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. Author manuscript; available in PMC: 2022 Oct 31.
Published in final edited form as: Drug Alcohol Depend. 2022 Jul 23;238:109585. doi: 10.1016/j.drugalcdep.2022.109585

A Pilot Study of a Mixed-Method Approach to Design an ED-based Peer mHealth Referral Tool for HIV/HCV and Opioid Overdose Prevention Services

Ross J Knaub a, Julie Evans a, Cui Yang b, Raúl Roura a, Tanner McGinn a, Benjamin Verschoore a, Erin P Ricketts a, Richard E Rothman a, Carl A Latkin b, Yu-Hsiang Hsieh a
PMCID: PMC9620482  NIHMSID: NIHMS1841933  PMID: 35926299

Abstract

Background:

The intersecting epidemics of opioid misuse, injection drug use, and HIV/HCV have resulted in record overdose deaths and sustained high levels of HIV/HCV transmissions. Literature on social networks suggests opportunities to connect people who use drugs (PWUD) and their peers to HIV/HCV and opioid overdose prevention services. However, little evidence exists on how to design such peer referral interventions in emergency department (ED) settings.

Methods:

A mixed-method study was conducted to assess the feasibility of an mHealth-facilitated ‘patient to peer social network referral program’ for PWUD. In-depth interviews (IDIs) and quantitative surveys were conducted with urban ED patients (n=15), along with 3 focus group discussions (FGDs) (n=19).

Results:

Overall, 34 participants were enrolled (71% males, 53% Black). 13/15 IDI participants reported a history of opioid overdose; all had witnessed overdose events; all received HIV/HCV testing. From survey responses, most would invite their peers for HIV/HCV testing and naloxone training; and anticipated peers to accept referrals (HIV: 60%, HCV: 73%, naloxone: 93%). Qualitative data showed PWUD shared health-related information with each other but preferred word of mouth rather than text messages. Participants used smartphones regularly and suggested using Internet advertising for prevention services. Participants expressed enthusiasm for ED-based peer mHealth referral platform to prevention services, as well as referring their peers to proposed services, with monetary incentives.

Conclusion:

ED-based peer referral intervention to HIV/HCV testing and naloxone training was viewed favorably by PWUD. Frequent smartphone use among PWUD suggests that the medium could be a promising mode for peer referral.

Keywords: Emergency Department, Patient-to-Peer Referral, Opioid Overdose, HIV, HCV, Prevention Services, mHealth, Mixed-Method Study

1. INTRODUCTION

The United States leads the world in opioid overdose fatalities, averaging 137 deaths per day in 2019 (Centers for Disease Control and Prevention, 2021; Chen et al., 2019; National Academies of Sciences, 2017). Between 2016–2017, American hospitals documented 2.88 million opioid-related emergency department (ED) visits (Langabeer et al., 2021). Beyond the risk of overdose, people who use drugs (PWUD) are at heightened risk of transmission of blood-borne diseases such as human immunodeficiency virus (HIV) or hepatitis C virus (HCV) (Anderson et al., 2020; Murdock et al., 2019; Schulte et al., 2015). Thus, the public health crisis of opioid overuse is compounded by the intersecting epidemics of HIV and HCV (Hsieh et al., 2018).

Naloxone, a rapid-acting opioid antagonist, is used in community and hospital settings to reverse opioid overdose (Houry et al., 2018; Walley et al., 2013). Combining community distribution sites with secondary distribution through social networks has proven to reduce overdose deaths at higher rates than community distribution sites (Keane et al., 2018). Notably, overdose events are more likely to be recognized and have fewer fatalities when witnessed by bystanders with naloxone training (Giglio et al., 2015). As a result, some EDs have begun distributing naloxone kits to patients and peers to increase naloxone access (Gunn et al., 2018), but one study revealed 40% of individuals who received a naloxone kit did not know how to use it, suggesting a need for naloxone administration training (Hurt et al., 2020).

Furthermore, PWUD populations are particularly difficult to engage in healthcare settings (Hoffman et al., 2019), and studies have shown that EDs are their primary source of healthcare in lieu of primary care (Martin et al., 2018; Wu et al., 2012). The comorbid relationship of HIV, HCV, and opioid use; combined with the high utilization of EDs by PWUD, presents an opportunity to utilize opioid-involved ED visits as a launch point for preventive intervention for HIV, HCV, and opioid overdose.

Mobile Health (mHealth) smartphone applications for patient health education have expanded in recent years (Steinhubl et al., 2015). Studies of mHealth applications have shown efficacy in educating PWUD about the risks of HIV and HCV, improving patient engagement, and expanding engagement of peers and family members (Leung et al., 2019; Ochalek et al., 2018). mHealth applications for opioid overdoses show promise in facilitating earlier overdose intervention via bystander naloxone administration (Marcu et al., 2019). Recently, pilot studies have demonstrated potential for mHealth applications to reduce opioid use and improve adherence to medications for opioid use disorder in PWUD (Langdon et al., 2021; Tsui et al., 2021). Although there have been calls to expand peer outreach and mHealth to address the opioid epidemic (Blanco et al., 2020; Krawczyk et al., 2018; Scherzer et al., 2020), currently there are no ED-based mHealth applications that collectively address opioid overdose, HIV, and HCV.

This study intends to introduce mHealth-facilitated patient-to-peer (PTP) referral programs as an additional method of intervention. mHealth PTP referral programs are a novel concept that aim to engage and incentivize PWUD to recruit their peers to community opioid overdose and HIV/HCV prevention services. However, research related to the perception, design, and efficacy of such mHealth PTP programs is limited.

To explore this conceptual idea, we conducted a study in an urban ED in Baltimore, Maryland, a city that has a significantly higher rate of HIV, HCV, and opioid overdose as compared to all other large cities in the U.S. in 2017 (Irwin et al., 2017). Previous studies on the Baltimore PWUD population have reported fatal overdose rates of 13 per 1000 person years in 2018, and an 8-fold increase in non-fatal overdose rates between 2014 and 2019 (Buresh et al., 2019). Additionally, 28% of PWUD in Baltimore reported ever having used fentanyl, known to require sequential doses of naloxone for effective treatment (Buresh et al., 2019; Moss and Carlo, 2019). Public health efforts aimed at ameliorating high seropositivity and overdose rates have been ongoing. This setting provides an ideal site for a pilot study to investigate initiatives aimed at quelling the opioid epidemic and associated bloodborne diseases such as HIV and HCV.

The goal of this study is to assess the perceptions of PWUD regarding the acceptance and utility of an mHealth-facilitated PTP referral program for recruitment of peers to HIV/HCV testing and naloxone training programs. First, we conducted a preliminary mixed-method study (including in-depth interview [IDI] and survey) to explore the perception of a conceptual PTP referral program among ED patients who were PWUD and the potential use of an mHealth tool to facilitate the program. Then, we conducted focus group discussions (FGDs) with PWUD and peers in their social network or family members to discuss their perceptions of the conceptual mHealth-facilitated PTP referral program (Figure 1).

Figure 1: Study design flow chart.

Figure 1:

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2. METHODS

2.1. Patient-to-Peer Referral Program Design

The prototype mHealth-facilitated PTP referral program was aimed at extending the reach of opioid-involved PWUD patient encounters beyond one index ED visit to a patient’s social network. An eligible patient’s index ED visit would be utilized to connect their peers to an mHealth-facilitated platform. This index patient would then recruit or solicit peers to engage in the mHealth platform, ultimately connecting referred individuals to community opioid overdose and HIV/HCV prevention services. Recruited individuals would then be solicited to further recruit more people within the community. A concept map of the mHealth-facilitated PTP referral program is outlined in Figure 2.

Figure 2: Concept map of the patient to peer referral program.

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2.2. Setting

The study site was an urban ED in Baltimore, Maryland with 67,500 annual visits with 2% of the ED patients indicating opioid use in the past 7 days in 2019 (Coupet et al., 2021). This ED has implemented a program offering non-targeted HIV and HCV screening to all eligible ED patients treated within the department yielding a 0.2–0.3% positivity rate with 5.6% seroprevalence of HIV and 5–6% positivity rate with 13.8% seroprevalence of HCV (Hsieh et al., 2016; Kelen et al., 2016).

2.3. Study Design

Our study included one-on-one IDIs with 15 patients, accompanying quantitative surveys (mixed-method study), followed by 3 FGDs (4–8 participants per FGD). All IDI participants who were PWUD were recruited during their ED visits, and both IDI and survey were conducted in the participant’s ED room to explore their perception of a potential PTP referral program and the use of mHealth tool as means to facilitate the program as the index patient. The FGDs conducted at a community-based behavioral research center invited PWUD who self-reported utilization of ED services in the past year and were recruited from a recovery program. They were encouraged to bring one of their peers in their social or PWUD network or family members to FGD to discuss further their perceived acceptability and utility of the conceptual mHealth-facilitated PTP referral program. The study was approved by The Johns Hopkins University School of Medicine Institutional Review Board and was reported using COREQ (COnsolidated criteria for REporting Qualitative research) Checklist (See Supplement Materials).

2.4. Eligibility and Exclusion Criteria

In-Depth Interview:

ED patients were eligible if they were 18 years or older, able to provide informed consent, actively injected drugs at the time of enrollment or had injected drugs in the past, or those who are current or past opioid users with a history of overdose. Patients were also eligible if patient’s close friends or family members had used injection drugs in the last year.

Focus Group Discussion Session:

Individuals were eligible if they were (1) Johns Hopkins Lighthouse clinic clients who were 18 years old or older, able to provide informed consent, actively injecting drugs at the time of enrollment, had injected drugs in the past, or those who are current or past opioid users with a history of overdose and had self-reported ED utilization in the past 12 months, (2) social network or drug use network peers of (1), or (3) family members of (1). Patients were excluded if they had a chief complaint of sexual assault, occupational exposure, or patients who were otherwise ineligible to consent due to medical condition (e.g., severe illness, altered mental status). Individuals who were previously enrolled in this study, less than 18 years of age, incarcerated, pregnant, or considered vulnerable populations were excluded.

2.5. Participant Recruitment

IDI participants were approached at bedside within the ED where, upon agreeing and meeting criteria, the interview was performed. Research coordinators (RC) staffing the ED from 0800 to 2400 seven days per week screened the electronic ED tracking board for patients that met study enrollment criteria. RC then approached the treating ED clinician for their patients regarding the research opportunity in our study. Then, clinicians referred eligible patients to the RC after getting permission from patients. This method of recruitment created a mixture of purposive and convenience sampling. FGD participant recruitment was via a study flyer that was distributed at a recovery program clinic. The flyer provided information regarding recruitment eligibility and contact information of the study RC. Participants were subsequently scheduled for FGD at a local behavioral health research center.

In order to determine if the patient was a person who actively uses drugs or had injected drugs in the past; the study staff used four screening questions. The four questions are as follows: 1) have you ever had a drug overdose in your life, 2) have you ever used injection drugs in your life, 3) have your close friends, with whom you have fun or drink beer with, used injection drugs in the past year, and 4) have your family members, who live with you or live close by in the area, used injection drugs in the past year. If the patient responded “yes” to any of these questions, they were considered eligible and went through the consent and enrollment procedures.

2.6. IDI, Survey, and FGD

IDIs were conducted between June and August of 2018. FGDs were conducted in September and October of 2018. IDI participants were informed that the intent of the interview was to help address HIV, HCV, and opioid overdose in the ED setting. FGD participants were provided the following information at the start of the session: (1) the reassurance of confidentiality and privacy, (2) the role of FGD moderator and assistants was to address drug treatment and HIV/HCV testing, (3) the purpose of the FGD was to develop a service to recruit PWUD and their peers to help spread information about testing and drug treatment services by learning about the participant’s experiences with healthcare, and (4) a prototype mHealth service that would serve as a communication hub to contact PWUDs and peers for referral. A visual diagram regarding our conceptual program was introduced to participants of FDG (Figure 3).

Figure 3: A visual diagram that illustrated the conceptual framework of an mHealth PTP referral program by the focus group discussion moderator.

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For quantitative data, surveys were conducted utilizing a Qualtrics platform on Apple iPads. For qualitative data, IDIs and FGDs were conducted by a Research Associate (JE, PhD) and Clinical Research Assistant (TM) who had no prior relationship to the participants. Participants were compensated for their time with a $20 gift card. Although recruitment criteria could have permitted a participant to be included in both the IDIs and FGDs, there were no participants in both groups in this study.

2.7. Data Collection

Information collected included demographics, history of HIV and HCV testing, drug use history, manner of exchange of health information between PWUD, modality of communication between PWUD, and perceptions regarding PTP referral services. Surveys distributed to participants assessed information such as HIV/HCV status, history of prescription opioids, healthcare utilization, history of HIV/HCV testing, experience with overdose, and the likelihood of participants recruiting peers to HIV/HCV testing or naloxone training. An interview guide (see Supplement Materials) was prepared and vetted by team investigators, although the interview style was open-ended and contingent upon responses by the interviewee. The duration of IDIs ranged from 17 to 51 minutes. Due to IDIs occurring in a clinical workspace, hospital staff may have entered the room during interviews. FGDs were between 45 and 57 minutes in duration. Interview transcripts were not provided to participants for comment or correction.

2.8. Data and Statistical Analysis

Field notes and audio recordings of the IDIs and FGDs were collected during the interview and manually transcribed and de-identified to electronic text using Microsoft Word 365 Version 2112 by clinical research assistants (RK, TM, RR, BV) listening to the audio recordings. Themes were derived from the data using constant comparison analysis to develop one or more themes that express the content (Onwuegbuzie et al., 2009). Thematic analysis was performed for IDI and FGD separately by three coders (RK, RR, and BV) reviewing interview transcriptions using Microsoft Excel 365 Version 2112, and any discrepancies were adjudicated by the primary investigator (Y-HH). The transcriptions were analyzed to evaluate the availability and use of smartphones, personal encounters with overdoses, naloxone training experience or access, social support or interactions, previous experiences with HIV/HCV testing, experiences with needle exchanges, and how health information related to HIV/HCV is shared among peer groups. The coding tree organized the transcriptions into the following themes: Smartphone access/use, daily routine, interactions with others, family or relationship situation, housing situation, drug use, needle sharing, experience with overdose, interactions with PWUDs, experience with HIV/HCV or HIV/HCV testing, participation in naloxone training, experience with HCV/HIV testing and opioid recovery programs, referring others to HCV/HIV testing and opioid recovery programs. The results of the qualitative data analysis were presented in 4 subsections, “Naloxone Training and Opioid Overdose”, “Experience with HIV/HCV Testing and Public Programs”, “Communication Modality, Social Circle, and Sharing Health Information with Peers”, and “Proposed Pilot Study Perception – Specific to Focus Group Discussions”, where the first 3 subsections contained themes that were identified from either IDIs or FDGs since similar topics were discussed. For quantitative data, only descriptive statistical analysis was performed due to the small sample size. All of data were stored on an internally secure server.

3. RESULTS

Quantitative Results

61 patients were identified as potentially eligible for participation in IDIs for the study. 35 patients were excluded for the following reasons: 14 were critically ill or had cognitive impairment, 10 were discharged prior to being approached, 5 due to lack of an available research assistant, 3 were admitted, 2 declined participation prior to eligibility questioning, and 1 due to provider’s recommendation. Ten of the 26 remaining patients were ineligible after screening due to declining to provide a history of drug use. Of the 16 eligible patients, 1 declined to participate in the study. No patients subsequently dropped out nor were lost to follow-up in the study. The remaining 15 patients were consented and enrolled for participation in the study.

There were 15 IDI participants and 19 participants (including 7 dyads; 4 of peers/family members were also PWUD) in three FGDs. The demographics of participants are outlined in Table 1. Almost 90% (13/15, 87%) of IDI participants reported a history of opioid overdose; all had witnessed overdose events; all had a lifetime history of HIV/HCV testing. From their survey responses, most reported that they would invite their peers for HIV/HCV testing and naloxone training; and reported expecting a positive response from their peers to accept their referral (HIV: 60%, HCV: 73%, naloxone: 93%) (Table 2).

Table 1:

Demographics of Study Participants

Total (n=34) Percentage IDI (n=15) FGD (n=19)
Age (years) <30 1 3% 1 0
30–39 5 15% 2 3
40–49 5 15% 5 0
50–59 15 44% 7 8
>60 2 6% 0 2
Unknown 6 18% 0 6
Race African American 20 59% 9 11
White 14 41% 6 8
Sex Male 24 71% 12 12
Female 10 29% 3 7
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Table 2:

Some example quantitative survey questions regarding perceived acceptability of the conceptual patient-to-peer referral program

1. How likely would your close friends or family members to accept your invitation to receive a free HIV test in a public health prevention program, if you invite them?
 □ Definitely would
 □ Likely
 □ Maybe
 □ Unlikely
 □ Definitely would not
2. How likely would your close friends or family members to accept your invitation to receive a free HCV test in a public health prevention program, if you invite them?
 □ Definitely would
 □ Likely
 □ Maybe
 □ Unlikely
 □ Definitely would not
3. How likely would your close friends or family members to accept your invitation to receive a free NARCAN training in a public health prevention program, if you invite them?
 □ Definitely would
 □ Likely
 □ Maybe
 □ Unlikely
 □ Definitely would not
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Qualitative Results

Throughout this section, we present the qualitative findings of the IDIs as well as the FDG sessions in four main subsections. The first subsection presents the results specifically related to naloxone training and opioid overdose, including their first-hand experience with both topics. The following subsection focuses on presenting findings specifically related to HIV/HCV testing and public health program services, including the participant’s awareness, perception, access to HIV/HCV testing, their awareness and disclosure of seropositive status and transmission risk, and their opinion as to possible barriers and incentives to HIV/HCV testing. The next subsection presents the results focused on communication modalities, social circles, and health information sharing between peers. The last subsection revolves around the participant’s perspective on a proposed pilot patient-to-peer referral program that was only discussed during the FGD sessions. A thematic roadmap of qualitative analysis results is presented in Figure 4.

Figure 4: Thematic roadmap of the qualitative analysis results.

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3.1. Naloxone Training and Opioid Overdose

All FGD participants either witnessed naloxone use on others or had been administered naloxone to reverse their own overdose. Of IDI participants, 11 (73%) stated they had undergone naloxone training or at least received an explanation of how to use naloxone. Several participants perceived naloxone training as a quick, effective, and simple process shown by the following quote: “In three minutes they [Dept. of Health Vehicle] showed me how to use it. … So that would be good if somebody’s out on the street saying…I will show you how to use it in a few seconds, cause like myself I was on my way to an appointment but it stopped me because they said it won’t take long to teach you how to use it.” P7-IDI

Participants also recognized the importance of quick administration of naloxone reversal and embraced the idea of community training. However, some participants expressed doubts about naloxone’s efficacy in reversing overdoses with stronger opioids such as fentanyl and carfentanil. In the following quote, one of the participants shared insight on the topic:

“It takes a lot [emphasis] of that [naloxone] to bring you from fentanyl and carfentanyl… They hit me three times…. It worked on heroin but the fentanyl and this carfentanyl you have to use so much of that stuff that, it really takes the emergency people to deal with it, not just someone like us.” P1-FGD1

Of participants without naloxone training, the majority witnessed the usage of naloxone. The majority of those with training expressed having used naloxone on family members, peers, or even random PWUD encountered on the streets as shown by the following quotes: “Walking by…I knew she was like sitting there and her eyes were rolled back and you,… she started doing the death rattle and I just grabbed her head and I hit her twice [meaning he gave her two shots of the naloxone nasal spray].” P2-IDI

“A friend of mine…. he ended up in the middle of the intersection completely unconscious, you know, under the influence, and they actually had to hit him with [naloxone] twice. It’s definitely a good thing to have on you, especially in the city here. You never know what you’re going to come across.” P5-IDI

3.2. Experience with HIV/HCV Testing and Public Programs

3.2.1. Awareness and Perception of HIV/HCV Testing

Participants stated a perceived increase in HCV testing due to rising awareness of HCV.

“The number of people that have it.” P7 “The number of people that have been tested, that have [HepC].” P4-FGD3 “That’s because people are now being tested because people are talking about it.” P1-FGD3 Group discourse-FGD3

Some participants wanted to know their serostatus (Q 2.3), yet the majority expressed a lack of knowledge regarding the severity of HCV and need for HCV testing, as shown by the following quote:

“Oh when I be going to the hospital… they wanna test …Might as well, I mean I’m there to find out what’s wrong with me anyway, you know…, I wanna know if I got something.” P15-IDI

Notably, most participants were not concerned with HIV/HCV testing or the risks of sharing needles as their drug dependence had priority over their health, as expressed by participants:

“When you’re deep in the [grab?] of addiction, you don’t care [emphasis].” P3-IDI

“For me getting Hep C was not supposed to be on my agenda. See I understood that I came across HIV, but in the crowd that I hung with everybody shared. Back then we didn’t care… I’ve even been around where I saw someone take another person they had blood in the syringe. They took it from that person and shot it in themselves.” P5-IDI

3.2.2. Participant Access to HIV/HCV Testing

All participants claimed they had been tested for HIV/HCV when surveyed and were aware of multiple venues that offer testing services, including community outreach programs, emergency rooms, hospitals, drug treatment programs, and prisons. Participants described several ways they were offered testing: “Myself, I’ve gotten tested at a methadone treatment, I’ve gotten tested at my doctor’s office, I’ve gotten tested at an emergency room before. And my regular medical doctor.” P1-IDI

“A lot of buses out there, a lot of people that they be giving the test.” P2-IDI

“They [drug treatment programs] ALL address Hep C and AIDS and all that.” P4-IDI

“A lot of us eventually one time or another got locked up, and of course once you get locked up you get tested there (jail).” P5-IDI

3.2.3. Disclosure of Seropositive Status and Recognition of Transmission Risk

The fear of positive HIV/HCV test results, along with social repercussions of a seropositive status, was cited as a primary reason preventing participants from disclosing their HIV/HCV positive serostatus, as described by the following quotes:

“A lot of people scared to get tested, that’s the bottom line.” P3-IDI

“They don’t want to find out. It’s fear. They don’t want to find out, you know it’s like er them slapping a foreclosure on your front door.” P4-IDI

“Well not just that, people are out, they know you get Hep C through IV use. So if you tell somebody you’re Hep C positive they’re gonna know that you’re shooting up. People don’t want people to know that. Of course.” P2-IDI

“No! No. They’ll never tell someone.” Entire group-FGD2

Although participants indicated that they were not concerned with HIV/HCV status dependent on their level of drug dependence, some still acknowledged the importance of HIV/HCV testing. While some participants were firmly against sharing needles, as portrayed by one participant, “Cause I won’t share a needle with anyone. I won’t do it.” P2-IDI, others would still inject in order to get high or avoid withdrawal, even though they were aware of the high risk for acquiring HIV/HCV as previously described by quotes from Section 3.2.1.

3.2.4. Incentives and Barriers to HIV/HCV Testing

Participants stated they had been tested for HIV/HCV when offered a financial incentive, as narrated by one of the participants “Let’s say like there was something for HIV and HepC testing, .…where it’s like “Hey look they’re doing testing they’ll give you a five dollar gift card.” People are all over that. And they’re willing to go get tested for a gift card.” P2-FGD3. Participants also described time as a limiting factor, since their focus was on obtaining money to support their addiction as described by a participant, “Basically taking the time to [get tested]. Like I said, all day is spent chasing money or chasing drug.” P14-IDI.

3.3. Communication Modality, Social Circle, and Sharing Health Information with Peers

From the IDI participants, 10 (66.7%) stated they had a smartphone, while 11 (73.3%) at least had access to a smartphone. Several participants with smartphones described texting as one of their main usages for the device; yet others stated that they did not utilize texting at all or only use their device for phone calls, as described in the following quotes:

“I never text, that’s been something I’ve been meaning to do. I never really learned how to really, you know, get into texting.” P15-IDI

“I ain’t too good with the texts. I can barely dial a phone. I’m old fashioned just dial the phone cause I don’t do all that texting cause I think texting is too personal some times.” P12-IDI

“Pretty much everyone has a phone nowadays, and the government provides free ones for people that can’t afford them”. P5-IDI

Additionally, some participants expressed other usages of the smartphone, besides phone-dialing or text-messaging, such as playing games and social media, including Facebook, messenger, and YouTube, as described by the following quote:

“Yeah yeah, just um yeah phone calls, text messages uh Facebook…… music mostly, probably music, maybe video, YouTube video, stuff like that or movies. And a little bit of social network, Facebook mostly… That’s pretty that’s just about it. Pretty much all the apps I would use music, videos, movies, and then a little of social network.” P14-IDI.

Overall, participants expressed willingness to use mobile phones for recruiting, but were apprehensive about the efficacy of mobile communication to be successful in referring PWUD to get tested or seek recovery programs, as portrayed in the following quotes:

“Certain people I still would do that with, but, and then there’s others, you know other people that I know that’s just not [there?] in the head because it just wouldn’t do no good… you know they’ll find a way to lose you, you know, lose in touch with you because they don’t want to hear it.” P3-IDI

“I believe for some, it depends on who wants to change, how you feel about it. If you want to change, you, you may consider, you know, you may consider any help cause you don’t know where to get help from, somebody that don’t want, just want to say they don’t” P10-IDI

While social isolation was a common theme, more social participants primarily interacted with other PWUD, while others spent most of their time alone, as shown by the following quotes:

“For the most part, you know I act with them because they’re doing the same thing I’m trying to do, you know, and that’s use drugs.” P3-IDI

“I mean, yeah every day, I mean I see um drug users you know” P15-IDI

“For the most part I’d spend most of the day probably by myself erm, small parts of the day I might spend with a friend or two” P14-IDI

“No one really…. I don’t really got too much friends or anything” P13-IDI

Some participants expressed having support from relationships that encourage PWUD to abstain from drug use, “She [Fiancée] said well it’s time to get clean. I said, I know. ……. You know. You done something in life wrong, you know. You was doing something you messed up. All types of stuff. You got to figure out what it is…” P6-IDI, although some intentionally isolated themselves from family members when using, as they were ashamed or their family disapproved of their behavior, as shown by these quotes:

“She only likes to see me when I’m not using. When she’s using she’s upset, she don’t come round, she don’t call. When I’m not using she used to call me every other day, or every day.“ P7-IDI

“Erm, I think it would have been more painful if they’d seen me getting high, not looking like myself.” P10-IDI

3.4. Proposed Pilot Study Perception – Specific to Focus Group Discussions

Participants expressed a positive attitude towards a PTP referral program that used index persons as community peer marketers and multimodal communication to involve PWUD in community health services, demonstrated in the following quotes:

“Yeh, yeh. They can pass it on or they can put it off to the side until they’re ready to do it, and then initiate on it.“ P1-FGD1

“It’ll work man if you get the people that go out there like when we leave here, calling people up, giving them this study and like you said put something on the phone” P2-FGD1 (Peer of P1-FGD1)

We found that PWUD shared health-related information with each other but preferred word-of-mouth communication rather than text messages. Some participants expressed that they would text with other peers to share health information in this quote, “And for like, let’s say like there was something for HIV and HepC testing, all it, this has happened a lot where it’s like “Hey look they’re doing testing they’ll give you a five-dollar gift card” P2-FGD3. However, participants expressed indifference towards the usefulness of texting for recruiting, and one participant instead suggested a word-of-mouth referral program with community recruiters, with this discordance expressed in the following quotes:

“A lot of people don’t even check their text messages.” P1-FGD1

“[Texting] wouldn’t matter. But I’d like the recruiting patients, …you could still recruit a team of people and they could go into their own, you know their own community, talk to those they know they could talk to…. first of all if I’m sitting up here and my phone beep do you think I’m gonna take time to read the message? That’s not happening. If I’m injecting and my phone right here receives a message that would mean nothing to me. You understand what I’m saying? It’s about getting people to pay attention too. P4-FGD3

Additionally, participants consistently emphasized financial incentives as motivating factors to engage in preventive health services- Please see the quote in Section 3.2.4 above from P2-FGD3. Notably, one participant expressed support for using a chain of recruiting in the program, suggesting that utilizing PWUD as recruiters would have a positive outcome for expanding PWUD utilization of health services, as described in the following quote: “So you make it so this group of people, you tell like five more people know and this group and this group let them five people tell them the benefits if you do this and then these people way down the [loop], the five hundred people down the loop, they tell so many people they get free, something for free medically” P7-FGD3

Participants were also asked about the possibility of their peers participating in programs centered around receiving health services such as HIV/HCV testing. Participants expressed enthusiasm for ED-based peer referral to proposed prevention services outside of the ED, as well as interest in recruiting their peers. Participants raised concerns regarding the motivation or willingness of PWUD to participate due to ambivalence about prioritizing their health, as described by participants, “We could get the information out there but responding to it is going to be a different story. If someone got set in their mind on getting high that’s what they’re going to do. I mean we could get it out there to them.” P2-FGD1 “Yeh, mm.” P1-FGD (Peer of P2-FGD1)

On the other hand, participants did express the idea that PWUD could reach a point of prioritizing their health over drug use, if under certain circumstances, as described by the following participant: “The only way they’re going to listen to a program is cause they’re forced to go to a program, ordered by the law, or by the courts, or by the fact that where they living they got put out of. Until, mainly until something tragic happens to you where you’re just tired of bring tired, you’re not going to try to get any help.” P6-FGD2

A discourse between three participants went as follows, “What you think brother? There ain’t too much that’s going to get them. Nothings going to get them here.” P2-FGD1 “Yeh, he right. I mean because you can provide all the information and the services all you want to but you know some people just are stubborn. You hear what I saying? Yeh some is willing and some is not, so. That’s kinda hard to really say if you provide the service for someone that they gonna use it or not. They might pass it onto somebody else.” P3-FGD1 “Yeh, yeh. They can pass it on or they can put it off to the side until they’re ready to do it, and then initiate on it.” P1-FGD1 (Peer of P2-FGD1), acknowledging that although some PWUDs may not utilize referral services themselves, they could share their knowledge of the program with others who are seeking a program.

Notably, participants expressed additional concern regarding potential index recruiters, as PWUD could identify recruiters as “self-righteous” for sending health information to PWUD or suggesting they get tested. A participant described the concern:

“And for us, I mean, that’ a good plan except [laughing] erm if we start sending erm data to our friends you know what they going to say? We’re self-righteous. We been there we even got well and then we self-righteous, and they trying to tell them what to do because they, you know they think they got cured now. You know it’s just so much, so it’ even with that it’ a way, a careful way you need to approach that. I mean we would be better off talking to them individually cause you know who you can talk to and who you can’t.” P4-FGD2

4. DISCUSSION

This is an exploratory, foundational study investigating the potential of an ED mHealth-facilitated PTP referral program to simultaneously address the overlapping risks of opioid overdose, HIV, and HCV. Research evaluating mHealth applications that specifically address opioid overdose prevention is limited, with most publications focused on mHealth applications for deployment of emergency services or bystanders trained in naloxone administration (Marcu et al., 2019). Prior studies have shown that a lack of successful linkage to care is one of the critical barriers to addressing opioid overdose and HIV/HCV in EDs (Anderson et al., 2017; D’Onofrio et al., 2017; Franco et al., 2016). Furthermore, it has been demonstrated that mHealth and peer involvement are effective in improving follow-up, medication adherence, and linkage to tertiary services (Rowland et al., 2020). Our findings reveal a positive perception by PWUD for PTP referral intervention for naloxone training and HIV/HCV prevention services among most participants. This finding suggests that our ED-based mHealth PTP referral program could be an effective next step in simultaneously ameliorating HIV, HCV, and opioid use in a population difficult to reach by traditional methods (Hoffman et al., 2019; Hurt et al., 2020).

4.1. Naloxone training and HIV/HCV testing referral programs

All participants either had received naloxone to prevent fatal overdose or had witnessed naloxone use on other PWUD. Additionally, participants who had not received formal naloxone training expressed desire and interest in such training for themselves and their peers. Naloxone training programs for PWUD in community settings have demonstrated efficacy in reducing opioid overdose deaths (Hurt et al., 2020; Keane et al., 2018).

Many participants described having been offered HIV/HCV testing through either healthcare or community programs. However, they may decline such services contingent on the stage or severity of their drug dependence. This reinforces the need for education and HIV/HCV testing. An mHealth PTP program might be more effective at providing intervention for peers prior to the stages of dependence where PWUD are seeking recovery or are in a state of recovery.

Another important finding of our study was that our participants feared knowing their HIV/HCV status although contemporary HIV/HCV treatments either significantly reduce disease burden or for HCV offer a cure. Participants also reported a fear of knowing their HIV/HCV serostatus, describing a stigma that other PWUD might not want to share needles or use drugs with someone known to be positive. Although HIV/HCV testing services are accessible and often free as reported by participants, some participants preferred not finding out their serostatus as it precluded social stigma or the need to disclose seropositivity to others. PTP referral programs may reduce fear by normalizing conversation among PWUD, similar to social movements for pre-exposure prophylaxis use for HIV (Gómez et al., 2022; Mehrotra et al., 2018; Reza-Paul et al., 2019).

Based on interview results relating to naloxone and HIV/HCV testing, participants described that it is well known that both HIV/HCV testing is available via community programs. Financial incentives were consistently described as motivating factors for PWUD to obtain HIV/HCV testing. Financial incentives that compensate both time and cost on behalf of participants for both recruitment and attendance to opioid overdose and HIV/HCV prevention services would likely yield greater outreach and utilization of services.

4.2. Communication, Smartphone Use, and Social Media

Our results reveal that smartphones and social media were utilized to varying degrees among PWUD. Approximately 75% of the IDI participants claimed to own or at least have access to a smartphone. Those who cannot afford a phone plan use their mobile devices via public Wi-Fi connections, suggesting that social media platforms might be a more consistent point of contact to engage more PWUD. Although the majority had access to a smartphone, participants still preferred word of mouth for communication among PWUD. This proposes that physical referral cards might be useful for referral in lieu of mobile phones to suit an individual’s communication preference.

Many participants described a lack of social support or that their social circles were not conducive to recovery. They also described that many of the people whom they interact with on a daily basis are only associated with drug use. A lack of positive social structure is a barrier to recovery and relapse prevention, wherein an mHealth-facilitated PTP program could connect PWUD with other PWUD oriented toward recovery.

4.3. Perception of a PTP Referral Program

Although generally positive, many participants expressed doubt about the efficacy of texting for peer recruitment. However, when texting was combined with financial incentives, participants were more receptive to texting as a recruitment effort for HIV/HCV testing stating, “you’d literally have [PWUD] lined up around the street”. In addition to texting, in-person communication, direct phone calls, and use of phone applications were described as potentially effective modalities for communication and referral. For PWUD who do not utilize mobile texting, a physical referral card could be substituted as suggested.

Furthermore, study participants described that designating certain individuals as peer opinion leaders would be helpful in engaging more PWUD and their peers into PTP referral programs. The concept of peer opinion leaders has been studied in multiple professions and has been investigated for utility in public health crises like the opioid epidemic (Sismondo, 2015; Young and Heinzerling, 2017). Utilizing opinion leaders would create an established point of contact for PTP referral programs. Establishing leaders within PTP referral programs might also help address the isolation and lack of support that is commonly described among PWUD. However, the utilization of peer leaders may also create a negative perception of that person as “self-righteous” or condescending by asking others to get tested for HIV/HCV as evidenced by P2-FGD2, which suggests the importance of training PWUD in health communication skills.

On the other hand, some participants said that PWUD would not attend programs without a concrete desire to change lifestyles, often precipitated by life tragedy such as a near-death experience or loss of a significant other. Moreover, a low priority of personal health due to severity of addiction was referenced as a factor that would reduce engagement of PTP referral services. Nevertheless, both P2-FGD3 and P4-FGD3 suggested that these barriers might be overcome with financial incentives which have been indicated as an appreciating approach to increase engagement for the hepatitis B vaccination as well as hepatitis C treatment (Marshall et al., 2022; Topp et al., 2013). A commonly mentioned theme was that even with effective communication to PWUD and their peers, health messages might not be received as some PWUD may solely utilize the service for the financial reward, suggesting that it could be better to use a financial incentive to recruit PWUD as well as incentivize repeat attendance. However, we need to consider historical and systemic barriers to care as well as racial/ethnic health disparities for sub-PWUD populations with significant trauma or criminal justice involvement (e.g. court-mandated treatment brought up by one participant) when we are customizing mHealth approaches to meet the needs of PWUD (Chau et al., 2021; Saraiya et al., 2020; Siddiqui and Urman, 2022).

Overall, the mHealth-facilitated PTP referral program was well-received by study participants. Threats to the program’s success would be a lack of motivation for enrollees and poor perceptions of peer leaders and recruiters. The impact of financial incentives in improving the efficacy of PTP referral programs must be considered as this was consistently a strong motivator among participants.

4.4. Strengths and Limitations of the Study

One of the strengths in our exploratory study is to enroll the index participants with their peers or family members as dyads to participate in the FDGs. This type of dyadic approach, which is still under-utilized in the research, could explore the interpersonal dynamics within the relationship of a dyad (Mendelsohn et al., 2015), which is indeed very crucial for our study to explore the conceptual and operational framework of the PTP referral program. Our findings from the dyads in the FDG (see interactive quotes between P1 and P2-FDG1 cited under the section 3.4) foster the potential acceptability and utility of the proposed mHealth-facilitated PTP referral program. Further studies are warranted since dyadic methodology, and analytical approaches in FDGs are still not fully established.

There were potential selection biases existing in this study, including many acutely ill ED patients who were ineligible for study enrollment due to altered mental status from overdose as well as those who declined to participate. Our inclusion and exclusion criteria did not specifically limit the index participants to opioid users, although all index participants (excluding peers/family members) reported opioid misuse in the study. Additionally, the generalizability of our findings may be an issue since many of the study participants were in the later stages of addiction or recovery, and over 45 years old, thus possibly more optimistic towards positive outcomes for mHealth-facilitated PTP referral programs. Saturation of themes was not possible due to our sample size. In addition, the perception of mobile phone use and social utility would likely differ in a younger population of PWUD. Furthermore, positive perceptions and attitudes toward mHealth peer referral programs may not translate to active attendance to programs or treatments. Finally, only a conceptual idea of an mHealth facilitated PTP referral program was brought up during the IDI, and a conceptual visual framework diagram was presented in FGDs so that a prototype version of an mHealth application for a PTP program was not assessed in the preliminary phase of our study.

5. Conclusion

In addressing the opioid epidemic, the need for outreach interventions goes well beyond that of the hospital system. This pilot study evaluating the concept of an ED-based peer referral intervention to HIV/HCV testing and naloxone training was viewed favorably by PWUD. Frequent smartphone use for video watching and social media access among PWUD suggests that social media advertising campaigns could be a promising mode for peer referral. Provision of financial compensation for referral and attendance to public health initiative programs was consistently referenced as a strong incentive for PWUD and peer attendance to PTP referral programs.

Supplementary Material

An interview guide
COREQ Checklist

Highlights.

  • This preliminary study revealed ED peer referral to HIV/HCV testing & naloxone training was viewed favorably by PWUD

  • All subjects had either received naloxone training or witnessed naloxone use on PWUD

  • Social media could be a useful mode to engage more PWUD with smartphone access

  • Social media and internet campaigns could be a promising mode for peer referral

  • Financial incentives likely improve peer referral to prevention services

Acknowledgment

The authors would like to thank Mr. Phoenix Underwood and Ms. Doyin Adeyemi for their assistance with the project. The authors would also like to thank the study participants for sharing their experiences with us.

Funding

This work was supported in part by JHU CFAR NIH/NIAID fund P30AI094189.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

An interview guide
NIHMS1841933-supplement-An_interview_guide.doc (106KB, doc)
COREQ Checklist
NIHMS1841933-supplement-COREQ_Checklist.pdf (437.2KB, pdf)

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