Project Orleu: Reducing Intersectional and HIV Stigma Among Health Care Providers and High Risk Women Who Use Drugs in Kazakhstan

Reducing Intersectional and HIV Stigma Among High Risk Women Who Use Drugs in Kazakhstan, Central Asia: A Multilevel Stigma Resistance and Enacted Stigma Reduction Intervention for Women and Providers

Suboptimal linkage to and retention in HIV prevention and care is prevalent among high-risk women who use or inject drugs in both the US and globally, including high HIV incidence contexts like Kazakhstan; addressing HIV and intersectional stigma, especially from health care providers (HCP) within clinics, is necessary to increase engagement in the HIV care and prevention continuum. To address this challenge and increase HIV prevention and care, the proposed study will involve the design and assessment of the acceptability, feasibility, and usability of a three component, multi-level participatory intervention to promote stigma resistance/coping and reduce anticipated/internalized stigma among high-risk women who use drugs as well as to reduce enacted stigma among HCP in Kazakhstan, Central Asia. Results of this study will generate information in order to power a future preliminary effectiveness trial and will be unique in utilizing multilevel anti-stigma approaches for both high risk women who use drugs and HCP, all of which will have important implications for advancing HIV prevention and care engagement among highly stigmatized populations in diverse settings.

Study Overview

• Status: Completed
• Conditions: Stigma, Social
• Intervention / Treatment: Behavioral: Health Care Provider Stigma Training and Clinic-Based Messaging Campaign

Detailed Description

Suboptimal linkage to and retention in HIV prevention and care is prevalent among high-risk women who use or inject drugs in both the US and globally, stemming, in part, from high levels of stigma. In Kazakhstan, increasing engagement in the HIV care and prevention continuum is a major public health goal, as the number of new HIV infections doubled from 2010 to 2017 and AIDS-related deaths increased by 32%. Among high-risk women who use drugs in this context, research has found that ~30% are HIV-infected and that they are less likely to test and receive care. Numerous studies have documented that experienced, anticipated and internalized stigma, especially from health care providers (HCP), are key barriers to HIV testing and treatment in global contexts. For high-risk women who use drugs, HIV and associated stigmas, specifically stigma related to sex and drug use, as well as gender discrimination, work independently and synergistically to inhibit access to HIV prevention and treatment; yet, there are no existing anti-stigma interventions designed and tested in Kazakhstan for this key population of women and that focus on HCP as sources of stigma. This study proposes to design and assess acceptability, feasibility, and generate information in order to power a preliminary effectiveness trial of a three component, multi-level participatory intervention to reduce HIV-associated and intersectional stigma - and thus increase access to HIV prevention and care. The first component is aimed at high-risk women and designed to increase stigma resistance/coping and reduce anticipated/internalized stigma via: a) crowdsourcing of anti-stigma messaging for HCP; and b) adaptation of an HCP training for optimal sexual health and healthcare engagement among high-risk women who used drugs. The second and third components, aimed at the HCP and other clinic staff and emerging from the execution of the first component, include: a) the resultant messaging campaign; and b) the training that will be delivered to HCP. Both the messaging campaign and the training components will be designed to reduce enacted stigma by HCP/staff (and thus experienced stigma among women) and increase stigma resistance and resilience among high-risk women who use drugs. All components will work synergistically to reduce enacted, experienced and internalized, intersectional stigma. The approach relies on evidence-based methods, including media campaigns, to reduce HCP enacted stigma, and integrates innovative methods, like crowdsourcing and participatory research, to increase stigma resistance. Results of this study will be unique in utilizing multilevel anti-stigma approaches for both high-risk women who use drugs and HCP and have important implications for advancing HIV prevention and care engagement among highly stigmatized populations globally and in the US.

• Study Type: Interventional
• Enrollment (Actual): 83
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Kazakhstan
  • Almaty, Kazakhstan
    • Global Health Research Center for Central Asia

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Providers (e.g., physicians, nurses, clinic directors, epidemiologists, outreach workers)
• Aged 18 years or older
• Currently employed part or full-time at an AIDS Center friendly clinic (city clinics focused on the provision of HIV and sexual health care).

Exclusion Criteria:

- Providers who are less than 18 years of age and/or do not work at an AIDS center friendly clinic.

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

Experimental: Provider Training and Clinic Messaging; Providers receive a 5-session stigma-free clinic training and anti-stigma messaging campaign materials to display in clinic.

Behavioral: Health Care Provider Stigma Training and Clinic-Based Messaging Campaign; Providers in 10 HIV clinics participated in a 5 session anti-stigma health facility training focused on: 1) raising awareness about stigma and discrimination at the facility; and 2) changing attitudes and behaviors towards women who use drugs and/or trade sex; and 3) building a stigma-free clinic. Each of these clinics also received anti-stigma messaging materials (i.e., pamphlets, posters) to display in their clinics over a 6 month period. Providers received text-based message twice a month during this time to reinforce skills learned during trainings and to empower providers to be stigma change agents. Providers completed pre/post survey assessments.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Provider HIV Enacted Stigma Measure	This 4-item measure is adapted from the "Measuring HIV Stigma and Discrimination among Health Facility Staff" questionnaire enacted stigma sub-scale. Across the 4 items, Likert-responses range from 1 (never observed) to 4 (always observed).	6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Total Number of PrEP Prescriptions Issued to Clients	Through review of clinic-level administrative data, this study will measure the total number of prescriptions for PrEP over a 6-month period.	6 months
Total Number of Clients	Through review of clinic-level administrative data, this study will measure the total number of clients over a 6-month period.	6 Months

Collaborators and Investigators

• Sponsor: Columbia University
• Collaborators: University of Pennsylvania; Fogarty International Center of the National Institute of Health

Study record dates

Study Major Dates

• Study Start (Actual): August 15, 2024
• Primary Completion (Actual): May 15, 2025
• Study Completion (Actual): May 15, 2025

Study Registration Dates

• First Submitted: April 10, 2025
• First Submitted That Met QC Criteria: April 10, 2025
• First Posted (Actual): April 17, 2025

Study Record Updates

• Last Update Posted (Actual): July 20, 2025
• Last Update Submitted That Met QC Criteria: July 16, 2025
• Last Verified: July 1, 2025

More Information

Terms related to this study

• Keywords: HIV; Women; Drug Use; Service Delivery; Intersectional Stigma; Linkage to Prevention and Care; Sex Work
• Other Study ID Numbers: AAAU3129; R01TW012405 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: After further testing, we will share study protocols.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No