“[I]t will be like a full course meal”: healthcare worker perspectives on strategies to optimize integration of PrEP into medication for opioid use disorder and needle and syringe exchange programs for people who use drugs in Kampala, Uganda

BACKGROUND: Integrating pre-exposure prophylaxis (PrEP) into facility-based medication for opioid use disorder (MOUD) and community-based needle and syringe exchange (NSP) programs may optimize service provision and reduce HIV acquisition among people who use drugs (PWUD). Healthcare workers (HCWs) providing PrEP or substance use services to PWUD offer important insight into potential challenges and strategies for effective integration. METHODS: Between March 2021-September 2022 HCWs experienced in PrEP or substance use service provision for PWUD were purposively sampled from five program sites in Kampala, Uganda that offered MOUD, NSP or in-patient and outpatient rehabilitation services. Interviews were guided by the Consolidated Framework for Implementation Research and conducted with a range of HCW cadres, including nurses and social workers. Sample size was determined based on information power. Interviews were conducted by Ugandan social scientists, audio recorded, translated, and transcribed verbatim. Directed content analysis was used to identify HCW perspectives on determinants affecting implementation of and priority strategies for integrating PrEP with MOUD and NSP services. RESULTS: Thirty HCW interviews were conducted; the median age of participants was 32 years (IQR: 28-36), and 54% identified as male. HCW knowledge about PrEP varied across program sites, but all recognized the importance of HIV prevention among PWUD and advocated for training to ensure successful integration of PrEP with MOUD and NSP service programs. By offering the "whole package" of services in one setting, HCWs felt that PrEP service integration prioritized client needs and provided a relative advantage when compared to existing facility-based delivery. HCWs were most enthusiastic about community-based PrEP integration strategies that would take "services to clients where they are," address client concerns about stigma experienced in facilities, and remove prohibitive transportation costs. HCWs recommended community-based refill models and longer-acting PrEP products to address transportation barriers, engaging peers in delivery approaches to reduce stigma and create "friendly" environments that improve service utilization and having a dedicated PrEP implementation "champion" to optimize integration. CONCLUSIONS: HCWs viewed PrEP integration with MOUD and NSP services as acceptable, appropriate, and feasible and recommended peer delivery as a best approach, especially in community settings, such as at drop-in centers focusing on service provision for PWUD.