‘Mothers moving towards empowerment’ intervention to reduce stigma and improve treatment adherence in pregnant women living with HIV in Botswana: study protocol for a pragmatic clinical trial

Abstract

Background With high rates of HIV and multiple vulnerable subgroups across diverse settings, there is a need for culturally based, HIV stigma reduction interventions. Pregnant women who are living with HIV are especially in need of services to protect not only their own but also their children’s lives. Uptake of HIV services worldwide is hindered by stigma towards persons living with HIV/AIDS. While cultural context plays a key role in shaping HIV stigma, these insights have not yet been fully integrated into stigma reduction strategies. By utilizing the “What Matters Most” stigma framework, we propose that an intervention to counter culturally salient aspects of HIV stigma will improve treatment adherence and other relevant outcomes. A pragmatic clinical trial in Botswana will evaluate the “Mothers Moving towards Empowerment” (MME) intervention, which seeks to address HIV stigma in Botswana and to specifically engage pregnant mothers so as to promote antiretroviral therapy (ART) adherence in the postpartum period. Methods This study will test MME against treatment as usual (TAU) among pregnant mothers diagnosed with HIV and their infants. Outcomes will be assessed during pregnancy and 16 weeks postpartum. Women who meet eligibility criteria are assigned to MME or TAU. Women assigned to MME are grouped with others with similar estimated delivery dates, completing up to eight intervention group sessions scheduled before week 36 of their pregnancies. Primary outcomes among mothers include (i) reducing self-stigma, which is hypothesized to mediate improvements in (ii) psychological outcomes (quality of life, depression and social functioning), and (iii) adherence to antenatal care and ART. We will also examine a set of follow-up infant birth outcomes (APGAR score, preterm delivery, mortality (at < 16 weeks), birth weight, vaccination record, and HIV status). Discussion Our trial will evaluate MME, a culturally based HIV stigma reduction intervention using the “What Matters Most” framework, to reduce stigma and improve treatment adherence among pregnant women and their infants. This study will help inform further refinement of MME and preparation for a future large-scale, multisite, randomized controlled trial (RCT) in Botswana. Trial registration ClinicalTrials.gov NCT03698981. Registered on October 8, 2018

Systematic Review of Cultural Aspects of Stigma and Mental Illness among Racial and Ethnic Minority Groups in the United States: Implications for Interventions

“…The next generation of interventions should also consider how to resist stigma by building individual and collective power in these communities (Campbell & Deacon, 2006), including to engage in valued social activities and roles in those cultures (Shinn, 2015). For example, our team recently used the “what matters most” theoretical framework to identify cultural aspects of HIV stigma in Botswana—and ways to resist them—and used these findings to adapt a stigma reduction intervention offered during antenatal care to promote achieving the cultural capabilities that “matters most” for pregnant mothers with HIV (Poku et al., 2020; Yang et al. 2021).…”

HIV-Related Stigma Research as a Priority at the National Institutes of Health

“…The collective array of interventions contemplated to counteract stigma through these awards involve mobile technologies, storytelling through group activities, peer-counseling, resilience building, and health care worker and family caregiver training. For example, developing culturally tailored interventions to empower women to overcome negative effects of stigma can be applied to educating women from diverse cultural backgrounds living with HIV in the U.S. [ 94 , 95 ]. Another study has developed a stigma reduction intervention at time of entry into antenatal care to improve prevention of mother-to-child transmission (PMTCT) services and is easily transferred to similar settings in the U.S. and can help in reducing HIV transmission in this key population [ 96 ].…”

A pilot pragmatic trial of a “what matters most”-based intervention targeting intersectional stigma related to being pregnant and living with HIV in Botswana

“…Implementation outcomes were assessed by what percentage of participants recruited into the intervention condition attended ≥ 1 session (i.e., adoption; [ 18 ]) and of these participants, what percentage attended ≥ 3 additional sessions (i.e., acceptability; [ 18 ]). All scales are described in more detail in the study protocol [ 15 ].…”

“…For pregnant WLHIV in Botswana, achieving full ‘womanhood’ can involve bearing a healthy child by mitigating risk for perinatal HIV transmission, including through ART adherence. This conceptualization provided the foundation for the resulting Moving Mothers towards Empowerment (MME) intervention, administered during pregnancy, which consists of 8 group sessions, is co-led by a trained counselor and a peer mother with HIV, and incorporates key empirically-based strategies to reduce stigma (i.e., psychoeducation, cognitive restructuring, coping skills) [ 15 ]. Each of these intervention components is targeted toward countering intersectional stigma by promoting the capabilities to achieve WMM among pregnant WLHIV.…”