BACKGROUND: High levels of stigma due to identifying as a sexual or gender minority (SGM) as well as living with HIV (i.e., intersectional stigma) are increasingly documented in the African setting, and often manifest as self-stigma (also called internalized stigma). Such stigmas impede psychosocial wellbeing as well as HIV prevention/care, and there are few (if any) evidence-based internalized stigma reduction interventions in this context. We developed and evaluated a novel, group-based CBT stigma intervention for men who have sex with men (MSM) and transgender women (TGW) at risk for/living with HIV in Lagos, Nigeria.
METHODS: The intervention, adapted from a Canadian curriculum, comprised four weekly in-person sessions facilitated by community health workers. We conducted a delayed intervention group randomized controlled trial, with pre-post surveys plus 3-month follow-up, as well as qualitative interviews with participants / program staff. Outcomes included internalized stigma related to SGM and HIV status, depression, resiliency, and PrEP / HIV treatment use.
RESULTS: Mean age of the 240 participants was 26 years (range 18-42). Seventy-seven percent were MSM and 23% TGW; 27% were living with HIV. Most (88%) participants attended all 4 sessions, and 98% expressed high intervention satisfaction. There was significant improvement in each psychosocial outcome between baseline and second surveys, in both the immediate (post intervention) and delayed (pre-intervention) arms. Qualitative data obtained from participants post intervention described enhanced self-confidence, resilience when facing stigma, and coping skills, and indicated that positive changes found in the delayed group (pre-intervention) were mainly due to perceived support from the interviewers / survey experience. There were further positive changes from baseline to three-month follow-up in e.g., intersectional internalized stigma and depression, for the immediate intervention group. Controlling for baseline levels of ever PrEP use, 75% of immediate-group participants reported currently using PrEP at three months post-intervention vs. 53% of delayed-group participants right after the intervention (p<0.01).
CONCLUSIONS: This study demonstrated feasibility and acceptability of a group-based CBT model in Nigeria. There were also indications of preliminary efficacy related to mental health outcomes and PrEP, despite the randomized design not holding up (where study participation/contact became an intervention in itself).