factors associated with lower anti-S prevalence. Substance use-related behaviors were not significantly associated with anti-N or anti-S prevalence. Conclusions SARS-CoV-2 seroprevalence increased over time among current and former PWID, suggesting cumulative increases in the incidence of SARS-CoV-2 infection and vaccination; however, there were disparities in infection-induced seroprevalence and infection and/or vaccine-induced seroprevalence within this study sample. Dedicated prevention and vaccination programs are needed to prevent disparities in infection and gaps in population immunity among PWID during emerging epidemics.
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Affiliation(s)
- Eshan U. Patel
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Shruti H. Mehta
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Becky L. Genberg
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Owen R. Baker
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Catherine G. Schluth
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Jacquie Astemborski
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Reinaldo E. Fernandez
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thomas C. Quinn
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Baltimore, MD, USA
| | - Gregory D. Kirk
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Oliver Laeyendecker
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Baltimore, MD, USA
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Kim JYH, Barth SK, Monroe AK, Ahsan S, Kovacic J, Senn S, Castel AD. The impact of COVID-19 on the HIV continuum of care: challenges, innovations, and opportunities. Expert Rev Anti Infect Ther 2023; 21:831-846. [PMID: 37470436 DOI: 10.1080/14787210.2023.2239503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/23/2023] [Accepted: 07/18/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION In February 2019, the United States (US) launched the Ending the HIV Epidemic (EHE) initiative with emphasis on improving the various steps of the Human Immunodeficiency Virus (HIV) prevention and care continuum. However, in March 2020, the Coronavirus Disease 2019 (COVID-19) pandemic was declared, curtailing efforts to end the epidemic in the US. AREAS COVERED To describe the impact of the pandemic on EHE in the US, the authors performed a comprehensive literature review focusing on outcomes at each step of the HIV care continuum. Simultaneously, they identified examples of pandemic-era innovations that may help EHE. EXPERT OPINION Numerous studies demonstrated pandemic-related disruptions across the care continuum as well as the impact on preexisting barriers to care among People with HIV (PWH) at higher risk for poor outcomes. As the pandemic progressed, innovative approaches to delivering healthcare and providing essential services emerged, including widespread use of telemedicine, expansion of home-based care, self-collected sexually transmitted infection (STI) and HIV testing, and co-located testing for COVID-19 and HIV/STIs. While the COVID-19 pandemic initially hindered achieving EHE in the US, the ability to be agile, flexible, and creative led to innovation in HIV care delivery that may ultimately assist in meeting EHE goals as we transition into the post-pandemic era.
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Affiliation(s)
- Jenny Yeon Hee Kim
- Department of Global Health, The George Washington University Milken School of Public Health, 950 New Hampshire Ave NW, 4th Floor, Washington, DC, 20052, USA
| | - Shannon K Barth
- Department of Epidemiology, The George Washington University Milken School of Public Health, 950 New Hampshire Ave NW, 5th Floor, Washington DC, 20052, USA
| | - Anne K Monroe
- Department of Epidemiology, The George Washington University Milken School of Public Health, 950 New Hampshire Ave NW, 5th Floor, Washington DC, 20052, USA
| | - Sarah Ahsan
- Department of Epidemiology, The George Washington University Milken School of Public Health, 950 New Hampshire Ave NW, 5th Floor, Washington DC, 20052, USA
| | - Janja Kovacic
- Department of Epidemiology, The George Washington University Milken School of Public Health, 950 New Hampshire Ave NW, 5th Floor, Washington DC, 20052, USA
| | - Siena Senn
- Department of Epidemiology, The George Washington University Milken School of Public Health, 950 New Hampshire Ave NW, 5th Floor, Washington DC, 20052, USA
| | - Amanda D Castel
- Department of Epidemiology, The George Washington University Milken School of Public Health, 950 New Hampshire Ave NW, 5th Floor, Washington DC, 20052, USA
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Heidari O, Tormohlen K, Dangerfield DT, Tobin KE, Farley J, Aronowitz SV. Barriers and facilitators to primary care engagement for people who inject drugs: A systematic review. J Nurs Scholarsh 2023; 55:605-622. [PMID: 36480158 PMCID: PMC10635283 DOI: 10.1111/jnu.12863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/09/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION People who inject drugs (PWID) have a greater burden of multimorbid chronic diseases than the general population. However, little attention has been paid to the engagement in primary care for services related specifically to injection drug use and management of underlying chronic comorbid diseases for this population. This systematic review identified facilitators and barriers to healthcare engagement in the primary care setting among PWID. DESIGN AND METHODS Studies were identified by a literature search of PubMed, CINAHL, and EMBASE, and by searching the references of retrieved articles. Studies were included if they measured active injection drug use, and outcomes related to primary care engagement characterized by: diagnosis of a health condition, linkage or retention in care, health condition-related outcomes, and reported patient-provider relationship. RESULTS Twenty-three articles were included. Using the behavioral model, factors within predisposing, enabling, need, and health behavior domains were identified. Having co-located services and a positive patient-provider relationship were among the strongest factors associated with healthcare utilization and engagement while active injection drug use was associated with decreased engagement. CONCLUSIONS To our knowledge, this is the only review of evidence that has examined factors related to primary care engagement for people who inject drugs. Most articles were observational studies utilizing descriptive designs. Although the assessment of the evidence was primarily rated 'Good', this review identifies a significant need to improve our understanding of primary care engagement for PWID. Future research and intervention strategies should consider these findings to better integrate the holistic care needs of PWID into primary care to reduce morbidity and mortality associated with injection drug use and chronic disease. CLINICAL RELEVANCE Primary care engagement is important for preventative care, early diagnosis of disease, and management of chronic diseases, including addressing problems of substance use. This review highlights factors nurses can utilize to facilitate primary care engagement of PWID.
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Affiliation(s)
- Omeid Heidari
- University of Washington, School of Nursing, Department of Child, Family, and Population Health Nursing, 1959 NE Pacific Street, Seattle, WA 98195
| | - Kayla Tormohlen
- Johns Hopkins University, Bloomberg School of Public Health, Department of Health Policy and Management, 615 N. Wolfe St, Baltimore, MD 21205
| | - Derek T. Dangerfield
- George Washington University, Milken Institute School of Public Health, Department of Prevention and Community Health, 950 New Hampshire Ave NW #2, Washington, DC 20052
- Us Helping Us, Inc. Georgia Ave. NW. Washington, DC 20010
| | - Karin E. Tobin
- Johns Hopkins University, School of Nursing, 525 N. Wolfe St, Baltimore, MD 21205
| | - Jason Farley
- Johns Hopkins University, Bloomberg School of Public Health, Department of Health, Behavior, and Society, 615 N. Wolfe St, Baltimore, MD 21205
| | - Shoshana V. Aronowitz
- University of Pennsylvania, School of Nursing, Department of Family and Community Health, 418 Curie Blvd, Pennsylvania, PA, 19104
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