Preferences for harm reduction vending machine design among rural people who use drugs

Globally, harm reduction vending machines (HRVMs) have been used for decades to dispense safe injection equipment and other supplies to people who use drugs (PWUD). However, HRVMs have only recently scaled up in the U.S. and few operate in rural settings. This study describes preferences for HRVM design among rural PWUD in two Appalachian Kentucky communities. Peer-referral and outreach were used to recruit participants (n=731). Eligibility criteria were ≥18 years, residing in the target counties, and having used any drug (excluding alcohol, cannabis, and tobacco) to get high within 6 months. Interviewer-administered questionnaires elicited data on behavioral/demographic characteristics and HRVM design preferences. Sample characteristics and site-level differences were estimated accounting for peer-referral chain clustering. Naloxone was the most desired supply (95.6%), followed by syringes (94.5%) and fentanyl test strips (83.7%). Supplies for basic needs were popular, including water (82.6%), food (72.8%), and personal care kits (71.3%). The most endorsed location was the health department (71.1%). More than twice the number of participants wanted HRVMs installed outdoors (52.3%) rather than indoors (19.6%), but for 25.4%, indoor/outdoor installation preference varies depending on the venue. While over three-quarters reported that a surveillance camera would not affect their HRVM use, a substantial minority indicated it would be a deterrent, highlighting a key consideration for implementation. There were significant differences in supply and location preferences across the two communities. HRVMs may expand harm reduction service access in rural settings, but PWUD input is needed to ensure that their design responds to community needs. Clinical trials registration NCT05657106