Multi-Level Intervention Addressing Intersectional Stigma to Improve HIV Testing in MSM

STUDY DESCRIPTION OVERVIEW. Our goal in this study is to determine the feasibility, acceptability and preliminary estimate of effect size of a multi- level intersectional stigma-reduction intervention on HIV testing among MSM in Ghana. This study has two phases: a formative phase and a test phase. The eight-step ADAPT-ITT framework will guide our approach to enhancing the interventions' content to address intersectional stigma and combine the three separate interventions into one multi- level approach. Aim 1 will encompass steps 1-7, leading to the combined multi-level intervention adapted to deepen intersectional stigma content and step 8 in which the study team will conduct a waitlist-controlled RCT of the adapted intervention for feasibility and acceptability. In Aim 2, data generated in the RCT will be used to estimate the effect size of the multi-level intervention on HIV testing among MSM (primary outcome) and intersectional stigma reduction (secondary outcome) among the MSM and HCF staff. In deciding on the RCT with wait-list control was considered with other designs such as factorial designs and a classic RCT design with time and attention-matched controls. It was determined that the RCT with wait-list control was superior to the other designs because our study is premised on the need for combined interventions. Since it is not intended yet to seek to isolate which component of the intervention had the greatest effect on our outcomes, a factorial design was not scientifically justified for our proposed study. Additionally, ethical and budgetary considerations informed our decision to forgo using a structurally equivalent control in favor of a wait-list control for the intervention given the evidence of each interventions' efficacy for reducing stigma among HCF staff and improving HIV testing among MSM.

FORMATIVE PHASE STEP 1: ASSESS Focus group discussions (FGDs) and in-depth interviews (IDIs) will be conducted with MSM and HCF staff to inform the adaptation of the three existing interventions to deepen intersectional stigma content and their integration with each other to address intersectional stigma at multiple levels. FGDs were chosen because of their demonstrated suitability in studies of sexual health and to capitalize on the spontaneous conversational interaction that occurs in groups. This re-creation of the social dynamic with the HCF staff and MSM is critical to the understanding of intersectional stigma from the social organization of these two groups. There are also plans to conduct a limited set of individual interviews to examine more in-depth, topics that elicit intimate personal accounts that may not be suitable for sharing in groups. For example, MSM PLHIV are targeted for IDIs to gain insight into whether and how intersectional stigma experiences influenced their pre- diagnosis prevention behaviors, access to prevention services, timing of HIV testing and linkage to care post-diagnosis.

Qualitatively, the following will be investigated:

1. the drivers and manifestations of HIV, same-sex and gender non-conforming stigmas (intersectional stigma) within HCFs and MSM peer groups
2. how these intersecting stigmas undermine HIV testing
3. perspectives on strategies for reducing intersectional stigma within HCFs and among MSM peer groups. This information will guide to what degree and how these stigmas are addressed within the intervention.

In each study city (Accra and Kumasi), 2-4 FGDs will take place in each with HCF staff and MSM, as well as IDIs with HP+ trainers from the pilot phase (n=10) and MSM with HIV (n=8). The purpose and expectations of involvement in the study will be explained to prospective participants.