Mitigating the Impact of Stigma and Shame as a Barrier to Viral Suppression Among MSM Living with HIV and Substance Use Disorders

摘要 男男性行为者(MSM)占美国艾滋病毒携带者的69%。在MSM和 与艾滋病毒携带者、物质使用障碍(SODS)携带者发生性行为的性别少数人是 与对艾滋病毒护理的参与不足有关，通常导致间歇性未抑制的病毒载量 (VL)或病毒反弹，从而通过增加艾滋病毒传播风险来推动流行病。行为 科学发现，由于经历过的耻辱和结构性不平等而持久存在的内在化耻辱， 影响艾滋病毒护理的次优参与度，由此产生的未抑制的VL，以及 加肥皂的味精。耻辱和相关的情绪(例如，羞耻)会直接损害健康结果 (例如，通过次优遵守和预约出席)和间接(例如，作为社交障碍 服务接洽)。需要干预措施来解决耻辱和羞耻作为病毒传播的障碍 对男男性接触者和感染艾滋病毒和肥胖症的性别少数人的压制。为了满足这一需求， 我们开发、改进和实施了一项试验RCT(K23DA043418)，以评估可行性和 事件干预的可接受性--证据和社区信息的心理行为 通过减少内化耻辱和羞耻对病毒的影响来促进病毒抑制的干预 患有肥胖症的男男性行为者对艾滋病护理的参与度。这一事件干预旨在缓解 内化的耻辱和羞耻对病毒抑制的负面行为后果) 行为自我照顾目标设定技能和相关自我效能，b)提高元认知意识 (即对认知和情绪的非评判意识)，以及c)同情的自我重组 (即，自我同情)。它包括5个一对一的虚拟治疗会议和双向个性化 短信以扩大干预的影响，同时使用较少的干预时间和电话- 基于资源导航。拟议的混合类型1功效-实施研究将使用RE- 目的评估框架：1)物质干预对最终病毒抑制的效果 12个月的随访期与时间匹配的对照组进行比较 对照试验(RCT；N=256)，2)建议的事件干预机制，以告知未来 干预措施，以减轻污名的影响；3)促进者和障碍， 实施和维持将在两个优先地点进行的事项干预 主要区别：波士顿、马萨诸塞州和佛罗里达州迈阿密大都市区。是否应该进行干预 有效，并确认创新的内部化耻辱缓解方法，我们将很好地- 定位于利用已确定的促进者和实施此干预的障碍 男男性接触者和少数性别人群与感染艾滋病毒和肥皂症的男性发生性关系 混合类型2试验，以评估可扩展性，包括全面的成本效益评估。

ABSTRACT Men who have sex with men (MSM) make up 69% of people living with HIV in the US. Among MSM and gender minority individuals who have sex with men living with HIV, substance use disorders (SUDs) are associated with inadequate engagement in HIV care, often leading to episodic unsuppressed viral load (VL) or viral rebound, thus driving the epidemic through elevated HIV transmission risk. Behavioral science identifies that internalized stigmas perpetuated by experienced stigma and structural inequities, influences sub-optimal engagement in HIV care, resultant unsuppressed VL, and transmission among MSM with SUDs. Stigma and related emotions (e.g., shame) compromise health outcomes both directly (e.g., via sub-optimal adherence and appointment attendance) and indirectly (e.g., as barriers to social services engagement). Interventions are needed to address stigma and shame as barriers to viral suppression among MSM and gender minority individuals living with HIV and SUDs. To meet this need, we developed, refined, and conducted a pilot RCT (K23DA043418) to assess the feasibility and acceptability of the MATTER intervention, an evidence- and community- informed psychobehavioral intervention to facilitate viral suppression by reducing the impact of internalized stigma and shame on engagement in HIV care among MSM with SUDs. The MATTER intervention aims to mitigate the negative behavioral consequences of internalized stigma and shame on viral suppression by a) behavioral self-care goal setting skills and related self-efficacy, b) increasing metacognitive awareness (i.e., non-judgmental awareness of cognitions and emotions), and c) compassionate self-restructuring (i.e., self- compassion). It involves 5- one-on-one virtual therapy sessions and bidirectional personalized text messaging to extend the impact of the intervention while using less interventionist time and phone- based resource navigation. The proposed hybrid type 1 efficacy-implementation study will use the RE- AIM framework to assess: 1) the efficacy of the MATTER intervention on viral suppression at the final 12-month follow up visit compared to a time-matched control arm using a fully powered randomized controlled trial (RCT; N=256), 2) the proposed mechanisms of the MATTER intervention to inform future interventions to mitigate the impact of stigma, and 3) facilitators and barriers to the reach, adoption, implementation, and maintenance of the MATTER intervention to be conducted in two priority locations with key differences: the Boston, Massachusetts and Miami, Florida metro areas. Should the intervention be efficacious, and the innovative internalized stigma mitigation approach be confirmed, we will be well- positioned to leverage the identified facilitators and barriers to implementing this intervention among MSM and gender minority people who have sex with men living with HIV and SUDs in a subsequent hybrid type 2 trial to assess the scalability, including a full cost-effectiveness assessment.