Author information
1School of Public Health, Georgia State University, 140 Decatur Street SE, Atlanta, GA 30303, USA; Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322, USA. Electronic address: aballard11@gsu.edu.
2Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322, USA.
3Department of Medicine, University of Washington, Seattle, WA, USA.
4School of Medicine, West Virginia University, Morgantown, WV, USA.
5Office of Research, University of Massachusetts Chan Medical School-Baystate, Springfield, MA, USA.
6Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
7School of Medicine, Southern Illinois University, Springfield, IL, USA.
8Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
9Department of Medicine, University of Chicago, Chicago, IL, USA.
10Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
11Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA.
12School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
13RTI International, Research Triangle Park, NC, USA.
14College of Public Health, University of Kentucky, 111 Washington Avenue, Lexington, KY 40536, USA.
Abstract
Background: Over the last two decades, houselessness and drug-related epidemics both have expanded from urban to rural regions across the United States (US). However, our understanding of the relationship between rural houselessness, drug use, and drug-related harms has not kept pace. The current study addresses this gap by describing houselessness among a large cohort of people who use drugs (PWUD) from rural communities across 10 states.
Design: PWUD were recruited using modified chain-referral sampling for a cross-sectional survey capturing houselessness in the prior six months, drug use, drug-related harms, stigma, health service access, and sociodemographic characteristics. Using bivariate logistic regressions, we assessed associations between houselessness and participant characteristics. We also compare site-specific houselessness prevalence to Housing and Urban Development Point-in-Time (PIT) estimates, which are based on counts of sheltered and unsheltered people experiencing houselessness on a single night.
Results: Among 3000 PWUD, 53.7 % reported experiencing houselessness. Houselessness was associated with multiple drug-related behaviors that increase the risk of overdose and acquisition of bloodborne infections. Houselessness prevalence was comparable and exceeded PIT estimates for several sites, even though study participants constituted <1 % of each site's adult population and were restricted to PWUD.
Conclusions: Our findings highlight that houselessness - historically considered an urban issue - is a significant public health concern for PWUD in rural areas. This demonstrates that addressing drug-related HIV, hepatitis C, and overdose epidemics, among others, in the rural US will require the provision of stable housing and harm reduction services as a pathway to treatment and recovery.