Mitigating sexual stigma within healthcare interactions to improve engagement of MSM in HIV prevention

Long-term objective. My long-term objective is to explore, identify and evaluate acceptable, feasible and appropriate techniques and mechanisms to mitigate HIV-related stigma in healthcare, and thereby to improve the quality of care and outcomes for populations that would otherwise remain deterred from HIV services. Specific aims. I plan to integrate stigma and implementation science frameworks to delineate components of human behavior and environment that influence the manifestation—and mitigation—of stigma during healthcare interactions. I will target a high HIV incidence population, men who have sex with men (MSM), and a rarely studied but important marker of HIV-related stigma, anal sexuality. First, I will explore stigma drivers and mitigators by interviewing 30 healthcare workers (HCWs) responsible for HIV-related screening and care, as well as 30 MSM, both purposively sampled for diversity and variable comfort discussing anal sexuality during healthcare encounters. Then I will develop, with an 8-person advisory board of HCWs and MSM, an intersectional stigma-mitigation intervention to help HCWs navigate discussion of this sensitive topic, improve the quality of care, and thereby promote prevention. The intervention will include educational mHealth, workshop and coaching components. Finally, I will pilot the intervention in a stepped wedge hybrid type 2 design to evaluate acceptability, feasibility, and appropriateness; preliminary impact on HCW behavior (e.g., knowledge, comfort, screening practices); and remaining barriers. The pilot will be among 120 HCWs working in two high MSM incidence regions but who do not specialize in MSM care. Aims respond to OAR priorities, including evaluation of interventions that lead to behavior change by consumers or providers to improve the quality of care and engagement in services. Career-development plan. The above aims rely on a robust, mentored training plan that will prepare me for a career as an independent investigator. My plan involves coursework, directed readings, workshops, and visits to research labs of mentors, to advance my knowledge, proficiency and capacity across five training goals: (1) to learn how to leverage health communication to mitigate stigma; (2) to understand how to develop theory- informed behavioral interventions; (3) to acquire advanced knowledge in mHealth tools; (4) to build expertise in implementation science to accelerate the uptake of interventions in settings where mitigation of stigma is urgently needed; and (5) to strengthen professional skills to develop a successful NIH-funded research career. Environment. NYSPI/Columbia will host my research and training, with mentorship from a team of internal experts in sexuality studies, health communication, and workforce development, and external experts in intersectional stigma (UAB), mHealth (UNC), implementation science (UW), and structural stigma (Yale). In Year 4, I plan to submit an R01 to test the K23 intervention’s techniques, mechanisms, and implementation in a larger stepped wedge trial, with the goal of reducing incidence and viremia. Skills and findings from this award will be broadly applicable to HIV stigmas; future technologies, like rectal microbicides; and other related health domains.