1. HIV Prevention 2.0 (HP2): Achieving an AIDS-Free Generation in Senegal
Stefan Baral
9th IAS Conference on HIV Science
Paris, France
July 23, 2017
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2. Outline Stigma, HIV, and Key populations Stigma Interventions
HIV Prevention 2.0 Study
Design
Intervention
Results
Stigma results
ART adherence results
Preliminary viral suppression results
Implementation Data
Conclusions

3. Where Stigma Data Are Available for Key Populations
Key populations have a disproportionate burden of HIV.
Where data are available, which is shown in this graph, key populations are also shown to experience high levels of stigma.
Source: Fitzgerald-Husek, Grosso, Van Wert, Ewing, Baral, Systematic Review of Stigma Metrics for Key Populations. JHU, 2014

4. Potential Causal Pathway for Stigma and HIV-Risks
Structural Equation Model
Indirect effect of stigma in health system on sexual risk practices
527 MSM from Lesotho
*p=0.072; **p<0.01
Stigma as upstream determinant of HIV risk
Opportunity
Target stigma to improve HIV risk
What we have learned from some of the data available is that there is a relationship between stigma and HIV infection and HIV related health outcomes in key populations.
We used structural equation model to assess the relationship between stigma and HIV risk behaviors, and we see that stigma is an upstream determinant of HIV and HIV risk behavioral,
The is potential to more effectively impact our traditional indicators of interest, it is important to address upstream indicators related to HIV risk, and in this case stigma
Source: Da, Stahlman, and Baral S. Depressive symptoms and Alcohol use as Mediators of HIV-related risk practices and stigma affecting men who have sex with men in Lesotho : a Structural Equation Modelling Approach, Annals of Epidemiology, 2016

5. A systematic review of interventions to reduce HIV-related stigma and discrimination
Results: Domains and levels targeted and approaches employed in the 48 studies.
Multiple intervention strategies
Target multiple stigma domains
Target multiple socioecological levels
Rationale: HIV-related stigma and discrimination continue to hamper efforts to prevent new infections and engage people in HIV treatment, care and support programmes. The identification of effective interventions to reduce stigma and discrimination that can be integrated into national responses is crucial to the success of the global AIDS response.
Results of Systematic Review
Intervention effectiveness seems to generally improve with more layered intervention
Addressing different domains (drivers, facilitators, appear to
Intervention addressing multiple levels of stigma
Lead to:
Informed interventions for HP2
Anne L Stangl§,1 , Jennifer K Lloyd2 , Laura M Brady1 , Claire E Holland2 and Stefan Baral2

6. HIV Prevention 2.0 Study
Objective: Develop and Evaluate Integrated Stigma Mitigation Interventions
Specific Aim 1: Systematically review the literature for existing stigma metrics that have been used for MSM and FSW.
Specific Aim 2: Use mixed methods approaches to characterize unbiased estimates of the current coverage of HIV prevention and treatment services as well as barriers and facilitators to the uptake of these services among MSM and FSW in Dakar, Mbour, and Thies, Senegal.
Specific Aim 3: Use a prospective cohort of MSM and FSW in Senegal followed for 24 months to evaluate non-randomized Integrated Stigma Mitigation Interventions (ISMI) including peer, clinic, and web-based components.

7. HP2 Study Design Study design: Longitudinal cohort Study Population:
Female sex workers
Men who have sex with men
Location: Senegal
Dakar
Mbour
Thies

8. Integrated Stigma Mitigation Intervention Framework for Key Populations
OUTCOMES
COMMUNITY (Preclinical)
Peer-based approach
Peer led groups sessions
Increase participants efficacy in preventing HIV infection
Reduction of perceived and anticipated stigma
Improve effectiveness of existing HIV services
Increased uptake of these services by key populations
Decrease in reported experienced and perceived stigma
Increased consistent use of condoms and condom compatible lubricants
Increased adherence to HIV treatment regimens
Decreased community HIV viral load
CLINICAL
Training of healthcare workers
Reinforce cultural and clinical competency in service provision to key populations
Reduction of experiences of stigma in health settings
POSTCLINICAL
(Web-based)
Peer-to-peer anonymous referral system
Information on health services and prevention
Reduction of individual stigma

9. MSM N=724 FSW N=758 MSM N=193 FSW N=190 Months
Baseline Month Follow up
MSM
N=724
MSM
N=193
FSW
N=758
FSW
N=190
Months
Abbreviated questionnaires (months 3,9,15, 21)
Full assessment (Baseline, 6, 12, 18, 24)
Analyses from survey data up to month 15

10. Health Care Related Stigma Measures Based on Factor Analyses
Anticipated Healthcare Stigma
Felt afraid seek health services because you worried someone may learn you sell sex/have sex with men
Anticipated
Avoided seeking health services because you worried someone may learn you sell sex/have sex with men
Experienced Healthcare Stigma
Denied health services or had someone keep you from receiving health services because you sell sex/have sex with men
Enacted
Mistreated in the health center because you sell sex/have sex with men
Perceived
Heard health care providers make discriminatory remarks or gossip about you because you sell sex/have sex with men
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11. HIV Prevalence
Source HIV prevalence adults 15-49: UNAIDS. Senegal. 2015;

12. Anticipated Health Care Stigma Among Female Sex Workers
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13. Experienced Health Care Stigma Among Female Sex Workers
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14. Female sex workers currently taking antiretroviral therapy
No significant change in treatment
However, all study visits show treatment above UNAIDS 90% goal
90% UNAIDS goal
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15. Viral suppression among female sex workers
Viral load data for months 9 – 15 are not yet ready for analyses
No significant change in viral suppression, however, viral suppression was high at baseline
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16. Anticipated Health Care Stigma Among Men Who Have Sex With Men
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17. Experienced Health Care Stigma Among Men Who Have Sex With Men
Increase in some enacted stigma measures
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18. Men who have sex with men currently taking antiretroviral therapy
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19. Viral suppression among men who have sex with men
Significant increase in viral suppression
Viral load data for months 9 – 15 are not yet ready for analyses
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20. Implementation outcomes among men who have sex with men
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21. Implementation outcomes among men who have sex with men
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22. Lessons from Preliminary Data
Female Sex Workers
Reduction was observed in anticipated, perceived, and enacted health care stigma
Engagement in ART was above 90% at baseline for female sex workers, and maintained over 15 months
Viral suppression among female sex workers was high at baseline, with no significant change in the first 6 months
Men who have sex with Men
Results showed increase resiliency in men who have with men with reductions in anticipated stigma despite increase in enacted health care stigma
Significant increase in engagement in ART and viral suppression among men who have sex with men
- May want to not use this slide an just highlight as you talk through results – but just in case.

23. Conclusions
There is a disconnect between the potential and actual measured impact of current interventions to address enacted stigmas in health care settings
Baseline and follow up data suggested the potential utility of the multicomponent integrated stigma mitigation intervention
Results reinforce the need for stigma mitigation interventions to be combined with HIV prevention and treatment interventions for key populations

24. Acknowledgements Study Participants JHSPH Key Populations Program
Stefan Baral, Carrie Lyons, Gnilane Turpin, Sosthenes Ketende, Ben Liestman, Karleen Coly, Sheree Schwartz, Remy Serge Manzi
Enda Santé
Daouda Diouf, Fatou Drame, Ibrahima Ba, Awa Kane, Nguissali Turpin
DANTEC
Souleymane Mboup, Nafi Diouf, Halimatou Diop, Coumba Toure-Kane
DLSI
Cheikh Ndour, Karim Diop, Abdoulaye Wade (Retired)
CNLS
Safiatou Thiam
USAID Headquarters and West And Central Africa
Alison Cheng, Delivette Castor, Aisha Yansaneh, Sarah Wiant, Tisha Wheeler, Cameron Wolf, Katie Harris