Global Health Division, International Development Group, RTI International, Washington, DC, USA.
Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA.
J Int AIDS Soc. 2022 Jul;25 Suppl 1(Suppl 1):e25908. doi: 10.1002/jia2.25908.
In Ghana, men who have sex with men (MSM) are estimated to be 11 times more likely to be living with HIV than the general population. Stigmas at the intersection of HIV, same-sex and gender non-conformity are potential key drivers behind this outsized HIV disease burden. Healthcare workers (HCWs) are essential to HIV prevention, care and treatment and can also be sources of stigma for people living with HIV and MSM. This article describes the process and results of adapting an evidence-based HIV stigma-reduction HCW training curriculum to address HIV, same-sex and gender non-conformity stigma among HCWs in the Greater Accra and Ashanti regions, Ghana.
Six steps were implemented from March 2020 to September 2021: formative research (in-depth interviews with stigma-reduction trainers [n = 8] and MSM living with HIV [n = 10], and focus group discussions with HCWs [n = 8] and MSM [n = 8]); rapid data analysis to inform a first-draft adapted curriculum; a stakeholder adaptation workshop; triangulation of adaptation with HCW baseline survey data (N = 200) and deeper analysis of formative data; iterative discussions with partner organizations for further refinement; external expert review; and final adaptation with the teams of HCWs and MSM being trained to deliver the curriculum.
Key themes emerging under four immediately actionable drivers of health facility intersectional stigma (awareness, fear, attitudes and facility environment) informed the adaptation of the HIV training curriculum. Based on the findings, existing curriculum exercises were placed in one of four categories: (1) Expand-existing exercises that needed modifications to incorporate deeper MSM and gender non-conformity stigma content; (2) Generate-new exercises to fill gaps; (3) Maintain-exercises to keep with no modifications; and (4) Eliminate-exercises that could be dropped given training time constraints. New exercises were developed to address gender norms, the belief that being MSM is a mental illness and stigmatizing attitudes towards MSM.
Getting to the "heart of stigma" requires understanding and responding to both HIV and other intersecting stigma targeting sexual and gender diversity. Findings from this study can inform health facility stigma reduction programming not only for MSM, but also for other populations affected by HIV-related and intersectional stigma in Ghana and beyond.
在加纳，男男性行为者（MSM）感染 HIV 的可能性比普通人群高 11 倍。HIV、同性恋和性别不一致之间的耻辱感是导致这一不成比例的 HIV 疾病负担的潜在关键驱动因素。医疗保健工作者（HCW）是 HIV 预防、护理和治疗的重要组成部分，他们也可能是 HIV 感染者和 MSM 面临耻辱的来源。本文描述了将一个基于证据的减少 HIV 耻辱感的 HCW 培训课程改编为解决加纳大阿克拉和阿散蒂地区 HCW 中的 HIV、同性恋和性别不一致耻辱感的过程和结果。
从 2020 年 3 月到 2021 年 9 月，实施了六个步骤：形成性研究（对减少耻辱感的培训师[n=8]和感染 HIV 的男男性行为者[ n=10]进行深入访谈，以及对 HCW[n=8]和男男性行为者[n=8]进行焦点小组讨论）；快速数据分析以提供第一份改编课程草案；利益相关者改编研讨会；与 HCW 基线调查数据（n=200）和形成性数据的更深入分析相结合的改编三角分析；与合作伙伴组织进行进一步改进的迭代讨论；外部专家审查；以及与接受培训以提供课程的 HCW 和男男性行为者团队的最终改编。
在卫生机构交叉耻辱感的四个直接可操作驱动因素（意识、恐惧、态度和设施环境）下出现的关键主题为 HIV 培训课程的改编提供了信息。根据调查结果，对现有的课程练习进行了分类：（1）扩大需要修改以纳入更深层次的男男性行为者和性别不一致耻辱感内容的现有练习；（2）生成新的练习以填补空白；（3）保持无需修改的练习；以及（4）删除由于培训时间限制而可以删除的练习。为了应对性别规范、认为男男性行为者是一种精神疾病以及对男男性行为者的歧视性态度，开发了新的练习。
要解决“耻辱感的核心”问题，需要了解和应对 HIV 以及针对性和性别多样性的其他交叉耻辱感。这项研究的结果不仅可以为 MSM，还可以为加纳和其他地区受 HIV 相关和交叉耻辱感影响的其他人群提供卫生机构减少耻辱感的方案。
