Reducing Stigma in People Who Inject Drugs with HIV Using a Rapid Start Antiretroviral Therapy Intervention

HIV transmission continues in low- and middle-income countries (LMIC), especially among key affected
populations (KAP) and in settings of high stigma and discrimination. In Malaysia, a LMIC in SE Asia, HIV
incidence and mortality is increasing. HIV is concentrated among KAPs, especially people who inject drugs
(PWID), a group that has substantially lower ART prescription and viral suppression (VS) levels relative to other
KAPs, undermining HIV treatment as prevention (TasP) goals. PWID are especially vulnerable to overlapping
and intersectional stigmas due to criminalization drug use and sex work, experiences with incarceration, social
class and the presence of HIV itself. Our preliminary studies confirm high levels of negative stereotypes,
prejudice and stigma toward PWID among medical students and HIV experts, with clear evidence of intention to
discriminate against PWID by withholding ART prescription. Stigma-reducing interventions have mostly centered
on educational and contact-based strategies. Such strategies, however, appear less effective where stereotypes
and stigma are deeply entrenched, as in Malaysia, thus requiring the introduction and testing of alternative
strategies. Behavioral design interventions are potentially effective ways to address stigma in such settings.
Behavioral design interventions use tools like framing, nudges, and choice architecture, which can be used to
re-design how physicians behave – or make non-discriminatory healthcare decisions. Rapid start antiretroviral
(RS-ART) is an evidence-based strategy to initiate ART immediately, thereby supporting TasP goals by reducing
time to VS, achieving VS and improving individual health. It has not been tested among PWID. It fits the criteria
for behavioral design interventions by re-arranging clinician decision-making by first focusing on eligibility criteria
(i.e., presence of opportunistic infections) rather than inaccurate perceptions of ART adherence or
deservedness. Behavioral design interventions have not been tested in HIV stigma research, nor has they been
assessed longitudinally or infusing clinically relevant dyads analyses of patients and clinicians. To guide the
behavioral design of RS-ART among PWID, we will use the Delphi method to develop guidelines. Then we will
use nominal group technique, a rank-ordering mixed method strategy to assess the multi-level barriers and
facilitators to RS-ART for PWID, in order to adapt existing RS-ART protocols for PWID. Once the new guideline
concordant RS-ART protocol is developed, we will pilot test it in 125 PWID over six months and conduct a
longitudinal dyadic analysis of patients and clinicians of stigma, physician trust and social support. The RS-ART
protocol will be refined further during pilot-testing to determine its utility as a stigma-reducing intervention that
can be tested in a future implementation trial. This proposal brings over 17 years of productive collaboration
between Yale and University of Malaya, with expertise in clinical HIV and addiction treatment, participation in
clinical guidelines development, mixed methods research, intervention development and refinement, multi-level
stigma assessment and intervention and dyadic analyses.

Grant Number: 5R01TW012674-03
NIH Institute/Center: NIH
Principal Investigator: FREDERICK ALTICE