PROJECT SUMMARY Ohio is at risk for a severe HIV outbreak, especially among people who inject drugs (PWID). Stigma, including internalized and anticipated stigma, obstructs the utilization of HIV prevention for PWID. PWID in Appalachia Ohio experience profound drug use stigma; however, less is known of the extent of HIV prevention stigma and the intersection with drug use stigma. To address pervasive intersectional stigma inhibiting HIV prevention utilization, resilience may be an essential process to counter traumatic stigmatizing events for PWID. PWID have unique experiences of stigma and need a well-validated measure of resiliency to intersectional drug use and HIV prevention stigma. Yet, there are no quantitative measures of resilience to intersectional stigma tailored explicitly for PWID. Without an appropriate resilience measurement, future interventions will be unable to address intersectional stigma among PWID. The goal of this proposed study is to explore mechanisms of resilience to intersectional drug use and HIV prevention stigma among PWID. We will build upon our existing NIDA and NCATS funded research infrastructure in rural Appalachia Ohio. The proposed work directly addresses the NIDA RFA (RFA-DA-21-002) as it “supports formative research to support the development of stigma reduction interventions” and develops a novel outcome measure that will inform an intervention addressing “multi-level factors (self, provider, and /or setting) to address intersectional stigmas to improve HIV prevention continuum outcomes”. The specific aims are to 1) Understand the mechanisms of resilience to drug use and HIV stigma among PWID in rural Ohio and 2) Develop and validate a PWID Resilience Scale to measure resilience to intersectional stigma for enhancing the HIV prevention continuum. To achieve this, in- depth interviews will be conducted among PWID in rural Appalachia. The interviews will explore how resilience processes are displayed, shared among peers, and enacted to counter the intersectional stigma of HIV and drug use among PWID. The data from these interviews will aid in the development of a PWID Resilience Scale. We will adapt the Conner-Davidson Resilience Scale, which has excellent reliability, validity, and practicality among less stigmatized populations. Cognitive interviews will also be conducted with PWID to ensure that the content is conceptually relevant in this context. Then, we will enroll a cohort of 250 PWID using respondent-driven sampling (RDS) to validate a PWID Resilience Scale in Appalachia Ohio. The culmination of this work will provide a deep understanding and measurement of a novel measure—resilience among PWID in need of HIV prevention. Ultimately, the PWID Resilience Scale will provide the groundwork to address intersectional drug use and HIV prevention stigma and HIV transmission among PWID.