Kupambana: A Combined Microeconomic Strengthening and Stigma Reduction Intervention for Young People with HIV in Zambia

ABSTRACT In low- and middle-income countries, young people with HIV (YPWH) experience the compounded effects of HIV and poverty stigmas that jointly contribute to suboptimal mental health and HIV care continuum outcomes. Our experience conducting research with YPWH in Zambia - which ranks among the ten countries with the highest HIV prevalence worldwide - has revealed linkages between intersectional HIV and poverty stigmas and mental health problems, which contribute onward to impact antiretroviral therapy (ART) initiation, retention in care, and medication adherence problems among YPWH. In turn, attrition along the HIV care continuum drives high mortality among YPWH. Our formative work establishes the promise for microeconomic interventions with YPWH as a foundation to improve well-being in this population of young adults experiencing the co-occurring challenges of HIV and poverty. However, our formative work also highlights the need to address intersectional stigmas related to HIV and poverty among young adults, in addition to providing livelihood intervention activities, as crucial components to jointly improve the continuum of HIV care and mental health outcomes. In response to PAR-23-190, we propose a combined intervention addressing intersectional HIV and poverty stigmas and strengthening economic capabilities to improve HIV care continuum and mental health outcomes in YPWH in Zambia. This intervention (tentatively named Kupambana or “to overcome”) includes an 8-week program involving two experimental components: (i) stigma reduction support group, consisting of eight weekly group-based educational sessions addressing self-care, health self-efficacy, resilience and empowerment, and coping strategies to minimize internalized stigmas and (ii) vocational and entrepreneurship training (VET) voucher, worth 2,500 Zambian kwacha [ZMW] (or ~150 USD), to pay for training fees and allow YPWH to obtain employable skills; and one usual care component: (iii) a one-time financial literacy group-based educational session. This application has two phases: adaptation and pilot test. Phase 1 will include interviews with ~25 YPLH and 15-20 key stakeholders and formation of a youth advisory board to inform the adaptation and implementation process. Phase 2 will include evaluation of the feasibility, acceptability, implementation costs, and preliminary effects of the Kupambana program on HIV care continuum, mental health outcomes, and mechanisms of change such as stigma. We will randomly assign 100 YPWH to either experimental (Kupambana) or control (usual care) group. We will conduct baseline, end-of-program, and two follow-up assessments at 3- and 6- months after end- of-program. We will also conduct exit interviews to assess fidelity and implementation procedures. If this research shows promise, we will use the findings to support a sufficiently powered R01 application to implement a type 1 hybrid effectiveness-implementation.