Estamos Juntos (We are Together): Improving HIV care delivery by capacitating health care providers

Project Summary
Mozambique has made progress towards their 95-95-95 goals, yet only 65% of people newly initiated in HIV
treatment remain in care at 12 months. HIV treatment adherence has been undermined by a lack of
compassionate health care service delivery. People living with HIV in our study region of Zambezia province
report being treated disrespectfully by health care workers as one of the leading causes of treatment
abandonment. Common complaints include insulting patients’ intellectual capacity, ignoring concerns with side
effects or co-occurring infections, and refusing to treat patients seen as “unworthy”. While health care worker
behavior is appalling, it is likely a reflection of high rates of burnout, job dissatisfaction, and frustration with
patients they perceive to be uncooperative.
The implementation of Estamos Juntos (We are Together) will allow us to test a multiprong intervention
designed to address provider-barriers to delivering compassionate care via two synergistic components: (1)
Resilience and well-being training for health care providers who have expressed low job satisfaction, frustration
with delivering care in an extremely resource-limited setting, and burnout; and (2) Anti-stigma training for health
care providers who see those with low socioeconomic status, low levels of education, and those living with HIV
as “lesser-than” themselves. We propose to pilot test the implementation and impact of each psychosocial
intervention individually, and in combination, using a randomized controlled trial design at four health facilities.
We hypothesize that the facility where health care workers receive both resilience and anti-stigma training will
see the greatest change in health care worker outcomes, including decreased stigmatizing attitudes, emotional
exhaustion, and depersonalize of their patients, as well as increased resilience and job satisfaction. Patients
receiving care and treatment from intervention providers will show increased retention and medication
adherence, as well as improvements in health care services satisfaction, medical mistrust, and perceived stigma
from health care providers.
The Specific Aims of this study are to: (1) Evaluate the impact of resilience training only, anti-stigma training
only, and resilience and anti-stigma training (vs. standard of care) on hypothesized mechanisms of behavior
change among health care providers employing the RE-AIM framework through a cluster randomized controlled
trial; and (2) Investigate the impact of provider training to reduce stigma and increase wellness and resilience on
patient adherence to HIV treatment.
Our study team has more than a decade experience developing and testing HIV and associated mental health
interventions in Mozambique. If successful, our intervention can be tested through the R01 mechanism in a fully
powered trial designed to improve both provider and patient health outcomes.

Grant Number: 5R34MH127975-03
NIH Institute/Center: NIH
Principal Investigator: Carolyn Audet