Harm Reduction Implementation Among HIV Service Organizations in the U.S. South

Background. The U.S. South is disproportionately impacted by the HIV and overdose crises. Addressing these intersecting epidemics requires implementation of evidence-based approaches - such as harm reduction (HR) - in HIV service organization settings. Specific HR services, such as syringe service programs or medication assisted treatment reduce the harms associated with drug use and HIV and Hepatitis transmission. HR is also an organizational approach to person-centered and community-responsive services which improves individual health outcomes and strengthens client-provider relationships and retention in care. However, little is known about the extent to which Southern HIV service organizations implement HR approaches and services. Furthermore, research has yet to examine the macro context of HR implementation in the South and its potential impact on HR adoption. To address this gap, this study addresses the following specific aims to: 1) examine the implementation context of HR in the South; 2) assess Southern HIV service organization implementation of HR; and 3) analyze the impact of different contexts on Southern HIV service organizations’ implementation of HR.

Methods. Aim 1: Authors analyzed nation-wide HR policy (e.g. syringe service program protections, ‘Good Samaritan' laws, Naloxone access laws, etc) and drug-related mortality data to articulate the shifting HR implementation context in the South from 2014-2019. Aim 2: To examine HIV service organization implementation of HR, authors surveyed Southern HIV service organizations (n=207 organizations) regarding implementation of specific HR services, HR training, and barriers to adopting an HR approach. Data were analyzed using frequency tables. Aim 3: Authors constructed logistic regressions, using state mortality data and policy context as predictors, to determine what contextual factors predicted HIV service organization implementation of HR.

Results. Increases in drug-related mortality in the South from 2014-2019 revealed an intensifying need for HR. HR policy data analysis additionally revealed an increased political openness to HR over that same period. Survey data indicated that approximately half of the HIV service organizations reported that their organizations reflect a HR orientation, and only 26% reported providing HR services. While only 36% of organizations had ever completed an organization-wide training in HR, 84% indicated interest in receiving such training. Logistic regressions revealed that while increased mortality rates did not predict HIV service organization implementation of HR, organizations in states with a HR-friendly policy context were more than twice as likely as those without such protections to have received training in HR (OR=2.31, p=0.02) and twice as likely to provide specific HR services (OR=2.28, p=0.05).

Conclusions and Implications. Study findings indicate a rapidly changing HR implementation context among Southern HIV service organizations wherein increased need has met increased political opportunity. However, there is a lag in HIV service organization’s ability to meet this opportunity and adopt HR approaches. Advocacy gains over the past eight years have facilitated the adoption of HR in some states, but financial resources, capacity building, and continued policy advocacy are required for increased HIV service organization adoption of HR.