Personal Trauma and Professional Exposure: A Sequential Explanatory Mixed-Methods Study Exploring Factors Influencing...

Stigma toward people who use drugs (PWUD) in HIV clinical settings undermines engagement in care and worsens health outcomes. Harm reduction (HR) offers relational and structural approaches that may reduce such stigma, yet little is known about how healthcare workers' (HCWs) own experiences shape HR integration into practice. In this sequential explanatory mixed-methods study, 128 HIV HCWs at three clinics in Pittsburgh, PA, and Birmingham, AL, completed surveys on attitudes toward PWUD and HR acceptability. In adjusted models, years of experience caring for people with HIV (PWH) predicted HR acceptability, whereas years of experience with PWUD did not: relative to HCWs with 5 or fewer years, those with 6-10 years (b = 0.45, 95% CI [0.15, 0.74], t = 3.03, p = .003) and more than 20 years (b = 0.62, 95% CI [0.09, 1.14], t = 2.37, p = .02) scored significantly higher on the Harm Reduction Acceptability Scale. Semi-structured interviews with 23 HCWs, analyzed thematically and stratified by years of HIV care, revealed three themes: HR was learned informally rather than through formal training, with HR champions described more often by experienced HCWs; substance use stigma was expressed and recognized differently across experience strata; and personal or family experience with substance use and overdose motivated compassionate care at every level. More experienced HCWs described having HR modeled by mentors and integrating HR into their professional identities. Findings highlight the need for training and mentorship that accelerate this learning so HR becomes a consistently supported standard of care.