The coronavirus disease (COVID-19) pandemic that started in 2019 had consequences on the daily life of everyone including PWUD through lockdowns, social distancing, impact on economy and by generating stress . These populations had to face both consequences of their addiction and consequences of COVID-19, making them a particularly vulnerable population. For instance, in England fewer HR materials were distributed with potential increase of material reuse and sharing . In other countries, closing HR structures induced higher overdoses during the pandemic . Nevertheless, COVID-19’s impact on HR services depended on the regulating rules implemented by the states or countries. For instance, in Sweden where the COVID-19-related policies were less restrictive compared to other countries like France, Spain, Germany, Belgium, USA, etc., the impact on HR services were relatively limited , whereas in other countries like Iran, Portugal or Spain the restrictions impacted much more drastically the HR structures [5,6,7,8].
Due to the COVID-19 related restrictions, several HR services had to adapt their activities to be able to keep delivering paraphernalia with social distancing, telehealth or restricted access opening hours [9,10,11]. Some HR structures developed creative solutions. For instance, in Los Angeles, an HR program implemented supply distribution through telephone booths to support homeless PWUD . Within the new alternatives proposed to adapt HR services to the COVID-19, telehealth services have been one of the most developed . In several countries, telehealth limited the impact of COVID-19-related restrictions on PWUD but only partially solves their difficulties. In particular, those who need paraphernalia distribution are still affected by the pandemic restrictions with less material available. In this context remote HR seems to be a promising avenue  combining the benefits of telehealth but with the logistic structure and funding to send the paraphernalia by mail. These remote HR structures were initially developed to access populations difficult to reach. Despite the many HR programs that exist in the world, there are still a significant number of drug users who do not have access to this type of service . The difficulties of access are varied and sometimes multiple. For example, they may live in rural areas and/or have difficulties in traveling to the nearest HR structure, or have working hours that are incompatible with the opening hours of the structures. Sometimes, HR structures or Syringe Service Programs (SSPs) do not offer the amount and/or variety of tools needed by users. Consumers may also be afraid of being judged and/or the lack of confidentiality (e.g., in pharmacies or small towns). Finally, the cost of equipment in pharmacies and lack of knowledge about the HR system can also be a barrier to accessing equipment.
It is important to note that COVID-19 pandemic consequences on HR services (e.g., structures closed, difficulties to attend in person) were observed before (example of the Hurricane Sandy in NY in 2012) and might be occurring again in the future [15, 16]. Indeed, big events, in particular related to global changes, are expected in the coming decades . Thus, the COVID-19 crisis can also be analyzed using the concept of big events defined as any social crises due to diseases, climate events, terrorist attacks, and other phenomena that negatively affect general and individual behaviors, with possible consequences on PWUD health through an impact on HR structures [17, 18].
In this context, we assumed that remote HR service can be a key resource to mitigate the big events impact on PWUD whatever the local context and we compared how two remote HR services in France and in the USA (HaRePo and NEXT Distro [19, 20]) were impacted by the COVID-19 pandemia.
The remote harm reduction program, called HaRePo, was initiated in Paris (France), by the association SAFE in 2011, and is the first of its kind in the world . It is free and intended for PWUD who have difficulty accessing HR tools and advice provided in specialized structures in France such as CAARUD (Centre d'Accueil et Accompagnement à la Réduction de Risques pour les Usagers de Drogues) and CSAPA (Centre de Soins, d'Accompagnement et de Prévention en Addictologie). The remote HR program does not require a physical meeting with the users. It is accessible by telephone and/or e-mail. An HR professional welcomes the users, provides advice and support and refers them to health care services and any other services adapted to their needs. Following the exchanges between the users and the professional, HR paraphernalia is registered and prepared under strict hygienic conditions. A package is personalized according to the person's needs and sent by the French Post Office to users in metropolitan France and overseas (Fig. 1). From 2011 to 2020, 2968 users have benefited from the program and 17,477 parcels have been sent, representing more than 2.6 million syringes and 10.2 million HR tools. The program has beneficial effects on users' practices and their perception of their health status. In an evaluation recently published, program users reported reduced risky practices when using drugs. Notably, the percentage of people who, after joining the program, never reuse and/or share HR tools increased significantly. In addition, some of them reported that their general physical condition (venous condition, injection sites, swelling of arms, legs and hands) had improved . Remote HR is complementary to specialized structures and other HR programs and is part of a general HR policy for all users.
Founded in New York City, NEXT Distro “NEXT” became the first legal online and remote syringe service program in the USA. NEXT operates in locations where there is no pre-existing HR service provider by delivering supplies in discreet packaging through the United States Postal Service. The application for NEXT’s remote service is publically accessible on its website and staff geolocate each incoming applicant’s zip code with a directory of HR providers to ensure there is no geographic duplication. Once accepted into the program, NEXT uses encrypted phone, text, and email channels to securely communicate with program participants. Supplies can be ordered once per month through a web-based ordering system using a URL that is only disclosed to approved participants. NEXT also provides a complimentary naloxone-mailing program for individuals who are friends and family of PWUD and unable to access naloxone through traditional in-person methods. To advance remote HR services in the USA, NEXT has program partners in 30 states who use their centralized website to access remote HR services. To advance drug user health information using the internet, NEXT has consolidated safer injection, disease transmission prevention, sexual health, and treatment resources which are open access on their organization’s website resource page.
The aim of the study is therefore to test if and possibly how much the activity of two independent remote HR services located in France and in the USA (HaRePo and NEXT Distro [19, 20]) were impacted by the COVID-19 crisis and how they modified their performance to limit the effects of COVID-19 restriction measures on PWUD.