Fayette County Health Department Harm Reduction Program Mobile Outreach

The Fayette County Health Department serves a rural WV population of just over 42,000.  Fayette County has been particularly stricken by substance use disorder, leading to downstream increases in overdose and increases in infectious diseases, ranking 1st for rates of death due to drug overdose (81.4 per 100,000) in the United States. Fayette County had 208 reported EMS responses to overdose in 2022, primarily in remote outlying communities. WV has seen an alarming increase in HIV cases related to persons who inject drugs, with our adjacent county (Kanawha) being named most at risk by the CDC, increasing by over 300% in 2021.   In 2017, the CDC ranked Fayette County #27th at risk for having an HIV outbreak. Fayette County is currently seeing a syphilis cluster, tripling in cases in 2022. 

The Fayette County Health Department opened the doors to its Harm Reduction Program with syringe services in October of 2017 in response the overdoses and infectious disease threats in Fayetteville, WV.  Uptake at the fixed site for participants was noted to decrease during the COVID-19 pandemic.  With increased transportation barriers, increased financial strains due to inflation and COVID-19, increasing overdoses in remote locations in Fayette County, and the noted increases in infectious diseases surrounding Fayette County (Hepatitis, HIV, and syphilis), the decision was made to pursue mobile outreach for Harm Reduction Services.  This would replicate the current fixed site, offering overdose education and naloxone distribution, sterile supplies including syringes, offering PrEP for HIV, testing and treatment for STIs, safe injection practices, fentanyl test strip delivery, rapid HIV and hepatitis testing and connection to care, vaccinations, wound care, primary care, family planning services, referral for treatment, and connection to needed local services to address social determinants of health.  After advisement by persons who use drugs and our advisory council, as well as discussions and support from local jurisdictions (as required by WV Legislation), we launched our Mobile services in 2022.  Our goal was to increase touchpoints in our community and enhance remote service offering at our two new locations, specifically distribution of naloxone, fentanyl test strips, and testing for HIV.  94 visits were added in the first 3 months of mobile programming.  

Having a peer led program with diverse lived experience along with strong community partnerships has been integral to the success of the program, enhancing uptake in these remote communities and facilitating dispersement of services.  By "meeting people where they are", and eliminating barriers, we have been able to increase both measures of naloxone distribution, fentanyl test strip use, and HIV testing.  This has also enhanced other services in the specific communities, such as treatment for Hepatitis C, enhanced behavioral health services, and improved access to food and financial supports through building of those local programs.  We have connected with new participants that we had not reached with our fixed site, allowing them services they desired, but were unable to obtain.  An example of this was observed at a mobile site, when participants organized a barbeque for the community while we were providing services to show their gratitude.  They were moved to tears that we came to their "holler".  

Another marker of success comes from the requests of other communities to bring harm reduction services there.  When local law enforcement and local governments reach out for these supports, it emphasizes the impact that mobile outreach provides, and highlights the needs of this vulnerable, marginalized population.  We are balancing our growth as we are seeing more participant touch points as well as providing more supplies, which requires more financial support and infrastructure to maintain.  Having local services in these remote communities further empowers them to be part of the solution and continue to create opportunities for change.  

By adequately addressing the social determinants of health and removing barriers for care, we are able to enhance the health and wellbeing of outlying communities in our marginalized populations.  By providing these services, participants are taking steps to reduce chaotic drug use as well as utilizing naloxone and fentanyl test strips to reduce overdose in these communities.  Persons who use drugs as well as the communities that they live are rallying around creating a healthier life.  

The Fayette County Health Department Harm Reduction Program is committed to continue to grow this life-saving, critical public health service, despite challenges it may face.  Our participants remind us of this with each encounter.  

www.fayettehealth.org

The population served by the Fayette County Harm Reduction Program Mobile Outreach are persons who are using drugs.  This includes demographics of race, ethnicity, gender, sexual orientaion, preferred language, housing status, insurance coverage, employment status.  It also collects social determinants of health including transportation needs, interpersonal safety, housing, food insecurity, financial strain, and mental health needs. According to the Kaiser Family Foundtion, 2.7% of adults and 3.3% of adolescents report illicit drug use, leading us to estimate just over an estimated 1,000 adults in our community that are using illicit substances.  Poverty, geographic isolation, and the Opiate epidemic have been the structural drivers of substance use disorder in our rural communities.  Our CDC Social Vulnerability Index is 0.6181 with 20% of our population living in poverty.   In the past, criminilization was the main method to address substance use disorders in rural communities, which has been proven to be ineffective in addressing the root causes and led to continued morbidity and mortality related to substance use disorder. 

By targeting areas that were highest risk for overdose, it identified citizens that would suffer from health inequities.  Using a peer based approach has also helped to create an environment of respect and safety, reducing further the barriers of seeking services for this marginalized population.  Also, utilizing mobile services in full capacity allows for "one-stop" resource allocation that circumvents transportation and financial barriers.  Mobile services have been provided for harm reduction in other jurisdictions, but this was the first launch of this practice in Fayette County, amidst a tenuous political climate in respect to syringe service provision.  

We strive to provide evidence-based practices to the best of our abilities under the limits of our current WV legislation.  We follow CDC, NACCHO, and public health publications to guide our practices.  

The goals and objectives of the Fayette County Health Department Harm Reduction Program Mobile Outreach were to create more touchpoints for participants, reduce overdose, and reduce acquisition for infectious disease.  By expanding services directly to these higher risk communities, we were able to more efficiently offer naloxone, overdose education, fentanyl test strips, sterile equipment, safe injection practice information, PrEP, immunizations, testing for infectious diseases to help meet these goals. 

To ensure compliance with WV state code and licensure requirements by the Office of Health Facility and Licensure Certification, we were required to obtain guidance from our Advisory Council, as well as secure letters of support from both the Fayette County Commission as well as letters from the local municipalities.  This also took planning and cooperation from local and county law enforcement.   We also leaned on collaboration from our Fayette County Quick Response Team to provide insight and data related to high risk areas in regards to overdose.  Moving services to outlying communities also led to more discovery of local resource needs/services, and discussions with municipalities about local resources.  We have partnered with the hospital (Montgomery General Hospital) which serves these two areas to grow treatment and recovery options, as well as to add further naloxone distributions sites, enhanced testing opportunities, and further treatment options for hepatitis C.  From the support of our Advisory Council and strong community stakeholders, we are able to continue programming and provide feedback locally on needs of this populaiton, in which both have been quite responsive.  We also continually elicit feedback from participants; this is THEIR program.  It needs to serve their unique individual needs.  

This program has been in place for 4 months, adding 124 encounters to our prior programming in the first 3 months of programming.   Per conversations with our Fayette County Quick Response Team, we are seeing less overdoses in those jurisdictions, and have not had any reports of concerns from local citizens, or from our licensing board.  

By having an established fixed site, we were able to start small and utilize similar resources and funding.  We are quickly learning that this is not sustainable and that we will need to consider doubling our current budget to meet the demands of mobile outreach.  Staff salaries (both contract and part/full time) and equipment are the biggest aspect of the budget at this juncture.  Currently, our harm reduction budget is around $150,000.  

Although this is an early snapshot of our Mobile Outreach, we are already seeing both subjective and objective measures being met from our goals.  We have learned through discussions with our participants that they are taking the next steps to attain treatment for Hepatitis C and have taken steps towards recovery (although not a primary goal).  Each participant is provided education on safe injection practices and overdose prevention, as well as offered naloxone.  With each week, we are continuing to see new participants and furthering the knowledge and understanding of the above, as well as reducing overall chaotic drug use.  On our first mobile outreach, we tested 20 participants (of 21) for HIV with rapid testing technologies, and then provided education and offered prescriptions for prevention of HIV to those participants.  We utilize REDCap to capture data for our program as well as to help enhance outcome measurements and lean on participants and other stakeholders to guide modifications for programming.  

Sustainability was discussed at a local, state and federal level in regards to syringe service programming.  We are actively pursuing funding opportunities to help continue this life-saving outreach, as well as considering other methods to sustain, such as developing a foundation, securing local donors, and identifying other community stakeholders to help support areas of the program.  Again, funding for syringe service programs are tenuous, and quite competitive, and restrictions on how that funding can be used (if federal) adds to the complexity.  Overall, we know that the upfront investment to pay for staff and sterile equipment (and overall harm reduction budget) will save the economic costs of lives lost to overdose as well as the cost of treating downstream complications of injection drug use, such as HIV, endocarditis, and hepatitis.  We are poised to continue to propose policy change at a local, state and federal level to help provide enhanced funding to this program.  An example would be to consider making this an accepted diagnosis under our state Medicaid plan, providing reimbursement for these services.  Again, this is our most challenging aspect of programming, along with navigating new policy related to syringe services in WV.  Despite this, we continue to have strong support from our stakeholders in healthcare, law enforcement, emergency response, local government, faith based communities, and persons who are using drugs.  This commitment continues to motivate our efforts and allow us to push forward despite challenges.