Inaugural State of Harm Reduction National Survey

Key Findings Harm Reduction Defined Workforce Organization Profiles Strategies Engagement Training Needs Advocacy & Policy Conclusion Methodology & Participants

Introduction

Since 1999, more than one million Americans have died from a drug overdose.¹ A significant portion of these deaths can be attributed to overdoses involving opioids, a class of drugs including heroin, synthetic opioids such as fentanyl, and prescription drugs such as oxycodone, hydrocodone, codeine, and morphine.² The exponential rise in opioid use and overdose over the past twenty-five years constitutes what is known as the opioid epidemic, a health crisis that reached unprecedented severity in the wake of the COVID-19 pandemic. Drug overdose deaths increased more than 16% from 2020 to 2021, and synthetic opioid-involved deaths increased more than 22%.²

However, overdose-related mortality is only one area of concern in the drug user health landscape. Drug overuse and addiction are also associated with a variety of negative health outcomes and injection drug use is a significant source of transmission for infections including HIV and the hepatitis C virus (HCV). People who inject drugs (PWID) account for about 10% of new HIV diagnoses in the U.S.³ Though HIV and injection drug use (IDU) have always been linked, the recent upswing in opioid addiction poses new challenges for the HIV workforce as the IDU community is particularly socially vulnerable. CDC estimates that as high as 64% of PWID are unhoused, nearly one-third may be incarcerated, and over 20% are uninsured.³ In addition to these barriers, PWID face considerable stigma in health services contexts—stigma that is often amplified for PWID who are also living with HIV.⁴

These unique challenges have driven the development of harm reduction practices in healthcare that recognize the inherent dignity of all humans regardless of their behaviors or mental healths status, prioritize safety and drug user health rather than criminalization, and strive to meet people where they are instead of demanding sobriety or abstinence as a prerequisite for service provision. Despite this, extraordinary stigma and a policy landscape that criminalizes drug use continue to prevent people who use illegal substances or live with addiction from seeking essential medical care and accessing services and equipment that make drug use safer.

HealthHIV administered the Inaugural State of Harm Reduction™ National Survey to better understand the current landscape of drug user health, the role of harm reduction policies and practices in healthcare settings, and the professionals who implement them. Topics covered include the identification and engagement of clients, drug user health services and supplies, substance use/addiction treatment, retention in care and recovery support, how organizations incorporate harm reduction principles, navigating funding sources, responses to infectious disease outbreaks, satisfaction with continuing education and current training opportunities, and more. Insights from the survey will be used to optimize the education and training of the healthcare and substance use workforce, and to better inform health advocacy, education, research, and training activities.

When asked what the State of Harm Reduction is in one word, respondents primarily stated: “lacking,” “poor,” and “improving.”

Key Findings and Implications

The Inaugural State of Harm Reduction National Survey engaged 795 healthcare workers spanning the public health workforce, including clinical and non-clinical providers. The following key findings represent the most significant insights gained from the survey:

Harm reductionists support policy-makers expanding access to supervised consumption assistance.
Legal barriers prevent practitioners across the majority of the U.S. from implementing this service.
Organizations must prioritize the equitable expansion of drug user health services.
Harm reductionists believe their organizations need to improve their reach to people who participate in sex work, people who are incarcerated or formerly incarcerated, and non-English-speaking individuals.
Progress towards widespread acceptance of harm reduction remains slow.
Many organizations are prevented from obtaining adequate funding due to stigma associated with harm reduction practices and limited availability of funding specifically dedicated to HR initiatives.
Social assistance remains integral to harm reduction.
Inadequate housing and transportation prevent clients/patients from engaging in care and/or harm reduction practices.
Over-policing and criminalization top primary concerns for drug user health services.
Racial inequities in drug user health services are reflected in over-policing and criminalization in communities of color. Harm reduction strategies can help protect those impacted by criminalization by reducing exposure to law enforcement.
Stigma and community resistance pose the greatest threat to harm reduction practices.
A significant majority of respondents believe community resistance to drug user services is the highest barrier to engaging new clients in care.

How is Harm Reduction Defined and Implemented in the Field?

Harm reduction is an emerging field and there is limited research on how organizations are defining and incorporating it into their practice.

The National Harm Eeduction Coalition (NHRC) defines harm reduction as “a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use.⁵ This encompasses both harm reduction as a political and philosophical movement that promotes autonomy, safety, and justice, and harm reduction as an individualized approach to drug user health that equips clients with resources to reduce the risk of overdose, disease transmission, and other negative health outcomes. There is no universal implementation guide, however the NHRC considers these principles central to harm reduction practice:

Accept that illicit drug use is part of our world
Understand drug use as a complex, multi-faceted approach
Establish quality of individual and community life as the criteria for successful interventions and policies
Call for non-judgemental, non-coercive provision of services and resources
Ensure that people who use drugs and those with a history of drug use have a real voice in the creation of programs
Affirm people who use drugs themselves as the primary agents of reducing the harms of drug use
Recognize the realities of social inequalities affect both people’s vulnerability to and capacity for effectively dealing with drug-related harm
Does not attempt to minimize or ignore the real and tragic harm and danger that can be associated with illicit drug use

Participants were asked to indicate the extent to which their organization incorporates harm reduction into their services as well as their alignment with the principles of harm reduction.

How is harm reduction incorporated into organization services?

The majority of respondents describe harm reduction as just one component of their organization’s work, with only 16% saying it is their organization’s primary goal.

To what extent do organizations uphold each of the following harm reduction principles provided by Harm Reduction International and the NHRC?

When asked to identify the extent to which their organization adheres to principles of harm reduction outlined by the NHRC, participant responses varied.

Over 80% believe their organizations respect the rights of people who use drugs, meet people “where they’re at,” acknowledge the impact of social inequalities on drug-related harm, and recognize the spectrum of drug use and safety. However, fewer participants believe their organizations provide non-judgmental support and empower drug users to actively participate in shaping programs and policies that serve their needs.

These findings reflect the great potential for healthcare providers, as fundamentally humanist, service-oriented professionals, to change the way we think about substance use and addiction as a society—and yet, they also reveal the challenge of integrating the most radical and subversive harm reduction values into traditional healthcare settings. This dissonance will be crucial for policy makers to examine and contend with as harm reduction strategies become more formalized components of substance use- and sexual health-care.

Workforce Profile and Challenges

Insights into staff burnout, workforce shortages, and increased workloads.

Professional Profile of Survey Participants

The majority of respondents were non-clinical professionals who do not prescribe medication.

Of the 26% of clinical professionals who participated, 19% also prescribe medication. Licensed clinical social workers, registered nurses, administrators, and harm/risk reductionists represented the majority of participants, with over 50% indicating they have been working in their role for less than four years.

Lived Experience Using Drugs

Critically, nearly half of the respondents (47%) reported personal lived experience with drug use, a considerable percentage of whom agree that it is crucial to their practice, empowers them to build trust with clients/patients, provides insight into client challenges, and increases their knowledge of available harm reduction resources.

However, respondents with lived experience also noted considerable emotional burden, with nearly a quarter strongly agreeing that doing harm reduction work could be re-traumatizing for them. This is an important barrier to providing sustainable community-based harm reduction services that must be considered by organizations.

It is clearly essential for organizations that practice harm reduction to rely on the expertise of community members—a fact reflected by the significant majority of respondents who report their organizations employ full-time staff with lived experience and provide or link to peer support services. However, only a third of respondents reported having leadership with lived experience, representing a key gap. Organizations, universities, and service providers must work harder to facilitate community leadership and develop pathways for people with lived expertise to get involved in program leadership. Prioritizing community voices in leadership is, in itself, a form of harm reduction, as it ensures any policies that impact client welfare are not only evidence-based, but informed by vernacular knowledge, empathy and understanding.

What Workforce Challenges are Harm Reductionists Facing in the U.S.?

A significant portion of respondents are grappling with workforce shortages, poor or stagnant compensation, and increased workloads, as each of these issues were ranked among the top 3 most challenging workforce concerns by over 45% of respondents.

However, workforce shortages were most frequently selected as a top challenge, with over 55% of respondents placing it in their top three.

To mitigate these challenges, strategies such as supporting staff wellness and self-care and allowing flexible schedules are being implemented.

Workforce Burnout and Resilience

About half of respondents indicated feeling emotionally drained from work at least a few times a month.

However, the majority have not considered quitting their job in the last six months. In fact, most participants indicated they accomplish worthwhile things in their jobs at least a few times a week and feel valued by clients/patients, colleagues, and organizational leadership. Respondents are split on their feelings of personal safety working in substance use care settings, with 51% saying they are not at all concerned about safety but with the remaining 49% reporting they feel somewhat or very concerned.

Burnout is a growing problem in many areas of healthcare and social work, including among harm reduction practitioners. Harm reductionists not only experience key markers of burnout, but also often face lack of safety at work, lack of control over work environment, and frequent task-shifting.⁶

As organization leaders and policy makers work to address the burnout crisis facing the American healthcare workforce, it will be essential to develop interventions tailored to the unique context of harm reduction work.

Where is Harm Reduction Practiced?

There are a wide range of organizations and settings where harm reduction is practiced, many of which are especially well-suited to caring for people who cannot afford traditional health services like primary care or chronic disease management.

Professional Profile of Participating Organizations

Nearly 60% of respondents work in community-based programs including non-profits and Syringe Service Providers (SSPs), while over a third work in health/medical centers and 12% work in government entities.

The majority of respondents work in urban settings, but a sizable 24% work in rural communities and 17% in suburbia, reflecting the wide geographic profile of substance-use and IDU in the U.S. and the prevalence of opioid-related mortality in rural America.

Program Funding

The majority of survey respondents say their organizations accept insurance including medicaid and medicare, and over 90% provide care to the uninsured, offer their services for free, or have a sliding/income dependent payment scale.

However, respondents report these crucial programs often face funding deficits due to their association with the harm reduction model, listing stigma and limited availability of funding specifically dedicated to harm reduction initiatives as the top barriers to funding. Additionally, over half of respondents expressed dissatisfaction with the funding their organization receives to implement harm reduction services.

Extensive research has shown that harm reduction strategies like sterile syringe provision and safe-injection facilitation are highly cost-effective at reducing HIV transmission and increasing engagement in healthcare.⁸ However, government funding is continually directed towards drug law enforcement or traditional medical-model programs which view all illicit substance use as abuse. The 2023 U.S. federal budget provides over $42 billion for agencies to implement national drug control policies.⁹ Harm reductionists ask us to imagine the potential power of that money were it directed towards programming that uplifts drug user health rather than framing drug-use as incompatible with health.

What Harm Reduction Strategies are Implemented in the Field?

Harm reduction is most frequently referenced in relation to substance use and IDU, but many providers use it as a broader framework that supports the safety of their clients in a large variety of contexts.

Sexual and Reproductive Healthcare

Respondents commonly report offering safer sex education and products, STI screening and treatment, and HIV pre-exposure prophylaxis (PrEP), as effective strategies that reduce STI transmission, sexual violence, and unplanned pregnancy without stigmatizing specific sexual practices or promoting abstinence.

Drug User Health Services

Much like sexual health, drug user health is a broad spectrum of care that includes IDU-related services for PWID but also extends to any strategies that support the well-being of people who use drugs more broadly.

This might involve mental health or addiction counseling, housing and social assistance, pharmacy and medical services, peer support, and more. These services are distinct from substance use treatment or medical detox services, as they are provided to individuals engaged in active substance use, regardless of their intention to stop or continue use.

Respondents report their organizations are most likely to offer SUD treatment referrals, harm reduction education, and overdose response training, but least likely to offer supervised consumption assistance and direct medical services. Accordingly, respondents overwhelmingly report they would like more opportunities to directly provide supervised consumption assistance and street medicine, services with immense potential to save lives.

Similarly, while many organizations distribute naloxone, drug testing strips, sterile syringes, and other IDU equipment like sterile water, gauze, and tourniquets, the majority of respondents cite community resistance as a considerable obstacle to obtaining and distributing supplies.

Despite widespread recognition of systemic healthcare inequities, the social determinants of health, and the broadscale suffering wrought by the opioid epidemic, substance use stigma and resistance to pragmatic drug policy remains high in the U.S.⁴, ¹⁰ The result, as reflected in the responses of survey participants, is the severe underdevelopment of harm reduction infrastructure nationwide. As of 2017, twenty-six states have no syringe exchange programs or limit these services to one or two major cities, and research suggests that the programs that do exist meet only 3% of estimated need.¹⁰ Additionally, though supervised consumption sites have been operating successfully in other countries since the 1980s, reducing overdose deaths by as much as 30% in some cities (e.g. Vancouver, Canada), the first legal/authorized American site did not open until 2021.¹¹

It is crucial that healthcare providers who understand the value of harm reduction and are committed to anti-oppressive practice, lead the movement to combat resistance to drug user health services and risk reduction in their communities and workplaces. This survey offers a place to begin this work, highlighting the reality that much of what the healthcare workforce already practices — namely, community education, service navigation, and social assistance — are forms of harm reduction . As the harm reduction movement grows and practitioners look to expand the framework into traditional healthcare settings, it will be crucial to make this connection to help more resistant providers understand harm reduction as a spectrum of care that could be compatible with their work.

Substance Use Treatment

Substance use treatment programs offer another site for harm reduction work.

One third of participants work at organizations that provide substance use treatment, the majority of which offer services like Medication Assisted Treatment (MAT) for Opioid Use Disorder (OUD), alcohol addiction treatment, individual and group counseling, and drug user counseling. In contrast, most participants report their organizations do not provide services requiring intensive clinical supervision like inpatient treatment and medical detoxification.

Buprenorphine and naltrexone are the most provided MAT products. Barriers to providing MAT services include lack of integration with other drug user health services, a shortage of authorized providers, client/patient difficulties adhering to appointment schedules, and stigma associated with accessing MAT.

MAT, in combination with behavioral counseling, aims to reduce cravings and maintain engagement in OUD treatment.¹² The use of combined buprenorphine/naloxone (Suboxone) has been found to be an effective treatment for the chronic, relapsing condition of OUD.¹³

Although methadone, naltrexone, and Suboxone have been found to be equally effective at reducing symptoms of OUD and increasing retention in treatment, Suboxone is more advantageous in some situations.¹⁴ Naltrexone requires full detoxification to initiate use and methadone is a full opioid agonist known for its potential for abuse and accidental overdose.¹⁴ In contrast, Suboxone is a partial agonist with longer acting duration that allows for non-daily dosing, reducing the risk of overdose and potential for abuse.¹⁵ Despite the growing availability of evidence supporting MAT as an effective treatment for reducing the rates of overdose death from opioid use, discrimination, bias, and stigma continue to limit access.

How Do Providers Engage Clients and the Community?

With community resistance posing significant barriers to harm reduction services, client engagement is a programmatic priority for many organizations.

Engagement Methods

A majority of respondents indicated their organizations actively work to identify and engage individuals in need of drug user services by providing safer substance use and safer sex educational materials and program promotion at health fairs and pop-up clinics.

Barriers to Engagement

Even among clients engaged in more formal substance use treatment like MAT, barriers to access remain high.

Respondents report many of their clients have extreme difficulty adhering to appointment schedules, live with fear of being seen accessing MAT, or lack insurance or resources to pay for MAT.

Additionally, individuals are often prevented from accessing drug user health resources by structural barriers (e.g. housing insecurity, lack of transportation, etc.) and the climate of stigma and shame surrounding substance use. These barriers are commonly reported by providers and clients across the healthcare landscape, but are particularly acute among substance users and PWID, who are more likely to be experiencing poverty and/or homelessness than their peers.¹⁶

What is the Role of Harm Reduction in the HCV Continuum?

Hepatitis C virus (HCV) is a bloodborne virus that can be transmitted sexually or via IDU. Accordingly, HCV prevention and care services are commonly provided by organizations that focus on substance use and/or drug user health.

Status neutral HCV prevention and care, based on principles of HIV status neutrality, is a “whole-person” approach to HCV care that emphasizes engagement and retention in services regardless of whether the individual is at risk for or currently living with HCV.¹⁷

Three-quarters of survey respondents report their organizations provide HCV testing and/or treatment. The following section recounts these respondents’ experiences providing HCV care, with special attention to the experiences of respondents who are personally involved with work at each step of the HCV continuum.

Step 1: Testing and Diagnosis

Among respondents who personally provide HCV testing and diagnosis services, the most significant provider challenges include client refusal to get tested and workforce shortages, while the greatest client barriers include distrust in the healthcare system and fear of stigma/discrimination.

Step 2: Linkage to Care

Linkage to care was identified as the component of the HCV care continuum that respondents believe needs the most attention in their organization.

This is attributed to the indirect costs of getting an appointment, insurance coverage concerns, and patient refusal to pursue care. Crucially, respondents suggest these barriers are the result of structural inequality and/or unmet psychological need, including housing instability, lack of transportation, and unwillingness or lack of readiness to engage due to ongoing drug use.

Respondents who personally link to HCV care report that integrating HCV treatment into other healthcare settings, establishing external collaborative partnerships with organizations, and co-locating HCV treatment with OUD treatment were the greatest facilitators to linking patients to HCV care.

Step 3: Receipt of HCV Care

Only 11% of respondents are personally involved in providing HCV care via direct-acting antiviral (DAA) medications.

However, those who do work in this area believe that DAA regimen simplicity is the greatest facilitator to HCV treatment, while lack of insurance and/or prohibitive copays are the greatest barriers to engaging clients in care. This is particularly problematic when we consider that over 20% of PWID are uninsured.¹⁶

Step 4: Sustained Virologic Response

In contrast, once clients are engaged in care, the greatest barriers to adhering to DAA and achieving sustained virologic response are lack of readiness due to ongoing addiction and mental health issues.

This supports the argument that HCV treatment programs need to be, not just financially accessible, but integrated into social support services and behavioral healthcare. They also need to be flexible and status neutral, in recognition of the reality that many clients will lapse in care and experience reinfection.

Step 5: Prevention of Reinfection

Significantly, a quarter of respondents involved in HCV reinfection education efforts named harm reduction as an effective prevention strategy.

While traditional HCV prevention models might promote sobriety/abstinence as the only path towards health, harm reduction programs believe safer sex and risk reduction techniques are more pragmatic, humanizing, and effective.

Improving HCV Services

Ultimately, what organizations need to combat HCV in their communities is more support staff to provide wraparound services to clients, more providers trained in HCV care, and increased funding to support HCV services.

The most striking theme from respondents’ answers in this section is the social complexity of HCV infection. When lack of resources and social support, fear of discrimination, housing instability, and mental health concerns are the greatest barriers to preventing infection and accessing and adhering to DAA, biomedical interventions are insufficient—particularly in the absence of harm reduction guidance and tools. The Biden administration’s Hepatitis C initiative, which respondents are only somewhat aware of, offers a critical first step towards reducing financial barriers to accessing HCV treatment. However, successful HCV prevention and care must also incorporate realistic strategies for reducing risk, tailored to the individual’s needs and readiness.

What are the Training and Capacity Building Needs of the Harm Reduction Workforce?

To meet harm reduction education and training needs, the majority of responding organizations rely on local or state health departments, followed by nonprofits and federal agencies such as the CDC and SAMHSA.

Respondents currently receive their training primarily from webinars, online conferences or meetings, and self-paced online courses.

However, they indicated a strong preference for in-person training, pointing towards the desire to return to a pre-COVID “normal” and facilitate greater inter-professional community building.

About one-third of respondents are neutral towards or dissatisfied with the amount and breadth of harm reduction training available to them, representing a key opportunity for medical education providers.

The most sought-after training topics in harm reduction include navigating community resistance, integrating harm reduction practices into healthcare, and implementing mobile outreach. Additionally, respondents expressed significant interest in general healthcare education on preventing stigma and discrimination, providing trauma-informed care, and addressing mental/behavioral health.

Harm reduction offers promising strategies for reaching populations that are typically challenging to retain in care.

For example, mobile syringe exchange units can provide services to PWID who cannot access stable housing or transportation. In fact, harm reduction research shows that many people living with active addiction or substance dependence are unable or unwilling to engage with formal/structured healthcare.²⁰ Rather than criminalizing continued substance use or framing so-called “high risk” behaviors as immoral or self-destructive, harm reductionists practice radical empathy and pragmatism, validating the full social context of each client and prioritizing quality of life over abstinence.⁸

However, respondents report that their organizations could be better at reaching people who participate in sex work, people who are incarcerated or formerly incarcerated, non-English-speaking individuals, undocumented persons, people experiencing homelessness, and BIPOC communities. Each of these groups are also disproportionately impacted by HIV and HCV, highlighting the potential utility of harm reduction practices in HIV, STI, and infectious disease care settings.²¹ Accordingly, organizations that develop training and capacity building for these provider groups should consider incorporating harm reduction content into their curriculums.

What is the State of Harm Reduction Advocacy and Policy?

The implementation and legality of harm reduction services are highly contested in many areas of the country and organizations report significant involvement in these ongoing policy conversations.

Respondents indicated varied levels of participation in harm reduction advocacy, with 39% actively involved, 37% not engaged, and 24% unsure.

Among the pressing harm reduction issues in 2023, decriminalization and drug policy reform lead, followed by housing and drug user health, and access to harm reduction services. Additionally, concerning racial inequities in drug user health services—over-policing in communities of color, lack of diverse decision-making voices, and the disproportionate impact of drug-related deaths were identified as major concerns.

The legality of safe consumption spaces varies, with under 8% of respondents operating in regions where they are legal (these respondents were almost exclusively from New York, where the nation’s first legal safe injection site was opened in 2021).¹¹

One-third of respondents are aware of community efforts to establish these spaces despite legal barriers, and over a quarter report their organization is participating in such efforts.

Even among those operating authorized sites, at least half continue to face legal challenges—a common theme for substance use and harm reduction care settings. Though organizations report a range of experiences with law enforcement, under 30% would describe those relationships as positive, and about a quarter of respondents say they have experienced harassment or intimidation and/or have had harm reduction supplies seized by local police. This finding is in line with prior research showing that even when legalized, syringe exchange operations are often hindered by excessive involvement of law enforcement.²²

The legality of harm reduction activities varies nationwide, which has led to a patchwork of federal and state laws and directives on the subject.²³ Accordingly, not all respondents are operating under the same legal framework, and this fact is essential context for accurately interpreting the survey findings. Responses suggest a need to seriously consider the advocacy and policy priorities of the harm reduction workforce to better include and focus on communities of color, to investigate the role of law enforcement in harm reduction activities, and to study the potential legal challenges to and efficacy of safe injection sites.

The survey also illustrates how a substantial portion of the harm reduction workforce seeks to be active change agents within their field. This is evident in the finding that nearly 30% of participating organizations are involved in efforts to provide safe consumption spaces despite local legislation. Harm reductionists are not just healthcare practitioners—they are political advocates working to subvert systemic inequities and structural barriers to care, pushing the boundaries of what it means to protect the community.

Implications and Conclusion

What is the State of Harm Reduction in the U.S.?

The image of harm reduction painted by survey participants is one rife with challenges — or, as many participants described it, “precarious,” “vulnerable,” and “complicated.”

Inconsistent legislation, definitional debates, funding restrictions, and pervasive stigma and community resistance pose serious barriers to the harm reduction movement, limiting the workforce’s ability to implement drug user health programs, distribute risk reduction supplies, and advocate for their clients who use substances. However, participants also assert the harm reduction framework is a crucial vehicle for culturally competent and respectful care, promoting unparalleled autonomy for clients, reducing the power divide between clients and “expert” clinicians, and offering realistic strategies for keeping clients safe and therefore more likely to experience positive health outcomes. The survey findings suggest that the future viability of harm reduction efforts depends on the extent of community acceptance. Widespread adoption of harm reduction philosophies and interventions will require their integration into primary health care, the reduction of legislative barriers, and the abolition of substance use stigma and criminalization.

Survey Methodology

A total of 759 respondents participated in the survey, responding to questions on harm reduction principles, training needs, drug user health, workforce burnout, and more. The survey was developed using the harm reduction definition and principles outlined by the National Harm Reduction Coalition, keeping in mind that there is no universal definition for harm reduction.

The survey consisted of a mix of 94 open- and closed-ended survey questions. Internal and external advisory groups reviewed the survey to ensure the questions encompassed salient issues facing harm reduction providers and people who use drugs as described in the literature.

The survey was administered online via Research Electronic Data Capture (REDCap) from September 14th, 2023 – October 25th, 2023. Respondents were recruited through HealthHIV’s constituent relationship management (CRM) database, SalsaLabs, which includes approximately 80,000 persons who reflect the diverse cross-section of people engaged in harm reduction practices in the U.S. There was wide representation of sexual and gender minorities, across geographic location, educational status, and income levels. No incentive was provided for participation.

Survey Eligibility

Participants were all members of the healthcare workforce with direct experience providing or supporting substance use care, harm reduction strategies, and/or sexual healthcare, including HIV and HCV prevention and treatment.

Data Analysis

Basic descriptive statistics were calculated in REDCap.²⁴ Additional univariate, bivariate, and multivariable analyses were calculated using R version 4.3.2 and RStudio 4.3.1 statistical software. Thematic content analysis was used to explore qualitative data and identify themes that captured respondent experiences.

Participant Demographics

Survey respondents are predominantly non-Hispanic White, followed by Black/African American individuals.

The majority identify as cis-gender women, ages 35 to 44, with notable genderqueer/gender non-conforming representation as well.

Respondents reside across the U.S., hailing from 43 states and 1 territory.

The survey’s predominantly white participation contrasts with the demographics of those most affected by substance use issues, particularly American Indian or Alaskan Native and Black or African American communities.²⁵ This represents an opportunity for improvement in future research endeavors.

Notes

CDC. Drug Overdose Deaths. CDC Injury Center. Published August 22, 2023. Accessed January 12, 2024. https://www.cdc.gov/drugoverdose/deaths/index.html
CDC. Understanding the Opioid Overdose Epidemic. CDC Injury Center. Published August 8, 2023. Accessed January 12, 2024. https://www.cdc.gov/opioids/basics/epidemic.html
CDC. HIV Among People Who Inject Drugs. HIV by Group. Published June 28, 2022. Accessed January 12, 2024. https://www.cdc.gov/hiv/group/hiv-idu.html
Paquette CE, Syvertsen JL, Pollini RA. Stigma at every turn: Health services experiences among people who inject drugs. Int J Drug Policy. 2018;57:104-110. doi:10.1016/j.drugpo.2018.04.004
National Harm Reduction Coalition. Principles of Harm Reduction. Published online 2020. https://harmreduction.org/wp-content/uploads/2022/12/NHRC-PDF-Principles_Of_Harm_Reduction.pdf
Unachukwu IC, Abrams MP, Dolan A, et al. “The new normal has become a nonstop crisis”: a qualitative study of burnout among Philadelphia’s harm reduction and substance use disorder treatment workers during the COVID-19 pandemic. Harm Reduct J. 2023;20(1):32. doi:10.1186/s12954-023-00752-7
Akhtar WZ, Feinberg J. Chapter 3 – Opioid use disorder and rural America. In: Norton BL, ed. The Opioid Epidemic and Infectious Diseases. Elsevier; 2021:25-38. doi:10.1016/B978-0-323-68328-9.00003-5
Hawk M, Coulter RWS, Egan JE, et al. Harm reduction principles for healthcare settings. Harm Reduct J. 2017;14:70. doi:10.1186/s12954-017-0196-4
Office of Management and Budget. Analytical Perspectives: Budget of the U.S. Government Fiscal Year 2023; 2022:275-276. https://www.govinfo.gov/content/pkg/BUDGET-2023-PER/pdf/BUDGET-2023-PER.pdf
Nadelmann E, LaSalle L. Two steps forward, one step back: current harm reduction policy and politics in the United States. Harm Reduct J. 2017;14(1):37. doi:10.1186/s12954-017-0157-y
Finke J, Chan J. The Case for Supervised Injection Sites in the United States. Am Fam Physician. 2022;105(5):454-455.
Connery HS. Medication-assisted treatment of opioid use disorder: review of the evidence and future directions. Harv Rev Psychiatry. 2015;23(2):63.
Bell J, Strang J. Medication treatment of opioid use disorder. Biol Psychiatry. 2020;87(1):82-88. doi:10.1016/j.biopsych.2019.06.020
Kreek MJ. Methadone-related opioid agonist pharmacotherapy for heroin addiction: history, recent molecular and neurochemical research and future in mainstream medicine. Ann N Y Acad Sci. 2006;909(1):186-216. doi:10.1111/j.1749-6632.2000.tb06683.x
Buprenorphine/Naloxone Versus Methadone for the Treatment of Opioid Dependence: A Review of Comparative Clinical Effectiveness, Cost-Effectiveness and Guidelines. Canadian Agency for Drugs and Technologies in Health; 2016. Accessed January 29, 2024. http://www.ncbi.nlm.nih.gov/books/NBK385163/
CDC. HIV Infection Risk, Prevention, and Testing Behaviors Among Persons Who Inject Drugs—National HIV Behavioral Surveillance: Injection Drug Use 23 U.S. Cities, 2018.; 2020:24.
CDC. Status Neutral HIV Prevention and Care. HIV. Published March 1, 2023. https://www.cdc.gov/hiv/effective-interventions/prevent/status-neutral-hiv-prevention-and-care/index.html
National Harm Reduction Coalition. Harm reduction education on-demand. Published n.d. Accessed December 8, 2023. https://harmreduction.org/our-work/training-capacity-building/online-training-institute/
CDC. The National Harm Reduction Technical Assistance Center – Home. https://harmreductionhelp.cdc.gov/s/
Kourounis G, Richards BDW, Kyprianou E, Symeonidou E, Malliori MM, Samartzis L. Opioid substitution therapy: Lowering the treatment thresholds. Drug Alcohol Depend. 2016;161:1-8. doi:10.1016/j.drugalcdep.2015.12.021
CDC. HIV by Group. HIV Home. Published April 14, 2022. Accessed January 20, 2024. https://www.cdc.gov/hiv/group/index.html
Morrissey B, Hughes T, Ostrach B, et al. “They don’t go by the law around here”: law enforcement interactions after the legalization of syringe services programs in North Carolina. Harm Reduct J. 2022;19(1):106. doi:10.1186/s12954-022-00690-w
Association of State and Territorial Health Officials. ASTHO’s Public Health Legal Mapping Center. Policy & Advocacy. Published July 31, 2023. Accessed January 29, 2024. https://www.astho.org/advocacy/state-health-policy/public-health-legal-mapping-center/
Harris P, Taylor R, Thielke R, Payne J, Gonzalez N, Conde J. Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inf. 377AD;42(2):2009. doi:doi:10.1016/j.jbi.2008.08.010
Highlights for the 2021 National Survey on Drug Use and Health. SAMHSA; 2021. https://www.samhsa.gov/data/sites/default/files/2022-12/2021NSDUHFFRHighlightsRE123022.pdf

HealthHIV Research and Evaluation

HealthHIV Research and Evaluation conducts regular national surveys to better inform ongoing advocacy, education, research, and training activities. These “State Of” surveys provide unique insight into patient and provider issues in order to optimize primary and support services for diverse communities. The regular reports offer the ability to study multi-year trend analyses illustrating changes, challenges, and opportunities to address the needs of providers and patients. HealthHIV, HealthHCV and the National Coalition for LGBTQ Health conduct State of surveys addressing HIV care, HCV care, LGBTQ healthcare, and aging with HIV.

HealthHIV.org/StateOf

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HealthHIV is a national non-profit working with healthcare organizations, communities, and providers to advance effective HIV and HCV prevention, care, and support through education and training, technical assistance and capacity building, advocacy, communications, and health services research and evaluation.

1630 Connecticut Avenue NW, Suite 500 • Washington, DC 20009
202-232-6749 • HealthHIV.org

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