(117) Implementing Harm Reduction in a Binational Context: Key Informant Perspectives

Background & Introduction: Syringe service programs (SSPs) are community-based harm reduction organizations that provide evidence-based interventions to reduce overdose mortality and infectious disease transmission among people who use drugs (PWUD).1 Despite demonstrated effectiveness, many SSPs are constrained in their capacity to implement evidence-based services, particularly in politically and socially complex settings. The San Diego–Tijuana border region (SDTBR) represents a unique implementation environment, characterized by divergent drug policies, funding structures, and social norms.2 Little research has examined how these multilevel contextual forces are experienced by the workforce responsible for delivering harm reduction services in this setting and its impacts on program implementation.3 Guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, this study addresses this gap by examining the harm reduction implementation ecosystem in the SDTBR through the perspectives of local service providers and policy makers.4

Methods: From March to June 2025, we conducted semi-structured qualitative interviews with 19 professional key informants from San Diego County (n=10) and northern Mexico (n=9) whose work relates to the implementation of harm reduction services in the SDTBR. Participants included harm reduction service providers (n=11), including executive directors and frontline staff (inner-context), and informants from outside the organizations (n=8), such as academics, public health officials, and public health figures within the government (outer-context). Interview guides explored EPIS constructs such as inner-context organizational dynamics (e.g., staffing capacity, burnout, internal procedures) and outer context factors (e.g., policies, stigma, funding) relevant to the implementation of harm reduction services. Interviews lasted approximately one hour and were audio recorded, professionally transcribed, and analyzed using a hybrid deductive–inductive coding approach. After data collection, two of our team independently generated themes and finalized them through consensus discussions.

Results: From the informative discussions with our informants, we identified four cross-cutting themes spanning EPIS domains. (1) Harm reduction service availability in the SDTBR was largely shaped by outer-context policymaking. In San Diego, a 2020 political shift overturned a longstanding SSP ban and enabled service implementation, though ongoing municipal opposition continues to limit geographic reach. Whilst in Mexico, a 2018 shift eliminated competitive grants resulting in complete funding cuts for community-based services, including SSPs, forcing reliance on international donations. (2) Policing practices emerged as persistent barriers in both settings. In San Diego, police confiscated legally protected supplies and arrested clients near harm reduction sites, while in Mexico, policing more directly limited-service delivery through client extortion and harassment of harm reduction staff. (3) Funding instability constrained service delivery and was inadequately offset by mutual aid collaboration between organizations within the region. San Diego organizations accessed state supply allocations and opioid settlement funds but faced federal purchasing restrictions and state budget limitations leading to a need for frugal allocation of resources, private fundraising, and alternative funding—particularly for staff salaries. In contrast, organizations in Mexico operated without government funding and relied solely on donated supplies from organizations’ professional networks, requiring strict supply distribution limits (e.g., five to ten syringes per person). (4) Finally, inner-context leadership and organizational structure influenced program adaptation to resource scarcity. SSPs embedded within larger health services organizations or public health departments navigated hierarchical approval processes, while independent, non-governmental SSPs lacked such hierarchical structures and could more rapidly adapt services (e.g., adoption of safer smoking supplies in response to client transitions from injecting to smoking opioids).

Conclusion & Discussion: Harm reduction implementation in the SDTBR is shaped by a complex interplay of politicization and criminalization of harm reduction, fragmented funding streams, and organizational structures. In Mexico, cross-border supply networks are essential for sustaining service delivery, and periodic material scarcity. By contrast, San Diego’s more formalized and bureaucratic infrastructure offered greater stability with supply procurement but lengthy approval and procurement processes limited program responsiveness to changing community needs. Addressing these structural constraints will require diversified and more stable funding mechanisms in Mexico alongside efforts to streamline procurement and administrative procedures in San Diego. Strengthening binational coordination with institutionalized training of officers and collaboration between organizations could further strengthen supply chains and collective policy advocacy between organizations and government. Findings support the need for these sorts of Coordinated efforts between areas and organizations, more supportive and structured funding mechanisms, and institutional changes that enable organizations to deliver evidence-based services across jurisdictions, ultimately reducing disparities in health outcomes for PWUD.

References: References
1. Ijioma, S. C., Pontinha, V. M., Holdford, D. A., & Carroll, N. V. (2021). Cost-effectiveness of syringe service programs, medications for opioid use disorder, and combination programs in hepatitis C harm reduction among opioid injection drug users: A public payer perspective using a decision tree. Journal of Managed Care & Specialty Pharmacy, 27(2), 137–146. https://doi.org/10.18553/jmcp.2021.27.2.137
2. Bailey K, Abramovitz D, Patterson TL, et al. Correlates of recent overdose among people who inject drugs in the San Diego/Tijuana border region. Drug and Alcohol Dependence. 2022/11/01/ 2022;240:109644. doi:https://doi.org/10.1016/j.drugalcdep.2022.109644

3. Bazzi AR, Valasek CJ, Stamos-Buesig T, et al. Health, harm reduction, and social service providers’ perspectives on the appropriateness and feasibility of peer distribution of HIV self-test kits among people who use drugs. Harm Reduction Journal. 2024/02/04 2024;21(1):29. doi:10.1186/s12954-024-00950-x
4. Aarons GA, Hurlburt M, Horwitz SM. Advancing a Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors. Administration and Policy in Mental Health and Mental Health Services Research. 2011/01/01 2011;38(1):4-23. doi:10.1007/s10488-010-0327-7
5. Robertson, A. M., Garfein, R. S., Wagner, K. D., Mehta, S. R., Magis-Rodriguez, C., Cuevas-Mota, J., Moreno-Zuniga, P. G., & Strathdee, S. A. (2014a). Evaluating the impact of Mexico’s drug policy reforms on people who inject drugs in Tijuana, B.C., Mexico, and San Diego, CA, United States: A binational mixed methods research agenda. Harm Reduction Journal, 11(1). https://doi.org/10.1186/1477-7517-11-4