Background: The harm reduction workforce serves underserved populations disproportionately impacted by HIV, substance use, and poverty. While heavy workload and limited support are thought to contribute to this trend, few studies have examined predictors of intent to leave among these providers. To understand this landscape, HealthHIV fielded the State of Harm Reduction™ Inaugural National Survey (N=763) in 2023 with harm reduction professionals across community and clinical and behavioral health settings.

Methods: Respondents were asked whether they considered leaving their job in the prior six months. Multivariable logistic regression (Model 1; n=474) examined predictors of attrition intent, including workload, emotional drain, personal safety, lived experience with drug use, workforce shortages, and compensation. A parallel model (Model 2; n=226) restricted the analysis to peers in the harm reduction workforce.

Results: Nearly half of respondents (45.6%) had considered leaving their job in the prior six months; 24.5% reported feeling emotionally drained at least weekly. In adjusted models, emotional drain was the dominant predictor of attrition intent in the full sample (AOR=5.65; 95% CI: 3.71–8.61; p<0.001), followed by poor/stagnant compensation (AOR=2.00; 95% CI: 1.32–3.03; p=0.001). Among the peer workforce, emotional drain remained the strongest predictor (AOR=6.83; 95% CI: 3.56–13.08; p<0.001), while low/neutral leadership respect was a significant independent predictor (AOR=3.03; 95% CI: 1.62–5.69; p<0.001). Personal safety, lived experience, and increased workload were not significant in adjusted models.

Conclusions: Emotional drain emerged as a dominant driver of attrition in the harm reduction workforce, eclipsing workload and safety concerns. For peer workers, disrespect from organizational leadership constituted a distinct structural risk factor. Interventions to retain the harm reduction workforce must address burnout prevention and ensure peer workers receive recognition to ensure the sustainability of HIV prevention and drug user health services nationwide.