Mitigating Sexual Stigma Within Healthcare Interactions Improve Engagement of MSM in HIV Prevention

Mitigating Sexual Stigma Within Healthcare Interactions to Improve Engagement of MSM in HIV Prevention

The purpose of this study is to explore drivers and mitigators of anal sex stigma in healthcare, and then to develop and pilot an intervention for health workers that mitigates the deterrent effects of this stigma on the engagement of gay and bisexual men in HIV-related services.

Study Overview

• Status: Completed
• Conditions: Patient Engagement; Human Immunodeficiency Virus; Stigma, Social
• Intervention / Treatment: Behavioral: A set of implementation strategies to reduce sexual stigma

Detailed Description

This 5-year study aims to understand determinants that perpetuate and mitigate stigma toward anal sex during healthcare encounters, in order to develop and pilot a strategy that responds to these determinants and thereby improves the quality of care and HIV service engagement among men who have sex with men (MSM). The study team collected data during in-depth interviews with 20 adult MSM as well as 20 adult healthcare workers (HCWs) to identify strategies that could be readily used in health services to reduce stigma. Analysis of this data then informed consultation with an advisory board of HCWs and healthcare consumers (not limited to MSM), to develop the content of a set of implementation strategies to mitigate stigma and thereby improve health service delivery. Evaluation of a set of implementation strategies was performed in the Southern US, a high incidence region, by pilot testing with 65 adult HCWs who in clinical sites where MSM are under-engaged in HIV services.

• Study Type: Interventional
• Enrollment (Actual): 113
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • New York
    • Bronx, New York, United States, 10461
      • Albert Einstein College of Medicine

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes

Description

MSM Participants

Inclusion Criteria:

1. be aged 18 or older
2. report being assigned male at birth and identifying currently as male
3. reside in the United States
4. read and communicate in English
5. have had anal intercourse with a man in the past year or intend to in the next year Exclusion Criteria: Not applicable

Healthcare Worker Participants

Inclusion Criteria:

1. be aged 18 or older
2. read and communicate in English
3. bear a role responsibility for HIV-related screening and referral (e.g., as a peer/outreach worker, test counselor, case manager, social worker, medical assistant, nurse, physician assistant, physician) Exclusion Criteria: Not applicable

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Other: Pre-post design; The pilot intervention will be evaluated using a pre-post design.

Behavioral: A set of implementation strategies to reduce sexual stigma; The set of implementation strategies was finalized based on formative interviews and consultation with an advisory board. This included an in-person workshop for skills development, environmental restructuring through a website of information resources for healthcare consumers and HCWs, and supportive coaching components (i.e., coaching calls, an optional email listserve) and quality improvement meetings with two clinics to encourage and respond to the implementation of recommended practices.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Acceptability, appropriateness, and feasibility of the in-person skills development workshop as assessed by the AFAS	Quantitative assessment using the 13-item Acceptability, Feasibility, & Appropriateness Scale (AFAS), with three subscales for each construct. Acceptability refers to satisfaction with the implementation strategies. Feasibility refers to compatibility of recommended practices with participants' current practices. Appropriateness refers to perceived fit with participants' work mission and goals. Mean scores for individual items and mean scores for subscales will reflect the response category range from 1 (Not at all) to 5 (Extremely), with higher scores indicating, respectively, greater acceptability, appropriateness and feasibility.	Post-intervention, 1 week after completion of the in-person workshop
Acceptability, appropriateness, and feasibility of the website component as assessed by the AFAS	Quantitative assessment using the 13-item Acceptability, Feasibility, & Appropriateness Scale (AFAS), with three subscales for each construct. Acceptability refers to satisfaction with the implementation strategies. Feasibility refers to compatibility of recommended practices with participants' current practices. Appropriateness refers to perceived fit with participants' work mission and goals. Mean scores for individual items and mean scores for subscales will reflect the response category range from 1 (Not at all) to 5 (Extremely), with higher scores indicating, respectively, greater acceptability, appropriateness and feasibility.	Post-intervention, 1 week after completion of all implementation strategies
Acceptability of the in-person skills development workshop as assessed by the AARP	Quantitative assessment using the 8-item Abbreviated Acceptability Rating Profile (AARP). Acceptability refers to satisfaction with the implementation strategies. Mean scores for individual items and mean scores for the overall scale will reflect the response category range from 0 (Strongly disagree) to 5 (Strongly agree), with higher scores indicating, respectively, greater acceptability.	Post-intervention, 1 week after completion of the in-person workshop
Determinants of implementation of the in-person skills development workshop as assessed by the DIBQ	Quantitative assessment using a 25-item adaptation to the Determinants of Implementation Behavior Questionnaire (DIBQ). The DIBQ measures multiple domains from within the Theoretical Domains Framework (e.g., behavioral control, reinforcement) that are posited as determinants of implementation. Mean scores for individual items and mean scores for subscales will reflect the response category range, from 1 (Very difficult) to 7 (Very easy), with higher scores indicating greater positive valence related to that domain.	Post-intervention 1 week after completion of the in-person workshop
Acceptability, appropriateness, and feasibility of the coaching calls as assessed by the AFAS	Quantitative assessment using the 13-item Acceptability, Feasibility, & Appropriateness Scale (AFAS), with three subscales for each construct. Acceptability refers to satisfaction with the implementation strategies. Feasibility refers to compatibility of recommended practices with participants' current practices. Appropriateness refers to perceived fit with participants' work mission and goals. Mean scores for individual items and mean scores for subscales will reflect the response category range from 1 (Not at all) to 5 (Extremely), with higher scores indicating, respectively, greater acceptability, appropriateness and feasibility.	Post-intervention, 1 week after completion of all implementation strategies
Acceptability, appropriateness, and feasibility of the quality improvement meetings as assessed by the AFAS	Quantitative assessment using the 13-item Acceptability, Feasibility, & Appropriateness Scale (AFAS), with three subscales for each construct. Acceptability refers to satisfaction with the implementation strategies. Feasibility refers to compatibility of recommended practices with participants' current practices. Appropriateness refers to perceived fit with participants' work mission and goals. Mean scores for individual items and mean scores for subscales will reflect the response category range from 1 (Not at all) to 5 (Extremely), with higher scores indicating, respectively, greater acceptability, appropriateness and feasibility.	Post-intervention, 1 week after completion of all implementation strategies
Acceptability, appropriateness, and feasibility of the set of implementation strategies as assessed by qualitative interviews	Acceptability, appropriateness, and feasibility will be assessed through in-depth interviews following completion of quantitative assessments, as part of an explanatory sequential mixed-methods design.	Post-workshop (1 week after delivery of the in-person workshop) and post-intervention ( 1 week after completion of all implementation strategies
Changes to determinants of implementation behavior as assessed by the DIBQ	Quantitative assessment using a 26-item adaptation to the Determinants of Implementation Behavior Questionnaire (DIBQ). The DIBQ measures multiple domains from within the Theoretical Domains Framework (e.g., role responsibility, confidence, positive and negative emotions) that are posited as mechanisms of action that mediate behavior change among health care workers. Mean scores for individual items and mean scores for subscales will reflect the response category range, from 1 (Very difficult) to 7 (Very easy), with higher scores indicating ease related to that domain.	(1) Baseline, pre-intervention, (2) Post-intervention 1 week after completion of the in-person workshop, (3) Post-intervention 1 week after completion of all implementation strategies
Changes to knowledge about anal health and sexuality as assessed by the iASK	Quantitative assessment using the 10-item Inventory of Anal Sex Knowledge (iASK). The iASK measures knowledge as a potential mediator of behavior change. All items are scored as True/False for a total percentage of correct responses, ranging from 0-10, with higher scores indicating greater knowledge.	(1) Baseline, pre-intervention, (2) Post-intervention 1 week after completion of the in-person workshop, (3) Post-intervention 1 week after completion of all implementation strategies
Changes to self-efficacy offering social support as assessed by the MOS-SSS Informational and Emotional Social Support Subscale	Quantitative assessment using 8 items adapted from the Medical Outcomes Study Social Support Survey to measure changes in self-efficacy offering social support (e.g., Be someone to give information to help a client understand a situation involving anal sex). Mean scores for individual items will reflect the response category range, from 1 (Very easy) to 5 (Very difficult), with lower scores indicating greater self-efficacy offering informational and emotional social support.	(1) Baseline, pre-intervention, (2) Post-intervention 1 week after completion of the in-person workshop, (3) Post-intervention 1 week after completion of all implementation strategies
Changes to comfort discussing anal health and sexuality as assessed by 10 study-specific items	Quantitative assessment using 10 items developed for the current study to measure changes to comfort discussing anal health and sexuality with clients (e.g., Asking clients about their sexual orientation; Asking clients about their anal sex practices; Initiating a conversation about anal health; Asking clients about their specific questions or concerns related to anal health). Mean scores for individual items will reflect the response category range, from 0 (Not at all comfortable) to 6 (Very comfortable), with higher scores indicating greater comfort related to that activity.	(1) Baseline, pre-intervention, (2) Post-intervention 1 week after completion of the in-person workshop, (3) Post-intervention 1 week after completion of all implementation strategies
Changes to the quality of care as assessed by 10 study-specific items	Quantitative assessment using 10 items developed for the current study to measure changes to frequency of discussing quality of care with clients (e.g., Asking clients about their sexual orientation; Asking clients about their anal sex practices; Initiating a conversation about anal health; Asking clients about their specific questions or concerns related to anal health). Mean scores for individual items will reflect the response category range, from 0 (Not at all comfortable) to 6 (Very comfortable), with higher scores indicating greater reported frequency of each activity.	(1) Baseline, pre-intervention, (2) Post-intervention 1 week after completion of all implementation strategies
Changes to the engagement in HIV-related services as measured by electronic health record (EHR) in two HIV service delivery sites	In two HIV service delivery sites, among all sites involved in the study, engagement of clients will be assessed via EHR by measuring the number over the past 30 days of patients who have sought (a) HIV testing, (b) screening for PrEP eligibility, (c) received anogenital cytology for sexually transmitted infection. EHR will also be reviewed to assess documentation of (a) anal health conditions, (b) sexual history and (c) sexual behavior.	(1) the 3-month period pre-intervention, (2) the 3-month period during intervention, and then (3) the 3-month post-intervention, up to 9 months total.
Impact of implementation strategies on the quality of care and engagement of clients as assessed by qualitative interviews	Impact of the implementation strategies (i.e., website and environmental restructuring, in-person workshop, coaching calls, email listserv, and any additional implementation strategies developed over the course of the study) assessed through in-depth interviews following completion of quantitative assessments, as part of an explanatory sequential mixed-methods design.	Post-intervention 1 month after completion of all implementation strategies

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Changes to determinants of implementation behavior as assessed by the DIBQ	Quantitative assessment using a 25-item adaptation to the Determinants of Implementation Behavior Questionnaire (DIBQ). The DIBQ measures multiple domains from within the Theoretical Domains Framework (e.g., perceived behavioral control, optimism, attitude, outcome expectancy, intentions) that are posited as mechanisms of action that mediate behavior change among health care workers. Mean scores for individual items and mean scores for subscales will reflect the response category range, from 1 (Very difficult) to 7 (Very easy), with higher scores indicating ease related to that domain.	(1) Baseline, pre-intervention, (2) Post-intervention 1 week after completion of mHealth component, (3) Post-intervention 1 week after completion of the in-person workshop, (4) Post-intervention 3 months after completion of all implementation strategies
Changes to knowledge about anal health and sexuality as assessed by the iASK	Quantitative assessment using the 10-item Inventory of Anal Sex Knowledge (iASK). The iASK measures knowledge as a potential mediator of behavior change. All items are scored as True/False for a total percentage of correct responses, ranging from 0-10, with higher scores indicating greater knowledge.	(1) Baseline, pre-intervention, (2) Post-intervention 1 week after completion of mHealth component, (3) Post-intervention 1 week after completion of the in-person workshop, (4) Post-intervention 3 months after completion of all implementation strategies
Changes to comfort discussing anal health and sexuality as assessed by 6 study-specific items	Quantitative assessment using 6 items developed for the current study to measure changes to comfort discussing anal health and sexuality with clients (e.g., Asking male clients about their sexual orientation; Asking male clients about their anal sex practices; Initiating a conversation about anal health; Asking MSM clients about their specific questions or concerns related to anal health). Mean scores for individual items will reflect the response category range, from 0 (Not at all comfortable) to 6 (Very comfortable), with higher scores indicating greater comfort related to that activity.	(1) Baseline, pre-intervention, (2) Post-intervention 1 week after completion of mHealth component, (3) Post-intervention 1 week after completion of the in-person workshop, (4) Post-intervention 3 months after completion of all implementation strategies
Impact of implementation strategies on the quality of care and engagement of MSM clients as assessed by qualitative interviews	Impact of the implementation strategies (i.e., mHealth education, in-person workshop, coaching calls, email listserv, and any additional implementation strategies developed over the course of the study) will be assessed through in-depth interviews following completion of quantitative assessments, as part of an explanatory sequential mixed-methods design.	Post-intervention 3 months after completion of all implementation strategies
Changes to the quality of care as assessed by 6 study-specific items	Quantitative assessment using 6 items developed for the current study to measure changes to frequency of discussing quality of care with clients (e.g., Asking male clients about their sexual orientation; Asking male clients about their anal sex practices; Initiating a conversation about anal health; Asking MSM clients about their specific questions or concerns related to anal health). Mean scores for individual items will reflect the response category range, from 0 (Not at all comfortable) to 6 (Very comfortable), with higher scores indicating greater reported frequency of each activity.	(1) Baseline, pre-intervention, (2) Post-intervention 3 months after completion of all implementation strategies
Changes to the engagement MSM in HIV-related services as measured by electronic health record (EHR) in two HIV service delivery sites	In two HIV service delivery sites, among all sites involved in the study, engagement of MSM will be assessed via EHR by measuring the number over the past 30 days of self-identified gay and bisexual men who have sought (a) HIV testing, (b) screening for PrEP eligibility, (c) received anogenital cytology for sexually transmitted infection, and (d) been retained in HIV care (as defined by returning for their most recent 3-month visit, if living with HIV). EHR will also be reviewed to assess documentation for self-identified gay and bisexual men over the past 30 days of (a) anal health conditions, (b) sexual history and (c) sexual behavior.	(1) the 3-month period pre-intervention, (2) the 3-month period during intervention, and then (3) the 3-month post-intervention, up to 9 months total.

Collaborators and Investigators

• Sponsor: Albert Einstein College of Medicine
• Collaborators: National Institute of Mental Health (NIMH); Columbia University; New York State Psychiatric Institute; GMR Transcription
• Investigators: Principal Investigator: Bryan Kutner, PhD, MPH, Albert Einstein College of Medicine

Study record dates

Study Major Dates

• Study Start (Actual): August 23, 2021
• Primary Completion (Actual): September 30, 2024
• Study Completion (Actual): January 31, 2025

Study Registration Dates

• First Submitted: January 21, 2021
• First Submitted That Met QC Criteria: February 27, 2021
• First Posted (Actual): March 3, 2021

Study Record Updates

• Last Update Posted (Actual): May 29, 2025
• Last Update Submitted That Met QC Criteria: May 23, 2025
• Last Verified: May 1, 2025

More Information

Terms related to this study

• Keywords: Men who have sex with men; Implementation science; Health stigma and discrimination framework; Theoretical domains framework; Theory and techniques tool; Anal sex stigma; Sexual and gender minority
• Additional Relevant MeSH Terms: Blood-Borne Infections; Urogenital Diseases; Genital Diseases; Immune System Diseases; Infections; RNA Virus Infections; Virus Diseases; Communicable Diseases; Sexually Transmitted Diseases, Viral; Sexually Transmitted Diseases; Lentivirus Infections; Retroviridae Infections; Immunologic Deficiency Syndromes; Slow Virus Diseases; HIV Infections; Acquired Immunodeficiency Syndrome
• Other Study ID Numbers: 2023-14892; K23MH124569 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No