Planning a Multi-Level Intervention to Reduce Substance Use Stigma in HIV Prevention and Care

摘要 物质使用障碍（SUD）和艾滋病毒都受到耻辱，即一个属性 被认为是非常不名誉的，容易受到偏见和歧视。对SUD和HIV的污名化 多种来源，包括政策或执行政策的个人（“结构性耻辱”）和卫生 专业人员（“基于提供者的污名”）。人们所经历或预期的来自卫生专业人员的污名 SUD可能会对获得高质量的卫生服务造成障碍。对于需要艾滋病毒的SUD患者 预防或护理，艾滋病毒的额外耻辱可能会加剧与药物使用有关的耻辱，以提高社会 医疗保健的障碍。然而，很少有研究探讨艾滋病毒医疗保健中物质使用耻辱的作用 背景下，或如何干预物质使用的耻辱在这个双重敏感的医疗保健领域。现存研究 在其他医疗保健环境中的物质使用耻辱发现， 反思技术和与吸毒者接触的机会可能会大大减少提供者- 基于耻辱。一个更大的限制是，基于提供者的污名干预研究缺乏实用性， 应用：它们主要侧重于专业人员的态度结果，但不衡量 污名干预措施如何影响医疗保健利用或患者健康结果。艾滋病毒预防 和护理环境，以改善SUD患者的医疗保健质量和结果，干预措施包括 需要减少长期以来与药物使用有关的基于提供者的结构性污名。我们的目标是 调整和完善利用专业教育和组织政策的多层次污名干预措施 解决污名化的结构性驱动因素以及决定污名化的职业态度和行为， 病人护理和健康。为了实现这一目标，这个规划项目将与联邦合格的健康中心合作 （1）为艾滋病毒预防和护理开设药物使用课程 试点测试所展示的环境显著改善了相关知识、态度和计划行动， 对吸毒者的专业污名; 2）使用与CNOHC管理人员的定性访谈 和人员，以确定改善专业决策条件的组织政策， 可能会增强专业教育对减少污名的影响; 3）制定、优化并最终确定一个 试验设计和方案，旨在测试多水平SUD污名干预如何影响 与SUD和专业及患者污名相关的中间结局，以及主要HIV结局 与预防和护理有关。该项目将使用社区参与的研究方法， 制定一个多层次的耻辱干预和试验协议，旨在测试是否结合教育和 组织政策干预措施解决艾滋病毒预防和护理背景下的药物使用污名问题， 最终影响患者的预后。随后的试验研究结果预计将告知未来 专业和组织干预措施，旨在改善对SUD患者的艾滋病毒服务。

SUMMARY ABSTRACT Both substance use disorders (SUDs) and HIV are subject to stigma, namely, the process by which an attribute is deemed deeply discrediting and prone to prejudice and discrimination. Stigma toward SUDs and HIV arises from multiple sources, including policies or individuals who carry out policies (“structural stigma”) and health professionals (“provider-based stigma”). Stigma from health professionals experienced or anticipated by people with SUDs can create barriers to accessing high-quality health services. For people with SUDs who need HIV prevention or care, the added stigma of HIV may compound substance use-related stigma to enhance social barriers to healthcare. However, few studies have examined the role of substance use stigma in HIV healthcare contexts, or how to intervene on substance use stigma in this doubly-sensitive area of healthcare. Extant studies on substance use stigma in other healthcare contexts found that educational interventions incorporating critical reflection techniques and opportunities for contact with people who use drugs may significantly reduce provider- based stigma. An even greater limitation is that provider-based stigma intervention studies fall short of practical application: they largely focus on attitudinal outcomes among professionals, but do not measure the effects of policies or how stigma interventions affect healthcare utilization or patient health outcomes. For HIV prevention and care contexts to improve healthcare quality and outcomes among people with SUDs, interventions are needed to reduce provider-based and structural stigma perennially attached to substance use. Our goal is to adapt and refine a multi-level stigma intervention that leverages professional education and organizational policy to address structural drivers of stigma and the stigmatizing professional attitudes and behaviors that determine patient care and health. To achieve this goal, this planning project will work with federally qualified health centers (FQHCs) to address three Specific Aims: 1) Create a substance use curriculum for HIV prevention and care contexts that pilot testing demonstrates significantly improves knowledge, attitudes, and planned actions related to professional stigma towards people who use drugs; 2) Use qualitative interviews with FQHC administrators and personnel to identify organizational policies that improve conditions of professional decision-making and may enhance the effects of professional education on stigma reduction; and 3) Develop, optimize, and finalize a trial design and protocol that is intended to test how the multi-level SUD stigma intervention influences intermediate outcomes related to SUDs and professional and patient stigma, as well as principal HIV outcomes related to prevention and care. This project will use community-engaged research methods with FQHCs to develop a multi-level stigma intervention and trial protocol that seeks to test whether combining educational and organizational policy interventions addresses substance use stigma in HIV prevention and care contexts, and ultimately affects patient outcomes. The subsequent results of the trial research are expected to inform future professional and organizational interventions seeking to improve HIV services for people with SUDs.