Intersectional stigma among rural buprenorphine providers as a barrier to diffusion of harm reduction strategies and interventions to enhance engagement in treatment for HIV and opioid use disorders

密苏里州(密苏里州)是结束艾滋病毒流行(EHE)的优先州，因为 在农村地区，艾滋病毒以及艾滋病毒护理连续体的参与率很低。相交的柱头 仍然是在墨西哥和其他农村地区结束艾滋病毒流行的一个重大障碍，因为它阻碍了技术 能力建设和综合循证减害战略与药物的整合 将治疗阿片类药物使用障碍(MOUD)纳入农村初级保健。交叉制定的毒品、艾滋病毒和性行为 定向污名是非洲人在艾滋病毒护理连续过程中参与率较低的驱动因素 美国密苏里州艾滋病毒携带者和艾滋病患者获得医疗服务。相交的制定的柱头存在障碍 通过阻碍提供商看到价值和兼容性的意愿来扩大全面减少危害的规模 将减少危害战略纳入其现有做法。缺乏研究来检验这一角色 在影响提供者决定为丁丙诺啡、纳曲酮和 密苏里州的预科学校。为了解决研究中的这些差距，我们将使用R21探索/开发奖 1)确定跨部门药物、艾滋病毒和基于性行为的污名影响的机制 丁丙诺啡提供者传播、接受和采用OUD和减少艾滋病毒预防危害 实践(目标1a)；丁丙诺啡、纳曲酮和PrEP处方(目标1b)，使用固定选择调查 对420家农村供应商进行管理；目标2)与关键利益攸关方进行深入访谈，以阐明 在个人、提供者、诊所、社区和政策层面上的多层次交叉污名，以及可能的 减少与(A)提供者(n=30)、(B)艾滋病毒感染者和吸毒者(n=24)、(C)社区的耻辱的战略 倡导者(n=6)和(D)艾滋病和艾滋病毒感染问题区域领导人(n=6)。这项研究的主要假设是 这种相互交错的污名抑制了农村MO向患者提供高质量服务所必需的技术能力建设 优质、全面的减少伤害服务和EBI的整合，并使他们继续从事护理工作。这个 建议的应用程序首先通过广泛的应用将关键利益相关者的使用嵌入到研究过程的一部分 从9个州协会和政府机构购买，然后通过定性访谈产生 可能的干预和可持续性的途径。为这项赠款申请提供的资金将在 并为推进减少危害和治疗方法的推广提供关键援助 在一个缺乏服务的地理区域。拟议的研究将导致开发一种 减少污名干预，以增加采用和传播减少伤害战略和丁丙诺啡 开处方。设计新的战略是优化的关键 和 治疗， 阿片类药物使用障碍的社区治疗 在墨尔本农村提供者中感染艾滋病毒，这对解决落后的参与率至关重要。 减刑和镇压。

Missouri (MO) is an Ending the HIV Epidemic (EHE) priority state because of the disproportionate occurrence of HIV as well as poor rates of engagement along the HIV care continuum in rural areas. Intersecting stigmas remain a significant barrier to ending the HIV epidemic in MO and other rural areas by impeding technical capacity building and integration of comprehensive evidence-based harm reduction strategies and medication treatment for opioid use disorders (MOUD) into rural primary care. Intersecting enacted drug, HIV and sexual orientation stigmas are drivers of lower rates of engagement along the HIV care continuum among African American people with HIV and OUD accessing care in Missouri. Intersecting enacted stigmas present barriers to scaling up comprehensive harm reduction by impeding providers' willingness to see value in and compatibility of integrating harm reduction strategies into their existing practices. Research is lacking that examines the role of intersecting stigmas in shaping providers' decisions to write prescriptions for buprenorphine, naltrexone and PrEP in Missouri. To address these gaps in the research, we will use this R21 Exploratory/Development award to 1) identify mechanisms through which intersectional drug, HIV, and sexuality-based stigmas influence buprenorphine providers' diffusion, acceptance and adoption of OUD and HIV prevention harm reduction practices (Aim 1a); buprenorphine, naltrexone and PrEP prescribing (Aim 1b) using fixed-choice surveys administered to 420 rural providers and; Aim 2) conduct in-depth interviews with key stakeholders to elucidate multi-level intersectional stigmas at the individual-, provider-, clinic-, community and policy-levels, and possible strategies to reduce stigma with (a) providers (n=30), (b) people living with HIV and OUD (n=24), (c) community advocates (n=6) and (d) regional leaders in OUD and HIV infection, (n=6). The main hypothesis of this study is that intersectional stigmas inhibit technical capacity building that is necessary for rural MO to offer patients high- quality, comprehensive harm reduction services and integration of EBIs and keep them engaged in care. The proposed application embeds the use of key stakeholders into part of the research process first through extensive buy-in from 9 state associations and government agencies then through qualitative interviews to generate avenues for possible intervention and sustainability. Funding for this grant application will break new ground in rural MO and provide critical assistance to advancing the scaling up of harm reduction and treatment approaches in a geographical area where services are lacking. The proposed research will lead to the development of a stigma reduction intervention to increase adoption and diffusion of harm reduction strategies and buprenorphine prescribing. Devising novel strategies is key to optimizing and treatment, community-based treatments for opioid use disorders HIV infection among rural providers in MO and is critical to addressing lagging rates of engagement in remission and suppression.