Multi-Level Intervention Addressing Intersectional Stigma to Improve HIV Testing in MSM - PROJECT SUMMARY
HIV prevalence among men with have sex with men (MSM) in Ghana is at least eight times higher than that of the general
population (2%). MSM in Ghana face high levels of stigma due to HIV status (actual or perceived), same-sex behavior, and
gender non-conformity. These stigmas are documented barriers to HIV prevention and treatment. In our preliminary work
in Ghana (N=137), one-third of MSM had never been tested for HIV. We propose a randomized controlled trial to evaluate
the feasibility, acceptability and estimate effect size of a multi-component, multi-level (organizational, interpersonal, and
intrapersonal-level) intersectional stigma-reduction intervention to increase HIV testing frequency among MSM in Ghana
where HIV, same-sex behavior and gender non-conformity are highly stigmatized. To date, stigma-reduction interventions
in Ghana have focused on uni-level targets (e.g., health care facilities (HCFs)) and addressed one type of stigma (e.g., HIV),
without engaging the intersectional character of the multiple stigmas that MSM encounter. Our specific aims are: (1) to
evaluate the feasibility and acceptability of a novel multi-component, multi-level intervention to address intersectional
stigma and (2) to estimate effect size of the intervention for scale up to a definitive efficacy trial. We will combine three
theory-based interventions that were previously implemented separately in Ghana for reducing stigma at HCF-level,
increasing HIV testing at the peer group-level, and increasing peer social support at the individual-level. We will use the
Convergence Framework for combining interventions. The ADAPT-ITT framework guides our approach to enhancing the
interventions’ content on intersectional stigma. To achieve these aims we will undergo a systematic adaptation that will
refine the individually developed HCF, peer- and individual-level interventions to produce a comprehensive multi-level
intersectional stigma reduction intervention. This will consist of focus groups and in-depth interviews with HCF staff and
MSM to sharpen content on drivers and manifestations of HIV, same-sex and gender non-conforming stigmas within HCFs
and peer groups and how these intersecting stigmas undermine HIV testing. This information will be used to refine the
content of the interventions which will then be reviewed by a workgroup of HCF and Ghanaian MSM. The trial involves 8
HCFs, matched on HCF staff size. Matched pairs will each be randomized to have an intervention and a control arm. Before
assignment to HCFs, 216 MSM, recruited through Starfish Sampling (combined time-location and peer-referral sampling),
will be randomized to receive the intervention or usual care. Each arm of MSM will have members randomized to one of
the four clinics per city and asked to stay in the assigned community-clinic pipeline. Using the RCT design, we will
formally test the following outcomes: HIV testing at 3 and 6 months, acceptability and feasibility. We will fit multi-level
regression models for the predictor variables at the HCF, peer and individual-levels. Based on the study’s findings, we will
finalize a protocol to test our intervention in a definitive efficacy trial.