Status-neutral community-based multilevel intervention to address intersectional stigma and discrimination, and increase HIV testing, PrEP, and ART uptake among YGBMSM in Ghanaian Slums

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Project Summary Young gay, bisexual, and other men who have sex with men (YGBMSM) make up 63% of the HIV prevalence (18%) among GBMSM in Ghana. Our previous studies show that intersectional stigma and discrimination (ISD) (around HIV, sex, and gender expression) and insufficient HIV knowledge impede HIV testing, PrEP, and ART (HPART) adherence among GBMSM. Those in slums face additional stigma associated with their communities; hence the social and economic barriers in slum communities can intertwine with ISD to exacerbate the risk of HIV infections and discourage HPART adherence among YGBMSM as they internalized stigma and avoid HCF. A status-neutral approach to HIV care can reduce ISD among YGBMSM and HCFs and improve HPART among YGBMSM. Yet, current HIV interventions and programs in Ghana have focused on separate services and predominantly address only testing. To this effect, we propose to adapt a multilevel intervention (LAFIYA, meaning wellness) to address ISD and HPART using status neutrality among YGBMSM and HCF in Ghanaian slums. LAFIYA showed early efficacy in increasing HIV testing/self-testing among HIV-negative or unknown- status YGBMSM in Ghanaian slums. Adaptation to a status-neutral intervention will extend its utility for HIV prevention and care by utilizing scientific advancements around intersectional stigma, HIVST, PrEP, and linkage to care. LAFIYA also mainly focused on GBMSM and involved providers from two facilities who received ISD reduction training. The proposed LAFIYA will include HCF-wide training, PrEP, and ART components. Guided by the eight steps of the ADAPTT-IT model, we will implement the two aims. 1) Adapt a multilevel intervention to address ISD and HPART using status neutrality among YGBMSM. We will conduct FGDs and in-depth interviews (IDI) with YGBMSM (n=70), GBMSM providers (n=20), and NURSES/HCWs (n=80) to deepen understanding of ISD, barriers, and facilitators of HPART adherence among YGBMSM. In a summative analysis, we will integrate realities from providers and YGBMSM to optimize the intervention potential to address ISD and increase HPART. 2) Test the preliminary efficacy of the intervention to address ISD and increase HPART adherence using CRT Design. We will assign YGBMSM (n=240) friend groups to control or intervention groups (n=120) and HCF(n=6) to control or intervention (n=3). The intervention arm will receive LAFIYA. We will collect 3, 6, and 9 months post-intervention data among YGBMSM (n=240) and HCWs(n=300). to measure HPART adherence (primary outcomes), ISD reduction, HIV and status-neutral knowledge (secondary outcomes), and acceptability, appropriateness, and feasibility of the intervention (implementation outcomes). We will conduct additional focus groups and interviews post-intervention among implementers and participants (sample sizes same as in AIM1) to evaluate their experiences with the intervention. The findings will inform intersectional stigma reduction and HIV status-neutral implementation strategies among YGBMSM, slums, SSA, and other high-risk populations in different settings.