Multi-level intersectional stigma reduction intervention to increase HIV testing among men who have sex with men in Ghana: Protocol for a cluster randomized controlled trial

Abstract

Background Men with have sex with men (MSM) in Africa face high levels of stigma due to elevated HIV exposure (actual or perceived), same-sex practices, and gender non-conformity. These stigmas are documented barriers to HIV prevention and treatment. Most stigma-reduction interventions have focused on single-level targets (e.g., health care facility level [HCF]) and addressed one type of stigma (e.g., HIV), without engaging the multiple intersecting stigmas that MSM encounter. Determining the feasibility and acceptability of multi-level intervention of reducing intersectional stigma and estimating its efficacy on increasing HIV testing are needed. Methods We proposed a mixed method study among MSM in Ghana. First, we will develop the intervention protocol using the Convergence Framework, which combines three interventions that were previously implemented separately in Ghana for reducing stigma at the HCF-level, increasing HIV testing at the peer group-level, and increasing peer social support at the individual-level. Then, we will conduct a cluster randomized controlled trial with four pairs of HCFs matched on staff size. HCFs within each pair are randomized to the HCF-level stigma-reduction intervention or control arm. MSM (n = 216) will be randomized to receive the group-level and individual-level interventions or standard of care control arm. MSM will be assigned to receive HIV testing at one of the HCFs that match their study assignment (intervention or control facility). The frequency of HIV testing between MSM in the study arms at 3 and 6 months will be compared, and the predictors of HIV testing uptake at the HCF, peer group and individual-levels will be assessed using multi-level regression models. Discussion These findings from this study will provide important evidence to inform a hybrid implementation-effectiveness trial of a public health intervention strategy for increasing HIV case detection among key populations in sub-Saharan African communities. Accurate information on HIV prevalence can facilitate epidemic control through more precise deployment of public health measures aimed at HIV treatment and viral load suppression, which eliminates risk of transmission. Trial registration This study was prospectively registered on ClinicalTrials.gov, Identifier: NCT04108078, on September 27, 2019.

Using a mixed‐methods approach to adapt an HIV stigma reduction intervention to address intersectional stigma faced by men who have sex with men in Ghana

“…Eligible HCF staff ( N = 200) included both clinical and non‐clinical staff employed at a hospital in the parent study [37]. Purposive sampling recruited staff likely to interact with MSM clients by selecting 60% of the sample from key departments (Antiretroviral therapy (ART) clinic, outpatient department, pharmacy and security/reception/management) and 40% from other departments.…”

“…Eligible HCF staff (N = 200) included both clinical and nonclinical staff employed at a hospital in the parent study [37].…”

“…In response, this article describes the process of adapting an evidence‐based HIV stigma‐reduction training curriculum, the Health Policy Plus (HP+) total facility approach [29], to address intersectional HCF stigma towards MSM in Ghana. This adaptation was conducted as an initial step in a study that is testing multi‐level, intersectional stigma‐reduction interventions to address HIV, same‐sex and gender non‐conformity stigma towards and among MSM in eight communities and HCFs in the Greater Accra and Ashanti regions, Ghana [37]. The latter region is more homogenous (most residents are Ashanti) and closely interconnected, whereas the former is more cosmopolitan and “anonymous,” and the traditional setting of the Ga may be more accepting of non‐conforming gender expression.…”

Multi-level Manifestations of Sexual Stigma among Men with Same-Gender Sexual Experience in Ghana

“…Government-sponsored research in Ghana, we also acknowledge the settler colonial history of taxonomizing humans (in Africa, Asia, the Americas, and elsewhere) into groups in order to render them and their sociocultural practices more interpretable and manageable to individuals viewing and administering them through a Western intellectual lens (38,39). Except when making references to speci c sexual identity groups, we use 'MSM' in this paper to refer to the men in the qualitative sample who were recruited in a larger HIV-prevention trial based solely on their self-reported potential HIV risk exposure category classi cation, not on their sexualities (40). We offer this clari cation here as an act of resistance to common practices that uncritically reduce men into behaviors as "MSM", a dehumanizing practice that is entrenched in HIV-prevention literature (41) and one which is admittedly observable in our previous publications (24,(42)(43)(44).…”

“…It is well established that stigma is a social determinant that negatively in uences health and other material and social aspects of daily life in the populations subjected to it (8)(9)(10)(11). In Ghana, the nearly ubiquitous presence of stigma and discrimination toward men with same-gender sexual experiences has the potential to limit the opportunities for these men to achieve and maintain equity in health, well-being, socio-emotional development, and economic progress (12,13).…”