Missouri (MO) is an Ending the HIV Epidemic (EHE) priority state because of the disproportionate occurrence of HIV as well as poor rates of engagement along the HIV care continuum in rural areas. Intersecting stigmas remain a significant barrier to ending the HIV epidemic in MO and other rural areas by impeding technical capacity building and integration of comprehensive evidence-based harm reduction strategies and medication treatment for opioid use disorders (MOUD) into rural primary care. Intersecting enacted drug, HIV and sexual orientation stigmas are drivers of lower rates of engagement along the HIV care continuum among African American people with HIV and OUD accessing care in Missouri. Intersecting enacted stigmas present barriers to scaling up comprehensive harm reduction by impeding providers' willingness to see value in and compatibility of integrating harm reduction strategies into their existing practices. Research is lacking that examines the role of intersecting stigmas in shaping providers' decisions to write prescriptions for buprenorphine, naltrexone and PrEP in Missouri. To address these gaps in the research, we will use this R21 Exploratory/Development award to 1) identify mechanisms through which intersectional drug, HIV, and sexuality-based stigmas influence buprenorphine providers' diffusion, acceptance and adoption of OUD and HIV prevention harm reduction practices (Aim 1a); buprenorphine, naltrexone and PrEP prescribing (Aim 1b) using fixed-choice surveys administered to 420 rural providers and; Aim 2) conduct in-depth interviews with key stakeholders to elucidate multi-level intersectional stigmas at the individual-, provider-, clinic-, community and policy-levels, and possible strategies to reduce stigma with (a) providers (n=30), (b) people living with HIV and OUD (n=24), (c) community advocates (n=6) and (d) regional leaders in OUD and HIV infection, (n=6). The main hypothesis of this study is that intersectional stigmas inhibit technical capacity building that is necessary for rural MO to offer patients high- quality, comprehensive harm reduction services and integration of EBIs and keep them engaged in care. The proposed application embeds the use of key stakeholders into part of the research process first through extensive buy-in from 9 state associations and government agencies then through qualitative interviews to generate avenues for possible intervention and sustainability. Funding for this grant application will break new ground in rural MO and provide critical assistance to advancing the scaling up of harm reduction and treatment approaches in a geographical area where services are lacking. The proposed research will lead to the development of a stigma reduction intervention to increase adoption and diffusion of harm reduction strategies and buprenorphine prescribing. Devising novel strategies is key to optimizing and treatment, community-based treatments for opioid use disorders HIV infection among rural ...