Document Type


Publication Date



School of Medicine


Emergency Medicine



The Central Appalachian region of the United States is in the midst of a hepatitis C virus epi- demic driven by injection of opioids, particularly heroin, with contaminated syringes. In response to this epidemic, several needle exchange programs (NEP) have opened to pro- vide clean needles and other supplies and services to people who inject drugs (PWID). How- ever, no studies have investigated the barriers and facilitators to implementing, operating, and expanding NEPs in less populous areas of the United States.


This qualitative case study consisted of interviews with program directors, police chiefs, law enforcement members, and PWID affiliated with two NEPs in the rural state of West Virginia. Interview transcripts were coded inductively and analyzed using qualitative data analysis software. Final common themes related to barriers and facilitators of past program open- ings, current program operations, and future program plans, were derived through a consen- sus of two data coders.


Both NEPs struggled to find existing model programs, but benefited from broad community support that facilitated implementation. The largest operational barrier was the legal conun- drum created by paraphernalia laws that criminalize syringe possession. However, both PWID and law enforcement appreciated the comprehensive services provided by these pro- grams. Program location and transportation difficulties were additional noted barriers. Future program operations are threatened by funding shortages and bans, but necessitated by unexpected program demand.


Despite broad community support, program operations are threatened by growing partici- pant volumes, funding shortages, and the federal government’s prohibition on the use of funds to purchase needles. Paraphernalia laws create a legal conundrum in the form of criminal sanctions for the possession of needles, which may inadvertently promote needle sharing and disease transmission. Future studies should examine additional barriers to using clean needles provided by rural NEPs that may blunt the effectiveness of NEPs in pre- venting disease transmission.

Source Citation

Citation: Davis SM, Davidov D, Kristjansson AL, Zullig K, Baus A, Fisher M (2018) Qualitative case study of needle exchange programs in the Central Appalachian region of the United States. PLoS ONE 13(10): e0205466. pone.0205466


Copyright: © 2018 Davis et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.



To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.