SUMMARY Due to the large, rural burden of HIV in the state, Alabama (AL) is one of seven priority states for the Ending the HIV Epidemic (EHE) initiative. Alabamians struggle with late HIV diagnosis and suboptimal linkage and retention in HIV care, at least in part due to poverty, rurality, and lack of public health infrastructure and Medicaid expansion. Further, historic events have impacted HIV efforts in AL in myriad ways, halting progress towards EHE goals: the pandemic and the Drug Crisis. At UAB Hospital, one hundred of persons who inject drugs (PWID) are hospitalized with serious complications from drug use annually. Over 25% of them are from rural counties where the absence of low barrier medical, harm reduction, and addiction services enables high risk injection practices and infections, like hepatitis C and HIV. Unfortunately, the hospital is a missed opportunity for HIV prevention: we found that hospitalized PWID are unaware of their HIV risk and providers are unlikely to offer PrEP to PWID. At the same time, few PWID in AL reside in communities that offer integrated HIV, harm reduction, and addiction services. Thus, PWID with life-threatening complications of drug use return to communities who are not equipped to care for them. While it is not feasible to rapidly scale up integrated care across Alabama, a combination of geospatial mapping and epidemiologic surveillance can allow us to identify and prioritize counties at greatest risk for an HIV outbreak among PWID. The objective of this application is to 1) leverage hospital and community-level data to identify AL counties at greatest risk for an HIV outbreak among PWID and 2) engage community partners to identify needs and opportunities to build community capacity. The overall goal of this proposal is to inform implementation strategies to integrate person-centered HIV, harm reduction, and addiction services for PWID in AL. To achieve our overall goal, we propose the following specific aims: AIM 1A. Using geospatial mapping and statewide HIV and opioid overdose surveillance data, we will identify AL counties with the greatest risk of an HIV outbreak during the contemporary drug crisis (fentanyl and methamphetamines). AIM 1B. Upon identifying counties with the greatest risk, we will work in partnership with our existing Community Advisory Board (CAB) to develop an engaged community of partners in counties at greatest risk, including health officials, AIDS Service Organizations, nonprofits, and addiction treatment centers. AIM 2. We will collaborate with Community Partners to identify hyperlocal opportunities for integrated HIV, harm reduction, and addiction services. Specifically, we will use qualitative methods to identify barriers and opportunities for integrated care from the perspective of service organizations and PWID.

NARRATIVE The proposed research activities will contribute a fundamental, hyperlocal knowledge of HIV risk among persons who inject drugs in Alabama. This data is essential to identify and prioritize communities for HIV prevention services, in addition to harm reduction and addiction interventions. We will not reach the ambitious aims of the Ending the HIV Epidemic Initiative without tailoring prevention efforts to meet the needs of PWID, a group who is most marginalized and at heightened risk of HIV.