“Trust and suspicion” Client and provider perspectives on the acceptability of medication for opioid use disorder among people who inject drugs in Kampala, Uganda

TL;DR

This study explores why people who inject drugs in Uganda accept or reject medication for opioid use disorder, highlighting factors like stigma, access barriers, and social norms.

Contribution

The study provides novel insights into MOUD acceptability in Uganda by analyzing perspectives from both clients and providers through a theoretical framework of acceptability.

Findings

MOUD was highly acceptable among participants and providers due to its perceived health benefits and effectiveness.

Structural barriers like transport costs and clinic hours, along with stigma and misinformation, hindered MOUD uptake.

Social norms around drug-sharing and reliance on traditional healing practices conflicted with MOUD enrollment.

Abstract

Despite 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 (PWID) in Kampala, Uganda.

We conducted a qualitative descriptive study during November and December 2023 in Kampala Capital City, Uganda. In-depth interviews with 20 PWID (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.

MOUD 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.

MOUD was highly acceptable among PWID and providers in Uganda, valued for its effectiveness in restoring health and stability. However, structural barriers, stigma, misinformation, and restrictive enrolment often drove PWID to non-evidence-based treatment. Flexible service models, simplified enrolment procedures, community sensitisation, and collaboration with abstinence-based providers and law enforcement are vital to improving MOUD acceptability.