The 2018 World AIDS Day theme, ?Know your Status,? highlighted global concern over lack of progress in HIV testing uptake. Nearly a quarter of people living with HIV remain untested, depriving them of opportunities to enter into the HIV prevention continuum and access to proven prevention tools like preexposure prophylaxis. Consistent data highlight the role of HIV-related stigma as a barrier to accessing prevention services. This barrier can be even more pronounced for individuals facing additional discrimination on account of behaviors considered societal taboos such as same sex practices. Such intersectional stigma, or the juncture of multiple stigmatized identities, can reinforce HIV prevention barriers by discouraging individuals from HIV testing for fear it will associate them with other taboo behaviors or by lowering the quality of healthcare received from providers who assume that all members of a certain key population have HIV. Disentangling the layered nature of HIV stigma to inform a better understanding of its complexity is critical to developing comprehensively effective stigma interventions. We propose a standardized patient (SP) approach to obtain an improved measure of enacted healthcare stigma and inform design of a stigma intervention to improve behaviors of healthcare providers and increase practice-level HIV test uptake. SPs are actors hired from the local community and trained to present standardized, unannounced disease cases in area clinics for the purposes of evaluation and feedback. Their ability to objectively document provider behaviors through unannounced visits presents an elegant solution to the classic challenges of stigma measurement: low provider willingness to self- report discriminatory behaviors and the common tendency to alter one?s behaviors under observation. We will dispatch SPs using an experimental audit approach that varies the sexual orientation and HIV status of presented cases in order to obtain discrete measures of HIV, sexual, and intersectional stigma. A return of these stigma results (RoR) with local providers and MSM will then be used to solicit their views on stigma drivers and to inform design of a tailored stigma reduction intervention. We hypothesize that an intervention incorporating the feedback of those closest to the problem?providers and MSM?will more effectively reduce HIV, sexual, and intersectional stigma and increase practice-level HIV test provision, relative to a standard of care. Our interdisciplinary team combines expertise in HIV prevention, LGBT health, HIV stigma, standardized patient research, and medical education to investigate the following aims: 1) develop an experimental audit to conduct baseline assessment of sexual, HIV, and intersectional stigma in STD practices; 2) conduct a RoR of the experimental audit to solicit input from providers and MSM on the stigma intervention; and 3) conduct a pilot cluster randomized control trial (RCT) to assess feasibility, acceptability, and preliminary impact of the intervention. Pilot study outcomes will directly inform design of a full scale, multi-site RCT to formally evaluate the effectiveness of SP-driven interventions to reduce enacted and intersectional stigma in healthcare settings.
Our awareness about the deleterious effects of intersectional stigma on entry into the HIV prevention continuum are at odds with the availability of viable solutions. Standardized patients provide a way to objectively measure intersectional stigma enacted in healthcare settings, and in so doing unlock novel strategies for intervening on its underlying causes. This research will reduce barriers to prevention services for gay, bisexual, and other men who have sex with men, a group facing disproportionately high risk of HIV infection in countries of low, middle, and high income countries.
