Transportation, fears of stigma and confidentiality the biggest barriers to accessing rural syringe exchanges

Clark, Owsley and Knox counties; click the image to enlarge it.

Rural residents who inject drugs recreationally say they are less likely to access needle exchange programs because of transportation problems, inability to get to the service while it's open, and concerns about stigma, lack of confidentiality, and law enforcement. That's according to a newly published study examining barriers that can prevent people who inject drugs (PWIDs) from accessing syringe service programs (SSPs) in Appalachian Kentucky.

The researchers surveyed 186 PWIDs who used their local health department SSPs in three rural counties in 2018: Clark, Knox and Owsley (though Clark has some metropolitan areas, much of it is rural). Kentucky leads the nation in the number of SSPs, partly because it has so many counties. As of July 2019, Kentucky has 52 SSPs in its 120 counties. Such programs aim to reduce the spread of HIV and hepatitis C by giving PWIDs clean needles and disposing of dirty ones, and often offer more information about addiction treatment services when the person is ready.

Among the study's participants, 53.2% percent were male, 92.5% were non-Hispanic white, and 78.5% receive Medicaid coverage. About 39% of participants said they injected more than one drug, methamphetamines were the single most popular drug, with 45.2% reporting it as the primary drug they inject. The next most popular primary injected drug was nonprescribed buprenorphine (25.8%), followed by heroin (16.1%), nonprescribed opioids (11.3%), and various other drugs (1.6%).

The biggest barrier to SSP use was the lack of transportation, with 18.3% reporting it as their primary barrier. Overall, other barriers were: inability to access the program during operating hours (12.9%); concerns about stigma, privacy, and/or law enforcement (9.1%), not enough syringes (5.4%); and the location of the program (4.8%). However, participants' concerns varied based on their county's rurality. In Clark and Knox counties, the least rural, transportation was the most frequently cited barrier. But in Owsley, the most rural county, fear of stigma and lack of confidentiality was the biggest barrier.

Rurality also factored into participants' consistency in accessing the SSPs. Participants in Knox and Owsley counties were more likely to consistently use the program than participants in Clark County, the least rural county. The researchers believe the more consistent uptake in rural areas is because people in rural areas tend to have higher residential stability. However, Clark County participants may be less likely to consistently use SSPs because they're more likely to have an alternate means of accessing clean needles.

The study is part of a larger National Institutes of Health-funded effort to learn about SSP uptake in rural areas. This study's authors recently published another study about PWIDs in the same three counties, focused on what kind of interventions are most effective and which drug users are most likely to seek treatment.