Exploring Stigmas and HIV Diagnosis Delay, Linkage and Retention for MSM in Ghana

 描述(申请人提供)：本申请书地址为PA-13-246。加纳男男性行为者(MSM)中艾滋病毒感染率为17.5%，是普通人群的15倍。对同性行为和身份的耻辱在加纳很常见，往往与与艾滋病毒相关的象征性耻辱信念交织在一起，使感染是对MSM的神圣惩罚的观念永久化。不符合当地男性性别规范的男男性接触者特别容易受到污名。这些耻辱可能是导致脱离艾滋病毒护理的主要原因，因为他们害怕受到嘲笑和虐待。与艾滋病毒护理的联系和保留对于实现病毒抑制、改善症状管理和降低死亡风险至关重要。脱离接触可能导致获得抗逆转录病毒治疗的机会减少，并随之而来的是艾滋病毒病毒载量、艾滋病毒症状和艾滋病毒症状痛苦的增加。然而，尽管加纳男男性接触者中艾滋病毒的流行率极高，但关于艾滋病毒、同性和性别不一致的污名如何与艾滋病毒护理联系和保留、艾滋病毒病毒载量和艾滋病毒症状困扰有关的科学知识存在空白。此外，尚不清楚耻辱和临床结果之间的联系是否由艾滋病毒护理中联系和保留的减少所调节。我们提出了三个目标来缩小这些知识差距，并支持未来的干预研究。在目标1中，我们将从艾滋病毒流行率最高的四个加纳城市招募基于地点(n=150)和同伴驱动(n=75)的艾滋病毒阳性男男性行为者样本，并比较两种策略，其中一种策略产生的男男性行为者脱离护理的产量最高。我们还将对同行驱动型样本中的一部分招聘人员进行简短访谈，以探索在招聘过程中遇到的挑战(包括耻辱)。在目标2中，我们将使用结构化调查数据来测试潜在的中介因素(即艾滋病毒护理联系和保留)，这些因素可能解释基于地点和同行驱动的组合样本(N=225)中耻辱和临床结果之间的关联。该调查将包括艾滋病毒、同性和性别不一致污名和艾滋病毒症状苦恼的心理测量学验证量表。HIV病毒载量将从静脉穿刺血样本中进行量化。在目标3中，我们将使用从组合样本中故意选择的男男性接触者的定性访谈进行解释性民族志研究，这些男男性接触者是因为他们在疾病病程后期被诊断为艾滋病毒感染者(n=10)，或者因为他们有很高的艾滋病毒症状痛苦评分，但与护理无关(n=10)，或者以前与艾滋病毒护理有关但目前没有参与(n=10)。访谈数据将与我们在实地收集的其他数据进行三角测量，包括不引人注目的观察、实地笔记和记录MSM社会和文化背景要素的数字照片(文物)。这项研究的结果将为设计实地艾滋病毒护理协调干预措施奠定基础，该干预措施结合了同伴外联以识别目前不在护理中的男男性行为者，以及同伴支持/辅导战略，以帮助减轻污名对联系和保留护理的影响。

 DESCRIPTION (provided by applicant): This application addresses PA-13-246. HIV prevalence among men who have sex with men (MSM) in Ghana is 17.5%, which is 15 times higher than that of the general population. Stigma against same-sex behaviors and identities are common in Ghana and often intertwined with symbolic HIV-related stigma beliefs, perpetuating the notion that infection is divine punishment for MSM. MSM who do not conform to local masculine gender norms are especially vulnerable to stigma. These stigmas can be major contributors to disengagement from HIV care for fear of ridicule and mistreatment. Linkage to and retention in HIV care are critical for achieving viral suppression, improving symptom management, and reducing risk of mortality. Disengagement can lead to decreased access to antiretroviral therapy and concomitant increases in HIV viral load, HIV symptoms and HIV symptom distress. Nonetheless, despite the extremely high HIV prevalence in MSM in Ghana, there are gaps in scientific knowledge regarding how intersecting HIV, same-sex, and gender nonconformity stigmas are associated with HIV care linkage and retention, HIV viral load and HIV symptom distress. Further, it is unknown if associations between stigmas and clinical outcomes are mediated by decreased linkage and retention in HIV care. We propose three aims to narrow these knowledge gaps and support future intervention research. In Aim 1 we will recruit venue-based (n=150) and peer-driven (n=75) samples of HIV positive MSM from four Ghanaian cities with the highest HIV prevalence in MSM, and compare the two strategies for which one produces the greatest yield of MSM that are disengaged from care. We will also conduct brief interviews with a subset of recruiters from the peer-driven sample to explore what challenges (including stigmas) were encountered during recruitment. In Aim 2 we will use structured survey data to test potential mediators (i.e., HIV care linkage and retention) that may explain associations between stigmas and clinical outcomes in the combined venue-based and peer-driven samples (N=225). The survey will include psychometrically validated scales for HIV, same-sex, and gender non-conformity stigmas and HIV symptom distress. HIV viral load will be quantified from venipuncture blood samples. In Aim 3 we will conduct an interpretive ethnography using qualitative interviews from MSM purposively selected from the combined sample because they were diagnosed with HIV late in the course of the disease (n=10) or because they have high HIV symptom distress scores, but are not linked to care (n=10) or were previously linked to HIV care but are not currently engaged (n=10). Interview data will be triangulated with other data collected throughout our time in the field, including unobtrusive observations, field notes, and digital photographs (artifacts) that document elements of the social and cultural contexts of the MSM. Findings from this study will lay the groundwork for the design of a field- based HIV care coordination intervention that integrates peer-outreach to identify MSM not currently in care and peer-support/mentoring strategies to help mitigate the impacts of stigmas on linkage and retention in care.