Multi-level stigma mitigation intervention for women living with HIV in Blantyre, Malawi

ABSTRACT The proposed research aims to adapt and assess a multi-level intervention package to improve antiretroviral 3 therapy (ART) adherence and viral suppression among women living with HIV (WLHIV) across the lifespan in 4 Blantyre, Malawi. This proposed intervention aims to achieve and maintain viral suppression through improved 5 ART by addressing challenges related to experiences across interpersonal, community, organizational, and 6 structural levels. WLHIV in Malawi experience challenges including violence, social isolation, limited access to 7 quality healthcare, and economic instability. These experiences are often driven by stigma related to HIV and 8 perceived risk behaviors that create obstacles for women and ultimately, epidemic control for HIV. In response, 9 interventions that can reduce both the occurrence and impact of stigma are needed to effectively improve 10 access to quality care, its uptake, and HIV outcomes among women. In response, we have developed a 11 practical, multi-level intervention package that targets facilitators and drivers of stigma at the organizational, 12 community, and interpersonal levels to achieve optimal HIV outcomes. The package aims to innovatively 13 combine evidence-based program components to reduce 1) the occurrence of enacted stigma in interpersonal, 14 community, and healthcare settings, and 2) interrupt key mechanisms through which stigma affects health by 15 improving economic stability, social support, and mental health. This study builds on a strong collaboration of 16 more than 30 years between the Johns Hopkins University, the Malawi Ministry of Health and the Kamuzu 17 University of Health Sciences in Blantyre, Malawi. To accomplish this goal, our specific aims are: 1: Adapt a 18 multilevel intervention package for WLHIV in Blantyre, Malawi using the ADAPT-ITT model; 2: Implement a 19 pilot trial of the adapted multi-level intervention package among WLHIV in Blantyre, Malawi; and 3: Evaluate 20 the implementation process of the adapted multi-level intervention using the Consolidated Framework for 21 Implementation Research (CFIR). Reducing the occurrence and impact of stigma has the potential to support 22 long-term viral suppression, improved health outcomes, and higher quality of life among WLHIV across the 23 lifespan in Malawi. This experienced, multi-disciplinary investigative team brings together clinical, 24 epidemiological, and research expertise across HIV, mental health, stigma measurement and intervention 25 development, as well as decades of experience in clinical trials, research-practice partnerships, and 26 community engagement in Malawi. Our study design elements reflect these rich experiences and leverage 27 both implementation science and conventional observational/interventional approaches.