Pre-implementation findings on the barriers and potential solutions to initiate same-day antiretroviral therapy among people who inject drugs in Malaysia.

Background: Rapid-start antiretroviral therapy (RS-ART), including same-day ART (SD-ART), effectively improves individual and public health by speeding up treatment initiation but is underutilized among people who inject drugs (PWID). As a pre-implementation activity, we assessed barriers and facilitators to SD-ART for PWID in Malaysia using insights from multiple stakeholders.

Methods: We conducted focus groups (n = 4) using nominal group technique (NGT), a mixed-methods research strategy, with PWID, HIV specialists, and community health workers (CHWs) in Greater Kuala Lumpur, Malaysia. This method involved open questions, round-robin listing of ideas, and participant voting to derive a rank-ordered consensus on major implementation barriers and facilitators, organized according to the socioecological model.

Results: Among PWID (n = 5: 15 votes), the highest-ranking barriers included fear of police (40 %), procedural complexity (30 %), and discomfort with HIV providers (27 %). HIV specialists (n = 12: 36 votes) ranked readiness for treatment (27 %), risk of opportunistic infections (20 %), and incarceration concerns (13 %) as key barriers. CHWs (n = 7: 21 votes) pointed to complex appointment systems (33 %), delays in confirmatory testing (19 %), and stigma-reinforcing interactions with clinicians (19 %) as obstacles. Facilitators for PWID included initiating ART before reviewing results (27 %) and same-day counseling (27 %). For HIV specialists, essential strategies were enhancing NGO partnerships (33 %) and expanding ART options like dolutegravir (20 %). CHWs recommended simplifying treatment processes (33 %) and creating a dedicated clinic for HIV services (29 %).

Conclusion: Despite available harm reduction and HIV treatment services, structural and interpersonal stigma significantly hinder SD-ART initiation among PWID in Malaysia. Addressing stigma through tailored ART initiation strategies is crucial for closing this implementation gap.