Danielle R. Fine

Methamphetamine use has increased substantially in the United States, particularly among people experiencing homelessness. While the association between methamphetamine use and HIV risk has been studied in other populations, its impact on HIV risk behaviors among people experiencing homelessness remains less well-studied. The objective of this study was to evaluate the relationship between methamphetamine use and HIV risk behaviors in a cohort of people experiencing homelessness who use drugs. We conducted a cross-sectional survey of adults with recent drug use recruited from three homeless-serving clinical sites in Boston, Massachusetts, between February 2024 and January 2025. The primary exposure was past 3-month methamphetamine use (any vs. none). The primary outcome was a composite measure of HIV risk behavior in the past 3 months, categorized as low (0 events), moderate (1–11 events), or high (≥ 12 events), based on self-reported condomless sex and shared needle events. Secondary outcomes included sex-related and injection-related HIV risk behaviors, examined separately. We used multinomial logistic regression to assess associations with overall and sex-related HIV risk behaviors, and bivariate analyses for injection-related HIV risk behavior due to sparse outcome data. Of 196 participants, the mean age was 48 years. 60% identified as cis-gender male, 56% as White, 31% as Black, and 20% as Hispanic. Methamphetamine use in the past 3 months was reported by 42% of participants. Its use was not independently associated with overall HIV risk behavior (aRR for high vs. low risk: 2.20; 95% CI: 0.84–5.77) or sex-related HIV risk behavior (aRR for high vs. low risk: 1.45; 95% CI: 0.53-4.00). However, in bivariate analyses, methamphetamine use was significantly associated with injection-related HIV risk behaviors: individuals who used methamphetamine were less likely to have low-risk behavior (27% vs. 79%) and more likely to have moderate-risk (43% vs. 8%) and high-risk (31% vs. 4%) behaviors (P < 0.001). Among homeless-experienced adults who use drugs, methamphetamine use was associated with higher-risk injection behaviors but not with sex-related HIV risk behaviors. HIV prevention strategies in this population should prioritize safer injection practices, evidence-based methamphetamine treatment, and equitable access to pre-exposure prophylaxis.

People experiencing homelessness are disproportionately affected by opioid use disorder (OUD), yet treatment engagement remains low. Understanding opioid-related health beliefs in this population may inform more tailored interventions. To characterize opioid-related health beliefs among homeless-experienced individuals with OUD and examine their alignment with opioid use severity. We conducted a cross-sectional survey of individuals initiating opioid treatment at a homeless healthcare program in Boston, Massachusetts. The survey assessed key Health Belief Model domains related to opioid use and incorporated the World Health Organization's Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) to quantify opioid use severity. We used nonparametric trend tests to examine associations between ASSIST quartiles (Q1 ≤ 23.5, Q2 23.6-33.0, Q3 33.1-38.0, and Q4 > 38.0) and belief domains. Among 148 participants, the mean age was 41.7 years; 51.4% identified as White, 16.2% as Black, and 38.5% as Hispanic. Higher ASSIST quartiles, indicating higher opioid use severity, were significantly associated with greater perceived threat, including being very worried about opioid use (25% in Q1 vs. 72.7% in Q4; p = 0.001), perceiving very high overdose risk (4.2% vs. 40.9%; p = 0.006), and viewing overdose as very dangerous (87.5% vs. 100%; p = 0.036). Higher ASSIST quartiles were also significantly associated with greater perceived benefits, including that abstaining from opioids (78.3% vs. 100%; p = 0.004) and taking MOUD (69.6% vs. 95.2%; p = 0.016) would improve quality of life. Individuals with greater opioid use severity endorsed higher perceived opioid-related threats and treatment-related benefits. Interventions that highlight these beliefs may help enhance treatment engagement in this high-risk population.

Background The opioid overdose epidemic disproportionately impacts people experiencing homelessness. Outpatient-based opioid treatment (OBOT) programs have been established in homeless health care settings across the USA, but little is known about the success of these programs in engaging and retaining this highly marginalized patient population in addiction care. Objective To evaluate predictors of initial engagement and subsequent attendance in a homeless-tailored OBOT program. Design Prospective cohort study with 4 months of follow-up. Participants A total of 148 homeless-experienced adults (≥18 years) who newly enrolled in the Boston Healthcare for the Homeless Program (BHCHP) OBOT program over a 1-year period (1/6/2022–1/5/2023). Main Measures The primary outcomes were (1) initial OBOT program engagement, defined as having ≥2 additional OBOT visits within 1 month of OBOT enrollment, and (2) subsequent OBOT program attendance, measured monthly from months 2 to 4 of follow-up. Key Results The average age was 41.7 years (SD 10.2); 23.6% were female, 35.8% were Hispanic, 12.8% were non-Hispanic Black, and 43.9% were non-Hispanic White. Over one-half (57.4%) were initially engaged. OBOT program attendances during months 2, 3, and 4 were 60.8%, 50.0%, and 41.2%, respectively. One-quarter (24.3%) were initially engaged and then attended the OBOT program every month during the follow-up period. Participants in housing or residential treatment programs (vs. unhoused; adjusted odds ratios (aORs) = 2.52; 95% CI = 1.17–5.44) and those who were already on or initiated a medication for opioid use disorder (OUD) (aOR = 6.53; 95% CI = 1.62–26.25) at the time of OBOT enrollment had higher odds of engagement. Older age (aOR = 1.74 per 10-year increment; 95% CI = 1.28–2.38) and initial engagement (aOR = 3.50; 95% CI = 1.86–6.59) conferred higher odds of attendance. Conclusions In this study, over half initially engaged with the OBOT program, with initial engagement emerging as a strong predictor of subsequent OBOT program attendance. Interventions aimed at enhancing initial OBOT program engagement, including those focused on housing and buprenorphine initiation, may improve longer-term outcomes in this marginalized population.

Background: Homeless-tailored office-based opioid treatment (OBOT) programs have been developed to address the ongoing opioid overdose crisis, which disproportionately affects people experiencing homelessness. The objective of this study was to evaluate the facilitators of and barriers to retention in a homeless-tailored OBOT program. Methods: We performed in-depth qualitative interviews with 24 homeless-experienced adults who newly enrolled in Boston Health Care for the Homeless Program’s OBOT program from January 6, 2022 through January 5, 2023. We purposively sampled participants based on whether they were retained at 1 month (n = 12) or not (n = 12). We used an abductive analytic process, applying codes to the interview transcripts from an a priori analytic framework based on the Behavioral Model for Vulnerable Populations and supplementing with emergent codes as needed. We compared themes by participants’ 1-month retention status to explore facilitators of and barriers to retention in OBOT care. Results: The average age was 41.9 years, 29.2% were female, 20.8% were Black, 58.3% were White, and 33.0% were Hispanic. Facilitators of retention common to many participants included the clinic experience, low-threshold model, clinic staff, and provision of comprehensive care. Among participants who were retained at 1-month, personal motivation, use of extended-release buprenorphine, and adequate buprenorphine efficacy were additional facilitators. Barriers to retention common to many participants included the clinic’s surrounding environment, competing subsistence difficulties, and transportation difficulty. Among participants who were not retained at 1-month, opioid use severity, drug use in social networks, and inadequate buprenorphine efficacy represented additional barriers. Conclusions: We identified several common determinants of OBOT retention among our homeless-experienced participants as well as some facilitators and barriers that differed by 1-month retention status. These divergent factors represent potential points of intervention to promote retention in homeless-tailored OBOT programs.

Background: Mobile health clinics improve access to care for marginalized individuals who are disengaged from the healthcare system. This study evaluated the association between a mobile addiction health clinic and health care utilization among people experiencing homelessness. Methods: Using Medicaid claims data, we evaluated adults who were seen by a mobile addiction health clinic in Boston, Massachusetts from 1/16/18-1/15/19 relative to a propensity score matched control cohort. We evaluated both cohorts from four years before to one year after the index visit date with the mobile clinic. The primary outcome was the number of outpatient visits; secondary outcomes were the number of hospitalizations and emergency department (ED) visits. We used Poisson regression to compare changes in outcomes from before to after the index date in a quasi-experimental design. Results: 138 adults were seen by the mobile clinic during the observation period; 29.7% were female, 16.7% were Black, 8.0% Hispanic, 68.1% White, and the mean age was 40.4 years. The mean number of mobile clinic encounters was 3.1. The yearly mean number of outpatient visits increased from 11.5 to 12.1 (p = 0.43; p_diff-in-diff = 0.15), the number of hospitalizations increased from 2.2 to 3.0 (p = 0.04; p_diff-in-diff = 0.87), and the number of ED visits increased from 5.4 to 6.5 (p = 0.04; p_diff-in-diff = 0.40). Conclusions: The mobile addiction health clinic was not associated with statistically significant changes in health care utilization in the first year. Further research in larger samples using a broader set of outcomes is needed to quantify the benefits of this innovative care delivery model.

This cohort study involves assessing causes of death among people experiencing homelessness in Boston from 2003 to 2018.

Drug overdose mortality has increased substantially over the past 20 years in the United States.¹ People experiencing homelessness have been disproportionately affected by this public health crisis, with drug overdose emerging as a leading cause of death at rates up to 30-fold higher than in the US general population.^2-4 Despite these circumstances, temporal patterns in drug overdose mortality and the types of drugs implicated in overdose deaths remain understudied in this population.