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Aims:  This study concerns the perspectives of Indigenous persons who use injection drugs (IPWIDs) and key stakeholders across multiple sectors regarding healthcare service and treatment accessibility in the United States.Methods:Sixty in-depth interviews were undertaken with selected participants (30 people who use injection drugs and 30 stakeholders) across three non-urban locations in the United States. An inductive analytic approach was used to explore perspectives regarding healthcare accessibility gaps.Results:IPWIDs described injecting stimulants, opioids, and diverted medications for opioid use disorder, as well as having unstable access to sterile syringes. Often, the most accessible treatment for IPWID substance use was engagement with punitive aspects of the criminal justice system. While local health and social services were described as providing limited or inadequate services for IPWIDs, human capital deficiencies in those agencies and institutions often reinforced barriers to accessibility for IPWIDs, further aggravating the epidemics of Hepatitis C Virus infection and overdose risk in Indigenous communities.Conclusions:Decolonizing approaches to IPWID-centered services are urgently needed to reduce disparities in transmission of infectious diseases and other health consequences of injection drug use among American Indian people. Potential pathways forward include moving away from punitive treatment of IPWIDs by the criminal justice system and toward local, tribally-centered, culturally appropriate treatment models. We identify an urgent need to provide reliable and local access to sterile injection equipment and opioid substitution treatment on or near reservations.

A qualitative study of services accessibility for indigenous persons who use injection drugs across three communities in the United States