The following description was taken from the R01 version of this FOA.
Despite scale-up of HIV testing services and access to pre-exposure prophylaxis (PrEP), many gaps in these services remain. A substantial number of people living with HIV (PLWH) remain undiagnosed and many individuals who are at high risk of HIV acquisition are not benefiting from evidence-based HIV prevention (e.g., pre-exposure prophylaxis, non-occupational post-exposure prophylaxis, needle exchange, risk reduction interventions, and voluntary male medical circumcision). Worldwide, there are an estimated 35-55% PLWH who do not know their HIV status. In the U.S., estimates of those living with undiagnosed HIV infection are as high as 46% for Black men who have sex with men (BMSM) and 37% for Latino men who have sex with men (LMSM). Many BMSM and LMSM learn they are infected with HIV less than a year before being diagnosed with AIDS, which means they miss the full benefits of early treatment. PrEP uptake is notably low among BMSM and LMSM as well. Transmission risk increases when large numbers of HIV positive individuals are unaware of their status, and acquisition risk increases when individuals at high risk are not linked to ongoing prevention. Sustained efforts to improve the uptake of HIV testing and linkage to prevention to reduce HIV incidence are needed. This area of research is a priority for the NIH Office of AIDS Research.
HIV-related stigma (at the individual, interpersonal and structural level) continues to be a critical barrier to HIV testing, as well as to the uptake of evidence-based prevention such as PrEP. These findings are highly problematic because this phase represents initial entry into the HIV prevention continuum. Along with several well-known social determinants such as economic inequality, unstable housing, and inadequate access to health services, HIV stigma and discrimination is a consistent barrier. Fear of HIV positive status, anticipated HIV stigma, and low perception of risk are common themes among never or infrequent testers. Other barriers to HIV testing include clinic or public testing facilities that are not welcoming to stigmatized populations, as well as stigmatizing attitudes and beliefs held by health care providers. A hostile immigration climate is increasingly a barrier to HIV testing in the U.S. and elsewhere, particularly for stigmatized communities such as racial-ethnic and religious minorities.
The concept of intersectional stigma examines the juncture of multiple stigmatized identities that fall within or across several categories: 1) one or more co-existing health conditions such as HIV, mental illness or substance use disorder; 2) sociodemographic characteristics such as racial, ethnic, gender, sexual orientation and immigration status; and 3) behaviors/experiences such as substance use and sex work. Each stigmatized identity can be further differentiated by type, such as internalized (personal endorsement of prejudice and stereotypes), enacted (experiences of discrimination from others), and anticipated (expectations of discrimination from others in the future, even if one has not experienced discrimination in the past). Few studies have used the concept of intersectionality to understand the multiple stigmatized identities (and the multiple discriminating forces) faced by the communities where HIV is most heavily concentrated. This is particularly important given the high rate of HIV and other sexually transmitted infections (STIs) among key populations such as MSM and other sexual and gender minority sub groups, particularly those who are young (under age 25), Black or Latino, transgender women, sex workers, injection drug users and living in the Southern region of the U.S., and in Sub-Saharan Africa or in other Low and Middle-Income Countries where stigma is strong. A context of marginalization where intersecting forms of disadvantage and discrimination, including criminalization of same-sex practices, sex work or immigration and rigid gender norms needs to be addressed to improve the HIV prevention continuum.
There is a need to understand the role of intersectional stigma and develop and test interventions designed to reduce intersectional stigma and improve HIV prevention outcomes. The bulk of the stigma-related research to date has focused on HIV-related stigma among PLWH. Tests of theoretical models linking hypothesized pathways between HIV stigma and antiretroviral (ART) adherence (taking HIV medicines as prescribed) and viral load suppression are underway, as well as intervention trials designed to reduce stigma and improve HIV treatment outcomes. Few studies have used the concept of intersectionality, and intervention studies designed to address intersectional stigma to improve HIV prevention outcomes are notably absent from the literature. Studies are needed to advance measurement and understanding of the mechanisms and pathways between intersectional stigma and HIV prevention outcomes, particularly among socially disadvantaged populations in highly stigmatized (and sometimes criminalized) environments. Interventions that address intersecting disadvantage and discrimination to improve HIV testing and linkage to HIV prevention services are needed as well.
For the purposes of this FOA:
- The concept of intersectionality must be applied.
- The multiple stigma identities or multiple discriminating forces should be clearly defined and justified.
- The proposed population should be limited to key populations who are at substantial risk of HIV acquisition and experience high rates of stigma and discrimination such as MSM, transgender women, and sex workers.
- Basic behavioral science applications (i.e., those that do not involve an intervention) should clearly indicate how this is the first step in a planned program of research that will lead to an intervention.
- An exclusive focus on one type of stigma (e.g., anticipated HIV stigma only) will not be considered responsive.
- At least one primary outcome should be an outcome related to the HIV prevention continuum (e.g., HIV testing, PrEP or post-exposure prophylaxis (PEP) , needle exchange, voluntary medical male circumcision (VMMC) , risk reduction).
- Applications that primarily focus on HIV care continuum outcomes such as antiretroviral adherence and viral suppression and treatment as prevention applications will not be considered responsive.
This initiative would target a gap in the scientific knowledge on intersectional stigma and HIV prevention that may help to reduce the incidence of HIV and HIV prevention/treatment disparities.
Research related to this initiative may include:
Research to understand mechanisms and intervention to improve the HIV prevention continuum, including, but not limited to:
- Studies to apply intersectional theory to measurements and analytical approaches of intersectional stigma to better understand the mechanisms and pathways by which it impacts HIV testing and HIV prevention uptake;
- Studies to develop and validate measurements of intersectional stigma that could be used in future research to meaningfully capture change over time;
- Studies to examine the resilience mechanisms and processes that protect against the negative effects of intersecting discriminating forces.
Intervention research to improve the HIV prevention continuum, including, but not limited to:
- Studies to develop interventions that will address the role of intersectional stigma in the uptake of HIV testing and linkage to HIV prevention services;
- Studies to address the multi-level factors facilitating intersectional stigma to improve HIV prevention continuum outcomes;
- Studies to determine the optimal combination of stigma reduction interventions to improve HIV prevention outcomes for those stigmatized populations at highest risk for HIV acquisition; and
Implementation science research to improve the HIV prevention continuum, including, but not limited to:
- Studies using implementation sciences approaches to integrate interventions focused on intersectional stigma into existing HIV testing and prevention services to improve the HIV prevention continuum.
- Studies to compare the relative effects of intersectional stigma reduction interventions on HIV testing and linkage to HIV prevention outcomes.
- Studies of cost-effectiveness for intersectional stigma interventions to improve the HIV prevention continuum.
National Institute on Minority Health and Health Disparities (NIMHD)
NIMHD leads scientific research to improve racial/ethnic minority health and eliminate health disparities in the United States. HIV/AIDS disproportionately effects racial and ethnic minority populations in the US, particularly African American and Hispanic/Latino MSM, and is increasing fastest amongst minorities and women. NIMHD is interested in research that addresses barriers to HIV testing and linkage to prevention, including stigma, within health disparity populations—which include socioeconomically disadvantaged and underserved rural populations. Areas of research interest include, but are not limited to:
- Effects of HIV-related stigma and discrimination on patient-clinician interactions and engagement with prevention activities (e.g., HIV testing) among health disparity populations;
- Interactions of cultural attitudes and beliefs of at risk individuals that impact health-promoting behaviors (e.g., diet, exercise) and help-seeking behaviors within health disparity populations; and
- Examination of coping strategies that help health disparity populations manage the stress of living with intersectional stigma and to live positively.
Deadline: December 23, 2018 (letters of intent); January 23, 2019 (full proposals)
- R01 – https://grants.nih.gov/grants/guide/rfa-files/RFA-MH-19-412.html
- R21 – https://grants.nih.gov/grants/guide/rfa-files/RFA-MH-19-411.html
- R34 – https://grants.nih.gov/grants/guide/rfa-files/RFA-MH-19-410.html
Filed Under: Funding Opportunities