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）是一个结束艾滋病毒流行（EHE）的优先状态，因为不成比例的发生， 艾滋病毒以及农村地区艾滋病毒护理连续体的参与率沿着很低。交叉柱头 仍然是结束MO和其他农村地区艾滋病毒流行的一个重大障碍， 能力建设和综合循证减少伤害战略与药物治疗的整合 将阿片类药物使用障碍治疗纳入农村初级保健。毒品、艾滋病毒和性行为相互交织 定向耻辱感是非洲艾滋病毒护理连续性沿着较低参与率的驱动因素， 在密苏里州，美国艾滋病毒感染者和OUD患者正在接受治疗。交叉制定的污名存在障碍 通过阻碍供应商看到价值和兼容性的意愿， 将减少危害战略纳入其现有做法。缺乏研究来考察 交叉的耻辱在塑造供应商的决定，写处方丁丙诺啡，纳洛酮和 密苏里州的预防措施。为了解决研究中的这些差距，我们将使用R21探索/开发奖 1）确定交叉毒品、艾滋病毒和基于性的污名影响的机制 丁丙诺啡提供者对OUD和HIV预防危害减少的传播、接受和采用 实践（目标1a）;使用固定选择调查的丁丙诺啡、纳洛酮和PrEP处方（目标1b） 管理420农村供应商;目标2）与关键利益相关者进行深入访谈，以阐明 在个人，提供者，诊所，社区和政策层面的多层次交叉污名， 减少污名化的战略：（a）提供者（n=30），（B）艾滋病毒感染者和OUD患者（n=24），（c）社区 倡导者（n=6）和（d）OUD和艾滋病毒感染方面的区域领导人（n=6）。本研究的主要假设是 交叉的耻辱阻碍了农村MO为患者提供高质量医疗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，并让他们继续参与护理。的 建议的应用程序嵌入到研究过程的一部分，首先通过广泛的关键利益相关者的使用 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。这项拨款申请的资金将在以下方面开辟新天地： 农村卫生组织，并提供关键援助，以推动扩大减少危害和治疗方法 在缺乏服务的地理区域。拟议的研究将导致开发一种 减少耻辱感干预措施，以增加减少伤害战略和丁丙诺啡的采用和传播 开处方设计新颖的策略是优化的关键 和 治疗， 阿片类药物使用障碍的社区治疗 在MO的农村提供者中感染艾滋病毒，对于解决参与率滞后的问题至关重要。 缓解和抑制。

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.