"Trust and suspicion" client and provider perspectives on the acceptability of medication for opioid use disorder among people who inject drugs in Kampala, Uganda.

backgroundDespite strong evidence supporting medication for opioid use disorder (MOUD), acceptability varies considerably across contexts. This study explored client and provider perspectives on MOUD acceptability among people who inject drugs in Kampala, Uganda.

methodsWe conducted a qualitative descriptive study during November and December 2023 in Kampala Capital City, Uganda. In-depth interviews with 20 people who inject drugs (10 enrolled, 10 not enrolled) and key informant interviews with 10 MOUD service providers were conducted. Data were analysed using thematic analysis, guided by the Theoretical Framework of Acceptability (TFA) and managed with ATLAS.ti software.

resultsMOUD was highly acceptable among providers, enrolled and non-enrolled participants. Facilitators included comprehensive, person-centered services that addressed health and psychosocial needs, supportive family relationships, alignment with personal recovery goals, and the safety and effectiveness of supervised medication therapy. However, participants encountered significant barriers. Structural challenges such as high transport costs, limited clinic operating hours, and strict enrolment criteria impeded access and continuity. Fear of arrest due to drug criminalization and stigma, both societal and within healthcare settings, further discouraged engagement. Additionally, some participants questioned methadone's effectiveness relative to heroin and reported widespread reliance on traditional and spiritual healing practices, often coerced by family members. Social norms promoting mutual drug-sharing as a symbol of trust were disrupted by MOUD enrolment, resulting in peer resistance and social isolation.

conclusionMOUD was acceptable to people who inject drugs and providers, offering health and social benefits, but barriers, including transport cost, dialysis attendance, stigma, fears of arrests, clinic rules, side effects, and misconceptions, limited access. Scaling up requires flexible clinic rules and service models, community sensitisation, counselling, and collaboration with private, religious, traditional, and law enforcement actors to promote early initiation and broader acceptability.