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 11/26/2018`1

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

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

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

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

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.

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

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

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

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 11/26/2018 FOOTER GOES HERE

HIV Prevalence Source HIV prevalence adults 15-49: UNAIDS. Senegal. 2015; http://www.unaids.org/en/regionscountries/countries/senegal, 2017.

Anticipated Health Care Stigma Among Female Sex Workers 11/26/2018

Experienced Health Care Stigma Among Female Sex Workers 11/26/2018

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 11/26/2018 FOOTER GOES HERE

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 11/26/2018 FOOTER GOES HERE

Anticipated Health Care Stigma Among Men Who Have Sex With Men 11/26/2018

Experienced Health Care Stigma Among Men Who Have Sex With Men Increase in some enacted stigma measures 11/26/2018

Men who have sex with men currently taking antiretroviral therapy 11/26/2018 FOOTER GOES HERE

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 11/26/2018 FOOTER GOES HERE

Implementation outcomes among men who have sex with men 11/26/2018 FOOTER GOES HERE

Implementation outcomes among men who have sex with men 11/26/2018 FOOTER GOES HERE

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.

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

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