Reducing Stigma and Promoting HIV Wellness/Mental Health of Sexual and Gender Minorities: RCT Results from a Group-based Programme in Nigeria

"Personally, it helped me in a way because there's something that happens when you get to talk about your challenges or your struggles even without solving them, talking about it alone has a way of relieving you."

High levels of HIV stigma and stigma directed towards sexual and/or gender minorities (SGMs) are well documented globally, and increasingly in sub-Saharan Africa (SSA). These intersecting stigmas impede psychosocial wellbeing and HIV prevention and care. Yet, there are few if any evidence-based interventions that focus on reducing internalised stigma and promoting mental health and HIV wellness for SGMs in Africa. This paper describes the development and evaluation of a group-based intervention drawing on cognitive behavioural therapy (CBT) strategies for men who have sex with men (MSM) and transgender women (TGW) at risk for or living with HIV in Lagos, Nigeria.

The intervention consisted of four weekly in-person sessions (2.5-3 hours in length each), which were facilitated by community health education workers with basic counselling skills and with experience working with SGM populations in Lagos. The intervention drew upon and adapted selected content from an evidence-based affirmative group-based CBT intervention to reduce psychosocial distress and improve social support and coping among SGM youth in Canada, called AFFIRM. Intersectional stigma was addressed by examining (and inviting contributions of) lived experiences in all their complexity, as well as structural factors that lead to these stigmas (e.g., discriminatory laws), with an emphasis on affirmative strategies to promote robust, shared resilience. The draft curriculum was pilot-tested and refined in consultation with community members including peer educators and key opinion leaders.

From April to September 2022, the researchers conducted a delayed intervention group randomised controlled trial (RCT), with pre-post surveys plus 3-month follow-up (immediate group only), as well as qualitative research with participants and programme staff. Outcomes included internalised stigma related to SGM and HIV status, depression, resiliency/coping, and pre-exposure prophylaxis (PrEP)/HIV treatment use.

The mean age of the 240 participants was 26 years (range 18-42). Seventy-seven percent self-identified as MSM and 23% TGW; 27% were people with HIV. Most (88%) participants attended all four sessions, and 98% expressed high intervention satisfaction. There was significant pre-post improvement in each psychosocial outcome (e.g., internalised stigma as measured by responses to questions such as "I deserve bad things happening to me because I have sex with men/am attracted to men"), in both the immediate and delayed arms. There were further positive changes for the immediate intervention group by 3-month follow-up (e.g., in intersectional internalised stigma, depression).

While baseline levels of ever-PrEP use were the same, 73% of immediate group respondents reported current PrEP use at 3 months after completing the intervention, versus 52% of delayed group participants right after they completed the intervention. This finding represents 4.4 times the odds of current PrEP use. HIV testing was also higher in the immediate group, but this finding did not reach statistical significance.

Participants post-intervention described (in qualitative interviews) less self-blame and enhanced social support and resilience when facing stigma, as well as motivation to use PrEP. In fact, several participants described initiating (or re-initiating) PrEP because of the programme. In general, participants described two main reasons why the intervention supported HIV service uptake. First, the intervention led to less internalised stigma and more resiliency and social support, which in turn enabled service use. Second, many participants reported that the workshops provided the time and welcoming space needed to learn about the available prevention and treatment/care options and services and how they support wellbeing. They indicated that positive pre-intervention changes in psychosocial factors found in the delayed group mainly reflected perceived support from the study interviewers.

Regarding the positive psychosocial shifts seen between baseline and start of the delayed intervention, respondents described benefits simply from participating in the two surveys (each with the same interviewer with whom they had developed a rapport) and from being invited for the first time to participate in a stigma and mental health programme. Implications include that one-on-one interventions that are not necessarily conducted by mental health professionals yet are less intensive than the four-session programme could also be beneficial for some outcomes. Future research could test the pros and cons of these options.

Some recommendations based on this experience include:

• The group format and use of community-based facilitators permit reaching a larger audience than one-on-one counselling, which is a strength in settings with limited access to mental health providers. However, given the programme time commitment involved, participants should be offered options for the timing of the sessions (as was done for this study).
• Regarding measurement, with shifting recommended terminology over time for terms such as "MSM" and "HIV-positive", it will be important to revisit survey/scale items when applying them in the future to ensure they are not further stigmatising.
• There are numerous locations across the globe where the LGBTQ+ community is criminalised and/or stigmatised, suggesting the potential widespread application of this type of intervention.

In conclusion, this study demonstrated the feasibility and acceptability of a group-based CBT model for MSM and TGW in Nigeria. There were also some indications of positive shifts related to stigma, mental health, and PrEP. "Given the critical need for HIV wellness and mental health promotion programmes for SGMs and other marginalized populations in Nigeria - and elsewhere - these initial results point to a promising option."