A scalable intervention is needed to remove one of the most potent and persistent drivers of disparities in HIV testing, prevention, and linkage to care globally: clinician stigma toward key populations. Key populations at risk of HIV who experience and/or anticipate stigma from clinicians are less likely to initiate, engage in, and adhere to care, including HIV testing, prevention, and linkage to care services. Researchers have uncovered evidence-based stigma reduction tools that hold promise to reduce stigma among clinicians and narrow HIV disparities globally. Yet, a vehicle to deliver these tools to clinicians at large scale (i.e., beyond single clinics) is currently lacking. The long-term goal of this work is to address clinician stigma globally via the widespread implementation of evidence-based stigma reduction tools via a popular teletraining platform. Project ECHO (Extension for Community Healthcare Outcomes) trains, supports, and empowers clinicians to provide a wide range of specialty care services globally, including HIV testing, prevention, and linkage to care. It uses a ?hub and spoke? model, wherein non-specialists in community setting ?spokes? learn from and collaborate with specialists at academic ?hubs? via videoconferencing technology. The objective of this R34 project is to incorporate evidence-based stigma reduction tools into Project ECHO and pilot test the resulting intervention with clinicians in Malaysia. Malaysia is an optimal testing ground for this project because it exemplifies many social contexts globally, and in the U.S., wherein clinician stigma and HIV disparities are substantial; and the University of Malaya is already a Project ECHO hub for several diseases.
The first aim of this project is to evaluate key elements that will influence the implementation of evidence-based stigma reduction tools via Project ECHO, including evidence, context, and facilitation, and is guided by the Promoting Action on Research Implementation in Health Services (PARiHS) framework. In Phase 1 of this aim, Photovoice will be used to collect evidence regarding experiences of clinician stigma among 30-35 key stakeholders, including key populations at risk of HIV and PLWH. In Phase 2, additional evidence will be collected regarding Malaysian clinician perspectives and the intervention context will be assessed via online focus groups with 30-40 general practitioners and family medicine clinicians. In Phase 3, factors related to facilitation will be assessed by pre-testing the intervention protocol with 5 clinicians.
The second aim i s to pilot test Project ECHO for HIV Prevention and Stigma Reduction among Malaysian clinicians and evaluate its acceptability, feasibility, and preliminary impact on clinician stigma and HIV testing, prevention, and linkage to care services among key populations. General practitioner and family medicine clinicians (n=78) will be randomized to one of 3 study arms: (1) Project ECHO for HIV Prevention and Stigma Reduction, (2) Project ECHO for HIV Prevention only, or (3) control. Following guidelines for Hybrid Type 1 Implementation Trials, the acceptability and feasibility of the intervention will be assessed as well as its preliminary impact. If results support the feasibility, acceptability, and preliminary impact of the intervention, funding will be sought to conduct a large-scale efficacy trial. This line of research will ultimately yield a highly scalable intervention that can be disseminated to practicing clinicians in Malaysia and other countries via an existing, popular teletraining platform to address clinician stigma toward key populations and reduce HIV disparities globally.
Key populations at risk of HIV (including men who have sex with men, people who inject drugs, transgender women, and female sex workers) are often more likely to be infected with HIV but less likely than members of the general population to know of their HIV status, receive HIV prevention counseling, or be linked to HIV care services. Clinician stigma towards these groups remains a potent and persistent driver of these HIV disparities in many places of the world. We propose to incorporate evidence-based stigma reduction tools into a popular teletraining platform for clinicians and pilot test our resulting intervention (Project ECHO for HIV Prevention and Stigma Reduction) with clinicians in Malaysia, a context wherein clinician stigma and HIV disparities are substantial.
