A Multi-level Intervention to Reduce Stigma to Improve HIV Prevention and Treatment Outcomes for People Struggling to Access and Remain in Care.

SCIENTIFIC PREMISE AND THEORETICAL MODEL This study is based on scientific and programmatic evidence that stigma occurring at multiple social-ecological levels hampers access to and motivation for HIV prevention and treatment. It highlights the need for multilevel, evidence-based interventions that use HIV status-neutral approaches. Guided by the social-ecological model, Logie's adaptation for stigma, previous research, and, most critically, input from people affected by HIV in Uganda on prioritizing intervention levels, we propose adapting and combining interventions at the individual and health facility levels. Specifically, at the macro/institutional level, we will focus on healthcare facilities (HCF) and adapt the Health Policy Plus Total Facility Approach for Stigma Reduction [HP+]. At the intrapersonal/individual level, we will adapt the HIV Empathy, Education & Empowerment (HIVE3) intervention. HCFs in Uganda are central to the delivery of HIV prevention and treatment services, and stigma within them impedes access for people affected by HIV. Also, they face ongoing stigma in all dimensions of their lives, fueling internalized, perceived, and anticipated stigma, which can undermine HIV prevention and treatment service engagement.

OVERALL DESIGN The overall goal of the Ssinga Nze study is to address HIV-related stigma and improve access to HIV care, including ART and PrEP uptake and linkage to care among people affected by HIV in Uganda. Specifically, we will adapt (Aim 1) and pilot test Ssinga Nze through a hybrid type 1 effectiveness-implementation trial of the HP+ intervention at the healthcare facility (HCF) level (organizational) and HIVE3 at the individual (intrapersonal) level (Aim 2) to (1) change stigmatizing interactions between HCF staff and people affected by HIV and create more welcoming health facilities by working at multiple levels within the health facility to reduce stigma; (2) offer peer support to individuals to help them cope with and challenge stigma and reduce internalized stigma; (3) develop skills, agency, and social assets among peers and within HCF staff to address stigma; and (4) strengthen partnerships between HCF and civil society organizations through joint intervention design and implementation.

FACILITY-LEVEL INTERVENTION - HP+ HIV stigma-reduction "Total Facility" Approach (TFA) In the PRISM-Ghana study, the original HP+ HIV stigma reduction TFA approach was adapted as part of a multilevel intervention to address HIV-related stigma at the healthcare level by changing drivers of stigma and discrimination among all facility staff, including clinical and nonclinical staff. Grounded in behavior change informed by social cognitive theory principles, the approach focuses on creating space for interpersonal interactions (contact strategies), creating empathy, and building efficacy for stigma reduction through awareness, skills, knowledge building, action planning, and design and implementation of stigma-reduction activities. Consequently, the intervention focuses on improving HCF staff capacity through participatory stigma-reduction training workshops for all staff and integrating a stigma-reduction focus into institutional processes and structures. HP+ addresses immediately actionable drivers of HIV-related stigma in health facilities, including lack of awareness of stigma, fear, attitudes, beliefs, and myths and misconceptions, through participatory training and facility-developed stigma-reduction activities. Doing so catalyzes tangible action because it makes HCF staff realize they can cause meaningful change, produce immediately visible results, and institute long-term changes to permanently reduce HIV-related stigma for people affected by HIV. Recognizing HCF staff as leaders within and beyond the facility helps them effectively use their new understanding of what HIV-related stigma is, why they should address it, and what they need to do to reduce it. Partnerships are built between HCF staff and people affected by HIV through joint training and stigma-reduction intervention implementation teams.

Selected HCF staff (from intervention facilities) and clients (usually not from intervention clinics) form joint intervention teams to deliver the participatory training to HFS and lead other stigma-reduction interventions at the facility. They receive a 5-day training-of-trainers workshop followed by on-site mentoring as they deliver the first round of participatory training to their peers at the HCF level. Each session includes a mix of selected clinical and nonclinical staff from across departments, with numbers, times, and dates determined by facility schedules. The modular training format and the mix of staff across levels and departments allow for flexibility in delivery to accommodate facility schedules and reduce disruption of service delivery. Stigma-reduction leaders, also called champions, are organically identified and supported by HCF management, and are provided with a small grant to develop and implement follow-up in-service stigma-reduction activities - such as a complaint system, staff recognition, and posters - for the HCF.

The initial development and pilot test of the HP+ approach were conducted in Ghana, in partnership with local government and civil society. It aimed to reduce HIV-related stigma in health facilities. At 6-month follow-up, there were greater reductions in intervention facilities relative to the control for most HIV-stigma drivers, such as unnecessary fear of HIV transmission (24%; p<0.001) and preferences not to treat people affected by HIV (14.2%; p=0.001) [50]. Feasibility and acceptability were demonstrated through (a) management demanding that the project train more staff than initially intended, (b) the high completion rate after 2 days of training (91%), (c) the large number of staff trained (1,228) in a short period, and (d) the ability of management and trainers to schedule staff training in a manner that did not disrupt facility operations. Additionally, facilities donated space for training and staff time to attend. Under the PRISM study, which further adapted HP+ to focus on HIV-related stigma, over 1,000 staff were trained in two 4-month waves (treatment and wait-list control). All trainees who started the 2-day training completed it, for a 100% attendance rate. Preliminary difference-in-difference results (unpublished) show that intervention facilities demonstrated significant improvements relative to control facilities on a subscale measuring beliefs and attitudes about gender nonconformity and sexual diversity at both 3 months (p=0.03) and 6 months (p=0.02) post-intervention.