The proposed project will test an innovative, peer-driven approach to address unmet harm reduction needs in two rural Kentucky counties at the epicenter of the opioid/stimulant epidemic, with the aim of reducing risk for overdose (OD), hepatitis C (HCV), skin and soft tissue infections (SSTIs), and HIV. Research has shown that these counties and the encompassing rural Appalachian region have high rates of drug-related harms including ODs, HCV, opioid use disorder, methamphetamine use, and SSTIs, and are at high risk for an HIV outbreak among people who inject drugs (PWID). In 2020, Kentucky was one of just seven states named in the Ending the HIV Epidemic initiative based on the percentage of new HIV diagnoses occurring in rural areas. In an effort to reduce drug-related harms, Kentucky has opened brick-and-mortar syringe service programs (SSPs) in 65 of its 120 counties, including those involved in this proposal. Unfortunately, this infrastructure remains vastly under-utilized. Our ongoing research has shown that only 50% of PWID are using the SSP, primarily due to fear of being seen by someone they know, concerns around law enforcement or child protective services, and anticipated judgment by staff, barriers similar to those reported elsewhere in the region. State data have revealed challenges with client retention, particularly in rural communities, and substantial recent declines in the number of SSP clients and visits. Together, these data highlight an urgent need to address barriers to SSP service utilization in rural Appalachia and expand service reach to the growing number of rural PWID with unmet harm reduction needs. To best overcome barriers related to privacy and fear of stigma and judgment, models must meet PWID where they are by engaging those whom they trust. For decades, scientists have called for the expansion of “intravention” wherein members of communities at risk are engaged in implementing the interventions intended to improve their community’s health. Engaging PWID who are trusted members of the community honors harm reduction principles and is critical to intravention success, as they are viewed as more credible, are likely to engage those most marginalized, and can intervene when and where risks are highest. Research has established that intraventions are effective, yet they have been far under- utilized in rural communities. In response, we will partner with local PWID and agency partners to co-develop and tailor a peer-driven, evidence-based intravention that engages PWID as interventionists’ to reach individuals with unmet harm reduction needs in rural Appalachia. The adapted intravention, hereafter referred to as ASSIST, will address interventionists’ knowledge gaps related to OD, HCV, SSTIs, and HIV risk reduction and equip them with harm reduction supplies for use and distribution. We will evaluate ASSIST’s impact on substance use related harms and implementation outcomes using a Type 1 hybrid effectiveness study, cost- effectiveness analysis, and mathematical modeling. The study will advance harm reduction science and provide much needed data to inform scale up to rural communities in Appalachia and beyond.

Narrative The proposed study will test the effectiveness, implementation outcomes, and cost effectiveness of a community-tailored, peer-driven “intravention” to reduce risk for overdose, hepatitis C, skin and soft tissue infections, and HIV in Appalachian Kentucky counties with extensive unmet harm reduction needs.