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

摘要 在艾滋病毒(PLHIV)携带者中，耻辱和精神疾病(MI)，如抑郁症，禁止获得 护理和恶化健康结果，特别是在马拉维这样的国家，那里10%的成年人感染艾滋病毒 高达25%的PLHIV患者患有共病抑郁症。随着抑郁症的治疗越来越多地融入 艾滋病毒护理，有助于减少对面临多重和交叉耻辱的患者的耻辱的干预措施-艾滋病毒， MI和跨部门的耻辱--对于参与护理和改善健康结果至关重要。然而， 大多数个人层面的减少污名干预措施只针对一种类型的污名。因此，有一个 错失了一次解决多个耻辱以服务患者的机会。这项建议的总体目标是 将以证据为基础的HIV-MI耻辱减少干预与抑郁症治疗结合起来治疗PLHIV和 进行混合有效性实施试点，以评估其实施及其对患者的影响 在马拉维取得的成果。我的长期职业目标是成为实施和 评估应对耻辱和满足艾滋病患者心理健康(MH)需求的跨部门干预措施。 这一K01奖项将使我能够在流行病学、合格方法和 实施科学，以解决我培训中的差距，并发展必要的专业知识以过渡到 一名独立调查员。我的培训目标是：1)获得跨部门污名方面的实质性知识 和个人层面的减少耻辱干预措施；2)理论和方法技能，以结合和 使用参与性社区研究方法合并多种循证干预措施； 以及3)设计和执行混合有效性--实施研究以评估两者的专门知识 执行情况和临床结果(例如艾滋病毒和MH)。这些目标将通过联合起来实现 直接指导、课程作业、研讨会、定向阅读、研讨会、会议和实践 经验。在我提议的研究中，我将首先结合针对艾滋病毒、心肌梗死和跨部门 耻辱，巩固对PLHIV的抑郁症关怀，并从重点制定实施计划 小组和访谈(目标1)。然后，我将评估艾滋病毒-MI综合耻辱的执行情况-- 减少干预及其对患者污名、抑郁和HIV护理参与度的影响 试点混合成效--实施试验(目标2)。这项创新研究将(A)解决艾滋病毒、MI和 利用现有保健服务的跨部门污名，(B)为多层次减少污名做准备 干预一揽子计划，以及c)对实施耻辱的障碍和促进者提供详细的见解- 低资源环境下的减排干预措施。最终，拟议的学习和培训将为我提供 具备实施完全混合有效性的R01提案的技能和初步数据 在马拉维实施和评估多层次减少污名干预措施的试验。

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.