Kentucky Outreach Service Kiosk (KyOSK): Reducing HIV, HCV, and Overdose Risk in Rural Appalachia through Harm Reduction Kiosks

摘要 拟议的项目将测试减少与注射流行病有关的危害的创新方法。 在阿巴拉契亚肯塔基州的农村地区，吸毒、过量服药、丙型肝炎(丙型肝炎)和即将爆发的艾滋病毒 长期以来一直是这些相互交织的危机的震中。我们的研究表明，该地区的失业率很高。 丙型肝炎病毒，过量用药，注射毒品，无安全套的性行为，以及可能引发艾滋病毒的密集风险网络 疫情爆发。在邻国印第安纳州2014年艾滋病毒爆发和对艾滋病毒/丙型肝炎病毒爆发的全国分析之后 注射吸毒者的脆弱性(PWID)显示，肯塔基州120个县中有54个县在 在全国排名前5%的人中，肯塔基州通过了里程碑式的立法，允许各县开展注射器服务 程序(SSP)。尽管有艰难的县级审批程序，肯塔基州还是成功地开设了80个 SSP，比美国任何其他州都多。不幸的是，这一强大的减少危害基础设施仍处于- 在农村环境中使用。由NIDA的全国农村阿片类药物倡议资助的研究数据显示， 近一半的PWID从未使用过现有的SSP，在超过24个月的跟踪调查中，SSP的使用率 保持在低水平，课程辍学并不少见。最常被引用的理由是 使用SSP是对耻辱的恐惧。有证据表明，该地区的PWID希望减少一系列危害 服务模式，以及那些报告污名是不使用SSP的原因的人中，最多的 想要的型号是自动售货机，或“售货亭”。减少伤害信息亭已经在全球范围内运营了更多 30多年来，研究表明，它们可以扩大注射器的使用范围。然而，极少有售货亭 在美国运营，没有一家在农村地区运营，在那里它们可能特别有益。研究 建议将售货亭与配备有工作人员的SSP结合使用，这可能是一种经济有效的方式来扩大注射器的使用范围 但它们的实施、影响和成本效益还没有得到严格的评估。作为回应，我们 建议进行第一类混合有效性试验，以测试有效性、实施结果和成本 为社区量身定做的减害亭在降低艾滋病毒、丙型肝炎和过量用药风险方面的有效性 阿巴拉契亚乡村的行为举止。我们的服务亭，或KyOSK(KY外展服务亭)，将提供 注射设备、纳洛酮、芬太尼试纸、卫生工具包、避孕套和其他用品以及 创新的回叫功能，便于训练有素的康复教练转介到所需的服务。KyOSK 将通过社区参与的流程和Kiosk设计团队根据当地情况量身定做 吸毒的人和地方和州的领导人。对减量亭的兴趣在全国范围内飙升， 拟议的项目将提供关键和及时的数据，为这一模式的推广提供信息，特别是在农村 该国受到与物质使用相关危害的严重影响的地区。

Abstract The proposed project will test an innovative approach to reducing harms related to the epidemics of injection drug use, overdoses, hepatitis C (HCV), and to imminent HIV outbreaks, in rural Appalachian Kentucky which has long been an epicenter of these intertwined crises. Our research has shown that the region has high rates of HCV, overdose, injection drug use, condomless sex, and dense risk networks that could kindle an HIV outbreak. Following a 2014 HIV outbreak in neighboring Indiana and a national analysis of HIV/HCV outbreak vulnerability among people who inject drugs (PWID) revealing that 54 of Kentucky’s 120 counties ranked in the top 5% nationally, Kentucky passed landmark legislation permitting counties to operate syringe service programs (SSPs). Despite an arduous county-level approval process, Kentucky has succeeded in opening 80 SSPs, more than any other U.S. state. Unfortunately, this robust harm reduction infrastructure remains under- utilized in rural settings. Data from our research funded by NIDA’s National Rural Opioid Initiative revealed that nearly half of PWID had never used the existing staffed SSPs and, over 24 months of follow-up, SSP uptake remained low and program drop-out was not uncommon. The most frequent reason cited for having never used an SSP was fear of stigma. Evidence suggests that PWID in the region want a range of harm reduction service models, and among those who report stigma as a reason for not using the staffed SSPs, the most desired model is a vending machine, or ‘kiosk’. Harm reduction kiosks have been operating globally for more than 30 years and research has demonstrated that they can expand syringe access. Yet very few kiosks operate in the U.S., and none operate in rural areas where they might be especially beneficial. Research suggests that kiosks might be a cost-effective way to expand syringe access when coupled with staffed SSPs but their implementation, impact, and cost-effectiveness have not been rigorously evaluated. In response, we propose a type 1 hybrid effectiveness trial to test the effectiveness, implementation outcomes, and cost effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C, and overdose risk behavior in rural Appalachia. Our kiosk, or KyOSK (KY Outreach Service Kiosk), will be supplied with injection equipment, naloxone, fentanyl test strips, hygiene kits, condoms, and other supplies as well as an innovative call-back feature for facilitated referral to needed services by trained recovery coaches. The KyOSK will be tailored to the local context through a community-engaged process and a Kiosk Design Team involving people who use drugs and local and state leaders. Interest in reduction kiosks is soaring nationwide and the proposed project would provide critical and timely data to inform scale-up of this model, especially in rural areas of the country that have been severely impacted by substance use related harms.