Exploring Stigmas and HIV Diagnosis Delay, Linkage and Retention for MSM in Ghana

Dates: 5/23/2016 - 4/30/2019


Principal Investigator: LaRon Earnest Nelson, PhD, RN, FNP, FNAP, FAAN

HIV prevalence among men who have sex with men (MSM) in Ghana is 17.5%, which is 15 times higher than that of the general population. Stigma against same-sex behaviors and identities are common in Ghana and often intertwined with symbolic HIV-related stigma beliefs, perpetuating the notion that infection is divine punishment for MSM. MSM who do not conform to local masculine gender norms are especially vulnerable to stigma. These stigmas can be major contributors to disengagement from HIV care for fear of ridicule and mistreatment. Linkage to and retention in HIV care are critical for achieving viral suppression, improving symptom management, and reducing risk of mortality. Disengagement can lead to decreased access to antiretroviral therapy and concomitant increases in HIV viral load, HIV symptoms and HIV symptom distress. Nonetheless, despite the extremely high HIV prevalence in MSM in Ghana, there are gaps in scientific knowledge regarding how intersecting HIV, same-sex, and gender nonconformity stigmas are associated with HIV care linkage and retention, HIV viral load and HIV symptom distress. Further, it is unknown if associations between stigmas and clinical outcomes are mediated by decreased linkage and retention in HIV care. We propose three aims to narrow these knowledge gaps and support future intervention research. In Aim 1 we will recruit venue-based (n=150) and peer-driven (n=75) samples of HIV positive MSM from four Ghanaian cities with the highest HIV prevalence in MSM, and compare the two strategies for which one produces the greatest yield of MSM that are disengaged from care. We will also conduct brief interviews with a subset of recruiters from the peer-driven sample to explore what challenges (including stigmas) were encountered during recruitment. In Aim 2 we will use structured survey data to test potential mediators (i.e., HIV care linkage and retention) that may explain associations between stigmas and clinical outcomes in the combined venue-based and peer-driven samples (N=225). The survey will include psychometrically validated scales for HIV, same-sex, and gender non-conformity stigmas and HIV symptom distress. HIV viral load will be quantified from venipuncture blood samples. In Aim 3 we will conduct an interpretive ethnography using qualitative interviews from MSM purposively selected from the combined sample because they were diagnosed with HIV late in the course of the disease (n=10) or because they have high HIV symptom distress scores, but are not linked to care (n=10) or were previously linked to HIV care but are not currently engaged (n=10). Interview data will be triangulated with other data collected throughout our time in the field, including unobtrusive observations, field notes, and digital photographs (artifacts) that document elements of the social and cultural contexts of the MSM. Findings from this study will lay the groundwork for the design of a field-based HIV care coordination intervention that integrates peer-outreach to identify MSM not currently in care and peer-support/mentoring strategies to help mitigate the impacts of stigmas on linkage and retention in care.