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.

Narrative The proposed study will 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. The proposed project will take place in two counties in Appalachian Kentucky, an epicenter for the intertwined national crises of injection drug use, overdoses, and hepatitis C.