Evaluating the Implementation and Impact of Harm Reduction Vending Machines in Veterans Supportive Housing Settings: A Mixed-Methods Study Protocol

Evaluating the Implementation and Impact of Harm Reduction Vending Machines in Veterans Supportive Housing Settings: A Mixed-Methods Study Protocol | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Method Article Evaluating the Implementation and Impact of Harm Reduction Vending Machines in Veterans Supportive Housing Settings: A Mixed-Methods Study Protocol Tessa Rife-Pennington, Michael Douglas, Nikki Apana, Sree Sinha, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7209082/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Jan, 2026 Read the published version in Harm Reduction Journal → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Lack of access to sterile supplies among people who use drugs contributes to increased rates of infectious disease transmission, including human immunodeficiency virus, hepatitis C virus, and sexually transmitted infections. People residing in California, United States Veterans, and those experiencing homelessness are disproportionately impacted. Syringe services programs (SSPs) are vital to reducing these harms, but access may be limited by hours of operation, geographic barriers, need for in-person interaction, and stigma. Harm reduction vending machines (HRVMs) which often dispense sterile syringes and condoms are an evidence-based strategy to increase access; however, no studies have evaluated implementation or impacts among these populations. This mixed-methods study aims to evaluate the first HRVM program designed for Veterans who experienced homelessness and reside in California supportive housing buildings. Methods: We will recruit 40 Veteran residents and 20 staff (Veterans Affairs [VA] and housing staff) at six housing buildings with a collocated HRVM. Participants will provide informed consent, complete a standardized electronic questionnaire, semi-structured qualitative interview, and be compensated via Visa gift cards ( $ 90 for Veterans; $ 60 for staff). Interview transcripts will be analyzed thematically using inductive coding. Program-level data will be collected from enrollment logs, facility records, and vending machine software to evaluate reach, effectiveness, adoption, implementation, and maintenance (RE-AIM). Discussion: Findings will provide essential evidence on how HRVMs may reduce longstanding access barriers and expand delivery of life-saving harm reduction supplies to underserved Veterans. This study is the first to evaluate HRVMs in Veterans supportive housing and among a population disproportionately affected by substance use, stigma, and homelessness. Results may inform the expansion of community-based and VA SSPs nationwide. Study strengths include a theory-informed design, real-world implementation data, and attention to user and staff experiences. Limitations include reliance on self-report data, lack of a control group, and limited generalizability beyond Veterans. Future research may examine long-term health outcomes, cost-effectiveness, and feasibility of HRVMs scaled up in diverse settings. Findings from this study may guide policymakers and public health practitioners in integrating HRVMs into broader harm reduction strategies to prevent overdose, infections, and other adverse outcomes. harm reduction naloxone overdose prevention implementation science HIV prevention Veterans BACKGROUND In the United States (US), the overall number of people experiencing homelessness and who were unsheltered decreased 10% from 2007 to 2022; however, rates in California are increasing and higher than all other states.[ 1 ] From 2007 to 2022, the number of individuals experiencing homelessness increased over 23%, and chronic homelessness increased by over 43%.[ 1 ] In 2022, half of all unsheltered people in the country were in California.[ 1 ] Veterans, or individuals who served on active duty in the US Armed Forces, Reserves, or National Guard, experience higher rates of homelessness compared to non-Veterans.[ 1 ] On a single night in 2022, California accounted for 32% of all Veterans experiencing homelessness and more than half of all unsheltered Veterans.[ 1 ] Among largely populated cities, San Francisco, California, had the fourth highest rates of unsheltered homelessness in 2022.[ 1 ] According to the annual point in time survey conducted February 23, 2022, an estimated 605 Veterans were homeless in San Francisco, and the most common causes were job loss, eviction, alcohol or drug use, incarceration/probation and parole restrictions, and mental health issues.[ 2 ] Evidence suggests that Veterans with substance use and mental health conditions experience the highest risk for homelessness, and Veterans report higher rates of substance use and mental health conditions as a primary cause of homelessness when compared to non-Veterans.[ 3 , 4 ] Drug-related morbidity and mortality in California, both among Veterans and people experiencing homelessness, is of increasing concern. There were nearly 58,000 emergency department visits and 11,000 deaths related to drug overdose in California in 2021.[ 5 ] Among Veterans, drug overdose deaths increased 53% from 2010 to 2019, and 13% had a diagnosed substance use disorder (SUD).[ 6 , 7 ] Among people experiencing homelessness in San Francisco, the most common cause of death prior to the coronavirus disease of 2019 (COVID-19) pandemic onset was acute drug toxicity (primarily methamphetamine, opioids, and alcohol).[ 8 ] In the first year of the COVID-19 pandemic, the rate of deaths from acute drug toxicity more than doubled.(8) Drug-related infections are also increasing in California, including rates of human immunodeficiency virus (HIV) which increased from 133,126 in 2016 to over 139,000 in 2020.[ 9 ] New hepatitis C virus (HCV) infections among Californians aged 15–29 increased 50% from 2014 to 2016, primarily due to injection drug use.[ 10 ] Furthermore, in 2020, California had the highest number of reported sexually transmitted infection (STI) cases (chlamydia, gonorrhea, syphilis) and the second most congenital syphilis cases of all states.[ 11 ] One primary resource for Veterans who are at risk for/experiencing homelessness is the US Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program, which provides short- and long-term supportive housing vouchers.[ 12 ] Some supportive housing facilities have collocated services (e.g., medical, mental health, SUD care) on site and/or available via referrals. This is essential, as current evidence suggests that 60% of homeless Veterans entering the HUD-VASH program have a SUD, and the majority (54%) have both an alcohol use disorder and a drug use disorder.[ 13 ] When Veterans first enter HUD-VASH programs, many demonstrate significant improvements in housing and clinical outcomes within the first six months.[ 13 ] However, those with substance use disorders often have increased difficulties over time with alcohol and drug use despite having housing needs met.[ 13 ] Harm reduction strategies, including syringe services programs (SSPs), are evidence-based practices which provide life-saving education and resources to people who use drugs.(14, 15) Through provision of services such as sterile syringes, overdose education, naloxone, and care for HIV, HCV, STIs, and SUDs, these programs reduce rates of overdose deaths and infections, while also increasing treatment engagement.(14, 15) Despite having over 30 years of evidence for SSPs, programs within the Veterans Health Administration (VHA) only began in 2017, and many barriers limit engagement.[ 14 , 15 ] For example, to receive services, Veterans must engage with a healthcare clinician during regular business hours to obtain information and resources.[ 15 ] This limits anonymity, confidentiality, and access during nights and weekends. Some Veterans do not enroll for healthcare services, and many may be ineligible due to exceeding income thresholds, dishonorable or other than honorable discharge from service, or lack of service connected conditions.[ 16 ] This limits access to VA-issued naloxone, which requires healthcare eligibility and a prescription. Furthermore, stigma and discrimination towards people who use drugs is common in healthcare settings and can have detrimental impacts on health outcomes.[ 17 – 20 ] The San Francisco Veterans Affairs Health Care System (SFVAHCS) Harm Reduction and SSP began offering services in 2019, and the program provides services to Veterans at the San Francisco VA Medical Center and its nine outpatient clinics located in downtown San Francisco, Oakland, San Bruno, Santa Rosa, Ukiah, Clearlake, and Eureka.[ 15 ] The program offer in-person outreach to Veterans who formerly experienced homelessness and reside in San Francisco Bay Area supportive housing. This has been essential for increased access to harm reduction services, as Veterans are often not engaged in care, unable to come into clinic, and/or do not have a working phone. However, challenges remain due to limited staffing and ability to deliver harm reduction supplies to housing sites in a meaningful way that meets Veteran needs. Supportive housing facilities often have limited/no parking or on-site secure storage space, challenges with mail-based delivery (e.g., items damaged in transit, packages returned to sender/lost/stolen, cost for shipping), and limited public transit options. Other access barriers include offering services only during regular business hours and requiring interaction with a healthcare team member.[ 21 – 24 ] Utilization of vending machines which dispense harm reduction supplies, such as sterile syringes and naloxone, is a strategy that complements traditional SSP service delivery and further reduces access barriers.[ 25 – 32 ] Harm reduction vending machines (HRVMs) promote increased anonymity, acceptance, accessibility, and convenience of SSP services.[ 27 , 29 , 31 ] Participants who may not access traditional SSPs due to stigma, limited hours of operation, and geographic and financial barriers are more likely to engage with HRVMs.[ 27 , 29 , 31 , 32 ] Access is also increased among people who inject drugs, have HIV, and are not engaged in treatment.[ 29 , 32 ] During the COVID-19 pandemic, implementation of a HRVM was associated with higher rates of participant engagement and supply distribution compared to traditional SSP delivery methods.[ 26 ] Importantly, reductions in opioid overdose deaths and HIV incidence were also demonstrated.[ 25 , 26 ] HRVMs help reduce syringe sharing, are likely to be cost efficient due to low staffing requirements, and do not lead to increased unsafe disposal of used syringes, community drug use, or vandalism.[ 28 , 30 ] Key contributors to successful deployment of HRVMs includes strategic geographic placement, proper maintenance, offering free supplies, and access outside of regular business hours.[ 27 , 30 , 31 ] In 2023, the SFVAHCS Harm Reduction and SSP expanded to be the first VHA healthcare system and the first SSP in the San Francisco to offer services through vending machines. A total of 15 machines were installed: 7 in VA outpatient clinics, 2 at the San Francisco VA Medical Center, and 6 in San Francisco Bay Area HUD-VASH housing facilities where Veterans live.[ 33 ] To date, no programs have examined implementation strategies and impacts of harm reduction services delivery through vending machines in California, among Veterans, and for people who have been at risk for/experienced homelessness. METHODS Study Aims and Objectives Our study aims to bridge this gap by evaluating the first HRVM program designed for Veterans who were at risk for/experienced homelessness and reside in San Francisco Bay Area supportive housing (Table 1 ). Table 1 Study Aims and Hypotheses (34–38). Aim Hypothesis Aim 1 – Reach We seek to evaluate the proportion of Veteran residents who register for access to HRVMs collocated at San Francisco Bay Area HUD-VASH housing facilities and characterize Veterans who do and do not access supplies. We will also explore Veteran and staff feedback on registering for HRVM access and accessing harm reduction supplies. We anticipate at least 80% of Veteran residents to register for HRVM access and that those who access supplies will report higher rates of past 30-day use of unregulated drugs, overdose in the past 6 months, and lifetime history of HIV, HCV, and STIs. Aim 2 – Effectiveness We seek to determine if access to HRVMs collocated at San Francisco Bay Area HUD-VASH housing facilities improves Veteran quality of life, and among Veteran residents with past 30-day injection drug use, evaluate the potential cost-benefit for sterile syringes dispensed in prevention of HIV and HCV transmission. We anticipate Veteran residents to report an overall positive impact on quality of life and to demonstrate positive net benefits for HRVM-dispensed sterile syringes to Veteran residents with past 30-day injection drug use. Aim 3 – Adoption We seek to understand barriers and facilitators for co-location of HRVMs at San Francisco Bay Area HUD-VASH housing facilities. We anticipate the most common barriers to be “not in my backyard” (NIMBY) ideology,(45) stigma, and lack of physical space and the most common facilitators to be staff support and high rates SUDs among Veteran residents. Aim 4 – Implementation, Maintenance, & Sustainment We seek to describe the overall direct costs, utilization, and modifications needed for implementation and maintenance of the San Francisco Bay Area HUD-VASH housing facility HRVMs. We will also explore Veteran- and staff feedback on the implementation, maintenance, and sustainment process. None Legend : Table 1 describes the proposed study aims and hypotheses mapped onto the RE-AIM framework. Acronyms: HRVM, harm reduction vending machine; HUD-VASH, Housing and Urban Development-Veterans Affairs Supportive Housing; HIV, human immunodeficiency virus; HCV, hepatitis C virus; STI, sexually transmitted infection; SUD, substance use disorder; RE-AIM, reach, effectiveness, adoption, implementation, maintenance. To do this, we will collect self-report data via standardized questionnaires and semi-structured qualitative interviews with Veteran residents and housing program staff to evaluate HRVM reach, effectiveness, adoption, implementation, and maintenance (RE-AIM).[ 34 – 38 ] Our study is guided by the RE-AIM Model for evaluation of individual and organizational factors which determine public health impacts of a program or policy (Table 2 ).[ 34 – 38 ] Table 2 Application of the RE-AIM Framework to the Proposed Study.(34–38) Dimensions How Operationalized in Proposed Study Source of Data Level R each the target population Number (%) Veteran residents who register for HRVM access, and among those, number (%) accessing supplies Program enrollment logs, facility housing logs, machine software Organizational Characteristics of Veteran residents who do and do not access supplies Qualtrics survey Individual Veteran and staff feedback on registering for HRVM access and accessing harm reduction supplies Semi-structured qualitative interviews Individual E ffectiveness or efficacy Veteran- and staff-reported impact on quality of life, potential unintended (negative) outcomes, and feedback on vending machine, location within the housing facilities, and harm reduction supplies Semi-structured qualitative interviews Individual Cost-benefit for prevention of HIV, HCV, and STIs Qualtrics survey, machine software Individual, Organizational A doption by target staff, settings, systems, and communities Number (percent) of Veteran housing facilities which accepted a HRVM Program staff Organizational Veteran- and staff-reported barriers and facilitators to co-location of HRVMs at Veteran housing facilities Semi-structured qualitative interviews Individual I mplementation consistency, costs, and adaptations made during delivery Names of vendors utilized for vending machine and initial stocked supplies Program staff Organizational Direct costs (vending machines, internal stocked supplies, personnel) Program staff Organizational Modifications needed to vending machine location, layout, and design Program staff Organizational Description of implementation steps Program staff Organizational Veteran and stakeholder feedback on the implementation process Semi-structured qualitative interviews Individual M aintenance/ sustainment of intervention effects in individuals and settings over time Direct costs (vending machine maintenance, replenishment supplies, personnel) Program staff Organizational Modifications needed to vending machine location, layout, and design Program staff Organizational Description of implementation steps Program staff Organizational Type, quantity, days/times of harm reduction supplies dispensed via vending machine Machine software Organizational Veteran and stakeholder feedback on the maintenance/sustainment process Semi-structured qualitative interviews Individual Legend : Table 2 describes the proposed study outcomes, data source, and data level (individual or organizational) mapped onto the RE-AIM framework. Acronyms: RE-AIM, reach, effectiveness, adoption, implementation, maintenance; HRVM, harm reduction vending machine; HIV, human immunodeficiency virus; HCV, hepatitis C virus; STI, sexually transmitted infection. Study Design and Methods Timeline The proposed study will be completed within 24 months. Months 1–3 will establish IRB protocols and approval. Months 4–18 will enroll 40 Veterans and 20 staff (VA and housing property staff). Participants will complete an electronic Qualtrics questionnaire (Additional Files 1 and 2) and semi-structured qualitative interview (Additional Files 3, 4, and 5). During this time, program implementation and utilization data will be tracked. Months 19–21 will be devoted to processing and analyzing data. Months 22–24 will include scientific dissemination of results and initiation of a larger-scale grant application. Settings Research study team members will complete weekly visits to San Francisco Bay Area HUD-VASH housing sites with a collocated HRVM (1–2 of 6 locations/week) to offer study participation. The research study team will also be available via telephone and video to assist with recruitment, enrollment, and collection of study measures. Recruitment and participant eligibility The research study team will post flyers in locations at the HUD-VASH housing buildings for self-referral. Social workers and on-site staff may also refer Veterans to participate in the study, or Veterans and staff may refer other known contacts. Staff will be recruited primarily via email by study personnel and announcements within team meetings. The research study will begin after all HRVMs have been operational for at least 3 months. To be included in the present study, Veterans must reside in a SFVAHCS HUD-VASH housing site with a collocated HRVM. Veterans with and without access to the HRVMs will be included. Staff participants will include HUD-VASH property staff and VA staff (e.g., social workers, registered nurses, physicians, nurse practitioners) who work at the housing buildings. Veterans and staff who do not meet these criteria will be excluded. Ethics approval and consent This study was approved by the University of California Institutional Review Board (23-39677) and the San Francisco Veterans Affairs Human Subjects Committee (1840329). The research study team will obtain written (Veterans) or electronic (staff) consent before beginning the study questionnaire and qualitative interview. Study Instruments The electronic Qualtrics questionnaire for Veterans will evaluate: sociodemographic characteristics; street drug use and practices; engagement in harm reduction services; syringe disposal practices; experiences with drug overdose and naloxone; history of HIV, HCV, and STI testing and treatment; sexual practices and self-efficacy; emergency room visits and hospitalizations; and interactions with police ( Additional File 1 ). Questions were adapted from the Collecting Demographic Data at SSPs guide[ 39 ], Core Questionnaire[ 40 ], Drug Use Disorders Identification Test (DUDIT)[ 41 ], Risk Behavior Survey (RBS)[ 42 ], internal VHA guidance on taking a brief sexual health history, and self-efficacy scale for HIV risk behaviors.[ 43 ] The electronic Qualtrics questionnaire for staff will evaluate sociodemographic characteristics, and questions were adapted from the Collecting Demographic Data at SSPs guide[ 39 ] and Core Questionnaire[ 40 ] ( Additional File 2 ). Semi-structured qualitative interview domains for both Veterans and staff were mapped onto the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.[ 34 – 38 ] Separate interview guides will be used for Veterans with and without access to the HRVMs ( Additional Files 3 and 4 ) and staff ( Additional File 5 ). Study administration and participant reimbursement Veteran participants (n = 40) will meet with a research team member in person and complete an electronic Qualtrics questionnaire via iPad (~ 15 min; $ 30 reimbursement). Veterans will also complete a semi-structured qualitative interview, which will be audio-recorded via Zoom and transcribed via Rev.com (~ 60 min, $ 60 reimbursement). Reimbursement (up to $ 90 total) will be provided afterwards via physical Visa gift card. Staff participants (n = 20) will meet with research team members virtually via Zoom to complete a virtual, audio-recorded and transcribed, semi-structured qualitative interview (~ 60 min). Afterwards, staff participants will receive an email link to complete a brief electronic Qualtrics questionnaire (~ 5 min). Staff will be reimbursed $ 60 via Visa gift card, which will be provided in person or mailed. Data collection and storage Interview audio recordings will be validated by research team members and independently verified using human translators from Rev (Rev.com, Austin, Texas, USA). Collected Qualtrics survey and semi-structured qualitative interview data will be secured in password-protected files on the SFVAHCS and University of California, San Francisco (UCSF) networks, and access will be restricted to research study staff. Participants will be assigned alpha-numeric identifiers, and files with identifying information will be destroyed upon completion. Supply dispensing data will be tracked regularly throughout the study using HRVM software (de-identified). Naloxone prescription dispensing will be tracked internally by the SSP clinical team via pre-existing mechanisms (secured, password-protected file on the SFVAHCS network). Outcomes Study outcomes will evaluate key facilitators and barriers across RE-AIM[ 34 – 38 ] domains for implementation of HRVMs in 6 San Francisco Bay Area Veterans supportive housing buildings. Data Analysis Descriptive statistics will be used to evaluate participant characteristics and numeric organizational-level data. Semi-structured qualitative interviews, an inductive coding process will be used employing a thematic coding method to examine the data from Veteran and staff.[ 44 ] The research team will assign a code to segments of qualitative data that can be grouped into categories and themes/concepts.[ 44 ] Research team members will independently blind-code three Veteran and two staff transcripts, resolve discrepancies and refine the code book collaboratively, and divide transcripts evenly among team members for coding. Patterns in coding, categories, and themes/concepts will be examined to draw conclusions about the data.[ 44 ] We will calculate total direct costs for the vending machines, harm reduction supplies, maintenance, personnel (hourly salary x time spent on intervention preparation, delivery, and training).[ 45 , 46 ] To examine the potential cost-benefit, we will calculate the direct medical costs averted, valuation of quality of life gained, and valuation of years of life gained, and we will subtract the total direct costs of the intervention.[ 45 , 46 ] DISCUSSION The proposed study represents a critical advancement in the evaluation of HRVMs as an innovative strategy to improve access for Veterans experiencing or at risk for homelessness. While prior research has demonstrated HRVM effectiveness in general populations, this is the first study to assess implementation in California, among Veterans, and within supportive housing facilities. Our findings will contribute much-needed data on how HRVMs can be used to overcome well-documented barriers to care, including stigma, limited service hours, transportation challenges, and the benefits of anonymity. By applying the RE-AIM framework[ 34 – 38 ], this study will provide a comprehensive understanding of HRVM reach, effectiveness, adoption, implementation, and maintenance in supportive housing buildings where Veterans live. These findings will inform efforts to expand access to sterile syringes, naloxone, and other harm reduction supplies in California and across the country. Importantly, this project has the potential to serve as a scalable model for integrating HRVMs into other high-need settings, including shelters, rural clinics, and non-VA community programs. The results may also support federal, state, and local policy changes to promote broader adoption of vending machine-based service delivery, contributing to reduced overdose deaths and infectious disease transmission. Limitations This study has several limitations. First, the evaluation is limited to a single geographic region and a specific Veteran population, which may affect generalizability to other contexts, including non-Veteran populations or rural areas. Second, the study relies on self-reported data, which may be subject to recall and social desirability biases. Third, while we aim to evaluate cost-benefit and implementation outcomes, the study may not capture longer-term health outcomes, such as HIV or HCV incidence, given the 24-month timeline. Additionally, participation may be influenced by differential access to technology, literacy, or trust in research staff. Future Directions Future research should build on this pilot by evaluating longer-term health outcomes, including changes in overdose rates, infectious disease transmission, and healthcare utilization among HRVM users. These efforts should incorporate implementation science frameworks to guide scale-up in both VHA and non-VHA settings, including rural and under-resourced communities. Comparative studies between HRVMs and traditional SSPs delivery models could also offer clarify which services are best suited for HRVM access versus direct staff engagement. Involving Veterans with lived and living expertise in co-design and implementation could enhance relevance, acceptability, and reach. This study serves as an initial step in a broader research agenda aimed at integrating HRVMs into public health infrastructure to expand access to harm reduction services and reduce substance use-related harms nationwide. Abbreviations Coronavirus Disease of 2019 COVID-19 Drug Use Disorders Identification Test DUDIT Harm reduction vending machines HRVMs Hepatitis C Virus HCV Human Immunodeficiency Virus HIV Institutional Review Board IRB Reach Effectiveness,Adoption,Implementation,and Maintenance,RE-AIM San Francisco Veterans Affairs Health Care System SFVAHCS Sexually Transmitted Infection STI Substance Use Disorder SUD Syringe Services Programs SSPs United States US US Housing and Urban Development-Veterans Affairs Supporting Housing HUD-VASH Veterans Affairs VA Veterans Health Administration VHA. Declarations Author Contribution CRediT Author Statement: Rife-Pennington: conceptualization, methodology, software, validation, formal analysis, investigation, resources, data curation, writing (original draft, review, and editing), visualization, supervision, project administration, funding acquisition; Douglas: methodology, software, validation, formal analysis, investigation, resources, data curation, writing (original draft, review, and editing), project administration; Apana: methodology, data curation, writing (review and editing); Sinha: methodology, writing (review and editing); Pennington: conceptualization, methodology, writing (review and editing), funding acquisition. Acknowledgement The authors wish to thank the support of Donna Dare, PharmD, FCSHP, Chief, Pharmacy Service, San Francisco VA Health Care System. References De Sousa T, Andrichik A, Cuellar M et al. 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Int J Drug Policy. 2008;19:436–41. Islam MM, Conigrave KM. Assessing the role of syringe dispensing machines and mobile van outlets in reaching hard-to-reach and high-risk groups of injecting drug users (IDUs): a review. Harm Reduct J. 2007;4:14. Islam MM, Conigrave KM, Stern T. Staff perceptions of syringe dispensing machines in Australia: a pilot study. Subst Use Misuse. 2009;44:490–501. McDonald D. The evaluation of a trial of syringe vending machines in Canberra, Australia. Int J Drug Policy. 2009;20:336–9. Moatti JP, Vlahov D, Feroni I, Perrin V, Obadia Y. Multiple access to sterile syringes for injection drug users: vending machines, needle exchange programs and legal pharmacy sales in Marseille, France. Eur Addict Res. 2001;7:40–5. Rife-Pennington T, Dare D, Huynh T. Implementing Harm Reduction Vending Machines in a California Veterans Affairs Syringe Services Program. In AMERSA National Conference ; 2023. NIH, National Cancer Institute, Evidence-Based Cancer Control Programs. RE-AIM Scoring Instrument. [ https://ebccp.cancercontrol.cancer.gov/reAimCriteria.do] Harden S, RE-AIM Workgroup. RE-AIM Planning Tool. [ https://re-aim.org/wp-content/uploads/2021/10/planning-tool.pdf] National Cancer Institute (NCI) Division of Cancer Control and Population Sciences (DCCPS). Implementation Science Team, key leaders, RE-AIM Authors. Measuring the Use of the RE-AIM Model Dimension Items Checklist. [ https://re-aim.org/wp-content/uploads/2016/09/checklistdimensions.pdf] Harden S, RE-AIM Workgroup. RE-AIM Coding Companion Guide. [ https://re-aim.org/resources-and-tools/measures-and-checklists/final_harden-et-al_re-aim-coding-companion-guide/] Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89:1322–7. University of Washington Supporting Harm Reduction Programs (SHaRP) Team. Collecting Demographic Data at Syringe Services Programs (May 2023) [ https://sites.uw.edu/sharpta/collecting-demographic-data ]. Drug Policy Alliance. Core Questionnaire for Supervised Consumption Services (SCS) Evaluations. Data Harmonization Meeting, January 11–12. 2018 [ https://astrosstudy.org/SCS_Core_questionnaire.pdf] European Union Drugs Agency. Drug Use Disorders Identification Test (DUDIT) [ https://www.euda.europa.eu/drugs-library/drug-use-disorders-identification-test-dudit_en] National Institute on Drug Abuse, Community Research Branch. Risk Behavior Survey [https: //datashare.nida.nih.gov/instrument/risk-behavior-survey] Smith KW, McGraw SA, Costa LA, McKinlay JB. A self-efficacy scale for HIV risk behaviors: development and evaluation. AIDS Educ Prev. 1996;8:97–105. Dill LJ. Engaging in Qualitative Research Methods: Opportunities for Prevention and Health Promotion. National Institutes of Health, Office of Disease Prevention [ https://prevention.nih.gov/education-training/methods-mind-gap/engaging-qualitative-research-methods-opportunities-prevention-and-health-promotion] Office of Policy. Performance, and Evaluation. Cost-Benefit Analysis. Centers for Disease Control and Prevention [ https://www.cdc.gov/policy/polaris/economics/cost-benefit/index.html] CDC TRAIN. Introduction to Economic Evaluation in Public Health. The Office of the Associate Director for Policy and Strategy at the Centers for Disease Control and Prevention [ https://www.train.org/cdctrain/welcome] Additional Declarations No competing interests reported. Supplementary Files AdditionalFile1QualtricsSurveyVeterans.pdf AdditionalFile2QualtricsSurveyStaff.pdf AdditionalFile3QualitativeInterviewGuideVeteransWithHRVMAccess.pdf AdditionalFile4QualitativeInterviewGuideVeteransWithoutHRVMAccess.pdf AdditionalFile5QualitativeInterviewGuideStaff.pdf Cite Share Download PDF Status: Published Journal Publication published 04 Jan, 2026 Read the published version in Harm Reduction Journal → Version 1 posted Editorial decision: Revision requested 19 Oct, 2025 Reviews received at journal 19 Oct, 2025 Reviews received at journal 02 Oct, 2025 Reviewers agreed at journal 25 Sep, 2025 Reviewers agreed at journal 10 Sep, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers invited by journal 12 Aug, 2025 Editor assigned by journal 25 Jul, 2025 Submission checks completed at journal 25 Jul, 2025 First submitted to journal 24 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Rife-Pennington","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIie3RLwsCMRjH8UeErfzAOrlD38JEsN5b8Yrp7BdUbBbB7OsQzJOBFn0PwoLlglfkwiEOBbFtNpF9y7PyGftDFAr9YIl6jjv4vKn8CHsNDSg2/I4QFKQn4QtzrUjH4MubqGjaka7zMRwH7aW9C3Da2sWh7yYiYwSqkIjxRoL26XruIt2LKWs6At3C9GovIkhGdnNAoGFAk3TlEPYu2SCKpX1kjHomlqrfchJ+MGWR6wRcn3dFPuswF3n1/hGp/cBns+9JKBQK/X0PIOw5/kxEGpgAAAAASUVORK5CYII=","orcid":"","institution":"San Francisco VA Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Tessa","middleName":"","lastName":"Rife-Pennington","suffix":""},{"id":500571953,"identity":"7c9e87d2-3767-4238-a098-71a5f7c6bcd5","order_by":1,"name":"Michael Douglas","email":"","orcid":"","institution":"University of California, San 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Study Protocol","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eIn the United States (US), the overall number of people experiencing homelessness and who were unsheltered decreased 10% from 2007 to 2022; however, rates in California are increasing and higher than all other states.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] From 2007 to 2022, the number of individuals experiencing homelessness increased over 23%, and chronic homelessness increased by over 43%.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] In 2022, half of all unsheltered people in the country were in California.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Veterans, or individuals who served on active duty in the US Armed Forces, Reserves, or National Guard, experience higher rates of homelessness compared to non-Veterans.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] On a single night in 2022, California accounted for 32% of all Veterans experiencing homelessness and more than half of all unsheltered Veterans.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eAmong largely populated cities, San Francisco, California, had the fourth highest rates of unsheltered homelessness in 2022.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] According to the annual point in time survey conducted February 23, 2022, an estimated 605 Veterans were homeless in San Francisco, and the most common causes were job loss, eviction, alcohol or drug use, incarceration/probation and parole restrictions, and mental health issues.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Evidence suggests that Veterans with substance use and mental health conditions experience the highest risk for homelessness, and Veterans report higher rates of substance use and mental health conditions as a primary cause of homelessness when compared to non-Veterans.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eDrug-related morbidity and mortality in California, both among Veterans and people experiencing homelessness, is of increasing concern. There were nearly 58,000 emergency department visits and 11,000 deaths related to drug overdose in California in 2021.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Among Veterans, drug overdose deaths increased 53% from 2010 to 2019, and 13% had a diagnosed substance use disorder (SUD).[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Among people experiencing homelessness in San Francisco, the most common cause of death prior to the coronavirus disease of 2019 (COVID-19) pandemic onset was acute drug toxicity (primarily methamphetamine, opioids, and alcohol).[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] In the first year of the COVID-19 pandemic, the rate of deaths from acute drug toxicity more than doubled.(8)\u003c/p\u003e\u003cp\u003eDrug-related infections are also increasing in California, including rates of human immunodeficiency virus (HIV) which increased from 133,126 in 2016 to over 139,000 in 2020.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] New hepatitis C virus (HCV) infections among Californians aged 15\u0026ndash;29 increased 50% from 2014 to 2016, primarily due to injection drug use.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Furthermore, in 2020, California had the highest number of reported sexually transmitted infection (STI) cases (chlamydia, gonorrhea, syphilis) and the second most congenital syphilis cases of all states.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eOne primary resource for Veterans who are at risk for/experiencing homelessness is the US Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program, which provides short- and long-term supportive housing vouchers.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Some supportive housing facilities have collocated services (e.g., medical, mental health, SUD care) on site and/or available via referrals. This is essential, as current evidence suggests that 60% of homeless Veterans entering the HUD-VASH program have a SUD, and the majority (54%) have both an alcohol use disorder and a drug use disorder.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] When Veterans first enter HUD-VASH programs, many demonstrate significant improvements in housing and clinical outcomes within the first six months.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] However, those with substance use disorders often have increased difficulties over time with alcohol and drug use despite having housing needs met.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eHarm reduction strategies, including syringe services programs (SSPs), are evidence-based practices which provide life-saving education and resources to people who use drugs.(14, 15) Through provision of services such as sterile syringes, overdose education, naloxone, and care for HIV, HCV, STIs, and SUDs, these programs reduce rates of overdose deaths and infections, while also increasing treatment engagement.(14, 15) Despite having over 30 years of evidence for SSPs, programs within the Veterans Health Administration (VHA) only began in 2017, and many barriers limit engagement.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] For example, to receive services, Veterans must engage with a healthcare clinician during regular business hours to obtain information and resources.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] This limits anonymity, confidentiality, and access during nights and weekends. Some Veterans do not enroll for healthcare services, and many may be ineligible due to exceeding income thresholds, dishonorable or other than honorable discharge from service, or lack of service connected conditions.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] This limits access to VA-issued naloxone, which requires healthcare eligibility and a prescription. Furthermore, stigma and discrimination towards people who use drugs is common in healthcare settings and can have detrimental impacts on health outcomes.[\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\u003cp\u003e The San Francisco Veterans Affairs Health Care System (SFVAHCS) Harm Reduction and SSP began offering services in 2019, and the program provides services to Veterans at the San Francisco VA Medical Center and its nine outpatient clinics located in downtown San Francisco, Oakland, San Bruno, Santa Rosa, Ukiah, Clearlake, and Eureka.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] The program offer in-person outreach to Veterans who formerly experienced homelessness and reside in San Francisco Bay Area supportive housing. This has been essential for increased access to harm reduction services, as Veterans are often not engaged in care, unable to come into clinic, and/or do not have a working phone. However, challenges remain due to limited staffing and ability to deliver harm reduction supplies to housing sites in a meaningful way that meets Veteran needs. Supportive housing facilities often have limited/no parking or on-site secure storage space, challenges with mail-based delivery (e.g., items damaged in transit, packages returned to sender/lost/stolen, cost for shipping), and limited public transit options. Other access barriers include offering services only during regular business hours and requiring interaction with a healthcare team member.[\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eUtilization of vending machines which dispense harm reduction supplies, such as sterile syringes and naloxone, is a strategy that complements traditional SSP service delivery and further reduces access barriers.[\u003cspan additionalcitationids=\"CR26 CR27 CR28 CR29 CR30 CR31\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] Harm reduction vending machines (HRVMs) promote increased anonymity, acceptance, accessibility, and convenience of SSP services.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] Participants who may not access traditional SSPs due to stigma, limited hours of operation, and geographic and financial barriers are more likely to engage with HRVMs.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] Access is also increased among people who inject drugs, have HIV, and are not engaged in treatment.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] During the COVID-19 pandemic, implementation of a HRVM was associated with higher rates of participant engagement and supply distribution compared to traditional SSP delivery methods.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] Importantly, reductions in opioid overdose deaths and HIV incidence were also demonstrated.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] HRVMs help reduce syringe sharing, are likely to be cost efficient due to low staffing requirements, and do not lead to increased unsafe disposal of used syringes, community drug use, or vandalism.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] Key contributors to successful deployment of HRVMs includes strategic geographic placement, proper maintenance, offering free supplies, and access outside of regular business hours.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIn 2023, the SFVAHCS Harm Reduction and SSP expanded to be the first VHA healthcare system and the first SSP in the San Francisco to offer services through vending machines. A total of 15 machines were installed: 7 in VA outpatient clinics, 2 at the San Francisco VA Medical Center, and 6 in San Francisco Bay Area HUD-VASH housing facilities where Veterans live.[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] To date, no programs have examined implementation strategies and impacts of harm reduction services delivery through vending machines in California, among Veterans, and for people who have been at risk for/experienced homelessness.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cb\u003eStudy Aims and Objectives\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOur study aims to bridge this gap by evaluating the first HRVM program designed for Veterans who were at risk for/experienced homelessness and reside in San Francisco Bay Area supportive housing (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStudy Aims and Hypotheses (34\u0026ndash;38).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAim\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHypothesis\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAim 1 \u0026ndash; Reach\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWe seek to \u003cem\u003eevaluate\u003c/em\u003e the proportion of Veteran residents who register for access to HRVMs collocated at San Francisco Bay Area HUD-VASH housing facilities and \u003cem\u003echaracterize\u003c/em\u003e Veterans who do and do not access supplies. We will also explore Veteran and staff feedback on registering for HRVM access and accessing harm reduction supplies.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWe anticipate at least 80% of Veteran residents to register for HRVM access and that those who access supplies will report higher rates of past 30-day use of unregulated drugs, overdose in the past 6 months, and lifetime history of HIV, HCV, and STIs.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAim 2 \u0026ndash; Effectiveness\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWe seek to \u003cem\u003edetermine\u003c/em\u003e if access to HRVMs collocated at San Francisco Bay Area HUD-VASH housing facilities improves Veteran quality of life, and among Veteran residents with past 30-day injection drug use, \u003cem\u003eevaluate\u003c/em\u003e the potential cost-benefit for sterile syringes dispensed in prevention of HIV and HCV transmission.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWe anticipate Veteran residents to report an overall positive impact on quality of life and to demonstrate positive net benefits for HRVM-dispensed sterile syringes to Veteran residents with past 30-day injection drug use.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAim 3 \u0026ndash; Adoption\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWe seek to \u003cem\u003eunderstand\u003c/em\u003e barriers and facilitators for co-location of HRVMs at San Francisco Bay Area HUD-VASH housing facilities.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWe anticipate the most common barriers to be \u0026ldquo;not in my backyard\u0026rdquo; (NIMBY) ideology,(45) stigma, and lack of physical space and the most common facilitators to be staff support and high rates SUDs among Veteran residents.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAim 4 \u0026ndash; Implementation, Maintenance, \u0026amp; Sustainment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWe seek to \u003cem\u003edescribe\u003c/em\u003e the overall direct costs, utilization, and modifications needed for implementation and maintenance of the San Francisco Bay Area HUD-VASH housing facility HRVMs. We will also explore Veteran- and staff feedback on the implementation, maintenance, and sustainment process.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eLegend\u003c/b\u003e: Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e describes the proposed study aims and hypotheses mapped onto the RE-AIM framework. Acronyms: HRVM, harm reduction vending machine; HUD-VASH, Housing and Urban Development-Veterans Affairs Supportive Housing; HIV, human immunodeficiency virus; HCV, hepatitis C virus; STI, sexually transmitted infection; SUD, substance use disorder; RE-AIM, reach, effectiveness, adoption, implementation, maintenance.\u003c/p\u003e\u003cp\u003eTo do this, we will collect self-report data via standardized questionnaires and semi-structured qualitative interviews with Veteran residents and housing program staff to evaluate HRVM reach, effectiveness, adoption, implementation, and maintenance (RE-AIM).[\u003cspan additionalcitationids=\"CR35 CR36 CR37\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] Our study is guided by the RE-AIM Model for evaluation of individual and organizational factors which determine public health impacts of a program or policy (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).[\u003cspan additionalcitationids=\"CR35 CR36 CR37\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eApplication of the RE-AIM Framework to the Proposed Study.(34\u0026ndash;38)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDimensions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHow Operationalized in Proposed Study\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSource of Data\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLevel\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eR\u003c/span\u003e\u003cb\u003eeach\u003c/b\u003e the target population\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber (%) Veteran residents who register for HRVM access, and among those, number (%) accessing supplies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram enrollment logs, facility housing logs, machine software\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOrganizational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCharacteristics of Veteran residents who do and do not access supplies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQualtrics survey\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIndividual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVeteran and staff feedback on registering for HRVM access and accessing harm reduction supplies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSemi-structured qualitative interviews\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIndividual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eE\u003c/span\u003e\u003cb\u003effectiveness\u003c/b\u003e or efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVeteran- and staff-reported impact on quality of life, potential unintended (negative) outcomes, and feedback on vending machine, location within the housing facilities, and harm reduction supplies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSemi-structured qualitative interviews\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIndividual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCost-benefit for prevention of HIV, HCV, and STIs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQualtrics survey, machine software\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIndividual, Organizational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eA\u003c/span\u003e\u003cb\u003edoption\u003c/b\u003e by target staff, settings, systems, and communities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber (percent) of Veteran housing facilities which accepted a HRVM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOrganizational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVeteran- and staff-reported barriers and facilitators to co-location of HRVMs at Veteran housing facilities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSemi-structured qualitative interviews\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIndividual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eI\u003c/span\u003e\u003cb\u003emplementation\u003c/b\u003e consistency, costs, and adaptations made during delivery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNames of vendors utilized for vending machine and initial stocked supplies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOrganizational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDirect costs (vending machines, internal stocked supplies, personnel)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOrganizational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModifications needed to vending machine location, layout, and design\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOrganizational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDescription of implementation steps\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOrganizational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVeteran and stakeholder feedback on the implementation process\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSemi-structured qualitative interviews\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIndividual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eM\u003c/span\u003e\u003cb\u003eaintenance/ sustainment\u003c/b\u003e of intervention effects in individuals and settings over time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDirect costs (vending machine maintenance, replenishment supplies, personnel)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOrganizational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModifications needed to vending machine location, layout, and design\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOrganizational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDescription of implementation steps\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOrganizational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eType, quantity, days/times of harm reduction supplies dispensed via vending machine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMachine software\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOrganizational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVeteran and stakeholder feedback on the maintenance/sustainment process\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSemi-structured qualitative interviews\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIndividual\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eLegend\u003c/b\u003e: Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e describes the proposed study outcomes, data source, and data level (individual or organizational) mapped onto the RE-AIM framework. Acronyms: RE-AIM, reach, effectiveness, adoption, implementation, maintenance; HRVM, harm reduction vending machine; HIV, human immunodeficiency virus; HCV, hepatitis C virus; STI, sexually transmitted infection.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy Design and Methods\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTimeline\u003c/span\u003e\u003c/p\u003e\u003cp\u003eThe proposed study will be completed within 24 months. Months 1\u0026ndash;3 will establish IRB protocols and approval. Months 4\u0026ndash;18 will enroll 40 Veterans and 20 staff (VA and housing property staff). Participants will complete an electronic Qualtrics questionnaire (Additional Files 1 and 2) and semi-structured qualitative interview (Additional Files 3, 4, and 5). During this time, program implementation and utilization data will be tracked. Months 19\u0026ndash;21 will be devoted to processing and analyzing data. Months 22\u0026ndash;24 will include scientific dissemination of results and initiation of a larger-scale grant application.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSettings\u003c/span\u003e\u003c/p\u003e\u003cp\u003eResearch study team members will complete weekly visits to San Francisco Bay Area HUD-VASH housing sites with a collocated HRVM (1\u0026ndash;2 of 6 locations/week) to offer study participation. The research study team will also be available via telephone and video to assist with recruitment, enrollment, and collection of study measures.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eRecruitment and participant eligibility\u003c/span\u003e\u003c/p\u003e\u003cp\u003eThe research study team will post flyers in locations at the HUD-VASH housing buildings for self-referral. Social workers and on-site staff may also refer Veterans to participate in the study, or Veterans and staff may refer other known contacts. Staff will be recruited primarily via email by study personnel and announcements within team meetings.\u003c/p\u003e\u003cp\u003eThe research study will begin after all HRVMs have been operational for at least 3 months. To be included in the present study, Veterans must reside in a SFVAHCS HUD-VASH housing site with a collocated HRVM. Veterans with and without access to the HRVMs will be included. Staff participants will include HUD-VASH property staff and VA staff (e.g., social workers, registered nurses, physicians, nurse practitioners) who work at the housing buildings. Veterans and staff who do not meet these criteria will be excluded.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eand consent\u003c/span\u003e\u003c/p\u003e\u003c/p\u003e\u003cp\u003e This study was approved by the University of California Institutional Review Board (23-39677) and the San Francisco Veterans Affairs Human Subjects Committee (1840329). The research study team will obtain written (Veterans) or electronic (staff) consent before beginning the study questionnaire and qualitative interview.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eStudy Instruments\u003c/span\u003e\u003c/p\u003e\u003cp\u003eThe electronic Qualtrics questionnaire for Veterans will evaluate: sociodemographic characteristics; street drug use and practices; engagement in harm reduction services; syringe disposal practices; experiences with drug overdose and naloxone; history of HIV, HCV, and STI testing and treatment; sexual practices and self-efficacy; emergency room visits and hospitalizations; and interactions with police (\u003cb\u003eAdditional File 1\u003c/b\u003e). Questions were adapted from the Collecting Demographic Data at SSPs guide[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], Core Questionnaire[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], Drug Use Disorders Identification Test (DUDIT)[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], Risk Behavior Survey (RBS)[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], internal VHA guidance on taking a brief sexual health history, and self-efficacy scale for HIV risk behaviors.[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] The electronic Qualtrics questionnaire for staff will evaluate sociodemographic characteristics, and questions were adapted from the Collecting Demographic Data at SSPs guide[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] and Core Questionnaire[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] (\u003cb\u003eAdditional File 2\u003c/b\u003e). Semi-structured qualitative interview domains for both Veterans and staff were mapped onto the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.[\u003cspan additionalcitationids=\"CR35 CR36 CR37\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] Separate interview guides will be used for Veterans with and without access to the HRVMs (\u003cb\u003eAdditional Files 3 and 4\u003c/b\u003e) and staff (\u003cb\u003eAdditional File 5\u003c/b\u003e).\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eStudy administration and participant reimbursement\u003c/span\u003e\u003c/p\u003e\u003cp\u003eVeteran participants (n\u0026thinsp;=\u0026thinsp;40) will meet with a research team member in person and complete an electronic Qualtrics questionnaire via iPad (~\u0026thinsp;15 min; \u003cspan\u003e$\u003c/span\u003e30 reimbursement). Veterans will also complete a semi-structured qualitative interview, which will be audio-recorded via Zoom and transcribed via Rev.com (~\u0026thinsp;60 min, \u003cspan\u003e$\u003c/span\u003e60 reimbursement). Reimbursement (up to \u003cspan\u003e$\u003c/span\u003e90 total) will be provided afterwards via physical Visa gift card.\u003c/p\u003e\u003cp\u003eStaff participants (n\u0026thinsp;=\u0026thinsp;20) will meet with research team members virtually via Zoom to complete a virtual, audio-recorded and transcribed, semi-structured qualitative interview (~\u0026thinsp;60 min). Afterwards, staff participants will receive an email link to complete a brief electronic Qualtrics questionnaire (~\u0026thinsp;5 min). Staff will be reimbursed \u003cspan\u003e$\u003c/span\u003e60 via Visa gift card, which will be provided in person or mailed.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eData collection and storage\u003c/span\u003e\u003c/p\u003e\u003cp\u003eInterview audio recordings will be validated by research team members and independently verified using human translators from Rev (Rev.com, Austin, Texas, USA). Collected Qualtrics survey and semi-structured qualitative interview data will be secured in password-protected files on the SFVAHCS and University of California, San Francisco (UCSF) networks, and access will be restricted to research study staff. Participants will be assigned alpha-numeric identifiers, and files with identifying information will be destroyed upon completion.\u003c/p\u003e\u003cp\u003eSupply dispensing data will be tracked regularly throughout the study using HRVM software (de-identified). Naloxone prescription dispensing will be tracked internally by the SSP clinical team via pre-existing mechanisms (secured, password-protected file on the SFVAHCS network).\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eOutcomes\u003c/span\u003e\u003c/p\u003e\u003cp\u003eStudy outcomes will evaluate key facilitators and barriers across RE-AIM[\u003cspan additionalcitationids=\"CR35 CR36 CR37\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] domains for implementation of HRVMs in 6 San Francisco Bay Area Veterans supportive housing buildings.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics will be used to evaluate participant characteristics and numeric organizational-level data. Semi-structured qualitative interviews, an inductive coding process will be used employing a thematic coding method to examine the data from Veteran and staff.[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] The research team will assign a code to segments of qualitative data that can be grouped into categories and themes/concepts.[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] Research team members will independently blind-code three Veteran and two staff transcripts, resolve discrepancies and refine the code book collaboratively, and divide transcripts evenly among team members for coding. Patterns in coding, categories, and themes/concepts will be examined to draw conclusions about the data.[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eWe will calculate total direct costs for the vending machines, harm reduction supplies, maintenance, personnel (hourly salary x time spent on intervention preparation, delivery, and training).[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] To examine the potential cost-benefit, we will calculate the direct medical costs averted, valuation of quality of life gained, and valuation of years of life gained, and we will subtract the total direct costs of the intervention.[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe proposed study represents a critical advancement in the evaluation of HRVMs as an innovative strategy to improve access for Veterans experiencing or at risk for homelessness. While prior research has demonstrated HRVM effectiveness in general populations, this is the first study to assess implementation in California, among Veterans, and within supportive housing facilities. Our findings will contribute much-needed data on how HRVMs can be used to overcome well-documented barriers to care, including stigma, limited service hours, transportation challenges, and the benefits of anonymity.\u003c/p\u003e\u003cp\u003eBy applying the RE-AIM framework[\u003cspan additionalcitationids=\"CR35 CR36 CR37\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], this study will provide a comprehensive understanding of HRVM reach, effectiveness, adoption, implementation, and maintenance in supportive housing buildings where Veterans live. These findings will inform efforts to expand access to sterile syringes, naloxone, and other harm reduction supplies in California and across the country. Importantly, this project has the potential to serve as a scalable model for integrating HRVMs into other high-need settings, including shelters, rural clinics, and non-VA community programs. The results may also support federal, state, and local policy changes to promote broader adoption of vending machine-based service delivery, contributing to reduced overdose deaths and infectious disease transmission.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, the evaluation is limited to a single geographic region and a specific Veteran population, which may affect generalizability to other contexts, including non-Veteran populations or rural areas. Second, the study relies on self-reported data, which may be subject to recall and social desirability biases. Third, while we aim to evaluate cost-benefit and implementation outcomes, the study may not capture longer-term health outcomes, such as HIV or HCV incidence, given the 24-month timeline. Additionally, participation may be influenced by differential access to technology, literacy, or trust in research staff.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFuture Directions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFuture research should build on this pilot by evaluating longer-term health outcomes, including changes in overdose rates, infectious disease transmission, and healthcare utilization among HRVM users. These efforts should incorporate implementation science frameworks to guide scale-up in both VHA and non-VHA settings, including rural and under-resourced communities. Comparative studies between HRVMs and traditional SSPs delivery models could also offer clarify which services are best suited for HRVM access versus direct staff engagement. Involving Veterans with lived and living expertise in co-design and implementation could enhance relevance, acceptability, and reach. This study serves as an initial step in a broader research agenda aimed at integrating HRVMs into public health infrastructure to expand access to harm reduction services and reduce substance use-related harms nationwide.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCoronavirus Disease of 2019\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCOVID-19\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDrug Use Disorders Identification Test\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDUDIT\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHarm reduction vending machines\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHRVMs\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHepatitis C Virus\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHCV\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHuman Immunodeficiency Virus\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHIV\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eInstitutional Review Board\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIRB\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eReach\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEffectiveness,Adoption,Implementation,and Maintenance,RE-AIM\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSan Francisco Veterans Affairs Health Care System\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSFVAHCS\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSexually Transmitted Infection\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSTI\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSubstance Use Disorder\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSUD\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSyringe Services Programs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSSPs\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUnited States\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUS\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUS Housing and Urban Development-Veterans Affairs Supporting Housing\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHUD-VASH\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVeterans Affairs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVA\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVeterans Health Administration\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVHA.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eCRediT Author Statement: Rife-Pennington: conceptualization, methodology, software, validation, formal analysis, investigation, resources, data curation, writing (original draft, review, and editing), visualization, supervision, project administration, funding acquisition; Douglas: methodology, software, validation, formal analysis, investigation, resources, data curation, writing (original draft, review, and editing), project administration; Apana: methodology, data curation, writing (review and editing); Sinha: methodology, writing (review and editing); Pennington: conceptualization, methodology, writing (review and editing), funding acquisition.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors wish to thank the support of Donna Dare, PharmD, FCSHP, Chief, Pharmacy Service, San Francisco VA Health Care System.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDe Sousa T, Andrichik A, Cuellar M et al. The 2022 Annual Homelessness Assessment Report (AHAR) to Congress, Part 1: Point-in-Time Estimates to Congress. The U.S. Department of Housing and Urban Development, Office of Community Planning and Development [\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.huduser.gov/portal/sites/default/files/pdf/2022-AHAR-Part-1.pdf\u003c/span\u003e\u003cspan address=\"https://www.huduser.gov/portal/sites/default/files/pdf/2022-AHAR-Part-1.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e ].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSan Francisco Homeless Count and Survey. 2022 Comprehensive Report. Applied Survey Research (ASR). 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[\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://skylab.cdph.ca.gov/ODdash/?tab=Home]\u003c/span\u003e\u003cspan address=\"https://skylab.cdph.ca.gov/ODdash/?tab=Home]\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBegley MR, Ravindran C, Peltzman T, Morley SW, Stephens BM, Ashrafioun L, McCarthy JF. Veteran drug overdose mortality, 2010\u0026ndash;2019. Drug Alcohol Depend. 2022;233:109296.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoggatt KJ, Harris AHS, Washington DL, Williams EC. Prevalence of substance use and substance-related disorders among US Veterans Health Administration patients. Drug Alcohol Depend. 2021;225:108791.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCawley CL, Kanzaria HK, Kushel M, Raven MC, Zevin B. Mortality Among People Experiencing Homelessness in San Francisco 2016\u0026ndash;2018. J Gen Intern Med. 2022;37:990\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCalifornia Department of Public Health. Center for Infectious Diseases, Office of AIDS, Sacramento, California. California HIV Surveillance Report \u0026ndash; 2020. [\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/California_HIV_Surveillance_Report2020_ADA.pdf\u003c/span\u003e\u003cspan address=\"https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/California_HIV_Surveillance_Report2020_ADA.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e ].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePolicy and Viral Hepatitis Prevention Section, Sexually Transmitted Disease Control Branch, Division of Communicable Disease Control, California Department of Public Health. 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[\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://re-aim.org/resources-and-tools/measures-and-checklists/final_harden-et-al_re-aim-coding-companion-guide/]\u003c/span\u003e\u003cspan address=\"https://re-aim.org/resources-and-tools/measures-and-checklists/final_harden-et-al_re-aim-coding-companion-guide/]\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGlasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89:1322\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUniversity of Washington Supporting Harm Reduction Programs (SHaRP) Team. Collecting Demographic Data at Syringe Services Programs (May 2023) [\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://sites.uw.edu/sharpta/collecting-demographic-data\u003c/span\u003e\u003cspan address=\"https://sites.uw.edu/sharpta/collecting-demographic-data\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e ].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDrug Policy Alliance. Core Questionnaire for Supervised Consumption Services (SCS) Evaluations. Data Harmonization Meeting, January 11\u0026ndash;12. 2018 [\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://astrosstudy.org/SCS_Core_questionnaire.pdf]\u003c/span\u003e\u003cspan address=\"https://astrosstudy.org/SCS_Core_questionnaire.pdf]\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEuropean Union Drugs Agency. 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A self-efficacy scale for HIV risk behaviors: development and evaluation. AIDS Educ Prev. 1996;8:97\u0026ndash;105.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDill LJ. Engaging in Qualitative Research Methods: Opportunities for Prevention and Health Promotion. National Institutes of Health, Office of Disease Prevention [\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://prevention.nih.gov/education-training/methods-mind-gap/engaging-qualitative-research-methods-opportunities-prevention-and-health-promotion]\u003c/span\u003e\u003cspan address=\"https://prevention.nih.gov/education-training/methods-mind-gap/engaging-qualitative-research-methods-opportunities-prevention-and-health-promotion]\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOffice of Policy. Performance, and Evaluation. Cost-Benefit Analysis. Centers for Disease Control and Prevention [\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/policy/polaris/economics/cost-benefit/index.html]\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/policy/polaris/economics/cost-benefit/index.html]\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCDC TRAIN. Introduction to Economic Evaluation in Public Health. The Office of the Associate Director for Policy and Strategy at the Centers for Disease Control and Prevention [\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.train.org/cdctrain/welcome]\u003c/span\u003e\u003cspan address=\"https://www.train.org/cdctrain/welcome]\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"harm reduction, naloxone, overdose prevention, implementation science, HIV prevention, Veterans","lastPublishedDoi":"10.21203/rs.3.rs-7209082/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7209082/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eLack of access to sterile supplies among people who use drugs contributes to increased rates of infectious disease transmission, including human immunodeficiency virus, hepatitis C virus, and sexually transmitted infections. People residing in California, United States Veterans, and those experiencing homelessness are disproportionately impacted. Syringe services programs (SSPs) are vital to reducing these harms, but access may be limited by hours of operation, geographic barriers, need for in-person interaction, and stigma. Harm reduction vending machines (HRVMs) which often dispense sterile syringes and condoms are an evidence-based strategy to increase access; however, no studies have evaluated implementation or impacts among these populations. This mixed-methods study aims to evaluate the first HRVM program designed for Veterans who experienced homelessness and reside in California supportive housing buildings.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eWe will recruit 40 Veteran residents and 20 staff (Veterans Affairs [VA] and housing staff) at six housing buildings with a collocated HRVM. Participants will provide informed consent, complete a standardized electronic questionnaire, semi-structured qualitative interview, and be compensated via Visa gift cards (\u003cspan\u003e$\u003c/span\u003e90 for Veterans; \u003cspan\u003e$\u003c/span\u003e60 for staff). Interview transcripts will be analyzed thematically using inductive coding. Program-level data will be collected from enrollment logs, facility records, and vending machine software to evaluate reach, effectiveness, adoption, implementation, and maintenance (RE-AIM).\u003c/p\u003e\u003ch2\u003eDiscussion:\u003c/h2\u003e\u003cp\u003eFindings will provide essential evidence on how HRVMs may reduce longstanding access barriers and expand delivery of life-saving harm reduction supplies to underserved Veterans. This study is the first to evaluate HRVMs in Veterans supportive housing and among a population disproportionately affected by substance use, stigma, and homelessness. Results may inform the expansion of community-based and VA SSPs nationwide. Study strengths include a theory-informed design, real-world implementation data, and attention to user and staff experiences. Limitations include reliance on self-report data, lack of a control group, and limited generalizability beyond Veterans. Future research may examine long-term health outcomes, cost-effectiveness, and feasibility of HRVMs scaled up in diverse settings. Findings from this study may guide policymakers and public health practitioners in integrating HRVMs into broader harm reduction strategies to prevent overdose, infections, and other adverse outcomes.\u003c/p\u003e","manuscriptTitle":"Evaluating the Implementation and Impact of Harm Reduction Vending Machines in Veterans Supportive Housing Settings: A Mixed-Methods Study Protocol","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-20 19:07:01","doi":"10.21203/rs.3.rs-7209082/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-19T06:55:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-19T06:42:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-02T21:25:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"239168716770140931827209778896987461068","date":"2025-09-25T15:30:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25509382903654402027628696319968246316","date":"2025-09-11T02:41:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"271728854216515989365069278154793338495","date":"2025-08-14T08:01:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-12T07:34:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-25T13:25:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-25T13:22:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Harm Reduction Journal","date":"2025-07-24T23:54:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b2c3a8b2-8d55-4a97-92df-cbde6c22d706","owner":[],"postedDate":"August 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T15:59:10+00:00","versionOfRecord":{"articleIdentity":"rs-7209082","link":"https://doi.org/10.1186/s12954-025-01385-8","journal":{"identity":"harm-reduction-journal","isVorOnly":false,"title":"Harm Reduction Journal"},"publishedOn":"2026-01-04 15:57:03","publishedOnDateReadable":"January 4th, 2026"},"versionCreatedAt":"2025-08-20 19:07:01","video":"","vorDoi":"10.1186/s12954-025-01385-8","vorDoiUrl":"https://doi.org/10.1186/s12954-025-01385-8","workflowStages":[]},"version":"v1","identity":"rs-7209082","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7209082","identity":"rs-7209082","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}