Kudos to Michael Relf, his Co-PI, Laura Nyblade (RTI, International) and their entire team for the submission of their NIH R21 application entitled “Stigma, discrimination and the HIV treatment cascade: Testing a theoretical model and developing psychometrically sound tools for East Africa.” This proposal requests funding for a two-year period with a start date of June 1, 2018.

Stigma is virtually synonymous with the experience of being a woman living with HIV (WLHW) in East Africa and around the world. The stigma associated with HIV, especially internalized stigma, yields a number of negative outcomes including depression, non-adherence to antiretroviral therapy, non-engagement in care, poor self-efficacy for disclosure, and a diminished quality of life. Compounding the negative effects of stigma are experiences with everyday discrimination and medical mistrust. Among WLWH, interventions to mitigate the negative effects of internalized stigma associated with HIV, and instruments to measure intervention efficacy, are limited and critically needed. In Rwanda and Tanzania, the two sites for this study, approximately 120,000 and 750,000 women are living with HIV, respectively. Through development of theoretically grounded, culturally sensitive, linguistically relevant, gender-specific internalized stigma reduction interventions, the long-term goal of this project, it is possible to help women successfully self-manage internalized stigma so they can achieve a variety of beneficial health outcomes including living with HIV, engaging in care, adhering to ART, and having an optimized quality of life. The first step in intervention adaptation and development is to systematically adapt and validate measurement instruments, which demonstrate linguistic and cultural equivalence, in 280 WLWH in Rwanda and Tanzania (total n = 560).

The specific aims of this study are to:

Aim 1: Evaluate the cultural and linguistic equivalence and psychometric properties of a set of adapted measurement instruments essential to determining the efficacy of an internalized stigma reduction intervention designed for WLWH in Rwanda and Tanzania.

Aim 2: Test a theoretical structural model examining the causal pathways between everyday discrimination, medical mistrust, and HIV-related stigma and their relationships to coping self-efficacy, depressive symptoms, disclosure, ART adherence, engagement in care, and quality of life among WLWH in Rwanda and Tanzania, with geography (urban vs. rural) and years positive since diagnosis (≤ 2 years vs. > 2 years) as independent exogenous factors.

Aim 3: Explore the moderating effects of geography (urban vs. rural) and years positive since diagnosis ( 2 years vs. >2 years) on the tested structural model of causal pathways between everyday discrimination, medical mistrust, and HIV-related stigma and their relationships to coping self-efficacy, depressive symptoms, disclosure, ART adherence, engagement in care, and quality of life among WLWH in Rwanda and Tanzania.