Intersecting stigma against MSM in clinical settings in Zambia

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Abstract Zambia is one of the top 10 countries with the highest HIV prevalence rates (~12.3% prevalence rate among adults) in the world1,2, with an estimated prevalence rate of 33% among men who have sex with men (MSM)3. Although the Zambian government has recently included MSM in its HIV prevention agenda, intervention efforts for MSM are limited due to criminalization of homosexual behaviors and persistent stigma and discrimination against MSM2-4. Stigma against homosexual behaviors is often intertwined with the religious notion that HIV infection is divine punishment for MSM5. The compounded effect of stigma associated with multiple marginalized identities (intersecting stigma) impede MSM’s access to the HIV treatment cascade (diagnosis, linkage to care, retention in care, initiation of antiretroviral therapy, treatment adherence, and viral suppression)6,7. The anticipation and experience of intersecting stigma in clinical settings further drive MSM away from receiving timely and quality HIV prevention and care services8,9. Although stigma reduction interventions among healthcare providers have been identified as a priority in the HIV prevention and care agenda for MSM in Sub-Saharan Africa8,10, none of such programs is available in Zambia. Research examining the drivers, manifestations, and effects of intersecting stigma among healthcare providers in the legal and cultural context of Zambia is extremely limited. Very few existing empirical studies have linked intersecting stigma with MSM’s (dis)engagement in HIV prevention and care which is critical to achieve the 90-90-90 goals. In addition, limited data are available regarding the needs and efficacious strategies for stigma reduction intervention in clinical settings in Zambia. To fill in these research gaps, we aim to conduct a mixed-methods study that will: a) examine drivers/facilitators and manifestations of intersecting stigma against MSM through policy reviews and in-depth qualitative interviews with MSM and key stakeholders; b) explore the effects of intersecting stigma and potential mechanisms of such effects in clinical settings on MSM’s (dis)engagement in the HIV treatment cascade through quantitative surveys among MSM and healthcare providers; and c) identify the needs and effective strategies for stigma reduction interventions in clinical settings in Zambia based on triangulation of data collected via policy reviews and qualitative and quantitative studies. The preliminary data and experience we gain from this study will position us to develop a healthcare provider intervention that aims to reduce intersecting stigma against MSM in clinical settings and to improve their linkage to the HIV treatment cascade.