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.
Ghana has an HIV prevalence of 17.5% in MSM and is designated as a high priority country by UNAIDS due to its generalized HIV epidemic, low treatment coverage and high gaps in treatment access. Although stigma and discrimination against MSM in Ghana is high, it is unknown whether certain stigmas undermine linkage and retention in HIV care and consequently increase their risk for poor HIV clinical outcomes. The proposed study will address these critical public health issues by (1) comparing the feasibility of venue-based versus peer- driven recruitment for reaching HIV positive MSM who are not in HIV care, (2) investigating associations between stigmas, HIV care linkage/retention, HIV viral load, and HIV symptom distress, and (3) using qualitative methods to investigate challenges that HIV positive MSM experience in the process of being linked to and retained in HIV care, including the ways in which stigmas contribute to these challenges as well as insights into the conditions necessary for their re-engagement in HIV care.
