The Policy Stack: How SAMHSA, the White House, and Louisiana Are Rewriting Drug and Homelessness Response
On April 24, 2026, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a Dear Colleague letter that withdraws federal funding eligibility from fentanyl test strips, sterile water, saline, ascorbic acid, sterile syringes, safer smoking supplies, and overdose hotlines. Signed by Principal Deputy Assistant Secretary Christopher Carroll, the letter operationalizes the July 2025 Executive Order directing the agency to defund what the order termed "so-called harm reduction" programs. This action arrives as Louisiana's House Bill 211 advances toward the state Senate, threatening fines and imprisonment for unauthorized public camping. Together, these federal and state moves construct a coordinated policy framework that abandons decades of evidence on what prevents HIV and HCV transmission, reduces overdose mortality, and connects people who use drugs to treatment.
For people living with HIV and HCV, people who inject drugs, and people experiencing homelessness, these are not parallel debates. They are the same policy question, asked at different levels of government.
What the Updated Guidance Actually Removes
The April 2026 letter preserves SAMHSA funding for naloxone and nalmefene, medication lock boxes, sharps disposal, wound care, FDA-approved home testing kits for HIV and viral hepatitis, navigation to PrEP and PEP, and condom distribution. It eliminates funding for fentanyl, xylazine, and medetomidine test strips intended for use by people who use drugs, alongside syringes, safer smoking supplies, sterile water, saline, ascorbic acid, and overdose hotlines that provide a remote companion to people while using.
This represents a significant retreat from the July 2025 SAMHSA guidance, which had preserved test strips even as it shifted the agency's overall framing. STAT News notes that the test strip policy reverses a position the federal government held since 2021. The carve-out permitting test strip purchases for law enforcement, emergency medical services, and healthcare professionals captures the structural problem: test strips work because they reach people before an overdose, not after. Each strip costs roughly one dollar. Rachel Winograd, who oversees Missouri's central warehouse for overdose prevention supplies, confirmed her usual order for 80,000 test strips on the afternoon the SAMHSA letter arrived in her inbox.
A second letter issued the same day warns grantees against medication-only treatment for opioid use disorder, encouraging clinicians to review continued use of methadone or buprenorphine "at least annually." As STAT observed, current standards of care do not support withholding medication from patients who decline psychosocial services, and the ASAM guideline the letter cites contradicts that framing.
The Evidence the Policy Discards
Syringe services programs (SSPs) are among the most studied public health interventions of the past three decades. A meta-analysis of more than 6,000 patients found a 58% HIV transmission risk reduction among SSP participants. High-coverage programs reduced HCV transmission by 52% in one UK meta-analysis and by 76% in a Cochrane review of nearly 2,500 patients. New York City saw a 29% reduction in HCV prevalence among people who inject drugs after SSP introduction. The economic case is equally clear: full harm reduction averts approximately 70 HCV treatments per 1,000 people who inject drugs, translating to roughly $2 million to $6.7 million in annual savings per 1,000 people based on direct-acting antiviral pricing.
The connection to current epidemiology is direct. HCV infections in the United States increased 124% between 2013 and 2020, largely driven by injection opioid use, and over 75% of overdose deaths in 2023 involved fentanyl. A meta-analysis published in Viruses demonstrated that combined harm reduction with medications for opioid use disorder reduced HCV transmission nearly fourfold compared to limited or absent access. The Department of Veterans Affairs, in its December 2025 analysis referenced in CANN's previous coverage, described SSPs as one of the most effective public health interventions ever devised, with reductions in new HIV and HCV cases of up to 67% and a five-fold increase in the likelihood of achieving abstinence among participants.
The evidence base is not contested in the medical literature. It is contested in federal policy.
The Executive Order's Architecture of Enforcement
The April 2026 SAMHSA letter does not stand alone. Section 4(a)(i) of Executive Order 14321, signed July 24, 2025, directed HHS to ensure SAMHSA grants "do not fund" harm reduction or safe consumption efforts. Section 3 instructs the Attorney General, HHS, HUD, and the Department of Transportation to prioritize discretionary grants for jurisdictions that enforce prohibitions on urban camping, loitering, and squatting, and that move people with mental health conditions or substance use disorder into treatment through civil commitment.
The order's foundational claims warrant examination. It asserts that the "overwhelming majority" of unhoused people are addicted to drugs or have a mental health condition. The data tell a different story: roughly one-third of people experiencing homelessness have a substance use disorder, and roughly one-third have a mental health condition. Penn LDI's Dennis Culhane has observed that housing affordability is the primary explanatory variable in modeling homelessness rates by city or county, and that 84% of households in shelters do not receive Housing First or rental assistance to exit homelessness. The Department of Veterans Affairs implementation of Housing First reduced veteran homelessness by 55%, and the administration has not modified that program.
A federal appeals court ruled on March 31, 2026 that HUD's attempt to cap permanent housing spending at 30% of grants was unlawful, describing the policy as a slapdash imposition of political whims. The administration must now go to Congress to alter that framework.
Louisiana HB 211: The Cascade in Practice
Louisiana's House Bill 211, authored by Representative Debbie Villio, criminalizes unauthorized public camping with fines up to $500 and six months imprisonment for a first conviction, escalating to $1,000 and one to two years with hard labor for subsequent convictions. The bill passed the Louisiana House in April 2026 and awaits action in the Senate Judiciary C Committee.
State officials have acknowledged that supporting the bill could improve Louisiana's standing with the Trump administration when discretionary federal grants are awarded. This is the EO's incentive structure functioning as designed. The downstream context matters: Louisiana has the nation's highest poverty rate and the highest incarceration rate in the Western world. About 60% of Louisiana's unhoused population is Black despite the state being 30% Black. Roughly one in three Louisiana households are extremely low income, and the National Low Income Housing Coalition estimates a shortage of more than 100,000 affordable homes for those families. New Orleans Councilmember Lesli Harris compared the bill to internment camps and warned it would produce no lasting housing or services.
The Homelessness Court program created by HB 211 allows participants to have charges dismissed upon successful completion, but defendants may be required to pay for treatment costs, with courts authorized to mandate unpaid labor when payment is impossible. Pastor Jeremy Babineaux, quoted in KPLC's coverage, asked the question that the bill's text does not answer: how do unhoused people pay fines and program fees when they cannot afford housing in the first place?
Where the Syndemics Compound
Harm reduction defunding does not happen in a vacuum. Encampment sweeps, civil commitment mandates, and treatment-first housing conditions interact with the loss of test strips, sterile supplies, and overdose hotlines to produce harms that exceed the sum of their parts. For people who inject drugs and live with or are at risk for HIV or HCV, the result is a policy environment that systematically severs the connections that public health depends on.
Sweeps and criminalization disrupt continuity of care in concrete, documented ways. Research compiled by the National Alliance to End Homelessness finds that enforcement actions cause loss or destruction of legal documents, medical equipment, prescriptions, and personal effects, while displacing people from the locations where outreach workers and providers know to find them. People moved from one public area to another lose contact with street medicine teams, syringe services, and the case managers who help them apply for Medicaid or get on antiretroviral therapy. Those connections are how the Ending the HIV Epidemic and HCV Elimination plans actually reach the populations that drive ongoing transmission.
The economics are not subtle. Chronic homelessness costs taxpayers approximately $31,000 per person per year under enforcement-driven approaches, while permanent supportive housing with case management costs roughly $10,000 per year. The U.S. Interagency Council on Homelessness has documented that anti-homeless enforcement can cost three times more than housing the same people. Housing First programs, when compared to treatment-first models, reduce homelessness by 88% and, among people living with HIV, decrease emergency department visits by 41%, hospitalizations by 36%, and mortality by 37% within two years, according to research summarized in the AMA Journal of Ethics.
The convergence is what makes the compounding harm difficult to undo. A person who loses access to sterile syringes is more likely to acquire HCV. A person whose encampment is swept loses the ID required to enroll in Medicaid coverage for direct-acting antivirals. A person facing civil commitment or a camping conviction acquires a record that disqualifies them from future housing applications. Each link in the chain, individually defensible to its proponents, produces a population less reachable by the public health system than it was a year ago.
Specific Actions for Advocates
The federal policy framework can be challenged at multiple points. The April 2026 SAMHSA guidance is administrative, not statutory, and Congress retains appropriations authority. The FY2026 Labor-HHS package, as we previously reported, already includes structural protections requiring advance notice before HHS reorganizations and grant terminations. The FY2027 cycle is the next opportunity to direct SAMHSA on allowable harm reduction expenses and to push back on the medication-only treatment framing in the second April 24 letter.
For people working in HIV and HCV care, the most immediate action is documentation. State health departments and Ryan White grantees should be tracking, in real time, the gaps that emerge as SAMHSA-funded programs lose access to test strips and sterile supplies. Quantifying lost services and projected transmission impacts gives appropriators and oversight committees the data they need to act. Sharing that documentation with state public health officials, congressional staff, and the press converts administrative changes into a public record.
For Louisiana readers, HB 211 sits before the Senate Judiciary C Committee. The cost-effectiveness data is unambiguous, and the bill's own structure invites scrutiny: a program that requires payment from people who cannot afford housing, with unpaid labor as the alternative, will not produce the rehabilitative outcomes its sponsors claim. Constituent contact with committee members, paired with testimony from clinicians and people with lived experience, is the most direct lever. The state's existing crisis with HIV transmission and HCV in rural and Delta communities makes the public health case immediate.
At the federal level, Representative Rashida Tlaib's Unhoused Persons Bill of Rights, reintroduced April 30, 2026, calls on HHS to declare the unhoused crisis a public health emergency and proposes universal housing vouchers, expanded rental assistance, and non-carceral approaches to unsheltered homelessness. The resolution will not pass the current Congress, but its cosponsors are the policymakers most likely to move incremental protections through appropriations and oversight.
The Pridgen et al. review published in Harm Reduction Journal in June 2025 outlines additional federal and state actions worth pursuing: amending 21 U.S.C. 863 to decriminalize syringes and drug-checking equipment; protecting Medicaid coverage of PrEP in light of the Braidwood litigation; expanding scope of practice for nurse practitioners and physician assistants to prescribe PrEP; and opposing Medicaid lockouts based on substance use. None of these require the current administration's cooperation. All of them require sustained engagement from the advocacy community.
The Cost of Choosing Ideology Over Evidence
The federal government has, simultaneously, committed to ending the HIV epidemic, eliminating hepatitis C as a public health threat, and reducing overdose mortality. Yet, achieving any of those goals requires reaching the populations whose injection drug use, housing instability, and disconnection from systems of care drive ongoing transmission and death. The April 24, 2026 SAMHSA guidance, the July 2025 Executive Order, and state bills like Louisiana HB 211 move in the opposite direction. They withdraw the tools that connect public health systems to the people they are meant to serve, and they create incentives for jurisdictions to use enforcement against the populations the federal government has committed to helping.
The evidence on syringe services programs, fentanyl test strips, Housing First, and medications for opioid use disorder is not preliminary. It spans decades, multiple meta-analyses, and the operational experience of the Department of Veterans Affairs, which the current administration has chosen to leave intact. The contradiction is the policy.
For us, the path forward is to keep the evidence in front of the people making decisions: appropriators, state legislators, Medicaid directors, hospital systems, and the press. Public health goals like ending the HIV epidemic and HCV elimination are not abstract aspirations. They depend on specific tools, specific funding streams, and specific connections to the populations most at risk. Each test strip removed, each encampment swept, each treatment-first mandate imposed represents a measurable cost to those goals.
Patients deserve policy grounded in what works. The administrative and legislative actions of the past nine months have moved in a different direction. We have the data, the clinical experience, and the cost analyses to make the case for course correction. The work now is to make that case loudly enough, often enough, and to the people with the authority to act.
The Promise of a Cure: Why Are We Still Failing People with HCV?
Hepatitis C virus (HCV) infection affects millions of Americans, contributing to thousands of preventable deaths each year. While a cure for HCV, in the form of direct-acting antiviral (DAA) medications, has been available for over a decade, achieving widespread treatment access has been a persistent challenge. This challenge is particularly acute among younger adults, who experience the highest rates of new HCV transmissions, often associated with injection drug use.
Historically, the high cost of DAAs led many state Medicaid programs to implement restrictive coverage policies, limiting treatment access based on factors like liver disease severity, sobriety, and prescriber specialty. In 2022, CANN highlighted in a blog post, these policies not only created barriers to care but also undermined public health efforts to interrupt HCV transmission. Advocacy and legal action have played a crucial role in dismantling these restrictions, as evidenced by the Center for Health Law and Policy Innovation's (CHLPI) successful litigation efforts in 13 states, which served as a model for similar efforts nationwide.
While this progress is encouraging, the fight to eliminate HCV as a public health threat is far from over. We must address the remaining barriers to care, particularly those that continue to disproportionately impact people who use drugs and those that persist within managed care organizations.
The Promise and Progress of HCV Treatment
Direct-acting antivirals represent a monumental advancement in HCV treatment. These medications offer cure rates of 95% or higher, achieving sustained virologic response in the vast majority of people treated. The benefits of DAA treatment extend far beyond individual health outcomes. Expanding access to these curative therapies holds immense promise for improving public health by reducing HCV-related mortality, interrupting transmission chains, and generating long-term cost savings.
The Centers for Disease Control and Prevention (CDC) has estimated that approximately 14,200 HCV-related deaths occurred in the United States in 2019 alone, a stark reminder of the urgent need for effective treatment. Treating HCV not only saves lives but also prevents ongoing transmission of the virus. When a person achieves sustained virologic response, they are no longer able to transmit HCV to others. Furthermore, a study published in JAMA Network Open found that HCV treatment is associated with reduced healthcare costs in the long term, as cure prevents the need for expensive interventions related to managing complications like cirrhosis and liver cancer.
The dismantling of restrictive Medicaid policies has been instrumental in increasing treatment access. A JAMA Health Forum study analyzing data from 39 state Medicaid programs found that easing or eliminating restrictions on DAAs led to a significant increase in treatment uptake. Specifically, these policy changes were associated with an increase of 966 DAA treatment courses per 100,000 Medicaid beneficiaries per quarter compared to states that maintained restrictions. This finding underscores the tangible impact of removing barriers to care.
Further progress is evident in the growing trend of states removing prior authorization requirements for DAAs. The 2024 National Snapshot Report from CHLPI and National Viral Hepatitis Roundtable (NVHR) reveals that, for the first time, more states have eliminated prior authorization for most patients than those that still require it. This shift toward streamlining access represents a critical step in ensuring timely treatment initiation.
Persistent Barriers to HCV Treatment Access
Despite the progress made in expanding HCV treatment access, significant barriers remain, particularly for people who use drugs. The 2024 National Snapshot Report from CHLPI and NVHR reveals that nine states still impose substance use restrictions, requiring sobriety or counseling as a prerequisite for DAA treatment. These restrictions are not only medically unnecessary but also demonstrably harmful, as the JAMA Network Open study found a significant association between sobriety requirements and reduced HCV treatment rates. The HealthHIV State of Harm Reduction survey further underscores this point, with respondents reporting that stigma and community resistance pose substantial obstacles to accessing drug user health services, including HCV care.
Retreatment restrictions present another hurdle for people seeking HCV care. According to the 2024 National Snapshot Report, 15 states impose stricter criteria for retreatment than for initial therapy, often denying access based on factors like adherence challenges or previous treatment failure. These policies fail to recognize the complex social and structural factors that can contribute to reinfection or treatment interruptions, particularly among people who use drugs.
Furthermore, disparities in treatment rates among Medicaid recipients persist. The CDC's Vital Signs report found that Medicaid recipients who are Black were 7% less likely to initiate timely DAA treatment compared to White recipients. These disparities reflect the systemic inequities that permeate the healthcare system and demand targeted interventions to ensure equitable access to care.
Discrepancies between state Medicaid policies and managed care organization (MCO) practices present an additional layer of complexity. While many states have eased restrictions on DAAs, the JAMA Health Forum study revealed that these policy changes did not translate into increased treatment uptake in states where DAAs were predominantly reimbursed by MCOs. This finding aligns with the 2022 National Summary Report from CHLPI and NVHR, which found that MCOs often impose more restrictive criteria for HCV treatment access than their fee-for-service counterparts.
These persistent barriers raise serious ethical concerns. Denying treatment based on substance use or adherence challenges perpetuates harmful stereotypes and undermines the principles of patient autonomy and healthcare equity. As Jen Laws argues, "We don't get to tell patients how to prioritize their care based on a payer or provider's biases." The HealthHIV harm reduction survey echoes this sentiment, with respondents emphasizing the importance of meeting people "where they're at" and respecting their right to make informed decisions about their health.
Other administrative barriers, such as requirements to fill prescriptions at specialty pharmacies, further complicate access. The 2022 National Summary Report highlights the challenges posed by specialty pharmacies, which often impose additional restrictions and logistical hurdles that can delay or prevent treatment initiation, particularly for people experiencing homelessness or housing instability.
Harm Reduction and HCV Elimination: A Holistic Approach
Achieving HCV elimination requires a holistic approach that goes beyond simply removing treatment restrictions. We must recognize that HCV treatment access is inextricably linked to broader harm reduction efforts. As Jen Laws aptly stated, "If we are to meaningfully invest in harm reduction policies at the intersection of drug use and HCV, we have to get a handle on what's working and what's not." This means embracing a comprehensive strategy that addresses the social, economic, and structural factors that contribute to HCV risk and disparities.
A 50-state survey of harm reduction laws conducted by the Network for Public Health Law revealed significant variations in the legal landscape surrounding syringe access and naloxone distribution. These variations underscore the need for a coordinated national effort to expand access to these life-saving interventions. The HealthHIV State of Harm Reduction survey further highlights the importance of harm reduction in HCV prevention and care, with respondents emphasizing the need for services that prioritize their safety and well-being.
A truly comprehensive approach to HCV elimination must encompass the following key elements:
Removal of All Remaining Medicaid Restrictions: Eliminating all restrictions based on substance use, retreatment history, and other arbitrary factors is essential for ensuring equitable access to DAAs.
Ensuring Parity Between State Medicaid Policies and MCO Practices: States must strengthen oversight and enforcement mechanisms to ensure that MCOs adhere to state Medicaid policies and do not impose additional barriers to HCV treatment.
Expanding Access to Harm Reduction Services: Increasing the availability of syringe exchange programs, naloxone distribution, and other harm reduction services is critical for preventing new HCV transmissions and connecting people who use drugs to care. However, even in states that do have syringe exchange programs, access can vary widely, with many programs facing funding limitations, geographic restrictions, and community resistance. For example, a 2017 report indicated that 26 states had either no syringe exchange programs or limited these services to one or two major cities. Research suggests that existing programs meet only a fraction of the estimated need, highlighting the need for continued advocacy and policy reform.
Addressing Social Determinants of Health: HCV elimination efforts must address the underlying social and economic factors that contribute to HCV risk and disparities, such as poverty, homelessness, and lack of access to healthcare. The HealthHIV harm reduction survey found that inadequate housing and transportation were significant barriers to clients engaging in care. Investing in housing, transportation, and other social support services is necessary for creating a more equitable and effective HCV response.
The Biden Administration's proposed HCV elimination plan offers a transformative framework for addressing many of these challenges. The plan's key elements include a subscription-based payment model for medications, investment in rapid point-of-care testing, and increased federal support for community-based healthcare infrastructure and provider training. However, as CANN CEO Jen Laws emphasizes, successful implementation requires more than just affordable drugs. The plan must prioritize reinvestment of cost savings into public health systems, support community-based testing and integrated treatment models, and address logistical barriers to care. Federal legislation mandating opt-out HCV screening in hospitals, universal screening in prisons, and cost-sharing limits on commercial insurance plans would further strengthen the plan's foundation.
Conclusion
While significant progress has been made in expanding HCV treatment access, the fight to eliminate HCV as a public health threat demands a sustained and multifaceted effort. The Biden Administration's proposed plan offers a promising roadmap, but its success hinges on congressional budget approval and addressing the systemic barriers that continue to impede progress.
To effectively combat HCV, we must move beyond a narrow focus on medication access and embrace a holistic approach that prioritizes harm reduction, addresses social determinants of health, and ensures equitable access to care for all. CANN’s latest HIV/HCV Co-Infection Watch report provides a valuable resource for understanding the current landscape of HCV treatment access and harm reduction programs across the United States, empowering advocates and communities to push for meaningful change. Together, we can translate the promise of a cure into a reality for all Americans affected by HCV.
All Together Now: West Virginia’s HIV Outbreak
On April 5th, 2021, Washington’s “Most Important Man”, Senator Joe Manchin, submitted a Congressional Inquiry to the Centers for Disease Control regarding the well-publicized HIV outbreak in Kanawha County, West Virginia. The CDC has called the West Virginia HIV outbreak “the most concerning” in the United States, with an unprecedented growth in new diagnoses related to intravenous drug use (IDU). For context, in 2018, the county reported just two new HIV diagnoses related to IDU compared to at least thirty-five new diagnoses related to IDU reported in 2020 – New York City, with a population almost forty-five times that of Kanawha County, reported thirty-six new HIV diagnoses related to IDU in 2019.
A. Toni Young, founder and executive director of Community Education Group and Rural Health Services Provider Network, said, “We kinda saw this coming, unfortunately. The state has been facing a Hepatitis C outbreak for years now [related to substance use] and the lack of coordinated response between stakeholders, specifically providers, with different areas of expertise has kept us siloed and limited in our response – we’re approaching this as multiple epidemics rather than a syndemic.”
Dr. Demetre Daskalakis, the CDC’s Director of HIV Prevention, told a news outlet, “It is possible the current case count represents the tip of the iceberg.” Young echoes this sentiment, “I think we have a state-wide outbreak.” They’re not wrong to believe this outbreak extends across the state, given a 2020 presentation on the Cabell County outbreak, also citing the state’s long fight against opioid use. Though, improvement in the outbreak in Cabell County has already begun, thanks, in large part, to a syringe exchange program – a situation near the mirror opposite of Kanawha County, where a similar county-run program closed its doors in 2018 after city officials and first responders complained about used syringes being improperly disposed of.
Local officials, however, seem steeped in their “moral panic” and rebuffed the CDC’s assessment of the outbreak and requested a federal inquiry into the data provided by the CDC.
While local, volunteer-lead program, Solutions Oriented Addiction Response (SOAR) has stepped in to fill the syringe exchange need, problems have plagued the organization. In January, while under police investigation – which found no wrong-doing on the part of the organization – the program paused operations. During that time, co-founder Sarah Stone, said clients requested bleach in order to clean syringes, even while volunteers advised those same clients such a practice would not guarantee safety.
All while this is transpiring, the state legislature is considering a bill that will significantly impact how syringe services programs operate. SB 334 would give county health departments more freedom to shut down SSPs, require clients provide identification in order to receive services, and require SSPs to obtain a special permit to operate. Opponents of the bill call it a move that may drastically harm community trust and willingness to engage the programs, give leeway to local political pressure as opposed to proven public health interventions, and potentially prevent these community-based programs from operating all together.
Young has a different perspective. “Ok. If this is the way we have to go, show me the data. Let’s use this chance to see exactly how much this move will cost or save the state in terms of all resources – I’m talking money and lives. We cannot forget people’s lives are stake here.” Young goes further and credits the state’s health department operations in their response to COVID-19 as successful – proof the state is able to response appropriately to a public health emergency, when provided enough resources. Young specifically cites resources to include financial of rural hospitals, community-based programming and services, and, rightly, the people-power to enact these services.
In order to meaningfully address the syndemic nature of the state’s situation, Young calls on public health officials and both federal and state legislators to prioritize a holistic, coordinated response to addressing HIV, HCV, SUD, and COVID-19. “Listen, we can do this. It’s just a matter on if we want to do this. We need MAT [medication assisted treatment] providers, addiction services providers, HCV screeners, Ryan White providers, county health departments – all of us need to be at the same table and seeing our clients, our community, as the same people. We cannot split a single person into multiple ‘problems’, we shouldn’t be treating our residents’ needs as if they can be split apart.” Indeed, the National HIV Strategy calls for this type of coordination. “We need an integrated plan – an integrated workgroup,” Young added.
Mirroring a sentiment other advocates have voiced, Young also thinks public health metrics should shift to be more reflective of the client experience, rather than the service provider’s experience, “A referral is not care and it shouldn’t count as care.”
“I’m not gonna sugar-coat this,” Young concluded, “we need money and people and the investment into meaningful, collaborative infrastructure to meet the needs of this community.”