Reducing Intersectional and HIV Stigma among High Risk Women who use Drugs in Kazakhstan, Central Asia: A Multilevel Stigma Resistance and Enacted Stigma Reduction Intervention for Women and Providers

摘要 与艾滋病毒预防和护理的联系不够理想和继续留在艾滋病毒预防和护理中的情况在使用或 注射毒品在美国和全球范围内，部分源于高度的耻辱感。在哈萨克斯坦， 参与艾滋病毒护理和预防的连续性是一个主要的公共卫生目标，因为新的艾滋病毒感染者的数量 从2010年到2017年，感染人数翻了一番，与艾滋病有关的死亡人数增加了32%。在高危妇女中， 在这种情况下使用药物，我们的研究发现，约30%的艾滋病毒感染者，他们不太可能测试 并得到照顾。许多研究表明，经历过、预期过和内化过的污名， 特别是来自卫生保健提供者的信息，是全球范围内艾滋病毒检测和治疗的主要障碍。为 吸毒、感染艾滋病毒和相关耻辱，特别是与性和吸毒有关的耻辱的高危妇女， 以及性别歧视，独立和协同作用，阻碍获得艾滋病毒预防， 然而，哈萨克斯坦目前还没有针对这一关键问题设计和测试的反污名干预措施。 妇女人口和重点对HCP的来源的耻辱。在这里，我们建议设计和评估 可接受性，可行性，并产生信息，以权力的初步有效性试验的三个 组成部分，多层次的参与性干预，以减少与艾滋病毒相关的和交叉的耻辱， 增加获得艾滋病毒预防和护理的机会。第一部分针对高危妇女， 通过以下方式提高对污名的抵制/应对能力，减少预期的/内在的污名： 针对HCP的污名信息;以及B）针对最佳性健康和医疗保健调整HCP培训 吸毒高危妇女的参与。第二和第三部分，针对HCP 和其他诊所工作人员以及从第一部分的执行中产生的信息，包括： 活动;和B）将向HCP提供的培训。无论是宣传活动还是培训， 组件将被设计为减少HCP/工作人员制定的耻辱（以及因此在HCP/工作人员中经历的耻辱）， 妇女），并提高吸毒高危妇女对污名的抵抗力和复原力。所有组件 将协同工作，以减少制定的，经验丰富的和内在的，交叉的耻辱。的方法 依靠基于证据的方法，包括媒体宣传，以减少HCP制定的耻辱，并整合 创新方法，如众包和参与性研究，以提高对污名的抵抗力。成果 这项研究将是独一无二的，它将利用多层次的反污名方法来治疗吸毒的高危妇女， HCP，并对促进艾滋病毒预防和护理参与高度 在全球和美国受到歧视的人群。

ABSTRACT Suboptimal linkage to and retention in HIV prevention and care is prevalent among high risk women who use or inject drugs in both the US and globally, stemming, in part, from high levels of stigma. In Kazakhstan, increasing engagement in the HIV care and prevention continuum is a major public health goal, as the number of new HIV infections doubled from 2010 to 2017 and AIDS-related deaths increased by 32%. Among high risk women who use drugs in this context, our research has found that ~30% are HIV-infected and that they are less likely to test and receive care. Numerous studies have documented that experienced, anticipated and internalized stigma, especially from health care providers (HCP), are key barriers to HIV testing and treatment in global contexts. For high risk women who use drugs, HIV and associated stigmas, specifically stigma related to sex and drug use, as well as gender discrimination, work independently and synergistically to inhibit access to HIV prevention and treatment; yet, there are no existing anti-stigma interventions designed and tested in Kazakhstan for this key population of women and that focus on HCP as sources of stigma. Here we propose to design and assess acceptability, feasibility, and generate information in order to power a preliminary effectiveness trial of a three component, multi-level participatory intervention to reduce HIV-associated and intersectional stigma - and thus increase access to HIV prevention and care. The first component is aimed at high risk women and designed to increase stigma resistance/coping and reduce anticipated/internalized stigma via: a) crowdsourcing of anti- stigma messaging for HCP; and b) adaptation of a HCP training for optimal sexual health and healthcare engagement among high risk women who used drugs. The second and third components, aimed at the HCP and other clinic staff and emerging from the execution of the first component, include: a) the resultant messaging campaign; and b) the training that will be delivered to HCP. Both the messaging campaign and the training components will be designed to reduce enacted stigma by HCP/staff (and thus experienced stigma among women) and increase stigma resistance and resilience among high risk women who use drugs. All components will work synergistically to reduce enacted, experienced and internalized, intersectional stigma. The approach relies on evidence-based methods, including media campaigns, to reduce HCP enacted stigma, and integrates innovative methods, like crowdsourcing and participatory research, to increase stigma resistance. Results of this study will be unique in utilizing multilevel anti-stigma approaches for both high risk women who use drugs and HCP and have important implications for advancing HIV prevention and care engagement among highly stigmatized populations globally and in the US.