Improving HIV and Depression Outcomes by Reducing HIV-Mental Illness Stigma in Malawi: a pilot effectiveness-implementation trial

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ABSTRACT Among people living with HIV (PLHIV), stigma and mental illness (MI), such as depression, bar access to care and worsen health outcomes, particularly in countries like Malawi where 10% of adults are living with HIV and up to a 25% of PLHIV have co-morbid depression. As depression treatment is increasingly integrated into HIV care, interventions helping to reduce stigma for patients facing multiple and intersecting stigmas— HIV, MI, and intersectional stigma— are crucial for engagement in care and improvement of health outcomes. Yet, most individual-level stigma-reduction interventions address only one type of stigma. As such, there is a missed opportunity to address multiple stigmas at once to serve patients. The overall aim of this proposal is to consolidate an evidence-based HIV-MI stigma-reduction intervention with depression treatment for PLHIV and conduct a hybrid effectiveness-implementation pilot to evaluate its implementation and impact on patient outcomes in Malawi. My long-term career goal is to become a leading researcher on implementing and evaluating intersectional interventions that address stigma and meet the mental health (MH) needs of PLHIV. This K01 award will enable me to build upon my strong foundations in epidemiology, qualitive methods, and implementation science to address gaps in my training and develop the necessary expertise to transition into an independent investigator. My training goals are to obtain: 1) substantive knowledge in intersectional stigma and individual-level stigma-reduction interventions; 2) theoretical and methodological skills to combine and consolidate multiple evidence-based interventions using a participatory community-based research approach; and 3) expertise in designing and executing hybrid effectiveness-implementation studies to evaluate both implementation and clinical (e.g., HIV and MH) outcomes. These goals will be achieved through a combination of direct mentorship, coursework, seminars, directed readings, workshops, conferences and hands-on experience. In my proposed research, I will first combine interventions that address HIV, MI and intersectional stigma, consolidate with depression care for PLHIV and develop plans for implementation drawing from focus groups and interviews (Aim 1). I will then evaluate the implementation of the consolidated HIV-MI stigma- reduction intervention and its impact on patient stigma, depression, and HIV care engagement in a two-site pilot hybrid effectiveness-implementation trial (Aim 2). This innovative research will (a) address HIV, MI and intersectional stigma while leveraging existing MH services, (b) prepare for multi-level stigma-reduction intervention packages, and c) yield detailed insights into barriers and facilitators of implementing stigma- reduction interventions in low-resource settings. Ultimately, the proposed study and training will provide me with the skills and preliminary data for an R01 proposal to conduct a full hybrid effectiveness-implementation trial to implement and evaluate a multi-level stigma-reduction intervention in Malawi.