RCT of an intersectional stigma intervention to sustain viral suppression among women living with serious mental illness and HIV in Botswana

抽象的。 减少耻辱以确保严重精神疾病(SMI)和HIV患者的病毒载量(VL)受到抑制是一种 全球优先事项，包括在博茨瓦纳，在那里，性传播疾病、艾滋病毒和妇女身份的污名是 边缘化的方式阻碍了对精神药物和抗逆转录病毒治疗(ART)的坚持， 这可能会威胁到VL的压制。我们将我们的小说《最重要的是什么》(WMM)方法应用于目标 博茨瓦纳SMI和HIV患者通过减少耻辱干预面临的跨部门耻辱 首次精神科住院出院后的高风险过渡期。WMM概念化如何 当人们不能通过参加活动来达到“完全的人格”时，耻辱感受最强烈。 这在他们当地的背景下是最重要的。在先前的研究中，我们发现“完整的女性”的核心价值在于 博茨瓦纳是通过成为家庭的基础而实现的，并受到以下方面的威胁：1) 不能履行与SMI相关的家庭照顾者的职责，以及2)与以下相关的滥交 感染了艾滋病毒。在博茨瓦纳，家庭被接受为可行的“家庭照顾者”也是获得“完整身份”的关键。 一个女人。因此，被确认为患有SMI和艾滋病毒(例如，抛弃伴侣/家庭)的风险可能 阻止精神疾病和抗逆转录病毒治疗的坚持。提升对实现“最充分”最重要的能力 女性身份可以在精神病患者出院后更长期地减少耻辱，当女性 重新融入他们的社区，提高抗逆转录病毒治疗的依从性，促进持续的VL抑制。我们的 以小组为基础的WMM耻辱干预由一名有效应对SMI和HIV的同龄人领导 耻辱。WMM污名干预模式在博茨瓦纳艾滋病毒携带者中试行， 有望在产后4个月内减少耻辱和抑郁症状。我们现在测试一个 为患有SMI和HIV的妇女量身定做的WMM干预将减少交叉耻辱并促进VL 压制。我们提出了一项双臂随机对照试验(RCT；N=180)，随访4个月 比较1)基于WMM的跨部门污名干预在客户过渡时的有效性 从精神科住院到门诊护理(WMM耻辱干预；n=90)；以及2)注意力控制 遵循类似的格式以隔离干预的影响(n=90)。因为家庭通常都牵涉其中 在SMI患者和面临严重耻辱的护理中，我们建议在以下人群中进行平行的群体耻辱干预 与家庭成员合作，因为解决家庭耻辱问题可促进坚持治疗。最后，因为 跨部门的耻辱在系统层面上得到加强，我们寻求赋予患有SMI和艾滋病毒的女性以影响 通过组织政策制定者研讨会进行结构性改革，以减少政策制定者的耻辱并刺激 政策制定者通过未来的政策解决患有SMI和艾滋病毒的妇女的独特需求。

Abstract. Reducing stigma to ensure viral load (VL) suppression for women with serious mental illness (SMI) and HIV is a global priority, including in Botswana, where the intersectional stigma of SMI, HIV and womanhood is marginalizing in ways that impede adherence to both psychiatric medications and antiretroviral therapy (ART), which can threaten VL suppression. We apply our novel ‘what matters most’ (WMM) approach to target intersectional stigma faced by women with SMI and HIV in Botswana via a stigma-reduction intervention in the high-risk transition period after discharge from an initial psychiatric hospitalization. WMM conceptualizes how stigma is felt most acutely when people are unable to achieve ‘full personhood’ by participating in the activities that ‘matter most’ in their local context. In prior research, we found the core value for ‘full womanhood’ in Botswana is achieved by being the ‘foundation of the household’ and is threatened by perceived: 1) incompetence in fulfilling the duties of a family caregiver associated with SMI and 2) promiscuity associated with having HIV. In Botswana, family acceptance as a viable ‘family caregiver’ is also key to achieving ‘full status’ as a woman. As such, the risks of being identified as having SMI and HIV (e.g., partner/family abandonment) can deter psychiatric and ART treatment adherence. Promoting capabilities that ‘matter most’ for achieving ‘full womanhood’ could enable longer-term stigma reduction after psychiatric discharge, when women are reintegrating into their communities, and improve ART adherence and promote sustained VL suppression. Our group-based WMM stigma intervention is co-led by a peer woman who has coped effectively with SMI and HIV stigma. The WMM stigma intervention model was piloted among pregnant women with HIV in Botswana with promising reductions in stigma and depressive symptoms up to 4-months postpartum. We now test whether a WMM intervention tailored for women with SMI and HIV will reduce intersectional stigma and facilitate VL suppression. We propose a two-arm randomized controlled trial (RCT; N=180) with a 4-month follow-up to compare the effectiveness of 1) WMM-based intersectional stigma intervention delivered as clients transition from psychiatric hospitalization to outpatient care (‘WMM Stigma Intervention;’ n=90); and 2) attention control following a similar format to isolate the effects of the intervention (n=90). Because family are commonly involved in the care of people with SMI and face severe stigma, we propose a parallel, group stigma intervention among family members, as addressing familial stigma could facilitate treatment adherence. Finally, because intersectional stigma is reinforced at systemic levels, we seek to empower women with SMI and HIV to influence structural change by coleading policymaker workshops to reduce stigma among policymakers and spur policymakers to address the unique needs of women with SMI and HIV via future policies.