This Trial Aims to Evaluate the Effect of Two HIV Stigma Reduction Interventions at the Health Facility Level and the Individual Level for People Struggling to Access and Remain in Care in Uganda.

Plain-language summary

The overall goal of the Ssinga Nze study ("Ssinga Nze" means "If it were me" in Luganda, the local language) is to reduce HIV-related stigma and improve access to HIV care, including antiretroviral treatment (ART) and HIV pre-exposure prophylaxis (PrEP), as well as increase linkage to care among people affected by HIV in Uganda. The HIV pandemic has a disproportionate impact on populations at risk of HIV, or living with HIV, who struggle to access and remain in HIV prevention or treatment. Stigma is 'a behavioral manifestation of self or societal disapproval of a condition affecting those who are stigmatized.' HIV-associated stigma is 'negative attitudes and beliefs about people with HIV.' The National Institutes of Health recognizes it as a critical and complex barrier to the uptake and use of PrEP and ART. Much work remains in addressing HIV-related stigma and scaling up treatment and prevention coverage for people affected by HIV. Two evidence-based HIV stigma reduction interventions are available -- (1) Health Policy Plus (HP+) Total Facility Approach (TFA) to Stigma Reduction (a clinic-level intervention) and (2) HIV Education, Empathy and Empowerment (HIVE3) (an individual-level intervention) -- but these have not been adapted and implemented for people affected by HIV in sub-Saharan Africa. HP+ and HIVE3 are complementary interventions that could be combined to reduce stigma at the health facility and individual levels. However, research is needed to determine if the adapted multi-level HP+/HIVE3 intervention, Ssinga Nze (which means "If it was me" in Luganda), reduces HIV-related stigma and improves HIV outcomes for people affected by HIV. To explore these questions, we will conduct a randomized wait-list controlled trial to evaluate the preliminary effectiveness of Ssinga Nze on PrEP adherence and viral suppression, compared to the standard of care, using a status-neutral approach-that is, engagement in care regardless of HIV status. We will also employ qualitative methods to examine the mechanisms of intervention delivery. By leveraging the interdisciplinary expertise of our multi-national research team and working at four health facilities in Central Uganda (Entebbe Regional Referral Hospital, Kisenyi Health Center IV, Kitebi Health Center III and Nsangi Health Center III), we will implement the following Specific Aims: Aim 1: Adapt the multilevel PRISM stigma reduction intervention to address HIV-related stigma for populations struggling to access and remain in HIV prevention and treatment in Uganda (intervention adaptation). Aim 2: Conduct a pilot hybrid type 1 effectiveness-implementation trial to test the preliminary effectiveness of the adapted multilevel Ssinga Nze HIV-related stigma reduction intervention on (a) HIV pre-exposure prophylaxis (PrEP) adherence or (b) viral suppression among people with HIV who struggle to remain on treatment using a status-neutral approach (intervention implementation). Aim 3: Evaluate the implementation of Ssinga Nze using qualitative methods (intervention evaluation). Clinic-level implementation outcomes include adoption, fidelity, and sustainability, assessed through key informant interviews, training attendance sheets, observation checklists, and rapid feedback surveys. Individual-level outcomes include: (1) PrEP adherence at 3 months post-intervention, assessed by urine tenofovir levels (primary outcome), (2) viral suppression defined as HIV viral load below 50 copies/mL, and (3) stigma reduction at 3 months post-intervention (secondary outcomes). This multi-level approach to implementing stigma reduction interventions will improve PrEP and antiretroviral treatment (ART) adherence outcomes among people affected by HIV, build stigma research capacity in Uganda, and generate actionable data for scale-up and program implementation in Uganda and sub-Saharan Africa.

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