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

摘要 拟议的项目将测试一种创新方法，以减少与注射流行病有关的危害 吸毒，过量，丙型肝炎（HCV），以及即将爆发的艾滋病毒，在农村阿巴拉契亚肯塔基州， 长期以来一直是这些相互交织的危机的中心。我们的研究表明， HCV，过量，注射毒品使用，无避孕套的性行为，以及可能引发艾滋病毒的密集风险网络 爆发继2014年邻近的印第安纳州艾滋病毒爆发和全国艾滋病毒/丙型肝炎病毒爆发分析之后， 注射毒品者的脆弱性（PWID）显示，肯塔基州的120个县中有54个县排在 全国前5%，肯塔基州通过了具有里程碑意义的立法，允许县经营注射器服务 方案（SSP）。尽管县一级的审批程序很艰难，肯塔基州还是成功地开设了80家 SSPs，比美国其他任何州都多。不幸的是，这一强大的减少危害基础设施仍然不足- 在农村使用。我们由NIDA的国家农村阿片类药物倡议资助的研究数据显示， 近一半的PWID从未使用过现有的配备人员的SSP，在24个月的随访中，SSP的使用率 仍然很低，方案辍学并不罕见。从未被引用的最常见原因 是害怕耻辱有证据表明，该地区的PWID希望减少一系列危害 服务模式，在那些报告耻辱是不使用配备人员的SSP的原因的人中， 理想的模型是自动售货机，或“kiosk”。减少伤害亭已经在全球范围内运营了更长时间， 30多年来，研究表明它们可以扩大注射器的使用范围。然而，很少有亭 在美国运营，没有一个在农村地区运作，在那里他们可能特别有益。研究 建议，亭可能是一个具有成本效益的方式，以扩大注射器的访问时，加上工作人员的SSP 但是，其执行、影响和成本效益尚未得到严格评估。作为回应，我们 建议进行1型混合有效性试验，以测试有效性、实施结果和成本 社区定制的减少伤害亭在减少艾滋病毒、丙型肝炎和药物过量风险方面的有效性 阿巴拉契亚乡村的行为。我们的信息亭，或KyOSK（KY外展服务亭），将提供 注射设备、纳洛酮、芬太尼试纸、卫生用品包、避孕套和其他用品以及 创新的回拨功能，便于由训练有素的康复教练转介到所需的服务。关于Kyosk 将通过社区参与的过程和一个信息亭设计团队， 吸毒者以及地方和州领导人。在全国范围内，人们对减价亭的兴趣正在飙升， 拟议的项目将提供关键和及时的数据，为扩大这一模式提供信息，特别是在农村地区 受物质使用相关危害严重影响的国家地区。

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.