M-Suubi: A Multi-level integrated intervention to reduce the impact of HIV stigma on HIV treatment outcomes among adolescents living with HIV in Uganda

项目摘要 为响应PA-20-144呼吁在艾滋病毒预防、检测、坚持和保留方面进行创新，以优化艾滋病毒预防和护理连续结果，我们研究了一种创新的多层次干预措施，即结合多个家庭团体(MFG-HIVSR)减少艾滋病毒污名(MFG-HIVSR)与家庭经济赋权(FE费)干预与基于群体的教育工作者艾滋病毒污名减少(GED-HIVSR)与MFG-HIVSR加FE费(以下简称M-Suubi)相结合的对乌干达在校青少年艾滋病毒感染(ALHIV)患者艾滋病毒治疗依从性和参与护理的影响和成本效益。艾滋病毒污名仍然是乌干达青少年坚持艾滋病毒治疗的一大障碍，导致服药依从率和病毒抑制率低(不到50%)和艾滋病毒治疗服务的高流失率。ALHIV病毒在包括家庭和学校在内的各种环境中经历艾滋病毒污名(内在化、预期化和实施化)，这是最重要的发展背景，否则应该支持他们的发展和福祉。乌干达和撒哈拉以南非洲其他国家教育的一个独特特点是，寄宿中学入学的在校青少年比例很高(超过60%)--寄宿中学是父母选择的制度化照料的一种形式。由于学校内艾滋病毒污名程度高、学校结构和惯例僵化、缺乏坚持治疗的支持以及粮食不安全，学校中的艾滋病病毒感染者处境更为不利，坚持艾滋病毒治疗的水平较低。在家庭内部，艾滋病毒污名以各种形式长期存在，包括歧视和暴力，这往往是由于对感染的毫无根据的恐惧--从而破坏了家庭关系的质量和对ALHIV的支持。基于我们的研究和当前关于减少艾滋病毒污名的证据，我们提出了一项多水平三臂组随机研究(M-Suubi)，具体目的如下：目的1：检查M-Suubi对艾滋病毒病毒抑制的影响(主要结果)；坚持艾滋病毒治疗(预约、药房续药、药片计数)和保留护理(次要结果)；目标2：检查M-Suubi对艾滋病毒污名的影响(内化、预期和实施)，并进行次级分析，以探索假想的改变机制(例如抑郁)和干预调解；目标3：评估每种干预条件的成本和成本效益；目标4：定性检查：a)参与者对HIV污名、HIV治疗依从性和干预的经历；2)教育工作者对ALHIV的态度、GED-HIVSR的经验，以及培训后的计划/政策实施。这项研究将从大Masaka地区42所受艾滋病毒严重影响的学校招募840名ALHIV(流行率为12%，全国平均水平为7.3%)。M-Suubi的提供期限为20个月，评估期限为基线、12、24和36个月。这些发现可能会为联合干预努力提供信息，以优化艾滋病毒治疗结果和ALHIV患者的护理参与。

PROJECT ABSTRACT In response to PA-20-144 calling for innovations in HIV prevention, testing, adherence and retention to optimize HIV prevention and care continuum outcomes, we examine the impact and cost-effectiveness of an innovative multilevel intervention combining Multiple Family Groups (MFGs) for HIV stigma reduction (MFG-HIVSR) with a family economic empowerment (FEE) intervention versus a group-based HIV stigma reduction for Educators (GED-HIVSR) combined with MFG-HIVSR plus FEE (hereafter M-Suubi) on HIV treatment adherence and engagement in care among school-going adolescents living with HIV (ALHIV) in Uganda. HIV stigma remains a formidable barrier to HIV treatment adherence among adolescents in Uganda, contributing to low rates of medication adherence and viral suppression (less than 50%) and high attrition from HIV treatment services. ALHIV experience HIV stigma (internalized, anticipated and enacted) in various settings, including families and schools, the most important developmental contexts that should otherwise be supportive of their development and wellbeing. One of the unique features about education in Uganda and other countries in Sub-Saharan Africa is the high proportion (over 60%) of school-going adolescents enrolled in boarding secondary schools – which represent a form of parental opt-in institutionalized care. ALHIV in schools are more disadvantaged and have lower levels of HIV treatment adherence due to high levels of HIV stigma within schools, rigid school structures and routines, lack of adherence support and food insecurity. Within families, HIV stigma is perpetuated in various forms including discrimination and violence, often due to unfounded fears of infection—hence undermining the quality of family relations and supports for ALHIV. Building on our research and current evidence on HIV stigma reduction, we propose a multi-level three-arm cluster randomized study (M-Suubi) with the following specific aims: Aim 1: Examine the impact of M-Suubi on HIV viral suppression (primary outcome); and adherence to HIV treatment (keeping appointments, pharmacy refills, pill counts), and retention in care (secondary outcome); Aim 2: Examine the effect of M-Suubi on HIV stigma (internalized, anticipated and enacted), with secondary analyses to explore hypothesized mechanisms of change (e.g. depression) and intervention mediation; Aim 3: Assess the cost and cost-effectiveness of each intervention condition; and Aim 4: Qualitatively examine: a) participants’ experiences with HIV stigma, HIV treatment adherence, and the intervention; and 2) educators’ attitudes towards ALHIV, experiences with GED-HIVSR, and program/policy implementation post-training. The study will enroll 840 ALHIV recruited from 42 schools located within the greater Masaka region, heavily affected by HIV (prevalence 12% vs 7.3% national average). M-Suubi will be provided for 20 months, with assessments at baseline, 12, 24 and 36 months. Findings may inform combination intervention efforts to optimize HIV treatment outcomes and engagements in care among ALHIV.