Injection Drug Use and Sexual Behaviors Associated With Infection Transmission and Access to Harm Reduction for People Who Use Drugs and Sell Sex in the Rural US

Background: Despite the recognition of substance use and sex work as public health issues, the intersection of these areas, especially within the rural US, is an area of special importance. Methods: The Rural Opioid Initiative comprises of eight research cohorts spanning 10 states and 65 rural US counties. Between 1/2018-3/2020, individuals who reported past 30-day substance injection or opioid misuse were recruited. Analyses were restricted to people who use drugs (PWUD) who reported trading "vaginal or anal sex for drugs, money, housing, or other things you need" in the past 30 days. We analyzed cross-sectional associations between injection drug use and sexual behaviors associated with hepatitis C virus (HCV)/HIV infection transmission, access to harm reduction, and HCV status among PWUD and engaged in sex work in rural US areas. Results: Of the 2045 participants, 9% (n=180) reported engagement with sex work, with just over half being women (58% [n=104]). In adjusted models, people who engaged in sex work, compared to PWUD who did not, had higher prevalence ratios of past 30-day receptive syringe sharing (adjusted prevalence ratio [aPR]=1.69, 95% Confidence Interval [95%CI]=1.44-1.98), practice of multiple injections per injection episode (aPR = 1.28, 95% CI = 1.15-1.43), practice of syringe mediated drug sharing (aPR=1.50, 95% CI=1.32-1.71), condomless sex (aPR=1.62, 95% CI=1.48-1.77) and condomless sex with someone who injects drugs (aPR=2.05, 95% CI=1.76-2.39). PWUD engaged in sex work were less likely to report easy condom access (aPR=0.88, 95% CI=0.80-0.96), while no significant differences were observed for most other harm reduction access measures. Conclusion: PWUD engaged in sex work in the rural US had higher likelihood of injection drug use and sexual behaviors associated with HCV/HIV infection transmission, while having lower use of and access to condoms. This study emphasizes the importance of ensuring affordable access to condoms within the context of harm reduction services, especially given the limited access to health care and supportive services, particularly in rural communities.