Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas - United States, 2013

Past-Year HIV Testing, Current Antiretroviral Therapy Use, and Participation in Services for People Who Inject Drugs

Evaluating routine HIV testing and treatment and use of services for people who inject drugs (PWID) is critical to curb the ongoing HIV epidemic. We analyzed data from the 2018 National HIV Behavioral Surveillance of PWID aged 18 years or older, recruited using respondent-driven sampling and offered anonymous HIV testing after survey. We performed bivariate and multivariable analyses with log-linked Poisson regression of the generalized linear models to examine the associations between demographics and PWID service use, past-year HIV testing, and current antiretroviral therapy (ART) use. Among 10,311 HIV-negative PWID, 56% reported past-year HIV testing, and of the 553 HIV-positive PWID, 69% reported current ART use. Of the HIV-negative PWID, 64% (2874/4482) in drug treatment and 62% (3386/5440) who used syringe service programs (SSPs) reported past-year HIV testing. Among HIV-positive PWID, 75% (187/248) in drug treatment and 67% (200/298) SSP participants were on ART. In the adjusted multivariable model, past-year HIV testing was associated with drug use treatment (aPR 1.26, 95% CI 1.23-1.31) and SSP participation (aPR 1.19, 95% CI 1.13-1.26) among HIV-negative PWID. Current ART use was associated with drug use treatment (aPR 1.13, 95% CI 1.00-1.28) but the link was not significant probably due to small sample size. Findings support the expansion and improvement of PWID-targeted services, into comprehensive programs, including drug use treatment, SSP, and HIV testing and treatment.

Prior incarceration, restrictive housing, and posttraumatic stress disorder symptoms in a community sample of persons who use drugs

BACKGROUND

Criminalization of drugs in the United States (US) has extensive consequences for people who use drugs (PWUD). Incarceration and substance use overlap with 65% of the US prison population meeting substance use disorder (SUD) criteria. Exposure to the criminal-legal system negatively impacts the health of PWUD. PTSD is commonly comorbid with SUDs, and exposure to restrictive housing (RH) during incarceration may worsen mental health. Because PWUD are disproportionately incarcerated, experiences occurring during incarceration, such as RH, may contribute to the development or exacerbation of PTSD and SUDs. This study of PWUD investigated prior criminal-legal system exposure and its association with PTSD symptoms in community-dwelling PWUD.

METHODS

This cross-sectional study recruited PWUD from syringe service programs (SSP). Inclusion criteria were: age 18+, current or past opioid use disorder, and SSP enrollment. Data collected included: sociodemographics; incarceration, substance use, SUD treatment history, and PTSD assessments (Life Events Checklist for DSM-5 and the PTSD Checklist for DSM-5). Bivariate testing and multivariate logistic regression analyses, with probable PTSD as the dependent variable and a three-level variable for criminal legal history as the independent variable, were conducted to determine whether incarceration and RH were associated with probable PTSD.

RESULTS

Of 139 participants, 78% had an incarceration history with 57% of these having a history of RH. 57% of participants screened positive for probable PTSD, and physical assault was the most common traumatic exposure. Any history of incarceration was not associated with probable PTSD diagnosis; however, in multivariate testing, adjusting for age, sex, and substance use, a history of RH (adjusted odds ratio [aOR]: 3.76, 95% CI 1.27-11.11) was significantly associated with probable PTSD.

CONCLUSIONS

RH and PTSD were both exceptionally common in a sample of SSP participants. RH can be detrimental to physical and mental health. Clinicians and policy makers may not consider incarceration as a traumatic experience for PWUD; however, our data suggest that among highly marginalized PWUD, prior exposure to incarceration and RH may add an additional burden to their daily struggles, namely PTSD.

Funding and Delivery of Syringe Services Programs in the United States, 2022

Objectives. To describe the current financial health of syringe services programs (SSPs) in the United States and to assess the predictors of SSP budget levels and associations with delivery of public health interventions. Methods. We surveyed all known SSPs operating in the United States from February to June 2022 (n = 456), of which 68% responded (n = 311). We used general estimating equations to assess factors influencing SSP budget size and estimated the effects of budget size on multiple measures of SSP services. Results. The median SSP annual budget was $100 000 (interquartile range = $20 159‒$290 000). SSPs operating in urban counties and counties with higher levels of opioid overdose mortality had significantly higher budget levels, while SSPs located in counties with higher levels of Republican voting in 2020 had significantly lower budget levels. SSP budget levels were significantly and positively associated with syringe and naloxone distribution coverage. Conclusions. Current SSP funding levels do not meet minimum benchmarks. Increased funding would help SSPs meet community health needs. Public Health Implications. Federal, state, and local initiatives should prioritize sustained SSP funding to optimize their potential in addressing multiple public health crises. (Am J Public Health. 2024;114(4):435-443. https://doi.org/10.2105/AJPH.2024.307583).

Equity of overdose education and naloxone distribution provided in the Kentucky HEALing Communities Study

Background

Opioid overdoses differentially affect demographic groups. Strategies to reduce overdose deaths, specifically overdose education and naloxone distribution (OEND), are not consistently delivered equitably.

Methods

The HEALing Communities StudySM (HCS) is a cluster-randomized trial designed to implement evidence-based practices, including OEND, to reduce overdose deaths across communities. Individuals receiving OEND in eight Kentucky counties between January 2020 and June 2022 provided demographics and overdose history. Recipient characteristics were compared to opioid overdose decedent characteristics to evaluate whether OEND was equitably delivered to the target population. Recipient characteristics were also analyzed based on whether OEND was delivered in criminal justice, behavioral health, or health care facilities.

Results

A total of 26,273 demographic records were analyzed from 137 partner agencies. Most agencies were in behavioral health (85.6 %) or criminal justice sectors (10.4 %). About half of OEND recipients were male (50.6 %), which was significantly lower than the 70.3 % of overdose decedents who were male, (p<0.001). OEND recipients tended to be younger than overdose decedents, but there were not significant differences in race/ethnicity between OEND recipients and overdose decedents. Over 40 % of OEND recipients had overdosed, and 68.9 % had witnessed a prior overdose. There were notable differences across facility types, as males and Black individuals accounted for fewer OEND recipients in addiction treatment facilities compared to jails.

Conclusion

Although OEND recipients' demographics resembled those of decedents, specific attention should be paid to ensuring equitable OEND access. Variation in OEND uptake by facility type may reflect biases and barriers to care.

Come back when you're infected: pharmacy access to sterile syringes in an Arizona Secret Shopper Study, 2023

BACKGROUND

Pharmacies are critical healthcare partners in community efforts to eliminate bloodborne illnesses. Pharmacy sale of sterile syringes is central to this effort.

METHODS

A mixed methods "secret shopper" syringe purchase study was conducted in the fall of 2022 with 38 community pharmacies in Maricopa and Pima Counties, Arizona. Pharmacies were geomapped to within 2 miles of areas identified as having a potentially high volume of illicit drug commerce. Daytime venue sampling was used whereby separate investigators with lived/living drug use experience attempted to purchase syringes without a prescription. Investigator response when prompted for purchase rationale was "to protect myself from HIV and hepatitis C." A 24-item instrument measured sales outcome, pharmacy staff interaction (hostile/neutral/friendly), and the buyer's subjective experience.

RESULTS

Only 24.6% (n = 28) of 114 purchase attempts across the 38 pharmacies resulted in syringe sale. Less than one quarter (21.1%) of pharmacies always sold, while 44.7% never sold. Independent and food store pharmacies tended not to sell syringes. There emerged distinct pharmacy staff interactions characterized by body language, customer query, normalization or othering response, response to purchase request and closure. Pharmacy discretion and pharmacy policy not to sell syringes without a prescription limited sterile syringe access. Investigators reported frequent and adverse emotional impact due to pharmacy staff negative and stigmatizing interactions.

CONCLUSIONS

Pharmacies miss opportunities to advance efforts to eliminate bloodborne infections by stringent no-sale policy and discretion about syringe sale. State regulatory policy facilitating pharmacy syringe sales, limiting pharmacist discretion for syringe sales, and targeting pharmacy-staff level education may help advance the achievement of public health goals to eliminate bloodborne infections in Arizona.

Primary care nurse practitioner work environments and emergency department utilization among older adults with substance use disorders in rural areas

INTRODUCTION

The prevalence of substance use disorders (SUDs) is growing among older adults, and older adults in rural areas face disparities in access to SUD care. Rural older adults with SUDs commonly have comorbid chronic conditions that puts them at risk for frequent acute healthcare utilization. In rural areas, primary care for patients with SUDs are increasingly provided by nurse practitioners (NPs), and quality primary care services may decrease ED visits in this population. Yet, NP-delivered primary care for rural older adults with SUDs may be limited by work environment barriers, which include lack of support, autonomy, and visibility. This study assessed the relationship between the NP work environment and ED utilization among rural older adults with SUDs.

METHODS

This was a secondary analysis of cross-sectional data from a large survey of NPs in six U.S. states merged with Medicare claims. The study measured the NP work environment by the four subscales of the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), which measure 1) independent practice and support, 2) NP-physician relations, 3) NP-administration, and 4) professional visibility. Multilevel logistic regression models, adjusted for practice and patient covariates, assess the relationship between the NP work environment and all-cause ED use.

RESULTS

The sample included 1152 older adults with SUDs who received care at 126 rural NP primary care practices. NP independent practice and support at the practice was associated with 49 % lower odds of all-cause ED visits among older adults with SUDs. There were no relationships between the other NP-PCOCQ subscales and all-cause ED visits.

CONCLUSIONS

Organizational support for NP independent practice is associated with lower odds of all-cause ED utilization among rural older adults with SUDs. Practice administrators should ensure that NPs have access to support and resources to enhance their ability to care for rural older adults with SUDs. Ultimately, these practice changes could reduce ED utilization and health disparities in this population.

Correlates of Recent HIV Testing Among People Who Inject Drugs in Rural Areas: A Multi-site Cross-Sectional Study, 2018-2020

The Rural Opioid Initiative surveyed 2693 people who inject drugs (PWID) in eight rural U.S. areas in 2018-2020 about self-reported HIV testing in the past 6 months. Correlates of interest included receipt of any drug-related services, incarceration history, and structural barriers to care (e.g., lack of insurance, proximity to syringe service programs [SSP]). Overall, 20% of participants reported receiving an HIV test within the past 6 months. Multivariable generalized estimating equations showed that attending substance use disorder (SUD) treatment (OR 2.11, 95%CI [1.58, 2.82]), having health insurance (OR 1.42, 95%CI [1.01, 2.00]) and recent incarceration (OR 1.49, 95%CI [1.08, 2.04]) were positively associated with HIV testing, while experiencing a resource barrier to healthcare (inability to pay, lack of transportation, inconvenient hours, or lack of child care) had inverse (OR 0.73, 95%CI [0.56, 0.94]) association with HIV testing. We found that the prevalence of HIV testing among rural PWID is low, indicating an unmet need for testing. While SUD treatment or incarceration may increase chances for HIV testing for rural PWID, other avenues for expanding HIV testing, such as SSP, need to be explored.

High Interest in Injectable Opioid Agonist Treatment With Hydromorphone Among Urban Syringe Service Program Participants

BACKGROUND

Injectable opioid agonist treatment with hydromorphone (iOAT-H) is effective for persons who inject drugs (PWID) with opioid use disorder (OUD) but remains unavailable in the United States. Our objective was to determine interest in iOAT-H among syringe services program (SSP) participants.

METHODS

We recruited PWID with OUD from SSPs in New York City. Interest in iOAT-H was assessed on a 4-point scale. We compared participants who were and were not interested in iOAT-H regarding sociodemographic characteristics and self-reported variables (past 30 days): heroin use, public injection practices, and participation in illegal activity other than drug possession. Participants reported their preferred OUD treatment and reasons for these preferences.

RESULTS

Of 108 participants, most were male (69%), Hispanic (68%), and median age was 42 years. The median number of prior OUD treatment episodes was 6 (interquartile range: 2-12). Most (65%) were interested in iOAT-H. Interested participants (vs not interested) reported, over the prior 30 days, greater heroin use days (mean, 26.4 vs 22.3), injecting in public more times (median, 15 vs 6), and a higher percentage having participated in illegal activity (40% vs 16%). Preferences for OUD treatment were: iOAT-H (43%), methadone (39%), and buprenorphine (9%). Participants who preferred iOAT-H to conventional OUD treatments reported preferring injection as a route of administration and that available OUD treatments helped them insufficiently.

CONCLUSIONS

SSP participants with OUD reported high interest in iOAT-H. Participants had attempted conventional treatments but still used heroin almost daily. We identified PWID at risk for opioid-related harms who potentially could benefit from iOAT-H.

Injection Behaviors and Use of Syringe Service Programs over Time among People Who Inject Drugs in Baltimore, Maryland

Introduction: People who inject drugs (PWID) are at increased risk for infectious disease transmission, including hepatitis C and HIV. Understanding trends in injection risk behaviors and syringe service program (SSP) use over time can help improve infectious disease prevention and other harm reduction services. Methods: Using National HIV Behavioral Surveillance System data from Baltimore, Maryland, we examined changes in receptive sharing of (1) syringes, (2) injection equipment, (3) syringes to divide drugs; and (4) receipt of syringes from SSPs among PWID from 2009 to 2018 (n = 518 in 2009, n = 638 in 2012, n = 586 in 2015, and n = 575 in 2018) using unadjusted and adjusted logistic models calculated across time for the total sample. Results: The conditional probability of receptive sharing of syringes and receipt of syringes from SSPs remained relatively stable, while receptive sharing of injection equipment and receptive sharing of syringes to divide drugs dropped substantially after 2009. White race and daily injection frequency were positively associated with sharing syringes and injection equipment and negatively associated with SSP use over time. In 2015, there was a notable shift such that women were twice as likely as men to receive syringes from SSPs and less likely than men to report the use of shared syringes or equipment. Conclusion: Findings indicate overall steady or decreasing trends in injection risk and steady trends in SSP usage over time, with some notable improvements among women and indications of shifting drug market patterns. Injection-related risk behaviors remain high among White PWID and may require targeted outreach and interventions.

Development of a systematic social observation tool for monitoring use of harm reduction supplies

BACKGROUND

Harm reduction services such as safer injection supply distribution are essential to reducing morbidity and mortality among people who use drugs (PWUD); however, local use of harm reduction supplies (e.g., tourniquets, saline solution) is difficult to routinely and systematically monitor. The purpose of this study was to develop and validate a systematic social observation tool designed to assess use of harm reduction supplies at the street block level.

METHODS

Data collection took place on a random sample of 150 blocks located throughout the Kensington neighborhood of North Philadelphia from November 2021 to January 2022. We measured inter-rater reliability by two-way mixed-effects intra-class correlation coefficients (ICC) with the consistency agreement definition and internal consistency reliability using Cronbach's alpha and McDonald's omega. Exploratory factor analysis with principal component extraction and promax rotation assessed internal consistency. We validated scales against locations of public syringe disposal boxes, a proxy measure for areas of concentrated drug use, using logistic regression.

RESULTS

Naloxone canisters, syringe caps, saline and sterile water solution bottles showed the highest reliability (ICC≥0.7). Items also showed high internal consistency (alpha, omega>0.7). Exploratory factor analysis identified one, three-item scale with high internal consistency: syringe caps, vials, and baggies (alpha = 0.85; omega = 0.85)-all supplies used concurrently with drug injection but not discarded in syringe disposal boxes. Drug use (OR = 1.78, 95 % CI = (1.48, 2.23)), harm reduction (OR = 3.53, 95 % CI = (2.20, 6.12)), and EFA scales (OR = 1.85, 95 %CI = (1.51, 2.34)) were significantly and positively associated with being within walking distance (≤0.25 miles or 0.4 km) of a syringe disposal box.

CONCLUSION

This study provides an efficient tool with high reliability and validity metrics to assess community uptake of harm reduction supplies designed for use by community organizations, policy makers, or other groups providing resources to PWUD.

Demographic patterns and disparities in new HIV diagnoses attributed to injection drug use in the United States

People who inject drugs (PWID) exhibit disproportionate HIV burdens in the United States. We characterized longitudinal patterns and demographic disparities in new HIV diagnoses attributed to injection drug use (IDU) in 2008-2020. Although new IDU-attributed HIV diagnoses fell by 53.9%, new HIV diagnoses remained disproportionately elevated in female (100.9/100 000), Black (258.8/100 000), and Hispanic (131.0/100 000) PWID. Despite considerable declines in new HIV diagnoses, disparities by race/ethnicity and sex persist among US PWID.

Houselessness and syringe service program utilization among people who inject drugs in eight rural areas across the USA: a cross-sectional analysis

BACKGROUND

Research conducted in urban areas has highlighted the impact of housing instability on people who inject drugs (PWID), revealing that it exacerbates vulnerability to drug-related harms and impedes syringe service program (SSP) use. However, few studies have explored the effects of houselessness on SSP use among rural PWID. This study examines the relationship between houselessness and SSP utilization among PWID in eight rural areas across 10 states.

METHODS

PWID were recruited using respondent-driven sampling for a cross-sectional survey that queried self-reported drug use and SSP utilization in the prior 30 days, houselessness in the prior 6 months and sociodemographic characteristics. Using binomial logistic regression, we examined the relationship between experiencing houselessness and any SSP use. To assess the relationship between houselessness and the frequency of SSP use, we conducted multinomial logistic regression analyses among participants reporting any past 30-day SSP use.

RESULTS

Among 2394 rural PWID, 56.5% had experienced houselessness in the prior 6 months, and 43.5% reported past 30-day SSP use. PWID who had experienced houselessness were more likely to report using an SSP compared to their housed counterparts (adjusted odds ratio [aOR] = 1.24 [95% confidence intervals [CI] 1.01, 1.52]). Among those who had used an SSP at least once (n = 972), those who experienced houselessness were just as likely to report SSP use two (aOR = 0.90 [95% CI 0.60, 1.36]) and three times (aOR = 1.18 [95% CI 0.77, 1.98]) compared to once. However, they were less likely to visit an SSP four or more times compared to once in the prior 30 days (aOR = 0.59 [95% CI 0.40, 0.85]).

CONCLUSION

This study provides evidence that rural PWID who experience houselessness utilize SSPs at similar or higher rates as their housed counterparts. However, housing instability may pose barriers to more frequent SSP use. These findings are significant as people who experience houselessness are at increased risk for drug-related harms and encounter additional challenges when attempting to access SSPs.

Availability of telehealth-based services at syringe services programs under the COVID-19 Public Health Emergency

INTRODUCTION

The expanded capacity of syringe services programs (SSPs) in the USA to integrate telehealth services was largely related to flexibility of buprenorphine prescription in response to the COVID-19 pandemic. SSPs demonstrated the potential of using telehealth to reach participants with both medical and non-medical services. The present study examines the implementation of medical and non-medical telehealth-based health services in 2020 at SSPs in the USA and organizational characteristics associated with adopting specific telehealth services.

METHODS

We administered a cross-sectional survey among all known SSPs operating in the USA as of 2021. The two primary study outcomes were (1) implementation of medical telehealth and (2) implementation of non-medical telehealth in 2020. Medical services included HIV counseling/care, hepatitis C virus (HCV) counseling/care, and buprenorphine. Non-medical services included wellbeing/check-ins, overdose prevention training, health navigation, harm reduction and psychological counseling. Bivariate and multivariable mixed effects logistic regression models were used to directly estimate the odds ratio associated with organizational characteristics on the implementation of telehealth-based health services.

RESULTS

Thirty percent of programs (n = 290) reported implementing telehealth-based health services. In multivariable logistic regression models, community-based organization SSPs had higher odds of implementing medical (aOR = 4.69, 95% CI [1.96, 11.19]) and non-medical (aOR = 2.18, 95% CI [1.10, 4.31]) health services compared to public health department SSPs. SSPs that received governmental funding had higher odds of implementing medical services via telehealth (aOR = 2.45, 95% CI [1.35, 4.47]) compared to programs without governmental funding.

CONCLUSION

Community-based organization SSPs and those with government funding had the highest odds of telehealth implementation in response to the COVID-19 Public Health Emergency. Federal, state, and local governments must increase funding for low-barrier venues like SSPs to support telehealth implementation to serve the needs of people who use drugs.

Transactional sex among rural, justice-involved Appalachian women who use drugs

PURPOSE

Transactional sex is associated with an array of other health risk behaviors and adverse health outcomes, including HIV. However, despite concerns regarding a potential HIV outbreak, there is limited understanding of transactional sex among rural Appalachians who engage in high-risk behaviors. Thus, the current study describes the prevalence and correlates of transactional sex among a sample of rural, justice-involved Appalachian women who use drugs.

METHODS

Participants (N = 400) were randomly selected, screened, and interviewed face-to-face at 3 rural Appalachian jails in Kentucky. Bivariate analyses were used to examine differences between those who reported trading sex for drugs, money, goods, or services in the year prior to incarceration and those who had not, and multivariable logistic regression was used to examine independent correlates of transactional sex.

FINDINGS

On average, participants were 33 years old with 11 years of education. They were predominantly White (99.0%), about half (43.7%) reported lifetime transactional sex, and 25.9% reported past year transactional sex. Past year transactional sex was positively associated with experiencing money problems, substance use problem severity, injection drug use, unprotected sex with a casual partner, and number of sexual partners in the year prior to incarceration.

CONCLUSIONS

Results suggest that transactional sex is fairly common among rural Appalachian women who use drugs and are justice-involved and may signal other HIV-related risk behaviors. Given limited service availability throughout rural Appalachia, findings emphasize a need for increased access to risk-reduction interventions, including jail-based interventions, to educate vulnerable, hard-to-reach populations on the risks associated with HIV.

Three decades of research in substance use disorder treatment for syringe services program participants: a scoping review of the literature

BACKGROUND

Syringe services programs (SSPs) provide a spectrum of health services to people who use drugs, with many providing referral and linkage to substance use disorder (SUD) treatment, and some offering co-located treatment with medications for opioid use disorder (MOUD). The objective of this study was to review the evidence for SSPs as an entry point for SUD treatment with particular attention to co-located (onsite) MOUD.

METHODS

We performed a scoping review of the literature on SUD treatment for SSP participants. Our initial query in PubMed led to title and abstract screening of 3587 articles, followed by full text review of 173, leading to a final total of 51 relevant articles. Most articles fell into four categories: (1) description of SSP participants' SUD treatment utilization; (2) interventions to link SSP participants to SUD treatment; (3) post-linkage SUD treatment outcomes; (4) onsite MOUD at SSPs.

RESULTS

SSP participation is associated with entering SUD treatment. Barriers to treatment entry for SSP participants include: use of stimulants, lack of health insurance, residing far from treatment programs, lack of available appointments, and work or childcare responsibilities. A small number of clinical trials demonstrate that two interventions (motivational enhancement therapy with financial incentives and strength-based case management) are effective for linking SSP participants to MOUD or any SUD treatment. SSP participants who initiate MOUD reduce their substance use, risk behaviors, and have moderate retention in treatment. An increasing number of SSPs across the United States offer onsite buprenorphine treatment, and a number of single-site studies demonstrate that patients who initiate buprenorphine treatment at SSPs reduce opioid use, risk behaviors, and have similar retention in treatment to patients in office-based treatment programs.

CONCLUSIONS

SSPs can successfully refer participants to SUD treatment and deliver onsite buprenorphine treatment. Future studies should explore strategies to optimize the implementation of onsite buprenorphine. Because linkage rates were suboptimal for methadone, offering onsite methadone treatment at SSPs may be an appealing solution, but would require changes in federal regulations. In tandem with continuing to develop onsite treatment capacity, funding should support evidence-based linkage interventions and increasing accessibility, availability, affordability and acceptability of SUD treatment programs.

Preliminary effectiveness of online opioid overdose and naloxone administration training and impact of naloxone possession on opioid use

BACKGROUND

Despite the demonstrated value of opioid overdose education and naloxone distribution (OEND) programs, uptake and utilization remains low. Accessibility to OEND is limited and traditional programs may not reach many high-risk individuals. This study evaluated the effectiveness of online opioid overdose and naloxone administration education and the impact of naloxone possession.

METHODS

Individuals with self-reported illicit use of opioids were recruited via Craigslist advertisements and completed all assessments and education online via REDCap. Participants watched a 20-minute video outlining signs of opioid overdose and how to administer naloxone. They were then randomized to either receive a naloxone kit or be given instructions on where to obtain a kit. Effectiveness of training was measured with pre- and post-training knowledge questionnaires. Naloxone kit possession, overdoses, opioid use frequency, and treatment interest were self-reported on monthly follow-up assessments.

RESULTS

Mean knowledge scores significantly increased from 6.82/9.00 to 8.22 after training (t(194)=6.85, p <0.001, 95% CI[1.00, 1.81], Cohen's d=0.85). Difference in naloxone possession between randomized groups was significant with a large effect size (p <0.001, diff=0.60, 95% CI[0.47, 0.73]). A bidirectional relationship was found between naloxone possession and frequency of opioid use. Overdoses and treatment interest were similar across possession status.

CONCLUSIONS

Overdose education is effective in online video format. Disparity in naloxone possession across groups indicates barriers to obtaining naloxone from pharmacies. Naloxone possession did not influence risky opioid use or treatment interest and its impact on frequency of use warrants further investigation.

TRIAL REGISTRATION

Clinitaltrials.gov-NCT04303000.

Feasibility and acceptability of online opioid overdose education and naloxone distribution: Study protocol and preliminary results from a randomized pilot clinical trial

Drug overdose is the leading cause of accidental death in the United States, with over 70% of drug related fatalities resulting from the use of opioids. Federal agencies have responded to this crisis with various recommendations including enhancing harm reduction approaches such as training laypersons to administer naloxone through Opioid Overdose Education and Naloxone Distribution (OEND) programs. Several studies have demonstrated that OEND programs effectively reduce opioid overdose mortality and are both safe and cost-effective, however, they are typically implemented in urban areas as part of large medical center research programs, needle exchanges, or drug treatment programs. Individuals living in areas without these programs or services lack access to critical and life-saving OEND. The current study examined the acceptability and feasibility of online recruitment, online opioid overdose education, and remote distribution of naloxone kits. Persons who illicitly use opioids and are at risk for overdose were recruited through online media and completed an opioid use questionnaire. If interested in receiving opioid overdose and naloxone administration training, participants completed pre- and post-intervention knowledge questionnaires, engaged in audiovisual training, and were randomized to either receive a naloxone kit or be given information on where they could obtain one. Preliminary results indicate feasibility and acceptability as evidenced by strong recruitment and retention, as well as high participant satisfaction ratings. Successful implementation of remote OEND through this project supports future employment of similar remote programs to expand this critical harm reduction strategy to high-risk individuals in areas lacking traditional OEND programs.

Trial Registration #

Clinitaltrials.gov- NCT04303000.

"Another tool in the toolkit"-Perceptions, suggestions, and concerns of emergency service providers about the implementation of a supervised consumption site

BACKGROUND

As Supervised Consumption Sites (SCS) are implemented in the United States, it is important to consider the needs and perceptions of impacted stakeholders. Emergency service providers (ESP) have a central role in responding to the overdose epidemic. This study intended to assess the how ESP perceive the potential implementation of an SCS in their community, as well as solicit program design and implementation-related concerns and suggestions.

METHODS

In-depth interviews were conducted by videoconference with 22 ESP, including firefighters, paramedics, police, and social workers in King County, Washington, USA. Data were analyzed using a thematic analysis approach.

RESULTS

Participants expressed the importance of feeling safe while responding to calls where drug use is involved and highlighted how this perception would be linked to ESP response times to calls from an SCS. Suggestions for improving the perceived safety of an SCS included training program staff in de-escalation as well as planning the layout of the SCS to accommodate ESP. The inadequacy of the emergency department as a point of care for PWUD was also identified as a theme, and some participants expressed enthusiasm regarding the prospect of the SCS as an alternative destination for transport. Finally, support for the SCS model was conditional on the appropriate utilization of emergency services and a reduction in call volume. Participants listed clarifying roles and pursuing opportunities for collaboration as ways to ensure appropriate utilization and maintain positive working relationships.

CONCLUSION

This study builds on literature regarding stakeholder perceptions of SCS by focusing on the perceptions of a critically important stakeholder group. Results enhance understanding of what motivates ESP to support SCS implementation in their community. Other novel insights pertain to ESP thoughts about alternative care delivery models and strategies for emergency department visit diversion.

A Scoping Review on the Effects of COVID-19 on Syringe Service Programs in the United States

The COVID-19 pandemic has had worldwide impacts, including disrupting community services. One interrupted service was syringe service programs (SSPs), community-established initiatives that provide sterile supplies and aid in overcoming addiction in drug-using participants. In the United States (U.S.), SSPs have been key in combating the recent opioid use crisis and associated infections such as the human immunodeficiency virus (HIV) and hepatitis C. While some published reports on the pandemic's overall impacts on SSPs exist, certain aspects such as operational changes and repercussions on staff and participants may still be lacking. Information about the impact of interrupted SSP services due to the pandemic may provide insight into how to prepare to mitigate similar outcomes during possible future health outbreaks. The aim of this scoping review was thus to explore the effects of the COVID-19 pandemic on the operations, staff, and participants of SSPs in the U.S. The initial search of the databases PubMed, Embase, and Web of Science with selected keywords yielded 117 articles published in English between January 1, 2020, and August 31, 2022. After screening each article for study eligibility, 11 articles were included in the final review. Of the seven articles exploring SSP operational impacts from the pandemic, five acknowledged that mitigation strategies influenced functions, seven highlighted supply changes, and four emphasized the resulting staffing changes. Four studies inspected the pandemic's impacts on SSP participants, which included two articles highlighting participants' struggles with isolation and loneliness, one referencing the fear of exposure to the SARS-CoV-2 virus, and two examining the overall negative psychological effects experienced during this time. SSPs in various settings and regions across the U.S. experienced changes due to the COVID-19 pandemic. Many of these modifications negatively impacted operations, staffing, and participant relationships. Examining the issues that individual SSPs encountered highlights opportunities for structured solutions for the present and in the case of future infectious disease outbreaks. With the severity of the opioid use crisis in the U.S. and the dependence on SSPs for its mitigation, future work in this space should be prioritized.

Factors associated with receptive injection equipment sharing among people who inject drugs: findings from a multistate study at the start of the COVID-19 pandemic

BACKGROUND

Receptive injection equipment sharing (i.e., injecting with syringes, cookers, rinse water previously used by another person) plays a central role in the transmission of infectious diseases (e.g., HIV, viral hepatitis) among people who inject drugs. Better understanding these behaviors in the context of COVID-19 may afford insights about potential intervention opportunities in future health crises.

OBJECTIVE

This study examines factors associated with receptive injection equipment sharing among people who inject drugs in the context of COVID-19.

METHODS

From August 2020 to January 2021, people who inject drugs were recruited from 22 substance use disorder treatment programs and harm reduction service providers in nine states and the District of Columbia to complete a survey that ascertained how the COVID-19 pandemic affected substance use behaviors. We used logistic regression to identify factors associated with people who inject drugs having recently engaged in receptive injection equipment sharing.

RESULTS

One in four people who inject drugs in our sample reported having engaged in receptive injection equipment sharing in the past month. Factors associated with greater odds of receptive injection equipment sharing included: having a high school education or equivalent (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [95% CI] 1.24, 3.69), experiencing hunger at least weekly (aOR = 1.89, 95% CI 1.01, 3.56), and number of drugs injected (aOR = 1.15, 95% CI 1.02, 1.30). Older age (aOR = 0.97, 95% CI 0.94, 1.00) and living in a non-metropolitan area (aOR = 0.43, 95% CI 0.18, 1.02) were marginally associated with decreased odds of receptive injection equipment sharing.

CONCLUSIONS

Receptive injection equipment sharing was relatively common among our sample during the early months of the COVID-19 pandemic. Our findings contribute to existing literature that examines receptive injection equipment sharing by demonstrating that this behavior was associated with factors identified in similar research that occurred before COVID. Eliminating high-risk injection practices among people who inject drugs requires investments in low-threshold and evidence-based services that ensure persons have access to sterile injection equipment.

I Don't Believe a Person Has to Die When Trying to Get High: Overdose Prevention and Response Strategies in Rural Illinois

BACKGROUND

Overdose is a leading cause of morbidity and mortality among people who inject drugs. Illicitly manufactured fentanyl is now a major driver of opioid overdose deaths.

METHODS

Semi-structured interviews were conducted with 23 participants (19 persons who inject drugs and 4 service providers) from rural southern Illinois. Data were analyzed using constant comparison and theoretical sampling methods.

RESULTS

Participants were concerned about the growing presence of fentanyl in both opioids and stimulants, and many disclosed overdose experiences. Strategies participants reported using to lower overdose risk included purchasing drugs from trusted sellers and modifying drug use practices by partially injecting and/or changing the route of transmission. Approximately half of persons who inject drugs sampled had heard of fentanyl test strips, however fentanyl test strip use was low. To reverse overdoses, participants reported using cold water baths. Use of naloxone to reverse overdose was low. Barriers to naloxone access and use included fear of arrest and opioid withdrawal.

CONCLUSIONS

People who inject drugs understood fentanyl to be a potential contaminant in their drug supply and actively engaged in harm reduction techniques to try to prevent overdose. Interventions to increase harm reduction education and information about and access to fentanyl test strips and naloxone would be beneficial.

Factors associated with perceived ease of access to syringes in Appalachian North Carolina

PURPOSE

To examine associations between perceived ease of syringe access, syringe sources, injection behaviors, and law enforcement (LE) interactions among people who inject drugs (PWID) in rural Appalachian North Carolina (NC).

METHODS

Using respondent-driven sampling, a diverse sample of 309 self-reported PWID were recruited from rural Appalachian NC. Data were collected via audio computer-assisted self-interview technology from February 2019 through March 2020. Respondents reported demographics, sources of syringes, LE interactions, and injection behaviors. Univariate, bivariate, and linear regression analyses were performed.

FINDINGS

Respondents most often obtained syringes from pharmacies and syringe service programs (SSPs). Twenty-one percent disagreed that it was easy to obtain sterile syringes, with 28% reporting low or no access to an SSP. PWID who reported longer physical distances to an SSP had greater difficulty accessing syringes (P<.001). PWID who reported greater ease of access to syringes reported engaging in receptive syringe sharing less often (P<.01). PWID who were stopped and searched by LE more often reported injecting drugs somebody else prepared with nonsterile supplies more often (P<.01). Participants shared used injection supplies more than twice as often than they shared used syringes.

CONCLUSIONS

These results underscore the importance of SSPs to mitigate the spread of human immunodeficiency virus and viral hepatitis in rural areas. Supporting mobile SSP services in rural areas could increase access to sterile syringes and injection supplies. SSPs should educate PWID about the importance of not sharing injection supplies. Pharmacies could increase syringe access in areas where SSPs do not operate.

A multi-site intervention using influencers to communicate about syringe service programmes

Introduction

In the USA, syringe services programmes (SSPs) provide a range of harm reduction services and have numerous benefits for communities. However, stigma, misconceptions about SSPs and changing policies/legislation remain a challenge to effective implementation. This study reviews the implementation of two digital interventions, Appalachian Influence and Shared Influence, which used social media influencers and digital volunteers to communicate positive information about harm reduction and SSPs.

Methods

The intervention was designed to deliver accurate and supportive messaging in locally relevant and meaningful ways. Messaging was informed by interviews with subject matter experts and community organisations, and was integrated into prompts used by local influencers (paid individuals with more than 1,000 followers) and digital volunteers (unpaid individuals with no following requirement, who joined the project independently).

Results

In the first 6 months of implementation, Appalachian Influence and Shared Influence engaged a total of 9,014 individuals, 236 of whom were paid influencers and 8,778 of whom were digital volunteers. Paid influencer posts achieved a total of 868,943 impressions, 42,432 engagements and 1,567 comments. Comments on paid influencer posts were overwhelmingly positive, with 87.4% positive and 0.8% negative. Interviews showed the importance of understanding local realities, leading with compassion and emphasising the 'human' aspects of dependency and addiction in messaging.

Conclusion

This study shows the potential to implement an influencer-led social media intervention to reach people with authentic and compassionate messaging about harm reduction and SSPs. Future research should examine intervention effectiveness and how this approach can be applied to other stigmatised topics.

Factors Associated with Exchange Sex Among Cisgender Persons Who Inject Drugs: Women and MSM-23 U.S. Cities, 2018

Persons who inject drugs (PWID) and exchange sex face disproportionate HIV rates. We assessed prevalence of exchange sex (receiving money/drugs for sex from ≥ 1 male partner(s) during the past year) among cisgender PWID, separately for women and men with a history of sex with men (MSM). We examined factors associated with exchange sex, including sociodemographic characteristics, sexual and drug use behaviors, and healthcare access/utilization. Over one-third of the 4657 participants reported exchange sex (women: 36.2%; MSM: 34.8%). Women who exchanged sex (WES) were significantly more likely to test HIV-positive than other women. Men who exchanged sex with men (MESM) showed a similar trend. WES and MESM shared many characteristics, including being uninsured, experiencing recent homelessness, condomless sex, polydrug use, and receptive/distributive needle sharing. These findings highlight a need to strengthen prevention interventions and address structural determinants of HIV for WES and MESM, particularly PWID who exchange sex.

HCV serostatus and injection sharing practices among those who obtain syringes from pharmacies and directly and indirectly from syringe services programs in rural New England

BACKGROUND

Among people who inject drugs (PWID), obtaining syringes via syringe services programs (SSPs) and pharmacies reduces injection sharing practices associated with hepatitis C virus (HCV). Whether indirect use of SSPs via secondary exchange confers a similar benefit remains unknown, particularly in rural settings. We compared HCV serostatus and injection sharing practices by primary syringe source among a sample of rural PWID.

METHODS

Data are from a cross-sectional study of adults who use drugs recruited from eleven rural counties in New Hampshire, Vermont, and Massachusetts using respondent-driven sampling (2018-2019). Study staff performed HCV antibody testing. An audio computer-assisted self-interview assessed sociodemographic characteristics, past 30-day injection practices, and past 30-day primary syringe source. Primary syringe source was classified as direct SSP, pharmacy, indirect SSP (secondary exchange), or "other" (friend/acquaintance, street seller, partner/relative, found them). Mixed effects modified Poisson models assessed the association of primary syringe source with HCV seroprevalence and injection sharing practices.

RESULTS

Among 397 PWID, the most common primary syringe source was "other" (33%), then pharmacies (27%), SSPs (22%), and secondary exchange (18%). In multivariable models, compared with those obtaining most syringes from "other" sources, those obtaining most syringes from pharmacies had a lower HCV seroprevalence [adjusted prevalence ratio (APR):0.85, 95% confidence interval (CI) 0.73-0.9985]; however, the upper bound of the 95% CI was close to 1.0. Compared with those obtaining most syringes from other sources, PWID obtaining most syringes directly from SSPs or pharmacies were less likely to report borrowing used syringes [APR(SSP):0.60, 95% CI 0.43-0.85 and APR(Pharmacies):0.70, 95% CI 0.52-0.93], borrowing used injection equipment [APR(SSP):0.59, 95% CI 0.50-0.69 and APR (Pharmacies):0.81, 95% CI 0.68-0.98], and backloading [APR(SSP):0.65, 95% CI 0.48-0.88 and APR(Pharmacies):0.78, 95% CI 0.67-0.91]. Potential inverse associations between obtaining most syringes via secondary exchange and injection sharing practices did not reach the threshold for statistical significance.

CONCLUSIONS

PWID in rural New England largely relied on informal syringe sources (i.e., secondary exchange or sources besides SSPs/pharmacies). Those obtaining most syringes from an SSP or pharmacy were less likely to share injection equipment/syringes and had a lower HCV seroprevalence, which suggests using these sources reduces the risk of new HCV infections or serves as proxy for past injection behavior.

Implementing syringe services programs within the Veterans Health Administration: facility experiences and next steps

Syringe services programs are community-based prevention programs that provide evidence-based, lifesaving services for people who use illicit drugs, including access to syringes, naloxone, fentanyl test strips, infection screening, and linkage to treatment. Historically, syringe services programs did not exist within the Veterans Health Administration owing to many factors, including lack of clarity regarding legality for federal agency-purchased syringes. Three champions at Veterans Affairs facilities in Danville, IL, Orlando, FL, and San Francisco, CA, worked to clarify legal considerations, address barriers, and implement syringe services programs that are integrated in the health care systems. Since 2017, these 3 programs have engaged approximately 400 Veterans and distributed nearly 10,000 syringes, 2500 fentanyl test strips, 50 wound care kits, and 45 safer sex kits. These programs, both led by and in collaboration with clinical pharmacist practitioners, paved the way for nationwide implementation within the Veterans Health Administration. This commentary describes successes, challenges, and proposed next steps to increase Veteran access to syringe services programs, written from the perspective of 3 facility-based champions.

Applications of research evidence during processes to acquire approvals for syringe services program implementation in rural counties in Kentucky

INTRODUCTION

Despite decades of empirical research in the US and internationally documenting the benefits of implementing syringe services programs (SSPs), their implementation may be controversial in many jurisdictions. Better understanding how research evidence is applied during SSP implementation processes may enable the public health workforce to advocate for program scale up. This study explores applications of research evidence during processes to acquire approvals for SSP implementation in rural counties in Kentucky.

METHODS

In-depth interviews were conducted among eighteen stakeholders (e.g. health department directors, SSP operators) involved in SSP implementation in rural Kentucky counties. Stakeholders were asked to describe the contexts surrounding SSP implementation processes. Interviews were transcribed and analysed for applications of research evidence. Research evidence-related quotes were subsequently categorised based on the typologies for applications of research evidence developed by Weiss et al. (instrumental, conceptual, and symbolic) and a fourth category for instances when research evidence was not used.

RESULTS

Instrumental applications of research evidence occurred at the intrapersonal and interpersonal levels to dispel concerns about SSPs and formed the basis for implementation support. SSP proponents used research evidence in a conceptual manner to address underlying attitudes and beliefs that were not evidence-based. Participants reported symbolic research evidence applications to justify pre-existing attitudes and beliefs about meeting the public health needs of people who inject drugs. Lastly, in some instances, research evidence was met with scepticism and an unwillingness to consider its merits.

CONCLUSION

Applications of research evidence during SSP implementation approval processes in rural Kentucky counties were heterogeneous in nature. Better understanding the diversity of ways in which research evidence may be employed during SSP implementation processes may support efforts to improve the public health of people who inject drugs.Key messagesApplications of research evidence during SSP implementation approval processes in rural Kentucky counties were heterogeneous in nature.Instrumental applications of research evidence occurred at the intrapersonal and interpersonal levels to dispel concerns about SSPs and formed the basis for implementation support.SSP proponents used research evidence in a conceptual manner to address underlying attitudes and beliefs that were not evidence-based.

NEXT: description, rationale, and evaluation of a novel internet-based mail-delivered syringe service program

Background

Despite proven health benefits, harm reduction services provided through in-person syringe services programs (SSPs) and pharmacies are largely unavailable to most people who inject drugs (PWID). Internet-based mail-delivered harm reduction services could overcome barriers to in-person SSPs. This manuscript describes Needle Exchange Technology (NEXT) Harm Reduction, the first formal internet-based mail delivery SSP in the US.

Methods

We examined the trajectory of NEXT's growth between February 2018 and August 2021. Descriptive statistics were used to characterize program participants. All analysis were run using STATA statistical software.

Results

Over the course of 42 months, 1,669 unique participants enrolled in NEXT. The program distributed 1,648,162 total syringes with a median of 79,449 syringes per month. Most participants ordered multiple times (61%); 31% had more 5 or more orders (upper range = 48 orders). The total number of syringes per month and total number of first-time syringe orders per month increased steadily over time, particularly after the onset of the COVID-19 pandemic.

Conclusions

The online platform and mail-delivery model appears successful in reaching PWID at high risk for harms from IDU. Changes to state laws and additional funding support are needed to make mail-delivery harm reduction more widely available throughout the US.

Trends and distinct profiles of persons who inject drugs in the United States, 2015-2019

Drug injection represents a major health problem in the US, with severe health consequences including the transmission of blood-borne infections. An examination of the most recent trends in drug injection is warranted by the fast-evolving drug epidemic and recent policy changes such as the federal funding ban on needle exchange programs. This research examines current drug injection trends, patterns, and socioeconomic and behavioral profiles of people who inject drugs (PWID). Data were derived from the 2002 to 2019 National Survey on Drug Use and Health (NSDUH). After examining the annual prevalence of drug injection since 2002, a latent class analysis was conducted to identify drug injection and other substance misuse patterns among PWID using the latest (2015-2019) NSDUH datasets. Associations between class membership and behavioral health comorbidities and treatment receipt were also assessed. The drug injection prevalence among US adults aged 18-64 increased from 0.21% in 2002/2004 to 0.36% in 2017/2019. Three distinctive groups were identified: the heroin injection group (45.2%), the methamphetamine injection group (28.0%), and the multi-drug injection group (26.8%). The methamphetamine injection group reported greater risks of experiencing serious psychological distress, suicidality, and limited substance use treatment. Special attention is needed for those who primarily injected methamphetamine. Programs to promote harm reduction and increase access to addiction treatment need to be expanded in at-risk communities while accounting for their distinct socioeconomic and drug use/misuse profiles.

Law enforcement and syringe services program implementation in rural counties in Kentucky: a qualitative exploration

BACKGROUND

Existing research in urban areas has documented a multitude of ways in which law enforcement may affect risks for bloodborne infectious disease acquisition among people who inject drugs (PWID), such as via syringe confiscation and engaging in practices that deter persons from accessing syringe services programs (SSPs). However, limited work has been conducted to explore how law enforcement may impact SSP implementation and operations in rural counties in the United States. This creates a significant gap in the HIV prevention literature given the volume of non-urban counties in the United States that are vulnerable to injection drug use-associated morbidity and mortality.

OBJECTIVE

This study explores the influence of law enforcement during processes to acquire approvals for SSP implementation and subsequent program operations in rural Kentucky counties.

METHODS

From August 2020 to October 2020, we conducted eighteen in-depth qualitative interviews among persons involved with SSP implementation in rural counties in Kentucky (USA). Interviews explored the factors that served as barriers and facilitators to SSP implementation and operations, including the role of law enforcement.

RESULTS

Participants described scenarios in which rural law enforcement advocated for SSP implementation; however, they also reported police opposing rural SSP implementation and engaging in adverse behaviors (e.g., targeting SSP clients) that may jeopardize the public health of PWID. Participants reported that efforts to educate rural law enforcement about SSPs were particularly impactful when they discussed how SSP implementation may prevent needlestick injuries.

CONCLUSIONS

The results of this study suggest that there are multiple ways in which rural SSP implementation and subsequent operations in rural Kentucky counties are affected by law enforcement. Future work is needed to explore how to expeditiously engage rural law enforcement, and communities more broadly, about SSPs, their benefits, and public health necessity.

A community-based study of abscess self-treatment and barriers to medical care among people who inject drugs in the United States

Skin and soft tissue infections (SSTIs) are the most common medical complication of injection drug use in the United States, though little work has been done assessing SSTI treatment among people who inject drugs (PWID). We examined past-3-month abscess characteristics, treatment utilization, and barriers to medical treatment among N = 494 community-recruited PWID. We used descriptive statistics to determine the frequencies of self-treatment and medical treatment for their most recent past-3-month abscess as well as barriers to seeking medical treatment. We then used bivariate and multivariate logistic regression to identify factors associated with having an abscess in the past 3 months. Overall, 67% of participating PWID ever had an abscess and 23% had one in the past 3 months. Only 29% got medical treatment for their most recent abscess whereas 79% self-treated. Methods for self-treatment included pressing the pus out (81%), applying a hot compress (79%), and applying hydrogen peroxide (67%). Most (91%) self-treated abscesses healed without further intervention. Barriers to medical treatment included long wait times (56%), being afraid to go (49%), and not wanting to be identified as a PWID (46%). Factors associated independently with having an abscess in the past 3 months were injecting purposely into muscle tissue (adjusted odds ratio [AOR] = 2.64), having difficulty finding a vein (AOR = 2.08), and sharing injection preparation equipment (AOR = 1.74). Our findings emphasize the importance of expanding community-based access to SSTI education and treatment services, particularly at syringe service programs where PWID may be more comfortable seeking resources.

Demographic and geographic shifts in the preferred route of methamphetamine administration among treatment cases in the US, 2010-2019

BACKGROUND

Methamphetamine use disorder has increased rapidly in the past decade. Injecting is also increasing and has multifaceted implications for disease severity, overall health, and treatment outcomes, but less is known about where or among whom injecting has shifted the most. This national study assessed temporal changes in the preferred route of methamphetamine administration by race/ethnicity and within urban/rural geographies.

METHODS

We used the Treatment Episode Dataset-Discharges (2010-2019) to identify outpatient treatment cases who reported methamphetamine as their primary drug of choice at admission (N = 531,799; 2010 n = 33,744; 2019 n = 81,885). We created a combined variable indicating race/ethnicity and the rural/urban location of treatment, and used logistic regression to model the predicted probability of cases reporting injection, smoking, or snorting as their preferred route of administration. We included an interaction term to determine differences over time (race/ethnicity/rurality*year).

RESULTS

Across all years, smoking methamphetamine was the most common route of administration (66%), followed by injection (24%) and snorting (10%). Over time and among most sub-groups, the rates of injection increased while the rates of smoking decreased. Compared to 2010, the odds of injecting methamphetamine in 2019 were highest among Black cases in urban areas (aOR = 2.30, 95% CI = 1.76-3.00, p < 0.0001).

CONCLUSION

Increasing methamphetamine injection was most pronounced among Black treatment cases in more urban areas, which is in contrast to the longstanding narrative that methamphetamine is a White and rural drug. Methamphetamine prevention, treatment, and harm reduction should target populations with high injection prevalence and growing incidence.

"We were building the plane as we were flying it, and we somehow made it to the other end": syringe service program staff experiences and well-being during the COVID-19 pandemic

BACKGROUND

Syringe service programs (SSPs) provide essential harm reduction and prevention services for people who inject drugs in the USA, where SSP coverage is expanding. During the COVID-19 pandemic, US SSPs underwent unprecedented shifts in operational procedures (e.g., closures of physical sites, staff redeployment into pandemic response efforts). Given the critical role of US SSP workers in the pandemic, we sought to explore the occupational experiences and well-being of SSP staff to inform future emergency response efforts.

METHODS

From July-October 2020, we conducted semi-structured interviews with staff members of four SSPs in diverse regions of Massachusetts. Trained interviewers administered qualitative interviews virtually. Interviews were coded in NVivo v12 and thematic analysis identified common occupational experiences and related impacts on staff well-being in the context of the COVID-19 pandemic.

RESULTS

Among 18 participants, 12 (67%) had client-facing roles such as harm reduction specialists and six (33%) worked in program management or leadership. We found that staff were frequently anxious about SARS-CoV-2 transmission, which contributed to staff turnover. SSPs rapidly adapted and expanded their services to meet increasing client needs during the pandemic (e.g., food distribution, COVID-19 testing), leading to staff overexertion. Simultaneously, public health measures such as physical distancing led to staff concerns about reduced social connections with clients and coworkers. Through these challenges, SSPs worked to protect staff well-being by implementing flexible and tangible COVID-19-related policies (e.g., paid sick leave), mental health resources, and frequent communication regarding pandemic-related operational changes.

CONCLUSION

SSPs in the USA adapted to the COVID-19 pandemic out of necessity, resulting in operational changes that threatened staff well-being. Despite the protective factors revealed in some narratives, our findings suggest that during prolonged, complex public health emergencies, SSPs may benefit from enhanced occupational supports to prevent burnout and promote wellness for this essential public health workforce.

Mechanisms for Expanding Harm Reduction for Opioid Use in Suburban and Rural U.S. Settings

The availability and adoption of Syringe Services Programs (SSPs) depends heavily on the towns and counties charged with implementing and sustaining these programs. Suburban and rural areas especially lack the community and political support for SSPs. We examined key informant in-depth interview data among professionals providing harm reduction services as well as some health department directors, doctors, and law enforcement officers from a three-state (Connecticut, Kentucky, and Wisconsin) study. Results revealed the challenges and emerging solutions for expanding harm reduction services in suburban and rural areas. Additional comparisons of experiences of those working in urban areas were highlighted. Overall, there were widespread similarities in challenges across the three states for providing harm reduction services in rural and suburban settings. Findings revealed potential directions to address the identified barriers and community-supported ideas to improve harm reduction efforts.

Peer support in small towns: A decentralized mobile Hepatitis C virus clinic for people who inject drugs

BACKGROUND & AIMS

New models of HCV care are needed to reach people who inject drugs (PWID). The primary aim was to evaluate HCV treatment uptake among HCV RNA positive individuals identified by point-of-care (POC) testing and liver disease assessment in a peer-driven decentralized mobile clinic.

METHODS

This prospective study included consecutive patients assessed in a mobile clinic visiting 32 small towns in Southern Norway from November 2019 to November 2020. The clinic was staffed by a bus driver and a social educator offering POC HCV RNA testing (GeneXpert®), liver disease staging (FibroScan® 402) and peer support. Viremic individuals were offered prompt pan-genotypic treatment prescribed by local hospital-employed specialists following a brief telephone assessment.

RESULTS

Among 296 tested individuals, 102 (34%) were HCV RNA positive (median age 51 years, 77% male, 24% advanced liver fibrosis/cirrhosis). All participants had a history of injecting drug use, 71% reported past 3 months injecting, and 37% received opioid agonist treatment. Treatment uptake within 6 months following enrolment was achieved in 88%. Treatment uptake was negatively associated with recent injecting (aHR 0.60; 95% CI 0.36-0.98), harmful alcohol consumption (aHR 0.44; 95% CI 0.20-0.99), and advanced liver fibrosis/cirrhosis (aHR 0.44; 95% CI 0.25-0.80). HCV RNA prevalence increased with age (OR 1.81 per 10-year increase; 95% 1.41-2.32), ranging from 3% among those <30 years to 55% among those ≥60 years.

CONCLUSIONS

A peer-driven mobile HCV clinic is an effective and feasible model of care that should be considered for broader implementation to reach PWID outside the urban centres.

'You feel how you look': Exploring the impacts of unmet water, sanitation, and hygiene needs among rural people experiencing homelessness and their intersection with drug use

Existing literature attests to water, sanitation, and hygiene (WASH) inequities among people experiencing homelessness (PEH) in the United States, but there is a dearth of research on such issues in rural areas. Homelessness is an emerging public health concern in rural areas where homelessness is on the rise, infectious disease outbreaks are becoming increasingly common, and PEH face unique WASH-related challenges compared to their urban counterparts. We conducted an exploratory study to understand the impacts of unmet WASH needs among rural PEH and their intersection with drug use through in-depth interviews (n = 10). Eligible participants were 18 years or older, lived in one of five Central Appalachian counties, and had experienced homelessness in the previous six months. Using thematic analysis, we identified factors that inhibit WASH access, and adverse health and well-being outcomes that result from unmet WASH needs. We also explore how WASH experiences compare among rural PEH who self-reported drug use to those who did not. Our findings revealed that factors at multiple levels inhibited WASH access, including stigma and place-based characteristics, which contributed to the adverse physical, mental, and emotional health of PEH. Comparisons between PEH who used drugs to those that did not revealed the intricate relationship between WASH, homelessness, and substance use in communities impacted by the opioid epidemic. Expanded WASH facilities that are safe and available with no prerequisites can address inadequate access among rural PEH and collaboration with harm reduction services may be advantageous to reach those who inject drugs.

The impact of syringe services program closure on the risk of rebound HIV outbreaks among people who inject drugs: a modeling study

OBJECTIVE

Despite their effectiveness in preventing the transmission of HIV among people who inject drugs (PWID), syringe services programs (SSPs) in many settings are hampered by social and political opposition. We aimed to estimate the impact of closure and temporary interruption of SSP on the HIV epidemic in a rural United States setting.

METHODS

Using an agent-based model (ABM) calibrated to observed surveillance data, we simulated HIV risk behaviors and transmission in adult populations who inject and do not inject drugs in Scott County, Indiana. We projected HIV incidence and prevalence between 2020 and 2025 for scenarios with permanent closure, delayed closure (one additional renewal for 24 months before closure), and temporary closure (lasting 12 months) of an SSP in comparison to persistent SSP operation.

RESULTS

With sustained SSP operation, we projected an incidence rate of 0.15 per 100 person-years among the overall population (95% simulation interval: 0.06-0.28). Permanently closing the SSP would cause an average of 58.4% increase in the overall incidence rate during 2021-2025, resulting in a higher prevalence of 60.8% (50.9-70.6%) (18.7% increase) among PWID by 2025. A delayed closure would increase the incidence rate by 38.9%. A temporary closure would cause 12 (35.3%) more infections during 2020-2021.

CONCLUSION

Our analysis suggests that temporary interruption and permanent closure of existing SSPs operating in rural United States may lead to 'rebound' HIV outbreaks among PWID. To reach and sustain HIV epidemic control, it will be necessary to maintain existing and implement new SSPs in combination with other prevention interventions.

Optimizing HIV Prevention Efforts to Achieve EHE Incidence Targets

BACKGROUND

A goal of the US Department of Health and Human Services' Ending the HIV Epidemic (EHE) in the United States initiative is to reduce the annual number of incident HIV infections in the United States by 75% within 5 years and by 90% within 10 years. We developed a resource allocation analysis to understand how these goals might be met.

METHODS

We estimated the current annual societal funding [$2.8 billion (B)/yr] for 14 interventions to prevent HIV and facilitate treatment of infected persons. These interventions included HIV testing for different transmission groups, HIV care continuum interventions, pre-exposure prophylaxis, and syringe services programs. We developed scenarios optimizing or reallocating this funding to minimize new infections, and we analyzed the impact of additional EHE funding over the period 2021-2030.

RESULTS

With constant current annual societal funding of $2.8 B/yr for 10 years starting in 2021, we estimated the annual incidence of 36,000 new cases in 2030. When we added annual EHE funding of $500 million (M)/yr for 2021-2022, $1.5 B/yr for 2023-2025, and $2.5 B/yr for 2026-2030, the annual incidence of infections decreased to 7600 cases (no optimization), 2900 cases (optimization beginning in 2026), and 2200 cases (optimization beginning in 2023) in 2030.

CONCLUSIONS

Even without optimization, significant increases in resources could lead to an 80% decrease in the annual HIV incidence in 10 years. However, to reach both EHE targets, optimization of prevention funding early in the EHE period is necessary. Implementing these efficient allocations would require flexibility of funding across agencies, which might be difficult to achieve.

Latent Classes of Polysubstance Use and Associations with HIV Risk and Structural Vulnerabilities among Cisgender Women Who Engage in Street-Based Transactional Sex in Baltimore City

We describe patterns of polysubstance use and associations with HIV risk-related behaviors among women engaged in street-based transactional sex, an understudied yet important population and area of research. This sample was restricted to cisgender women who reported drug use (n = 244) in the baseline of the longitudinal SAPPHIRE cohort study. Latent class analysis (LCA) was conducted using drug use measures (route of administration (injection/non-injection); type of drug (specific opioids, stimulants)) and selection based on fit statistics and qualitative interpretation of the classes. Polysubstance use was prevalent (89% ≥ 2), and 68% had injected drugs in the past 3 months. A three-class solution was selected: Class 1 ("heroin/cocaine use", 48.4% of sample), Class 2 ("poly-opioid use", 21.3%), and Class 3 ("poly-route, polysubstance use", 30.3%). Class 3 was significantly younger, and Class 2 was disproportionately non-White. Women reported high levels of housing (63%) and food (55%) insecurity, condomless sex with clients (40%), and client-perpetrated violence (35%), with no significant differences by class. Obtaining syringes from syringe services programs differed significantly by class, despite injection behaviors in all classes. Tailored HIV and overdose prevention programming that considers drug use patterns would strengthen their impact.

Harm reduction and health services provided by syringe services programs in 2019 and subsequent impact of COVID-19 on services in 2020

OBJECTIVES

This study describes harm reduction and health services provided by U.S syringe services programs (SSPs) in 2019 and changes in provision of those services in 2020.

METHODS

SSPs were invited to participate in the Dave Purchase Memorial survey in August 2020. We collected programmatic data on services provided in 2019 and at the time of the survey in 2020. We conducted descriptive analyses using Chi-square and McNemar's tests.

RESULTS

At the time of the survey, > 60% of SSPs reported increased monthly syringe and naloxone distribution and expansion of home-based and mail-based naloxone delivery in Fall 2020 compared to 2019. Approximately three-quarters of SSPs decreased or stopped providing on-site HIV and HCV testing. Nearly half of SSPs offering on-site medications for opioid use disorder (MOUD) in 2019 increased provision of MOUD in 2020. The proportion of SSPs offering on-site mental health care services and primary care services statistically significantly decreased from 2019 to Fall 2020, but telehealth offerings of these services increased.

CONCLUSIONS

Many SSPs that offered health services in 2019 and remained operational in 2020 increased telehealth provision of mental health and primary care services, increased MOUD provision, and expanded harm reduction services, but most SSPs reduced or stopped on-site HIV and HCV testing. Sustaining SSP growth and innovation is paramount for preventing overdose deaths and HIV/HCV outbreaks after the deadliest year of the opioid epidemic in 2020.

A qualitative study on pharmacy policies toward over-the-counter syringe sales in a rural epicenter of US drug-related epidemics

Background

Expanding access to sterile syringes in rural areas is vital, as injection-related epidemics expand beyond metropolitan areas globally. While pharmacies have potential to be an easily accessible source of sterile syringes, research in cities has identified moral, legal and ethical barriers that preclude over-the-counter (OTC) sales to people who inject drugs (PWID). The current study builds on prior urban-based research by elucidating (1) pharmacy OTC policies and (2) pharmacists’ rationale for, and barriers and facilitators to, OTC syringe sales in a US rural area hard hit by drug-related epidemics.

Methods

We conducted 14 semi-structured interviews with pharmacists recruited from two Eastern Kentucky health districts. Interview domains included experiences with, and attitudes toward, selling OTC syringes to PWID. Constructivist grounded theory methods were used to analyze verbatim transcripts.

Results

Most pharmacists operated “restrictive OTC” pharmacies (n = 8), where patients were required to have a prescription or proof of medical need to purchase a syringe. The remainder (n = 6) operated “open OTC” pharmacies, which allowed OTC syringe sales to most patients. Both groups believed their pharmacy policies protected their community and pharmacy from further drug-related harm, but diverging policies emerged because of stigma toward PWID, perceptions of Kentucky law, and belief OTC syringe sales were harmful rather than protective to the community.

Conclusion

Our results suggest that restrictive OTC pharmacy policies are rooted in stigmatizing views of PWID. Anti-stigma education about substance use disorder (SUD), human immunodeficiency virus (HIV), and Hepatitis C (HCV) is likely needed to truly shift restrictive pharmacy policy.

Onsite buprenorphine inductions at harm reduction agencies to increase treatment engagement and reduce HIV risk: Design and rationale

BACKGROUND

Despite dramatic increases in opioid use disorder (OUD) and overdose deaths, the U.S. has been unable to consistently deliver OUD treatment to those who need it. Syringe services programs (SSPs) can engage an out-of-treatment population of people with OUD that has elevated overdose risk. Buprenorphine treatment is safe and effective, and US regulations allow for prescribing from diverse locations, including SSPs. This study's objective is to test buprenorphine treatment initiation at SSPs. We hypothesize that offering onsite buprenorphine treatment initiation will improve OUD treatment engagement without reducing buprenorphine treatment effectiveness or safety.

METHODS

We will recruit 250 out-of-treatment SSP participants with OUD in a large urban area. Participants will be randomized to onsite buprenorphine treatment initiation or enhanced referral. Over 2 weeks, participants in the onsite treatment arm will see a buprenorphine provider twice at the SSP, receive weekly medication packs, and then their care will be transferred to a community health center for treatment continuation. In the control arm, within one week, participants will receive an appointment at the same community health center as in the intervention arm for buprenorphine initiation and continuation. Participants will be assessed with urine drug tests, questionnaires, and medical record review. The primary outcome will be engagement in buprenorphine treatment at 30 days. Secondary outcomes include buprenorphine diversion, opioid-free urine drug tests, and intervention cost-effectiveness.

DISCUSSION

Our study will contribute to the growing literature on SSPs as a conduit to OUD treatment. SSPs hold promise to deliver needed care to people with OUD.

Hepatitis C Virus Exposure and Infection in the Perinatal Period

BACKGROUND

Hepatitis C virus infection is a leading cause of blood-borne hepatitis disease worldwide. Hepatitis C is a silent liver disease that, without treatment, leads to late-onset complications, including chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma, in 10-40% of patients.

OBJECTIVE

This study aimed to review the epidemiology, clinical features, diagnosis, treatment, and prevention of hepatitis C among perinatally exposed children.

METHODS

Public databases, including MEDLINE and PubMed, and websites from the Centers for Disease Control and Prevention, the Food and Drug Administration, the World Health Organization, and the National Institutes of Health were searched for relevant articles published between 2006 and 2021.

RESULTS

The prevalence of hepatitis C has increased among women of childbearing age in the United States and is associated with risk factors, such as intravenous drug use, health inequities, and low socioeconomic background. Infants born to hepatitis C virus-infected mothers have a 6% risk of vertical transmission, and among those infected, 75% will develop chronic hepatitis C and late complications. However, hepatitis C-exposed infants are frequently lost to follow-up, and those infected have delayed diagnosis and treatment and are at high risk for late-onset complications. Direct- acting antivirals and the establishment of effective treatment guidelines cure hepatitis C virus infections.

CONCLUSION

Hepatitis C predominantly affects underserved communities. Early screening of mothers and infants is critical for the diagnosis, treatment, and prevention of chronic infections and lateonset complications. New policies are needed to address hepatitis C health care inequities affecting mothers and infants in the United States.

Identifying unique barriers to implementing rural emergency department-based peer services for opioid use disorder through qualitative comparison with urban sites

BACKGROUND

In an effort to address the current opioid epidemic, a number of hospitals across the United States have implemented emergency department-based interventions for engaging patients presenting with opioid use disorder. The current study seeks to address gaps in knowledge regarding implementation of a sub-type of such interventions, emergency department-based peer support services, in rural areas by comparing implementation of rural and urban programs that participated in Indiana's Recovery Coach and Peer Support Initiative (RCPSI).

METHODS

We conducted a secondary analysis of qualitative semi-structured implementation interviews collected as part of an evaluation of 10 programs (4 rural and 6 urban) participating in the RCPSI. We conducted interviews with representatives from each program at 3 time points over the course of the first year of implementation. Our deductive coding process was guided by the Consolidated Framework for Implementation Research (CFIR) and an external context taxonomy.

RESULTS

We identified key differences for rural programs corresponding to each of the 5 primary constructs in the coding scheme. (1) Intervention characteristics: rural sites questioned intervention fit with their context, required more adaptations, and encountered unexpected costs. (2) External context: rural sites were not appropriately staffed to meet patient needs, encountered logistical and legal barriers regarding patient privacy, and had limited patient transportation options. (3) Inner setting: rural sites lacked strong mechanisms for internal communication and difficulties integrating with pre-existing culture and climate. (4) Characteristics of individuals: some rural providers resisted working with peers due to pre-existing attitudes and beliefs. (5) Implementation process: rural sites spent more time identifying external partners and abandoned more components of their initial implementation plans.

CONCLUSIONS

Findings demonstrate how rural programs faced greater challenges implementing emergency department-based peer services over time. These challenges required flexible adaptations to originally intended plans. Rural programs likely require flexibility to adapt interventions that were developed in urban settings to ensure success considering local contextual constraints that were identified by our analysis.

Client Characteristics Associated with Desire for Additional Services at Syringe Exchange Programs

Objectives

The objective of this study was to explore the relationship between client characteristics and desired services offered at syringe exchange program (SEP) sites among women who inject drugs (WWID). We investigated whether a desire for additional services varied as a function of these client characteristics.

Methods

A sample of 69 women who were syringe exchange clients participated in a survey about adding services to syringe exchange programs. Three Poisson regression analyses were run to examine if client age, education, housing status, polysubstance use, and previous pregnancies were associated with overall desire for services, desire for health-related services, and desire basic needs services.

Results

Participant characteristics of polysubstance use (IRR 1.62, 95% CI 1.34-1.96; p < .01) and greater number of previous pregnancies (IRR 1.14, 95% CI 1.08-1.22; p < .05), were predictive of a greater number of desired services. Engagement in polysubstance use was predictive of a greater number of desired basic need services (IRR 1.45, 95% CI 1.23-1.70; p < .05).

Conclusions

WWID desired services at SEP sites can inform policymakers to formulate policies to better promote utilization of health-related and basic need services among WWID and, in turn, facilitate improved outcomes for WWID.

Participants of a mail delivery syringe services program are underserved by other safe sources for sterile injection supplies

BACKGROUND

In the United States, accessing sterile injection supplies remains challenging for many people who inject drugs (PWID). Although women are less likely to inject drugs than men, women who do inject are disproportionately affected by IDU-related complications. Needle Exchange Technology (NEXT), the first formal online accessed mail delivery syringe services program (SSP) in the US, may overcome access barriers. We evaluated whether NEXT was reaching women participants and people without access to other safe sources of sterile injection supplies.

METHODS

This cross-sectional study examined NEXT participants who enrolled in the mail-delivery SSP from February 2018 through March 2021. All NEXT participants completed an online questionnaire during enrollment, which included sociodemographic and clinical characteristics and injection-related risk factors (including prior sources of sterile injection supplies). Multivariable logistic regression (MVR) was used to examine associations between gender and prior use of safe sources of injection supplies (i.e., SSPs or pharmacies).

RESULTS

1,032 participants received injection supplies. Median age was 34 and participants were mostly cis-gendered women (55%) and white (93%). 34% reported infection with HCV; women were more likely to report HCV infection than men (38% vs 28%; p < 0.01). 68% of participants acquired injection supplies from less safe sources. Few participants exclusively used safe sources for injection supplies (26%). In adjusted MVR analysis, women participants had significantly lower odds than men of having exclusively used safe sources for injection supplies (adjusted OR 0.71, 95% CI 0.52, 0.98).

CONCLUSION

Our findings suggest that NEXT services are utilized by women and people without prior access to sterile injection supplies. Women participants were less likely than men to have exclusively used safe sources for sterile injection supplies. Future research should explore women's preference for mail-delivery over in-person SSPs and determine whether online accessed mail delivery services can reach other underserved populations of PWID.

Suboptimal uptake, retention, and adherence of daily oral PrEP among people with OUD receiving HCV treatment

Background

Daily oral preexposure prophylaxis (PrEP) with tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) prevents human immunodeficiency (HIV) among people who inject drugs (PWID). Despite rising HIV incidence and injection drug use (IDU), PrEP use remains low and there is limited research about uptake, adherence, and retention among PWID.

Methods

The ANCHOR investigation evaluated a community-based care model collocating hepatitis C virus (HCV) treatment, medication for opioid use disorder (OUD), and PrEP in individuals in Washington, DC, and Baltimore, Maryland. PrEP counseling was conducted from HCV treatment day 0 until week 24. Subjects could start any time during this window, were followed for 48 weeks, and were assessed for adherence by self-report and dried blood spot TDF analysis.

Results

One hundred ninety-eight participants were enrolled, of whom 185 (93%) were HIV negative. Twenty-nine individuals (15.7% of HIV-negative cohort) initiated PrEP. One hundred sixteen participants (62.7%) met 2014 Centers for Disease Control and Prevention (CDC) PrEP criteria due to IDU (82 [44.3%]), sex (9 [4.9%]), or both practices (25 [13.5%]). Providers recommended PrEP to 94 individuals (50.8%), and recommendation was associated with PrEP uptake. Median treatment duration was 104 days (interquartile range, 28–276 days), with 8 participants retained through week 48. Adherence was variable over time by self-report and declined by TDF analysis. No HIV seroconversions occurred.

Conclusions

This cohort of people with HCV and OUD experienced low uptake of PrEP despite the majority meeting CDC criteria. High rates of disruption and discontinuation, compounded by variable adherence, made TDF/FTC a suboptimal prevention strategy. Emerging modalities like long-acting formulations may address these barriers, but PWID have been excluded from their development to date.

Community pharmacist engagement in HIV and HCV prevention: Current practices and potential for service uptake

Background

Objective

Methods

Results

Conclusions

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Pharmacists are largely willing to help people who need HIV/HCV prevention services.

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Perception of HIV/HCV prevention fit with pharmacist professional identity varies.

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Cognitive HIV/HCV prevention services are preferred over hands-on clinical services.

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Pharmacists often engage in gatekeeping to limit sales of non-prescription syringes.

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Willingness to sell syringes potentially hinges on minimal contact with requestors.

Syringe Services Programs' Role in Ending the HIV Epidemic in the U.S.: Why We Cannot Do It Without Them

Diagnoses of HIV among people who inject drugs have increased in the U.S. during 2014-2018 for the first time in 2 decades, and multiple HIV outbreaks have been detected among people who inject drugs since 2015. These epidemiologic trends pose a significant concern for achieving goals of the federal initiative for Ending the HIV Epidemic in the U.S. Syringe services programs are cost effective, safe, and highly effective in reducing HIV transmission and are an essential component of a comprehensive, integrated approach to addressing these concerns. Yet, geographic coverage of these programs remains limited in the U.S., and many jurisdictions continue to have laws and policies that limit or disallow syringe services programs. An in-depth literature review was conducted on the role of syringe services programs in the Ending the HIV Epidemic initiative. Empirical and model-based evidence consistently shows that syringe services programs have the highest impact in HIV prevention when combined with access to medications for substance use disorder and antiretroviral therapy. Their effectiveness is further maximized when they provide services without restrictions and include proven and innovative strategies to expand access to harm-reduction and clinical services (e.g., peer outreach, telehealth). Increasing geographic and service coverage of syringe services programs requires strong and sustainable policy, funding, and community support and will need to address new challenges related to the COVID-19 pandemic. Syringe services programs have a key role in all 4 Ending the HIV Epidemic initiative strategies-Prevent, Diagnose, Treat, and Respond-and thus are instrumental to its success in preventing disease and saving lives.

Attitudes toward syringe exchange programs in a rural Appalachian community

OBJECTIVES

To evaluate community attitudes concerning syringe exchange programs (SEPs) in a rural community as part of an effort to implement evidence-based harm reduction strategies and improve health outcomes related to opioid use disorder.

METHODS

Dissemination of a 24-item survey to individuals living in a rural community followed by comparative analysis of survey results based on support for SEPs.

RESULTS

Three hundred and sixty-one individuals responded. Overall, 49.3% of respondents indicated support for syringe exchange. Individuals who support syringe exchange as a harm reduction service are more likely to: agree that opioid use disorder is a real illness (p < 0.0001); agree that anyone can become addicted to pain medications (p = 0.01); agree that medication assisted treatment is effective (p < 0.0001); agree that individuals with OUD have the same right to a job (p < 0.0001); be willing to administer naloxone to a stranger (p < 0.0001); support HIV and HCV screening (p < 0.0001), condom distribution (p < 0.0001), and medication for opioid use disorder (p < 0.0001). They are less likely to believe that harm reduction services encourage drug use (p < 0.0001).

CONCLUSIONS

Positive correlations exist between support for SEPs, awareness of OUD as a chronic illness, less stigmatizing attitudes toward individuals with OUD, and support for other harm reduction strategies. Efforts to increase awareness of OUD as a chronic illness may lead to greater acceptance of harm reduction strategies in rural areas, easing evolution of evidence-based healthy policy.