SCRIPT – Stigma, Risk Behaviors and Health Care among HIV-infected Russian People Who Inject Drugs
Karsten Lunze, MD, MPH, DrPH– Boston Medical Center
Evgeny Krupitsky, MD, PhD, DMSci, PI of Russia Subcontract
Elena Blokhina, MD, PhD, Co-Investigator
Dmitry Lioznov, MD, PhD, Co-Investigator
Edwin Zvartau, MD, PhD, DMSci, Co-Investigator
Sarah Lodi, PhD, Biostatistician
Sally Bendiks, MPH
Olga Toussova, PhD – Russian Project Manager
Sarah Rossi – Research Assistant
The SCRIPT (Stigma Coping to Reduce HIV Risks and Improve substance use Prevention and Treatment) R00 study’s overall goal is to pilot-test an intervention to support affected HIV-positive people who inject drugs (PWID) cope with the dual, internalized stigma related to both HIV and substance use. PWID often experience multiple layers of stigma when they are living with HIV1 Stigma is defined as the social exclusion and dehumanization of individuals in an undesirable social category. Interventions to help affected PWID living with HIV cope with the dual stigma have not been studied. Among people living with HIV, stigma adversely impacts all aspects of the care cascade: timely HIV testing, diagnosis, treatment, adherence and retention in care. Among PWID, drug use may add to adverse social factors and create particular stigma vulnerability. Russia is a country where PWID and other HIV key populations are highly stigmatized and face discrimination. In the K99 phase of this grant, we examined stigma determinants and its specific impact on HIV-positive PWID in Russia, a key population in the HIV/AIDS epidemic. In quantitative analysis of an existing cohort of people living with HIV who are in addiction care in St. Petersburg, we did not find associations of intense drug use as dual stigma risk factor, nor was social support a mitigating factor. We did not detect a direct association of stigma and care utilization. As a consequence of these negative findings, in the R00 phase, we will focus on stigma affecting PWID who are not in care. Preliminary qualitative results from the K99 phase indicate that the high persistent public stigma in Russia creates the feelings of hopelessness, shame and guilt among affected people. Further qualitative findings suggest that in the absence of public anti-stigma campaigns in Russia, stigma reduction interventions should address internalized stigma and their determinants to help affected people cope with the dual stigma. Stigma interventions should be adapted to address not only affected people’s shame and guilt, but also their felt hopelessness. These emotions and related feelings such as avoidance and fear of being rejected may negatively affect people’s agency and mental health.Our K99 findings thus support Acceptance and Commitment Therapy (ACT) as a potential behavioral intervention to target the emotions underlying internalized stigma and thus empower affected people. ACT has been shown to increase engagement in addiction care. Its use and efficacy to reduce stigma has not yet been explored among HIV-positive PWID. The R00 phase of the SCRIPT study will thus leverage the K99 research findings and the existing access we have to affected people in Russia to study a dual stigma intervention. SCRIPT has the following research aim addressing the key population of HIV-positive PWID:
Specific Aim: To adapt and test the feasibility of ACT as a stigma intervention, targeted to HIV-positive PWID in Russia to help them cope with dual stigma. In a randomized, 2-arm pilot study, we will compare ACT with standard of care. Participants will be randomized to receive the ACT group intervention or standard of care. We will assess participants’ satisfaction with the intervention and its effect on stigma scores, entry and retention in HIV and substance use care, HIV and substance use risk behaviors and health outcomes.
Hypothesis: An adapted form of ACT, targeted to PWID living with HIV, is feasible and can be delivered to decrease HIV and substance use stigma scores.
SCRIPT will adapt and pilot test a stigma intervention that might serve as a model to (re)engage various key populations in care. This pilot study will provide the effect size data for an appropriately powered R01 trial evaluating the intervention’s effectiveness. The SCRIPT study will thus solidify the candidate’s independence as a clinician investigator with research expertise in stigma relevant to addictions. Most importantly, this R00 will build a platform for the candidate’s subsequent research agenda addressing various forms of stigma affecting people with addictions both domestically and internationally.