PROJECT SUMMARY Ohio is facing an HIV epidemic and people who inject drugs (PWID) are at high risk. According to a nation- wide vulnerability assessment, Ohio counties Scioto, Pike, Jackson, Gallia, Meigs, and Vinton are among the top 5% most vulnerable to an HIV outbreak due to injection drug-use (IDU). IDU increases engagement in risky drug-use and sexual behaviors which in turn make PWID vulnerable to HIV acquisition. Stigma, a complex social process where personal attributes or identities are met by social exclusion, rejection, blame, and discrimination, is a significant barrier to HIV prevention utilization. PWID in rural Ohio experience intersecting stigmas related to their substance use and HIV. Drug-use stigma among PWID in rural Ohio has led to healthcare avoidance and anticipation of disrespectful treatment by both providers and the wider community. HIV-related stigma among PWID, while less recognized, is equally pervasive and functions to hinder HIV testing due to concerns about disclosure. Early detection and linkage to care is critical in the fight against HIV. Without a thorough understanding of intersecting drug-use and HIV stigma, PWID will remain at significant risk for HIV. Evidence suggests that at-risk populations, such as PWID, can overcome intersectional stigma by building resilience. Resilience is a process in which individuals positively adapt to adversity through coping strategies that may ultimately improve health-seeking behaviors. PWID in rural Appalachia experience profound drug-use and HIV stigma, yet little is known about the mediating potential of resiliency. A thorough understanding of the mediating potential of resilience is needed to inform effective stigma mitigation interventions among PWID and improve engagement with the HIV treatment and prevention continuum. The overarching objective of this application is to quantitatively examine the joint and independent association of sources of stigma on HIV test utilization and evaluate whether resilience mediates these relationships among PWID in rural Appalachia Ohio. Committee chairmen supporting this application are currently conducting National Institute on Drug and National Center for Advancing Translational Sciences funded research on substance use and treatment among PWID in rural Appalachia Ohio. These existing networks will be leveraged and serve to benefit the current application by providing culturally relevant, quantitative data on mechanisms of resilience as measured by a newly developed and validated PWID Resilience Scale. Our specific aims are to: Aim 1: Examine the independent and joint association of perceived drug-use stigma from everyday and healthcare related interactions on HIV test utilization among PWID in rural Appalachia Ohio. Aim 2: Evaluate whether resiliency mediates the relationship between intersectional drug-use stigma and HIV test utilization among PWID in rural Appalachia Ohio.

PROJECT NARRATIVE The proposed research makes a significant contribution to public health by providing a deeper understanding of the impact of intersecting drug-use and HIV stigma on engagement in the HIV prevention continuum, and the mediating potential of resilience among PWID in rural Appalachia Ohio. Stigma serves as a pervasive barrier to HIV prevention and treatment services, which can increase risky drug-use and sexual behaviors and ultimately the risk for acquiring and transmitting HIV. However, PWID can overcome intersectional stigmas and improve healthcare utilization by building resilience.