(126) Care Barriers & Health Complaints: People Who Inject Drugs in San Antonio

Background & Introduction: People who inject drugs (PWID), many of whom also experience homelessness, face multiple barriers to healthcare. Past research has found judgment from providers, internalized shame, and financial constraints as some of these barriers. This avoidance increases morbidity and mortality, potentially turning minor injection-site issues to life- or limb-threatening complications like sepsis or amputation. In San Antonio (Bexar County), this population encounters unique challenges amplified by local inequities: high poverty, uninsured rates, and limited access in ZIP codes like 78207 on the Northwest Side, which lead Bexar County in poverty, uninsured individuals, disability, and violent crime while having low higher education attainment. These social determinants exacerbate injection-related health issues, including acute and chronic wounds (often infected), abscesses, and comorbidities (e.g., hepatitis C, HIV, diabetes, vascular disease) that impair healing. Prior studies highlight care avoidance among unhoused PWID due to stigma, costs, and logistical barriers. This student-led initiative at Bexar Area Harm Reduction Coalition (BAHRC) addresses these gaps through on-site wound care to characterize wound presentations, infections, and barriers to care among PWID in San Antonio.

Aims/

Objectives:

Characterize wound types, chronicity, causes, and anatomical locations in PWID engaging with BAHRC.

Identify key barriers to healthcare access reported by this population.

Methods: This was a prospective, observational, community-based quality improvement and service project embedded in weekly BAHRC harm reduction sessions (Saturdays 10:00am-12:00pm, expanding to Fridays). PWID and unhoused individuals seeking supplies were offered voluntary wound care in a dedicated tent to avoid coercion and stigma. Medical students triaged participants, obtained history and physical (H&P), assessed wounds for chronicity ( < 1 month acute; >3 months chronic), stated cause, anatomical site, and signs of infection (e.g., erythema, purulence). On-site attending physicians (internal medicine, family medicine, and emergency medicine) supervised care, prescribed antibiotics when indicated, and triaged for higher-level needs. Willing participants completed a Likert-scale survey (1-5) assessing barriers to care (e.g., transportation, cost, insurance, ID requirements, stigma, apathy). Encounters were documented de-identified for analysis via descriptive statistics. All activities occurred under approved IRB determination with physician oversight.

Results: From outreach sessions, 68% of wound presentations were acute ( < 1 month duration), while 24% were chronic (>3 months). Infection rates were high: 72% of acute wounds and 55% of chronic wounds showed signs of infection. The most common stated cause was injection drug use (49%), followed by trauma (24%), unknown (11%), environmental (10%), and indirect sequelae of IVDU (5%). Anatomically, wounds affected upper extremities (44%), lower extremities (46%), trunk (9%), and head (1%), largely reflecting typical injection sites. Comorbid conditions (e.g., hepatitis C, HIV, vascular disease, diabetes) contributing to delayed healing were also addressed alongside wounds.

Barriers to care were assessed via Likert-scale surveys (1=low to 5=high barrier). Transportation emerged as the strongest perceived barrier (mean 3.85), followed by lack of ID (3.77), lack of health insurance (3.73) and cost (3.70). These logistical issues align with local inequities in Bexar County (e.g., 78207 area: high poverty/uninsured rates). Interestingly, participants rated fear of judgement the least as a barrier to care (2.64). Client volume increased 53% from Spring (average 2.72 people/session) to Fall (4.15 people/session), suggesting growing trust and demand for accessible care. Overall, findings demonstrate high burden of preventable, infection-prone injection-related wounds and dominant non-clinical barriers impeding timely intervention.

Conclusion & Discussion: This project reveals that PWID with medical complaints in San Antonio experience a high prevalence of acute, infected injection-related wounds, often progressing due to logistical barriers like transportation (strongest reported issue), cost, lack of insurance/ID, and stigma—exacerbated by local inequities in high-need areas (e.g., zip code 78207). Acute presentations and infections underscore the need for early, low-barrier street medicine to prevent severe outcomes (e.g., sepsis, ED visits, amputations) and rebuild trust in the healthcare system.

Implications include expanding harm reduction-integrated wound care, addressing transportation (e.g., referrals, partnerships, bus passes and/or arranged transportation), and scaling student-led models with physician supervision to meet PWID where they are. This supports street medicine as patient-centered care reducing disparities and addressing residents of Bexar County who are least likely to seek care for their wounds. Limitations include convenience sampling at BAHRC (may not represent all PWID), self-reported barriers (potential bias), descriptive (non-statistical) analysis without formal controls, and reliance on voluntary participation. Future work could incorporate longitudinal follow-up and broader sampling.

References: Klop HT, Evenblij K, Gootjes JRG, de Veer AJE, Onwuteaka-Philipsen BD. Care avoidance among homeless people and access to care: an interview study among spiritual caregivers, street pastors, homeless outreach workers and formerly homeless people. BMC Public Health. 2018;18(1):1095. doi:10.1186/s12889-018-5989-1

Goto T, Wang C, Kwiat C, Nguyen C, Saligan LN. Community-Based Wound Care Programs for Unhoused Individuals. J Epidemiol Glob Health. 2023;13(4):604-614. doi:10.1007/s44197-023-00157-6

The Health Collaborative. 2022 Bexar County community needs health assessment report. https://www.healthcollaborativechna.com/2022chnabexar

Thorndike AL, Yetman HE, Thorndike AN, Jeffrys M, Rowe M. Unmet health needs and barriers to health care among people experiencing homelessness in San Francisco's Mission District: a qualitative study. BMC Public Health. 2022;22(1):1071. doi:10.1186/s12889-022-13499-w

Miller JP, O'Reilly GM, Mackelprang JL, Mitra B. Trauma in adults experiencing homelessness. Injury. 2020;51(4):897-905. doi:10.1016/j.injury.2020.02.086