Assessing the feasibility and acceptability of a pilot peer led intervention to reduce stigma and improve ART adherence among young men having sex with men and transgender women living with HIV in low resource settings in Southern Africa

Assessing the feasibility and acceptability of a pilot peer led intervention to reduce stigma and improve ART adherence among young men having sex with men and transgender women living with HIV in low resource settings in Southern Africa | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing the feasibility and acceptability of a pilot peer led intervention to reduce stigma and improve ART adherence among young men having sex with men and transgender women living with HIV in low resource settings in Southern Africa Kaymarlin Govender, Patrick Nyamaruze, Joseph Mumba Zulu, Nelson Muparamoto, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8826781/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Young men who have sex with men (MSM) and transgender women (TGW) in Southern Africa experience a disproportionate burden of HIV, compounded by intersecting stigma related to HIV status and sexual orientation or gender identity (SOGI). These stigmas undermine mental health and antiretroviral therapy (ART) adherence, yet few integrated, community-informed interventions exist in low-resource settings. This study assessed the feasibility, acceptability, and preliminary impact of a peer-led pilot intervention to reduce stigma, improve mental health, and strengthen ART adherence among young MSM and TGW living with HIV in Malawi, Zambia, and Zimbabwe. Methods A mixed-methods parallel design was used, combining quantitative self-administered questionnaires with qualitative in-depth interviews. Seventy-two participants aged 18–24 years were recruited through community-based organisations, with 64 completing baseline and endline assessments. The 8-week intervention, grounded in the information–motivation-behavioural skills (IMB) model, was delivered by trained peer facilitators under clinical supervision. Quantitative outcomes included measures of HIV-related stigma, SOGI stigma, depressive symptoms (CES-D-10), alcohol use (AUDIT), and ART adherence self-efficacy. Descriptive statistics were generated, paired sample t-tests were used for continuous variables, and McNemar’s tests assessed changes in categorical outcomes. Qualitative data were analysed thematically to explore participant experiences and perceptions of the intervention. Results Statistically significant improvements were observed from baseline to endline, including reductions in internalised HIV stigma (p = 0.01), anticipated HIV stigma (p = 0.01), healthcare-related stigma (p < 0.001), SOGI-related harassment (p = 0.02), and depressive symptoms (p = 0.01). ART adherence self-efficacy increased significantly (p < 0.001). Although changes in sexual risk behaviours were not statistically significant, trends suggested increased condom use and reduced substance use before sex. Qualitative findings indicated enhanced self-acceptance, improved coping strategies (including reduced reliance on alcohol), increased confidence around disclosure, and strong acceptability of the peer-led, group-based intervention, despite some concerns about session pacing. Conclusions This pilot peer-led intervention was feasible, acceptable, and showed promising improvements in stigma, mental health, and ART adherence self-efficacy among young MSM and TGW in three Southern African countries. The findings support the potential value of theory-informed, peer-delivered interventions to address intersecting stigma and adherence challenges in highly marginalised populations, warranting further evaluation through larger and longer-term studies. Intersectional stigma mental health peer-led intervention information–motivation–behavioural skills (IMB) model Figures Figure 1 Figure 2 Figure 3 Contributions to the literature This study extends implementation science evidence by demonstrating the feasibility of a peer-led, theory-informed intervention that addresses intersecting stigma, mental health, and ART adherence in highly criminalised, low-resource Southern African settings. Findings advance understanding of how the information-motivation behavioural skills (IMB) model can be operationalised through peer delivery to support complex behaviour change among sexual and gender minority populations. By foregrounding intersectional stigma as a central implementation barrier and intervention target, the study informs the design of scalable, equity-oriented HIV adherence interventions. Introduction Young men who have sex with men (MSM) and transgender women (TGW) are among the populations most disproportionately affected by the global HIV epidemic [ 1 ]. This pattern is evident in Southern Africa, where key populations experience high HIV prevalence rates: in Zambia, HIV prevalence in 2020 was 21% among MSM and 22% among TGW [ 2 ]; in Zimbabwe the estimated HIV prevalence among MSM was 31% in 2017, almost four times the general adult male prevalence of 8.7% [ 3 ]-while TGW faced a prevalence of 39.4% [ 4 ]. Despite the high burden of HIV and poor mental health outcomes among young MSM and TGW in southern Africa, there is a critical shortage of tailored interventions addressing both ART adherence and mental health in an integrated way. Existing HIV programs often overlook the complex interplay between psychosocial stressors such as intersecting stigma and adherence behaviours, leaving significant service gaps [ 5 , 6 ]. Moreover, available interventions are rarely theory-based or co-designed with community input, limiting their relevance and sustainability. This highlights the urgent need for comprehensive, evidence-informed approaches that support both mental health resilience and ART adherence, especially in contexts marked by intersecting vulnerabilities. Building on previous research into stigma related to sexual orientation and gender identity [ 7 ], the current study describes the design and implementation of a pilot intervention aimed at mitigating stigma, improving mental health and enhancing ART uptake and adherence among young MSM and TGW. Intervention design and conceptual framework Through a series of workshops, stakeholders including researchers, representatives from NGOs working with MSM and TGW (Centre for the Development of People in Malawi, Women’s Alliance for Equality in Zambia, and An Association of LGBTI People in Zimbabwe), national health ministries, and research participants were recruited to collaboratively develop an 8-week intervention. The pilot intervention was designed to address stigma-related barriers to ART adherence and improve mental health among young MSM and TGW living with HIV. The intervention was informed by: (1) engaging with key stakeholders such as community-based organizations, healthcare providers, and MSM and transgender community members, and (2) an evidence-based review of academic and grey literature on HIV stigma, mental health, and ART adherence in low-resource, high-stigma settings. This participatory process ensured the intervention was grounded in both the lived experience of PLWH and current evidence, enhancing its cultural relevance and theoretical strength. Crucially, the intervention was co-designed with representatives from the target populations to ensure its appropriateness and effectiveness. The information-motivation-behaviour (IMB) model was used as a framework for understanding and promoting HIV prevention and medication adherence [ 8 ]. Its relevance was demonstrated in South Africa through an intervention addressing stigma-related barriers to ART adherence among PLHIV [ 9 ]. The intervention was based on evidence that peer-led small group sessions, supported by professional healthcare oversight, improve mental health and adherence outcomes [ 9 ]. This informed the adoption of a peer-delivery model, where trained community peers facilitated weekly sessions under supervision from qualified health professionals. This hybrid approach combines peer relatability and contextual insight with clinical expertise and accountability (see Fig. 1 below) The IMB model identifies key determinants of ART adherence. Adherence information refers to understanding ART specifics, dosage, side effects, and the importance of consistent intake. Adherence motivation involves personal attitudes, beliefs, perceived outcomes, and social support. Adherence behavioral skills represent practical capabilities, such as self-efficacy, to follow ART regimens and seek support. The components—information, motivation, and behavioral skills culminate in adherence behavior and improved health outcomes. Moderators, such as socio-economic conditions and stigma, can influence the relationships between IMB components and adherence. Intervention outline The intervention involved small groups of participants (12 MSM and 12 TGW) attending eight sessions over an 8- week period covering topics such as experiences, fears, anxieties regarding stigma; HIV/SOGI disclosure intentions; coping and recovery mechanisms; mental health; perceptions regarding ART adherence; and perceptions of change linked to components of the intervention. Amongst the range of topics covered, most were delivered for all participants, while some were adapted to be delivered separately to either the MSM or TGW groups (all sessions had the same overall theme). While sessions where initially designed to take place at one-week intervals, 2 sessions were delivered weekly because of time-constraints. Each session has two 60-minute sections (A and B) with a 30-minute break between sections. The sessions were delivered separately for the MSM and TGW participants. An additional 30–60 minutes of 'open time' was made available following each session for social networking and for access to other services provided by the organisation hosting the intervention. This included, for example, opportunities for individual counselling and support with qualified individuals. The session topics were adapted from interventions designed by Fisher et al. [ 10 ] and Rose et al. [ 11 ]. Methodology Study design The study used a mixed-methods, parallel design, collecting qualitative and quantitative data simultaneously [ 12 ]. The quantitative component involved a self-administered, confidential questionnaire. Regionally validated screening tools were available to provide a quantitative lens on the presence or absence of signs of health challenges and their severity linked to experiences of stigma. In addition, the questionnaire was able to capture the acceptability and feasibility of the intervention among the sample. In-depth interviews explored individual experiences of intersectional stigma, health status, and participation in the intervention. Using the two approaches allowed for triangulation and a richer analysis of the complex phenomena underlying intersectional stigma for the study participants [ 13 , 14 , 15 ]. The study population included young gay, bisexual, and other MSM, and TGW, aged 18–24, self-identifying as living with HIV and on antiretroviral therapy (ART) for at least six months. Eligibility criteria were: (1) self-identification as gay, bisexual, other MSM, or TGW; (2) current ART use for at least six months; (3) self-reported non-adherence (at least one missed dose in the past three months); (4) willingness to join group sessions; (5) commitment to completing the 8-week program; and (6) consent to audio-recorded interviews at baseline and follow-up. Participants not meeting these criteria were excluded. Seventy-two participants were recruited from sites at community-based organisations in Blantyre, Lusaka, and Harare (24 per site) via snowball sampling, with recruitment supported by peer navigators and healthcare workers involved in HIV and sexual health services providing ART. Initial contact was made through peer navigators, counselors, or healthcare providers who directed individuals to a researcher for eligibility screening. Eligible participants were referred to trained research assistants for consent and baseline data collection. Data collection occurred between May and June 2024. One participant (from Malawi) withdrew before the baseline interview. The data collection and intervention were conducted between May and July 2024 in safe locations selected through consultation with key populations representatives in each country. The Drop-In Centres (DIC) at CEDEP (Blantyre, Malawi), WAFE (Lusaka, Zambia) and GALZ (Harare, Zimbabwe) were used. These locations had adequate measures in place for assuring the confidentiality, privacy, safety and security of participants. Peer facilitators were given a spacious meeting room capable of accommodating 20–25 individuals in a private setting. The peer facilitators furnished the room to make it more comfortable by including chairs, mats and pillows. Participants were given personal workbooks containing instructions and materials for each session as well as information and exercises for self-directed learning and practice between sessions. Data collection and intervention implementation The intervention was delivered by trained peer facilitators, two per site who were existing peer educators working with the study population and recommended by employers and stakeholders. Two researchers interviewed candidates before confirming their selection for a five-day intensive training prior to the intervention launch. Peer facilitators received ongoing supervision from a clinical officer and a mental health professional, including proactive risk identification, weekly debriefs, and a mid-term review after session four to address challenges. Drop-in center (DIC) coordinators were present during sessions to support timely responses to risks. Implementation was synchronized across the three countries, following a standard procedure of two daily sessions—one for MSM and one for TGW—scheduled according to local arrangements. Sessions began with an overview, followed by participants sharing expectations on index cards. The intervention comprised a structured series of sessions covering key topics related to HIV treatment, mental health, stigma, relationships, and resilience. Content covered included mindfulness-based stress reduction, HIV and ART knowledge, HIV disclosure, lifelong adherence and adherence skills, mental health and coping strategies (including alcohol use), stigma and intersectional stigma, positive sexuality, love and relationships, resilience, and integration of self, culminating in reflection and future-oriented goal setting. Sessions were delivered through a mix of facilitated group discussions, expert-led presentations, role-play, experience sharing, and reflective exercises. These interactive and participatory methods were designed to build knowledge, practical skills, self-confidence, mutual solidarity, and sustained commitment to ART adherence and overall wellbeing. Peer facilitators and participants jointly set ground rules emphasizing privacy, confidentiality, support, and teamwork. While the session manual guided implementation, facilitators had flexibility for creative activities. Data collection occurred at baseline and endline through self-administered questionnaires and in-depth interviews using the same tools, with the endline including questions on intervention experiences. The self-administered questionnaire included sections on alcohol use, using the Alcohol Use Disorders Identification Test (AUDIT), and experiences with physical or sexual violence [ 16 , 17 ]. One specific item addressed mental health: the Center for Epidemiological Studies-Depression (CES-D) 10 item scale, which had been previously validated in a similar African setting although not with the specific population for this study [ 18 ]. No adaptations were made to the content of these scales or assessment tools. Additional sections addressed experiences of stigma and discrimination related to sexual orientation, gender identity, and HIV status using questions adapted from the PLHIV Stigma Index 2.0 tool [ 19 ]. A final section of the questionnaire captured data on most recent sexual activity, including condom use and disclosure of HIV status with sexual partners (questions were adapted from WHO [ 17 ]). The interview guide explored stigma, discrimination, mental health effects, coping strategies, ART experiences, adherence challenges, self-efficacy, and intervention expectations. Two trained research assistants per country conducted interviews after attending country-specific training workshops prioritizing safety and psychosocial risk management. Data collection took place in secure, confidential settings. After eligibility screening and informed consent, participants consented to audio recording and completed semi-structured interviews lasting 30–40 minutes. Interviews were conducted in local languages—Chichewa and Chitumbuka (Malawi); Bemba, Lozi, and Nyanja (Zambia); and Ndebele and Shona (Zimbabwe)—based on participant preference and interviewer capacity. No personal identifying information was collected. Research supervisors were available to assist with any adverse reactions or risks (none occurred). Participants received the local equivalent of US $ 10 after data collection to cover transport costs. Following the 8-week intervention, endline data collection followed the same procedures. The study received ethical approval from the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (BREC/00001655/2020), and the research ethics committees of Kamuzu University of Health Sciences (P.04/24–0654), University of Zambia (REF. NO. 1070–2020), and the Medical Research Council of Zimbabwe (MRCZ/A/3185). Data analysis Audio recordings were transcribed into English by the interviewers and translated when needed, with ongoing quality checks by the research teams. Thematic analysis combined structural and inductive coding aligned with the conceptual framework [ 20 , 21 ]. Initial analysis was conducted separately in each country by the Lead Researcher and Research Coordinator, who independently coded the data, then compared and reconciled codes. Together, they grouped codes into broader themes, refined and clearly defined each theme to ensure coherence, and produced detailed reports with supporting excerpts. Regular discussions and cross-checking enhanced the reliability and depth of the analysis. After country-level analyses, two researchers reviewed the themes for clarity and relevance, followed by cross-country comparisons. Descriptive statistics were used to describe the sample of individuals in the study. Furthermore, paired samples t-tests were used to assess the change from pre-test to post-test for the continuous data. While a McNemar’s test was used to assess the changes from pre-test to post-test for the categorical data. All analysis were conducted in IBM SPSS version 28. Across all analysis processes, attention was paid to similarities and differences between countries. A flexible, dialogic approach to triangulation was employed to build complementary, reflexive links between the two types of data [ 14 , 22 ]. Findings Participant characteristics There was a total of 64 participants across the three countries with a mean age of 22 (Table 1 ). Regarding gender identity, 48.4% of the participants identified as male, while 37.5% identified as transgender. When describing their sexual orientation, 45.3% of the participants identified as gay or homosexual, 51.6% identified as transgender, and only 3.1% described themselves as bisexual. All participants in the sample were living with HIV, and were currently on ART. Table 1 A summary of the main characteristics of participants Mean Count Column N % Mean age 22 Do you consider yourself Male 31 48,4% Female 8 12,5% Transgender 24 37,5% Other 1 1,6% How would you describe yourself Gay/homosexual 29 45,3% Bisexual 2 3,1% Transgender 33 51,6% Living with HIV Yes 64 100,0% Currently on ART Yes 64 100,0% Quantitative intervention impact results Table 2 highlights the differences in mean scores from baseline to endline data on numerous scales relating to HIV stigma, SOGI stigma, SOGI related harassment, depressive symptoms, alcohol use and ART adherence self-efficacy. The data highlight that the mean internalised HIV stigma scale score decreased from baseline to endline (p = 0.01). Furthermore, mean HIV anticipated stigma decreased from baseline to endline (p = 0.01). HIV stigma experienced by individuals in the health care setting decreased as well from baseline to endline (p < 0.001). SOGI harassment or assault decreased as well from the baseline to endline (p = 0.01). The mean number of depressive symptoms decreased from baseline to endline (p = 0.01). Finally, mean ART adherence self-efficacy increased from baseline to endline (p < 0.001). Table 2 Stigmas, depressive symptoms, alcohol use and ART adherence self-efficacy Variables Mean Differences t-value p-value Internalised HIV stigma baseline – Internalised HIV stigma endline 3,10 2,50 0,01 Anticipated HIV stigma baseline - Anticipated HIV stigma endline 0,58 2,66 0,01 Social exclusion stigma baseline - Social exclusion stigma endline 0,15 1,09 0,14 Experienced stigma baseline - Experienced stigma endline -0,10 -0,80 0,21 Health care stigma baseline - Health care stigma endline 0,39 2,99 < 0,001 Sexual orientation and gender identity stigma baseline - Sexual orientation and gender identity stigma endline -0,53 -0,77 0,22 SOGI harassment/assault baseline – SOGI harassment/assault endline 0.36 2.05 0.02 Depressive symptoms baseline - Depressive symptoms endline 2,44 2,44 0,01 Alcohol use baseline – Alcohol use endline 1,72 1,05 0,15 ART adherence self-efficacy baseline - ART adherence self-efficacy endline -11,93 -2,71 < 0,001 Table 3 highlights numerous sexual risk variables and the change in proportions from baseline to endline. However, there were no statistically significant changes from baseline to endline, although the proportion of individuals who used a condom last time they had anal sex appeared to increase from baseline to endline. Furthermore, the proportion of individuals who used drugs before sex appears to have decreased from baseline to endline, although these findings are based off a very small sample of individuals. Sample size limitations may have played a role in the lack of statistically significant findings in these two t-tests. Table 3 Sexual risk variables score baseline and endline Variables Baseline %(n) Endline %(n) p-value* Used a condom last time they had anal sex 58.6(34) 75.9(44) 0.05 Drinking before sex 39.7(23) 36.2(21) 0.82 Drugs before sex 24.1(14) 8.8(5) 0.05 Multiple concurrent partners 55.2(32) 60.3(35) 0.66 Received good or money for sex 13.8(8) 13.8(8) 0.61 Notes: The p-value is for the McNemar test. McNemar's test is a statistical test used on paired nominal data. The post-intervention data suggest that there was a significant change in depressive symptoms (Fig. 2 ). The decrease in depressive symptoms (as measured by the CES-D10 scale) was statistically significant (t = 2.44, df: 58; p = 0.009). The difference in depressive scores was 2.4 from pre-test to post-test. Baseline findings in the exploratory phase of the overall study indicated that one third of participants (37%) had missed at least one dose of their HIV medication. The baseline findings also indicate that some participants had missed at least one dose in the past three months. Reasons for missing dosses included forgetfulness, being away from home, avoiding being noticed and depression. The post-intervention data indicate there was an increase in treatment adherence self-efficacy (as measured in the HIV Adherence Self-Efficacy Scale; Fig. 3 ). The increase was statistically significant (t=-3.09, df: 54; p = 0.005). The difference in treatment adherence self-efficacy was 11.9 points. The modest increase in ART adherence self-efficacy indicates that the intervention may have provided useful strategies or emotional support that helped participants feel more in control of their treatment taking behavior. Qualitative findings This section highlights participants' experiences post-intervention regarding HIV status and sexual orientation/gender identity (SOGI) disclosure, stigma, mental health, and antiretroviral therapy (ART) adherence. It also presents their perceptions of the intervention's acceptability, feasibility, and areas for improvement. The intervention, grounded in the information-motivation-behavior (IMB) model, addressed disclosure complexities, intersectional stigma, alcohol abuse, and mental health challenges influencing ART adherence. Informal group sessions delivered in-depth knowledge and coping skills through expert-led and peer discussions, and role-playing. Alcohol abuse and coping mechanisms Participants reported a shift from relying on alcohol as a coping mechanism to adopting healthier alternatives. One participant shared: “Before getting involved in the sessions whenever I had stress, I used to go and drink beer…But through this session I was taught that finishing stress from beer and sex is not good for my health. So, now I usually finish my stress from listening to music” (ZAM-NN-MSM-EL-04). Another participant explained that the intervention opened new avenues for coping, positively impacting their mental health: “...before the sessions I only had alcohol as my copying strategy which sometimes led me to missing the dose when drunk but during and after the sessions of the intervention I have learnt some new positive copying strategies like mindfulness, going to some places where people are doing exciting things which helps relax the mind and positively influence my adherence to treatment” (MAL-BT-MM-PI-MSM1). These narratives indicate a move towards healthier coping strategies, reducing reliance on alcohol. Experiences of stigma and resilience Stigma related to both HIV status and SOGI was a prevalent issue. A significant theme was the increased confidence gained through the intervention. Participants attributed their growing ability to resist stigma to the skills, support, and knowledge acquired. One participant noted: “I can say for now I have more confidence, and I can now walk in the community as who I am” (ZIM-TM-TGW-PI-05). This reflects a sense of empowerment and self-acceptance. Some participants described diminished internalized stigma: “I used to feel guilty and even ask myself questions like how many years am I going to live on this earth with me being HIV positive...But through this session that I went through I am now seeing all these as being normal things” (ZAM-NN-MSM-EL-04). Self-acceptance emerged as fundamental in overcoming internalized stigma. One participant reflected: “You know there is no need for me to be discouraging myself or putting myself out when there is something taking place because all of us are human beings. So, I just have to accept that because if I don’t accept that thing [HIV] myself then who else is going to accept it for me” (ZAM-NN-MSM-EL-01). Building resilience was a crucial aspect of the intervention. Participants incorporated skills to handle stigma while enhancing confidence: “I am more confident now because during the sessions I learnt resilience strategies to deal with negative responses from people after disclosure. For example, walking away from people who react negatively towards me” (MAL-BT-MM-PI-MSM4). Managing HIV and SOGI disclosure Participants were more inclined to adopt disclosure strategies taught during the intervention, integrating them into their HIV and SOGI disclosure journeys. Some felt more confident speaking about their HIV-positive status: “The intervention built my self-confidence and self-esteem...but now I can do whatever I want as a person who is living with HIV” (ZIM-TM-TGW-PI-09). The benefits of HIV status disclosure were highlighted: “It was difficult for me, but now it (HIV status) no longer affects me...But now it doesn’t matter. I can even take them when they are around because I told them” (ZIM-TM- TGW-PI-06). Another participant described a newfound confidence in relation to both living with HIV and identifying as a sexual minority: “...now I can stand bold in a group of people and disclose my status and sexual orientation without doubting myself or fearing anything a thing which in the past before the intervention I could not” (MAL-BT-MM-PI-MSM2). Mental health status and coping strategies Participants reported improvements in mental health and increased happiness following the intervention. Many felt more emotionally stable and content. One participant noted: “I was facing lows and downs in the past month, but when I started attending this intervention, everything changed drastically...but now I’m okay” (ZIM-TM-TGW-PI- 02). The intervention helped participants overcome social isolation by promoting peer interaction and self-acceptance. It fostered a sense of community where participants could share experiences and support one another: “Before the intervention, I was that kind of person who was not interacting with others...but after the intervention, I learnt that not being interactive with others is not good for your mental health” (ZIM-TM-MSM-PI-04). Participants adopted positive coping strategies, particularly mindfulness: “The sessions we use to have, we use to do the mindfulness sessions where we could do the breathing in and the breath out technique, so I think doing that has really been very helpful” (ZAM-WC-MSM-EL-02). Another participant remarked, “ I learnt to do mindful exercises... whenever I’m stressed, I can do my mindfulness, and things work out ” (ZIM-TM-TGW-PI-05). While many reported improvements, some still experienced stress, indicating that the intervention may not have fully resolved all mental health issues: “Sometimes I feel bad and get stressed because of my sexual orientation and because I’m living with HIV” (ZIM-TM-TGW-PI-04). Mental health and ART adherence Participants reported a positive association between improved mental health and adherence to ART. One participant noted: “...after these interventions and the sessions that I had I have come to understand what mental health is and what am supposed to do to continue treatment” (ZAM-WC-MSM- EL-01). Participating in the intervention boosted confidence and the ability to resist the negative influences of stigma: “...before I came for the interviews, I used to skip my medication due to like stigma and I did not know how to take care of myself but after the interview and the meeting I learned how to control my stigma...” (ZAM-II-TG-EL-01). Another indicated improved ART adherence due to disclosure and social support: “...in this recent month I have been a free minded person whenever I am taking my pill just because I managed to disclose my status and ART treatment to my close friend...” (MAL-BT-MM-PI-MSM3). Learning about resilience, self-acceptance, and self-care also supported adherence: “I feel like the most important part that helped me to adhere to ART is resilience…and also having self-care, this really made me start adhering to it [ART]” (ZAM-WC- MSM-EL-01). Perceived suitability, practicality, and satisfaction with the intervention A key facilitator that may have contributed to the acceptability of the intervention was the sense of peer support and the perceived relatability of the facilitators. The peer-led approach made participants feel understood and supported, making the intervention more accessible and meaningful. One participant mentioned, “The facilitators understood us, and we could relate to them because they have been through the same things as us” (ZIM-TM-TGW-PI-11). Additionally, the peer-led facilitation, interactive mode of delivery and short sessions contributed to the participants accepting the intervention: The ability to stand in front of people or to speak in a group of people. I had always doubted myself to face a group of people and discussing topics but during the sessions with confidence and courage built by and from each one of us has made it a success for me. The sessions were short, the environment was good and safe, and the facilitators did their job well as they were accommodative of all comments and suggestions and open enough making the intervention worth it and delivered appropriately hence, we also accepted the intervention and everything in it with open hands (MAL-BT-MM-PI-MSM5). The participants found the intervention's content highly relevant and practical, particularly in stress management, adherence to ART, and life skills. One participant explained that: “ The content was very good. We learnt about many different things, and it helped us understand how to improve our ART adherence ” (ZIM-TM-TGW-PI-11). This indicates that the participants viewed the material as valuable and well-suited. Most participants were satisfied with the venue of the intervention as well as the set-up: And I enjoyed the fact that the room was circular, not like a classroom, because a classroom would have felt very…it’s extremely formal. I liked that we felt like we’re all together. Everything that was happening, we’re all in it at the same time (ZAM- NN-MSM-EL-01). However, some participants felt that certain sessions did not fully account for individual learning speeds. This occasionally left participants feeling they could not fully process or engage with the material before moving on to the next topic. One participant mentioned: Sometimes the delivery felt rushed, and I didn’t fully understand everything during the sessions (ZIM-TM-MSM-PI-06). This indicates that although the content was valuable, the pace at which it was delivered could be improved to ensure all participants had the opportunity to grasp the material fully. Discussion The study set out to assess the feasibility and acceptability of a pilot intervention to improve ART adherence and mental health, while reducing stigma affecting young HIV-positive MSM and TGW in Malawi, Zambia and Zimbabwe. Using the IMB model, the intervention addressed the complexities of disclosure, stigma, and mental health challenges that influence ART adherence. The IMB model posits that information, motivation, and behavioural skills are critical to fostering and sustaining health-promoting behaviours [ 8 ]. During the intervention, participants were equipped with knowledge about the health implications of ART adherence and the risks associated with non-adherence. The intervention also provided an opportunity for participants to explore and adopt alternative, healthier coping mechanisms. Alcohol abuse is a critical barrier to ART adherence among people living with HIV as it impairs judgment and disrupts the consistency required for optimum adherence, ultimately compromising treatment efficacy and increasing the risk of viral resistance [ 23 ]. The intervention provided a space for participants to explore and adopt alternative, healthier coping mechanisms leading to a decrease in alcohol abuse and risky sexual behaviours. For instance, participants shared the transition from reliance on alcohol and sexual activity to listening to music, adoption of mindfulness techniques, engaging in social activities, and practicing self-control as stress-relief strategies. These positive behaviours underscore the potential for people centred interventions to not only address immediate alcohol abuse concerns but also foster sustainable lifestyle changes. The disclosure of HIV status and aspects of one's SOGI remains a deeply personal and complex decision influenced by various factors, including the fear of stigma, anticipated negative consequences, and social context [ 24 , 25 ]. Findings suggest that targeted strategies to support disclosure can be effective in helping individuals navigate the complexities of revealing their HIV status and SOGI. The intervention equipped participants with some skills to improve their confidence and self-esteem, enabling them to feel more empowered to disclose in contexts where they previously felt vulnerable. Improved confidence contributed to overall well-being among participants by reducing the psychological burden associated with concealing their HIV status or sexual identity. The participant's experience illustrates how disclosure, when managed more effectively, can lead to positive health outcomes and enhanced social relationships [ 26 ]. Through the promotion of peer interaction and self-acceptance, participants appeared to recognise the importance of social connection in sustaining mental well-being [ 27 , 28 ]. The intervention seemed to help participants connect with their peers, which may have fostered a sense of belonging and support. Participants learned strategies to handle negative societal responses, such as walking away from stigmatizing encounters, seeking social support and embracing affirmations of self-worth. This finding is in line with findings from a study by Bridge et al. [ 29 ] which showed that sexual minority young adults utilised positive coping responses such as relying on social relationships for support and noting their own successes or positive qualities. The empowerment potentially fostered through the provision of knowledge, emotional support, and coping strategies enabled participants to begin confronting and mitigating the impact of stigma (including internalised, anticipated and experienced stigma). However, despite these improvements because of participating in the intervention, some participants expressed ongoing struggles. Internalized stigma, particularly related to SOGI and living with HIV, remained a source of compounded emotional distress for certain individuals. This may stem from deeply rooted heteronormative norms, religious condemnation, and the criminalisation of same-sex relationships in the countries where participants reside [ 30 , 31 ], all of which reinforce feelings of shame and self-stigma. While the intervention offered tools such as knowledge, emotional support, and coping strategies to manage these challenges, it became clear that some deeper issues, such as societal stigma and the complexities of living with a chronic illness, may require more prolonged or specialized support. This suggests that while the intervention was effective in many ways, it may not have been sufficient to fully address the mental health needs of all participants in group settings. The quantitative findings and interview data collectively demonstrate that the intervention had a significant positive effect on participants’ mental health and overall wellbeing. Recurring themes such as enhanced emotional stability and the adoption of positive coping strategies, particularly mindfulness underscore its effectiveness in addressing mental health challenges, aligning with evidence that mindfulness reduces depression and anxiety while improving cognitive and social outcomes [ 32 , 33 ]. The findings further show that improved mental health played a central role in supporting adherence to ART, as participants reported that the intervention helped them manage depression, anxiety, and stigma in ways that strengthened their commitment to treatment. Although it did not fully resolve these challenges, the intervention helped to foster self-acceptance and introduced coping skills that mitigated the negative effects of stigma on adherence. Grounded in the IMB model, the intervention sought to combine essential ART education with motivation to confront stigma and develop disclosure strategies, while reinforcing behavioral practices such as using reminders and engaging social support [ 34 ]. Together, these elements created conditions that enabled effective treatment management and equipped participants with the knowledge, skills, and confidence necessary for sustained adherence. The use of peer facilitators to deliver the intervention significantly contributed to the acceptability of the intervention. Peer-facilitated interventions appear to enhance medication adherence as well as other healthful behaviours, such as exercise [ 35 , 36 ]. Participants reported feeling more comfortable and engaged when interacting with facilitators and fellow participants who shared their experiences. This relatability between peer facilitators and the participants created an environment where participants felt understood, leading to a more meaningful experience. The structure of the intervention, characterized by short, interactive sessions, also contributed to its acceptability. Participants appreciated the collaborative atmosphere fostered through group work, where they could share personal stories and learn from one another. This aligns with educational theories that advocate for active participation to enhance retention and understanding of complex topics [ 37 ]. Despite the overall positive feedback of the pilot intervention, some study limitations are noted. Participants voiced concerns regarding the overall length of the intervention. Some participants felt that the sessions were a bit rushed. The 4-week timeframe may have limited deeper exploration and reflection on the covered topics. Participants' preference for longer interventions underscores the need to extend future programs, allowing deeper topic exploration and fuller engagement. Data was also collected by trained peer research assistants, some of whom were themselves members of the study population. Respondents might have responded to questions in a way they think is more socially acceptable or favourable rather than reflecting their true thoughts to avoid judgment from peer research assistants. However, because of the sensitive nature of the study, we felt that peer facilitators and researcher assistants were better positioned to facilitate the intervention and collect data due to their shared background, lived experience, and ability to foster trust within these communities. Lastly, while the preliminary findings are promising, the sustained impact of the intervention over time is yet to be established and warrants further longitudinal research to assess its long-term effectiveness and durability. Conclusions The findings highlight the potential of a peer facilitator intervention in managing intersectional stigma and improving mental health outcomes and ART adherence for HIV-positive young MSM and TGW in Malawi, Zambia, and Zimbabwe. Using the IMB model, the intervention showed promise in addressing the complexities of disclosure, intersectional stigma, and mental health challenges that influence ART adherence. By providing essential information on HIV and ART, fostering motivation through peer support and empowerment, and reinforcing practical adherence strategies such as mindfulness techniques and coping mechanisms, the intervention seemed to support the development of personal agency and emotional resilience, which may have contributed to improved overall well-being. However, the study also revealed that some participants continued to struggle with internalized stigma and emotional distress, underscoring the need for more prolonged and specialized support in future interventions. Overall, this intervention represents a meaningful step toward supporting ART adherence and mental health in a highly stigmatized and vulnerable population. Abbreviations ART Antiretroviral therapy AUDIT Alcohol use disorders identification test CES-D Center for epidemiological studies-depression 10 item IMB Information–motivation-behavioural skills model MSM men who have sex with men (MSM) SOGI Sexual orientation or gender identity TGW Transgender women Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki. The study received ethical approval from the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (BREC/00001655/2020), and the research ethics committees of Kamuzu University of Health Sciences (P.04/24–0654), University of Zambia (REF. NO. 1070–2020), and the Medical Research Council of Zimbabwe (MRCZ/A/3185). All participants provided informed consent for participation and for the inclusion of anonymised data in this manuscript. Consent for publication All participants provided written informed consent before participating in the study, which included consent to publish anonymous quotes from individual participants. Competing interests The authors declare that they have no competing interests. Funding The study was funded under HIV Special Fund Round III managed by the Southern African Development Community (CON7932 1/10/2020–30/9/2023). Author Contribution Study and concept design: RA, PN, KG, JZ, NM, VJ, AM. Data analysis and interpretation: PN, JZ, NM, VJ, AM. Additional quantitative analysis: SB, KG. Drafting of the manuscript: PN, KG, JZ. Review and revision of the manuscript: PN, KG, JZ, NM, VJ, AM. All authors read and approved the final manuscript. Acknowledgement We acknowledge the young individuals who volunteered to share their experiences as gender and/or sexuality minorities and as individuals living with HIV in a challenging environment. Special thanks go to the organisation working with young key populations in Malawi, Zambia and Zimbabwe that helped promote the study and provided safe and secure spaces for the data collection. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Please note that all data have been carefully anonymized to protect privacy and ensure compliance with ethical standards. Access will only be granted for legitimate research purposes after appropriate review. References ‌UNAIDS. 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Glob Ment Health. 2022;9:439–47. https://doi.org/10.1017/gmh.2022.47 . ‌Tashakkori A, Johnson RB, Teddlie C. Foundations of mixed methods research: Integrating quantitative and qualitative approaches in the social and behavioral sciences. 2nd ed. Sage; 2020. Bowleg L. When Black + Lesbian + Woman ≠ Black Lesbian Woman: The Methodological Challenges of Qualitative and Quantitative Intersectionality Research. Sex Roles. 2008;59(5–6):312–25. ‌Flick U. Mantras and Myths: The Disenchantment of Mixed-Methods Research and Revisiting Triangulation as a Perspective. Qual Inq. 2016;23(1):46–57. Hancock AM. Intersectionality as a Normative and Empirical Paradigm. Politics Gend. 2007;3(02):248–54. ‌ Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG, World Health Organization. AUDIT: the alcohol use disorders identification test: guidelines for use in primary health care. World Health Organization; 2001. World Health OrganizatioN. (WHO). 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ART Adherence Among Men Who Have Sex with Men Living with HIV: Key Challenges and Opportunities. Curr HIV/AIDS Rep. 2020;17(4):290–300. https://doi.org/10.1007/s11904-020-00510-5 . Dada D, Abu-Ba’are GR, Turner D, Mashoud IW, Owusu-Dampare F, Apreku A, et al. Scoping review of HIV-related intersectional stigma among sexual and gender minorities in sub-Saharan Africa. BMJ Open. 2024;14(2):e078794–4. https://doi.org/10.1136/bmjopen-2023-078794 . ‌Zulu JM, Budhwani H, Wang B, Menon A, Kim D, Zulu M, et al. Living a private lie: intersectional stigma, depression and suicidal thoughts for selected young key populations living with HIV in Zambia. BMC Public Health. 2024;24(1). https://doi.org/10.1186/s12889-024-19278-z . Li JY, Qiao S, Harrison S, Li X. Utilizing an interpersonal communication framework to understand information behaviors involved in HIV disclosure. Int J Inf Manage. 2017;37(4):250–6. https://doi.org/10.1016/j.ijinfomgt.2016.12.001 . ‌ Camp J, Vitoratou S, Rimes KA. LGBQ+ Self-Acceptance and Its Relationship with Minority Stressors and Mental Health: A Systematic Literature Review. Arch Sex Behav. 2020;49(7). https://doi.org/10.1007/s10508-020-01755-2 . ‌ Orth Z, van Wyk B. Discourses of Mental Wellness Among Adolescents Living with HIV in Cape Town, South Africa. Psychol Res Behav Manag. 2022;15:1435–50. https://doi.org/10.2147/PRBM.S360145 . ‌Bridge L, Smith P, Rimes KA. Self-esteem in sexual minority young adults: a qualitative interview study exploring protective factors and helpful coping responses. Int Rev Psychiatry. 2022;34(3–4):1–9. https://doi.org/10.1080/09540261.2022.2051446 . Jjuuko A, Tabengwa M. Expanded criminalisation of consensual same-sex relations in Africa: Contextualising recent developments. In: Jjuuko A, Nicol N, Lusimbo R, Mulé NJ, Ursel S, Wahab A, Waugh P, editors. Envisioning global LGBT human rights: (Neo)colonialism, neoliberalism, resistance and hope. University of London; 2018. pp. 63–96. Meer T, Lunau M, Oberth G, Daskilewicz K, Muller A. Lesbian, gay, bisexual, transgender and intersex human rights in Southern Africa: A contemporary literature review. Hivos South Africa and the DiDiRi Collective; 2017. Borquist-Conlon DS, Maynard BR, Brendel KE, Farina ASJ. Mindfulness-Based Interventions for Youth With Anxiety: A Systematic Review and Meta-Analysis. Res Soc Work Pract. 2017;29(2):195–205. https://doi.org/10.1177/1049731516684961 . Creswell JD. Mindfulness interventions. Annu Rev Psychol. 2017;68(2017):491–516. https://doi.org/10.1146/annurev-psych-042716-051139 ‌ Mukumbang FC, Van Belle S, Marchal B, van Wyk B. Exploring generative mechanisms of the antiretroviral adherence club intervention using the realist approach: a scoping review of research-based antiretroviral treatment adherence theories. BMC Public Health. 2017;17(1). https://doi.org/10.1186/s12889-017-4322-8 . Ahmed CV, Doyle R, Gallagher D, Olore Imoohi U, Ofoegbu, Wright R, et al. A Systematic Review of Peer Support Interventions for Adolescents Living with HIV in Sub-Saharan Africa. AIDS Patient Care STDs. 2023;37(11):535–59. https://doi.org/10.1089/apc.2023.0094 . Enriquez M, Conn VS. Peers as Facilitators of Medication Adherence Interventions. J Prim Care Community Health. 2015;7(1):44–55. https://doi.org/10.1177/2150131915601794 . ‌Kahu ER, Nelson K. Student engagement in the educational interface: understanding the mechanisms of student success. High Educ Res Dev. 2018;37(1):58–71. https://doi.org/10.1080/07294360.2017.1344197 . Additional Declarations No competing interests reported. Supplementary Files InterventionManual.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Apr, 2026 Reviews received at journal 30 Mar, 2026 Reviews received at journal 17 Mar, 2026 Reviewers agreed at journal 09 Mar, 2026 Reviewers agreed at journal 08 Mar, 2026 Reviewers agreed at journal 21 Feb, 2026 Reviewers invited by journal 12 Feb, 2026 Editor invited by journal 11 Feb, 2026 Editor assigned by journal 10 Feb, 2026 Submission checks completed at journal 10 Feb, 2026 First submitted to journal 09 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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04:22:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":15920,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMean number of depressive scores, pre-test and post-test\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8826781/v1/b2dcef486c5d0b621b11d618.png"},{"id":102940238,"identity":"89fd4eee-d4f3-4e63-ae6e-e5f386631460","added_by":"auto","created_at":"2026-02-18 17:04:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":16371,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMean ART adherence self-efficacy score\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8826781/v1/fe787d3ba54bcf01de614d13.png"},{"id":104835035,"identity":"38d406b8-0cef-49ec-ae09-b9dca52afd2b","added_by":"auto","created_at":"2026-03-17 17:39:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1066988,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8826781/v1/431e905f-5216-4cfa-b9b0-7922cf0f41d0.pdf"},{"id":102940240,"identity":"95817e8b-9b0e-4d27-99a4-df0f4337226d","added_by":"auto","created_at":"2026-02-18 17:04:39","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":65777,"visible":true,"origin":"","legend":"","description":"","filename":"InterventionManual.docx","url":"https://assets-eu.researchsquare.com/files/rs-8826781/v1/68eb19247d8e607eb2202cb0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing the feasibility and acceptability of a pilot peer led intervention to reduce stigma and improve ART adherence among young men having sex with men and transgender women living with HIV in low resource settings in Southern Africa","fulltext":[{"header":"Contributions to the literature","content":"\u003cul\u003e\n \u003cli\u003eThis study extends implementation science evidence by demonstrating the feasibility of a peer-led, theory-informed intervention that addresses intersecting stigma, mental health, and ART adherence in highly criminalised, low-resource Southern African settings.\u003c/li\u003e\n \u003cli\u003eFindings advance understanding of how the information-motivation behavioural skills (IMB) model can be operationalised through peer delivery to support complex behaviour change among sexual and gender minority populations.\u003c/li\u003e\n \u003cli\u003eBy foregrounding intersectional stigma as a central implementation barrier and intervention target, the study informs the design of scalable, equity-oriented HIV adherence interventions.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eYoung men who have sex with men (MSM) and transgender women (TGW) are among the populations most disproportionately affected by the global HIV epidemic [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This pattern is evident in Southern Africa, where key populations experience high HIV prevalence rates: in Zambia, HIV prevalence in 2020 was 21% among MSM and 22% among TGW [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]; in Zimbabwe the estimated HIV prevalence among MSM was 31% in 2017, almost four times the general adult male prevalence of 8.7% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]-while TGW faced a prevalence of 39.4% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite the high burden of HIV and poor mental health outcomes among young MSM and TGW in southern Africa, there is a critical shortage of tailored interventions addressing both ART adherence and mental health in an integrated way. Existing HIV programs often overlook the complex interplay between psychosocial stressors such as intersecting stigma and adherence behaviours, leaving significant service gaps [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Moreover, available interventions are rarely theory-based or co-designed with community input, limiting their relevance and sustainability. This highlights the urgent need for comprehensive, evidence-informed approaches that support both mental health resilience and ART adherence, especially in contexts marked by intersecting vulnerabilities. Building on previous research into stigma related to sexual orientation and gender identity [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], the current study describes the design and implementation of a pilot intervention aimed at mitigating stigma, improving mental health and enhancing ART uptake and adherence among young MSM and TGW.\u003c/p\u003e\n\u003ch3\u003eIntervention design and conceptual framework\u003c/h3\u003e\n\u003cp\u003e Through a series of workshops, stakeholders including researchers, representatives from NGOs working with MSM and TGW (Centre for the Development of People in Malawi, Women\u0026rsquo;s Alliance for Equality in Zambia, and An Association of LGBTI People in Zimbabwe), national health ministries, and research participants were recruited to collaboratively develop an 8-week intervention. The pilot intervention was designed to address stigma-related barriers to ART adherence and improve mental health among young MSM and TGW living with HIV. The intervention was informed by: (1) engaging with key stakeholders such as community-based organizations, healthcare providers, and MSM and transgender community members, and (2) an evidence-based review of academic and grey literature on HIV stigma, mental health, and ART adherence in low-resource, high-stigma settings. This participatory process ensured the intervention was grounded in both the lived experience of PLWH and current evidence, enhancing its cultural relevance and theoretical strength. Crucially, the intervention was co-designed with representatives from the target populations to ensure its appropriateness and effectiveness.\u003c/p\u003e \u003cp\u003eThe information-motivation-behaviour (IMB) model was used as a framework for understanding and promoting HIV prevention and medication adherence [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Its relevance was demonstrated in South Africa through an intervention addressing stigma-related barriers to ART adherence among PLHIV [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The intervention was based on evidence that peer-led small group sessions, supported by professional healthcare oversight, improve mental health and adherence outcomes [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This informed the adoption of a peer-delivery model, where trained community peers facilitated weekly sessions under supervision from qualified health professionals. This hybrid approach combines peer relatability and contextual insight with clinical expertise and accountability (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe IMB model identifies key determinants of ART adherence. Adherence information refers to understanding ART specifics, dosage, side effects, and the importance of consistent intake. Adherence motivation involves personal attitudes, beliefs, perceived outcomes, and social support. Adherence behavioral skills represent practical capabilities, such as self-efficacy, to follow ART regimens and seek support. The components\u0026mdash;information, motivation, and behavioral skills culminate in adherence behavior and improved health outcomes. Moderators, such as socio-economic conditions and stigma, can influence the relationships between IMB components and adherence.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eIntervention outline\u003c/h2\u003e \u003cp\u003eThe intervention involved small groups of participants (12 MSM and 12 TGW) attending eight sessions over an 8- week period covering topics such as experiences, fears, anxieties regarding stigma; HIV/SOGI disclosure intentions; coping and recovery mechanisms; mental health; perceptions regarding ART adherence; and perceptions of change linked to components of the intervention. Amongst the range of topics covered, most were delivered for all participants, while some were adapted to be delivered separately to either the MSM or TGW groups (all sessions had the same overall theme). While sessions where initially designed to take place at one-week intervals, 2 sessions were delivered weekly because of time-constraints. Each session has two 60-minute sections (A and B) with a 30-minute break between sections. The sessions were delivered separately for the MSM and TGW participants. An additional 30\u0026ndash;60 minutes of 'open time' was made available following each session for social networking and for access to other services provided by the organisation hosting the intervention. This included, for example, opportunities for individual counselling and support with qualified individuals. The session topics were adapted from interventions designed by Fisher et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and Rose et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThe study used a mixed-methods, parallel design, collecting qualitative and quantitative data simultaneously [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. The quantitative component involved a self-administered, confidential questionnaire. Regionally validated screening tools were available to provide a quantitative lens on the presence or absence of signs of health challenges and their severity linked to experiences of stigma. In addition, the questionnaire was able to capture the acceptability and feasibility of the intervention among the sample. In-depth interviews explored individual experiences of intersectional stigma, health status, and participation in the intervention. Using the two approaches allowed for triangulation and a richer analysis of the complex phenomena underlying intersectional stigma for the study participants [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study population included young gay, bisexual, and other MSM, and TGW, aged 18–24, self-identifying as living with HIV and on antiretroviral therapy (ART) for at least six months. Eligibility criteria were: (1) self-identification as gay, bisexual, other MSM, or TGW; (2) current ART use for at least six months; (3) self-reported non-adherence (at least one missed dose in the past three months); (4) willingness to join group sessions; (5) commitment to completing the 8-week program; and (6) consent to audio-recorded interviews at baseline and follow-up. Participants not meeting these criteria were excluded.\u003c/p\u003e \u003cp\u003eSeventy-two participants were recruited from sites at community-based organisations in Blantyre, Lusaka, and Harare (24 per site) via snowball sampling, with recruitment supported by peer navigators and healthcare workers involved in HIV and sexual health services providing ART. Initial contact was made through peer navigators, counselors, or healthcare providers who directed individuals to a researcher for eligibility screening. Eligible participants were referred to trained research assistants for consent and baseline data collection. Data collection occurred between May and June 2024. One participant (from Malawi) withdrew before the baseline interview.\u003c/p\u003e \u003cp\u003eThe data collection and intervention were conducted between May and July 2024 in safe locations selected through consultation with key populations representatives in each country. The Drop-In Centres (DIC) at CEDEP (Blantyre, Malawi), WAFE (Lusaka, Zambia) and GALZ (Harare, Zimbabwe) were used. These locations had adequate measures in place for assuring the confidentiality, privacy, safety and security of participants. Peer facilitators were given a spacious meeting room capable of accommodating 20–25 individuals in a private setting. The peer facilitators furnished the room to make it more comfortable by including chairs, mats and pillows. Participants were given personal workbooks containing instructions and materials for each session as well as information and exercises for self-directed learning and practice between sessions.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection and intervention implementation\u003c/h3\u003e\n\u003cp\u003eThe intervention was delivered by trained peer facilitators, two per site who were existing peer educators working with the study population and recommended by employers and stakeholders. Two researchers interviewed candidates before confirming their selection for a five-day intensive training prior to the intervention launch. Peer facilitators received ongoing supervision from a clinical officer and a mental health professional, including proactive risk identification, weekly debriefs, and a mid-term review after session four to address challenges. Drop-in center (DIC) coordinators were present during sessions to support timely responses to risks. Implementation was synchronized across the three countries, following a standard procedure of two daily sessions—one for MSM and one for TGW—scheduled according to local arrangements. Sessions began with an overview, followed by participants sharing expectations on index cards.\u003c/p\u003e \u003cp\u003eThe intervention comprised a structured series of sessions covering key topics related to HIV treatment, mental health, stigma, relationships, and resilience. Content covered included mindfulness-based stress reduction, HIV and ART knowledge, HIV disclosure, lifelong adherence and adherence skills, mental health and coping strategies (including alcohol use), stigma and intersectional stigma, positive sexuality, love and relationships, resilience, and integration of self, culminating in reflection and future-oriented goal setting. Sessions were delivered through a mix of facilitated group discussions, expert-led presentations, role-play, experience sharing, and reflective exercises. These interactive and participatory methods were designed to build knowledge, practical skills, self-confidence, mutual solidarity, and sustained commitment to ART adherence and overall wellbeing. Peer facilitators and participants jointly set ground rules emphasizing privacy, confidentiality, support, and teamwork. While the session manual guided implementation, facilitators had flexibility for creative activities.\u003c/p\u003e \u003cp\u003eData collection occurred at baseline and endline through self-administered questionnaires and in-depth interviews using the same tools, with the endline including questions on intervention experiences. The self-administered questionnaire included sections on alcohol use, using the Alcohol Use Disorders Identification Test (AUDIT), and experiences with physical or sexual violence [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. One specific item addressed mental health: the Center for Epidemiological Studies-Depression (CES-D) 10 item scale, which had been previously validated in a similar African setting although not with the specific population for this study [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. No adaptations were made to the content of these scales or assessment tools. Additional sections addressed experiences of stigma and discrimination related to sexual orientation, gender identity, and HIV status using questions adapted from the PLHIV Stigma Index 2.0 tool [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. A final section of the questionnaire captured data on most recent sexual activity, including condom use and disclosure of HIV status with sexual partners (questions were adapted from WHO [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]). The interview guide explored stigma, discrimination, mental health effects, coping strategies, ART experiences, adherence challenges, self-efficacy, and intervention expectations.\u003c/p\u003e \u003cp\u003eTwo trained research assistants per country conducted interviews after attending country-specific training workshops prioritizing safety and psychosocial risk management. Data collection took place in secure, confidential settings. After eligibility screening and informed consent, participants consented to audio recording and completed semi-structured interviews lasting 30–40 minutes. Interviews were conducted in local languages—Chichewa and Chitumbuka (Malawi); Bemba, Lozi, and Nyanja (Zambia); and Ndebele and Shona (Zimbabwe)—based on participant preference and interviewer capacity. No personal identifying information was collected. Research supervisors were available to assist with any adverse reactions or risks (none occurred). Participants received the local equivalent of US\u003cspan\u003e$\u003c/span\u003e10 after data collection to cover transport costs.\u003c/p\u003e \u003cp\u003eFollowing the 8-week intervention, endline data collection followed the same procedures. The study received ethical approval from the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (BREC/00001655/2020), and the research ethics committees of Kamuzu University of Health Sciences (P.04/24–0654), University of Zambia (REF. NO. 1070–2020), and the Medical Research Council of Zimbabwe (MRCZ/A/3185).\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAudio recordings were transcribed into English by the interviewers and translated when needed, with ongoing quality checks by the research teams. Thematic analysis combined structural and inductive coding aligned with the conceptual framework [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. Initial analysis was conducted separately in each country by the Lead Researcher and Research Coordinator, who independently coded the data, then compared and reconciled codes. Together, they grouped codes into broader themes, refined and clearly defined each theme to ensure coherence, and produced detailed reports with supporting excerpts. Regular discussions and cross-checking enhanced the reliability and depth of the analysis. After country-level analyses, two researchers reviewed the themes for clarity and relevance, followed by cross-country comparisons. Descriptive statistics were used to describe the sample of individuals in the study. Furthermore, paired samples t-tests were used to assess the change from pre-test to post-test for the continuous data. While a McNemar’s test was used to assess the changes from pre-test to post-test for the categorical data. All analysis were conducted in IBM SPSS version 28. Across all analysis processes, attention was paid to similarities and differences between countries. A flexible, dialogic approach to triangulation was employed to build complementary, reflexive links between the two types of data [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e\n\n "},{"header":"Findings","content":"\u003ch2\u003eParticipant characteristics\u003c/h2\u003e\u003cp\u003eThere was a total of 64 participants across the three countries with a mean age of 22 (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Regarding gender identity, 48.4% of the participants identified as male, while 37.5% identified as transgender. When describing their sexual orientation, 45.3% of the participants identified as gay or homosexual, 51.6% identified as transgender, and only 3.1% described themselves as bisexual. All participants in the sample were living with HIV, and were currently on ART.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eA summary of the main characteristics of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eColumn N %\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\"\u003e \u003cp\u003eMean age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" rowspan=\"4\"\u003e \u003cp\u003eDo you consider yourself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e48,4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e12,5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTransgender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e37,5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e1,6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" rowspan=\"3\"\u003e \u003cp\u003eHow would you describe yourself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGay/homosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e45,3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eBisexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e3,1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTransgender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e51,6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLiving with HIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e100,0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCurrently on ART\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e100,0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003ch3\u003eQuantitative intervention impact results\u003c/h3\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e highlights the differences in mean scores from baseline to endline data on numerous scales relating to HIV stigma, SOGI stigma, SOGI related harassment, depressive symptoms, alcohol use and ART adherence self-efficacy. The data highlight that the mean internalised HIV stigma scale score decreased from baseline to endline (p = 0.01). Furthermore, mean HIV anticipated stigma decreased from baseline to endline (p = 0.01). HIV stigma experienced by individuals in the health care setting decreased as well from baseline to endline (p \u0026lt; 0.001). SOGI harassment or assault decreased as well from the baseline to endline (p = 0.01). The mean number of depressive symptoms decreased from baseline to endline (p = 0.01). Finally, mean ART adherence self-efficacy increased from baseline to endline (p \u0026lt; 0.001).\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab2\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStigmas, depressive symptoms, alcohol use and ART adherence self-efficacy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eMean Differences\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003et-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eInternalised HIV stigma baseline – Internalised HIV stigma endline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e3,10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e2,50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0,01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAnticipated HIV stigma baseline - Anticipated HIV stigma endline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0,58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e2,66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0,01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSocial exclusion stigma baseline - Social exclusion stigma endline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0,15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e1,09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0,14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExperienced stigma baseline - Experienced stigma endline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e-0,10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e-0,80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0,21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHealth care stigma baseline - Health care stigma endline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0,39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e2,99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u0026lt; 0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSexual orientation and gender identity stigma baseline - Sexual orientation and gender identity stigma endline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e-0,53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e-0,77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0,22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSOGI harassment/assault baseline – SOGI harassment/assault endline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e2.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDepressive symptoms baseline - Depressive symptoms endline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e2,44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e2,44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0,01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAlcohol use baseline – Alcohol use endline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e1,72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e1,05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0,15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eART adherence self-efficacy baseline - ART adherence self-efficacy endline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e-11,93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e-2,71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u0026lt; 0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e highlights numerous sexual risk variables and the change in proportions from baseline to endline. However, there were no statistically significant changes from baseline to endline, although the proportion of individuals who used a condom last time they had anal sex appeared to increase from baseline to endline. Furthermore, the proportion of individuals who used drugs before sex appears to have decreased from baseline to endline, although these findings are based off a very small sample of individuals. Sample size limitations may have played a role in the lack of statistically significant findings in these two t-tests.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab3\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSexual risk variables score baseline and endline\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eBaseline %(n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eEndline %(n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003ep-value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eUsed a condom last time they had anal sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e58.6(34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e75.9(44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDrinking before sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e39.7(23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e36.2(21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDrugs before sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e24.1(14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e8.8(5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMultiple concurrent partners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e55.2(32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e60.3(35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eReceived good or money for sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e13.8(8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e13.8(8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNotes: The p-value is for the McNemar test. McNemar's test is a statistical test used on paired nominal data.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe post-intervention data suggest that there was a significant change in depressive symptoms (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The decrease in depressive symptoms (as measured by the CES-D10 scale) was statistically significant (t = 2.44, df: 58; p = 0.009). The difference in depressive scores was 2.4 from pre-test to post-test.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cp\u003eBaseline findings in the exploratory phase of the overall study indicated that one third of participants (37%) had missed at least one dose of their HIV medication. The baseline findings also indicate that some participants had missed at least one dose in the past three months. Reasons for missing dosses included forgetfulness, being away from home, avoiding being noticed and depression. The post-intervention data indicate there was an increase in treatment adherence self-efficacy (as measured in the HIV Adherence Self-Efficacy Scale; Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). The increase was statistically significant (t=-3.09, df: 54; p = 0.005). The difference in treatment adherence self-efficacy was 11.9 points. The modest increase in ART adherence self-efficacy indicates that the intervention may have provided useful strategies or emotional support that helped participants feel more in control of their treatment taking behavior.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003ch2\u003eQualitative findings\u003c/h2\u003e\u003cp\u003eThis section highlights participants' experiences post-intervention regarding HIV status and sexual orientation/gender identity (SOGI) disclosure, stigma, mental health, and antiretroviral therapy (ART) adherence. It also presents their perceptions of the intervention's acceptability, feasibility, and areas for improvement. The intervention, grounded in the information-motivation-behavior (IMB) model, addressed disclosure complexities, intersectional stigma, alcohol abuse, and mental health challenges influencing ART adherence. Informal group sessions delivered in-depth knowledge and coping skills through expert-led and peer discussions, and role-playing.\u003c/p\u003e\u003ch2\u003eAlcohol abuse and coping mechanisms\u003c/h2\u003e\u003cp\u003eParticipants reported a shift from relying on alcohol as a coping mechanism to adopting healthier alternatives. One participant shared:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“Before getting involved in the sessions whenever I had stress, I used to go and drink beer…But through this session I was taught that finishing stress from beer and sex is not good for my health. So, now I usually finish my stress from listening to music”\u003c/em\u003e (ZAM-NN-MSM-EL-04).\u003c/p\u003e\u003cp\u003eAnother participant explained that the intervention opened new avenues for coping, positively impacting their mental health:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“...before the sessions I only had alcohol as my copying strategy which sometimes led me to missing the dose when drunk but during and after the sessions of the intervention I have learnt some new positive copying strategies like mindfulness, going to some places where people are doing exciting things which helps relax the mind and positively influence my adherence to treatment”\u003c/em\u003e (MAL-BT-MM-PI-MSM1).\u003c/p\u003e\u003cp\u003eThese narratives indicate a move towards healthier coping strategies, reducing reliance on alcohol.\u003c/p\u003e\u003ch2\u003eExperiences of stigma and resilience\u003c/h2\u003e\u003cp\u003eStigma related to both HIV status and SOGI was a prevalent issue. A significant theme was the increased confidence gained through the intervention. Participants attributed their growing ability to resist stigma to the skills, support, and knowledge acquired. One participant noted:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“I can say for now I have more confidence, and I can now walk in the community as who I am”\u003c/em\u003e (ZIM-TM-TGW-PI-05).\u003c/p\u003e\u003cp\u003eThis reflects a sense of empowerment and self-acceptance. Some participants described diminished internalized stigma:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“I used to feel guilty and even ask myself questions like how many years am I going to live on this earth with me being HIV positive...But through this session that I went through I am now seeing all these as being normal things”\u003c/em\u003e (ZAM-NN-MSM-EL-04).\u003c/p\u003e\u003cp\u003eSelf-acceptance emerged as fundamental in overcoming internalized stigma. One participant reflected:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“You know there is no need for me to be discouraging myself or putting myself out when there is something taking place because all of us are human beings. So, I just have to accept that because if I don’t accept that thing [HIV] myself then who else is going to accept it for me”\u003c/em\u003e (ZAM-NN-MSM-EL-01).\u003c/p\u003e\u003cp\u003eBuilding resilience was a crucial aspect of the intervention. Participants incorporated skills to handle stigma while enhancing confidence:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“I am more confident now because during the sessions I learnt resilience strategies to deal with negative responses from people after disclosure. For example, walking away from people who react negatively towards me”\u003c/em\u003e (MAL-BT-MM-PI-MSM4).\u003c/p\u003e\u003ch2\u003eManaging HIV and SOGI disclosure\u003c/h2\u003e\u003cp\u003e Participants were more inclined to adopt disclosure strategies taught during the intervention, integrating them into their HIV and SOGI disclosure journeys. Some felt more confident speaking about their HIV-positive status:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“The intervention built my self-confidence and self-esteem...but now I can do whatever I want as a person who is living with HIV”\u003c/em\u003e (ZIM-TM-TGW-PI-09).\u003c/p\u003e\u003cp\u003eThe benefits of HIV status disclosure were highlighted:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“It was difficult for me, but now it (HIV status) no longer affects me...But now it doesn’t matter. I can even take them when they are around because I told them”\u003c/em\u003e (ZIM-TM- TGW-PI-06).\u003c/p\u003e\u003cp\u003eAnother participant described a newfound confidence in relation to both living with HIV and identifying as a sexual minority:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“...now I can stand bold in a group of people and disclose my status and sexual orientation without doubting myself or fearing anything a thing which in the past before the intervention I could not”\u003c/em\u003e (MAL-BT-MM-PI-MSM2).\u003c/p\u003e\u003ch2\u003eMental health status and coping strategies\u003c/h2\u003e\u003cp\u003eParticipants reported improvements in mental health and increased happiness following the intervention. Many felt more emotionally stable and content. One participant noted:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“I was facing lows and downs in the past month, but when I started attending this intervention, everything changed drastically...but now I’m okay”\u003c/em\u003e (ZIM-TM-TGW-PI- 02).\u003c/p\u003e\u003cp\u003eThe intervention helped participants overcome social isolation by promoting peer interaction and self-acceptance. It fostered a sense of community where participants could share experiences and support one another:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“Before the intervention, I was that kind of person who was not interacting with others...but after the intervention, I learnt that not being interactive with others is not good for your mental health”\u003c/em\u003e (ZIM-TM-MSM-PI-04).\u003c/p\u003e\u003cp\u003e Participants adopted positive coping strategies, particularly mindfulness:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“The sessions we use to have, we use to do the mindfulness sessions where we could do the breathing in and the breath out technique, so I think doing that has really been very helpful”\u003c/em\u003e (ZAM-WC-MSM-EL-02).\u003c/p\u003e\u003cp\u003eAnother participant remarked, “\u003cem\u003eI learnt to do mindful exercises... whenever I’m stressed, I can do my mindfulness, and things work out\u003c/em\u003e” (ZIM-TM-TGW-PI-05).\u003c/p\u003e\u003cp\u003eWhile many reported improvements, some still experienced stress, indicating that the intervention may not have fully resolved all mental health issues:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“Sometimes I feel bad and get stressed because of my sexual orientation and because I’m living with HIV”\u003c/em\u003e (ZIM-TM-TGW-PI-04).\u003c/p\u003e\u003ch2\u003eMental health and ART adherence\u003c/h2\u003e\u003cp\u003eParticipants reported a positive association between improved mental health and adherence to ART. One participant noted:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“...after these interventions and the sessions that I had I have come to understand what mental health is and what am supposed to do to continue treatment”\u003c/em\u003e (ZAM-WC-MSM- EL-01).\u003c/p\u003e\u003cp\u003eParticipating in the intervention boosted confidence and the ability to resist the negative influences of stigma:\u003c/p\u003e\u003cp\u003e\u003cem\u003e“...before I came for the interviews, I used to skip my medication due to like stigma and I did not know how to take care of myself but after the interview and the meeting I learned how to control my stigma...”\u003c/em\u003e (ZAM-II-TG-EL-01).\u003c/p\u003e\u003cp\u003eAnother indicated improved ART adherence due to disclosure and social support:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“...in this recent month I have been a free minded person whenever I am taking my pill just because I managed to disclose my status and ART treatment to my close friend...”\u003c/em\u003e (MAL-BT-MM-PI-MSM3).\u003c/p\u003e\u003cp\u003eLearning about resilience, self-acceptance, and self-care also supported adherence:\u003c/p\u003e\u003cp\u003e \u003cem\u003e“I feel like the most important part that helped me to adhere to ART is resilience…and also having self-care, this really made me start adhering to it [ART]”\u003c/em\u003e (ZAM-WC- MSM-EL-01).\u003c/p\u003e\u003ch2\u003ePerceived suitability, practicality, and satisfaction with the intervention\u003c/h2\u003e\u003cp\u003eA key facilitator that may have contributed to the acceptability of the intervention was the sense of peer support and the perceived relatability of the facilitators. The peer-led approach made participants feel understood and supported, making the intervention more accessible and meaningful. One participant mentioned, \u003cem\u003e“The facilitators understood us, and we could relate to them because they have been through the same things as us”\u003c/em\u003e (ZIM-TM-TGW-PI-11).\u003c/p\u003e\u003cp\u003e Additionally, the peer-led facilitation, interactive mode of delivery and short sessions contributed to the participants accepting the intervention:\u003c/p\u003e\u003cp\u003e \u003cem\u003eThe ability to stand in front of people or to speak in a group of people. I had always doubted myself to face a group of people and discussing topics but during the sessions with confidence and courage built by and from each one of us has made it a success for me. The sessions were short, the environment was good and safe, and the facilitators did their job well as they were accommodative of all comments and suggestions and open enough making the intervention worth it and delivered appropriately hence, we also accepted the intervention and everything in it with open hands (MAL-BT-MM-PI-MSM5).\u003c/em\u003e \u003c/p\u003e\u003cp\u003eThe participants found the intervention's content highly relevant and practical, particularly in stress management, adherence to ART, and life skills. One participant explained that:\u003c/p\u003e\u003cp\u003e“\u003cem\u003eThe content was very good. We learnt about many different things, and it helped us understand how to improve our ART adherence\u003c/em\u003e” (ZIM-TM-TGW-PI-11).\u003c/p\u003e\u003cp\u003eThis indicates that the participants viewed the material as valuable and well-suited. Most participants were satisfied with the venue of the intervention as well as the set-up:\u003c/p\u003e\u003cp\u003e \u003cem\u003eAnd I enjoyed the fact that the room was circular, not like a classroom, because a classroom would have felt very…it’s extremely formal. I liked that we felt like we’re all together. Everything that was happening, we’re all in it at the same time\u003c/em\u003e (ZAM- NN-MSM-EL-01).\u003c/p\u003e\u003cp\u003eHowever, some participants felt that certain sessions did not fully account for individual learning speeds. This occasionally left participants feeling they could not fully process or engage with the material before moving on to the next topic. One participant mentioned:\u003c/p\u003e\u003cp\u003e \u003cem\u003eSometimes the delivery felt rushed, and I didn’t fully understand everything during the sessions\u003c/em\u003e (ZIM-TM-MSM-PI-06).\u003c/p\u003e\u003cp\u003eThis indicates that although the content was valuable, the pace at which it was delivered could be improved to ensure all participants had the opportunity to grasp the material fully.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study set out to assess the feasibility and acceptability of a pilot intervention to improve ART adherence and mental health, while reducing stigma affecting young HIV-positive MSM and TGW in Malawi, Zambia and Zimbabwe. Using the IMB model, the intervention addressed the complexities of disclosure, stigma, and mental health challenges that influence ART adherence. The IMB model posits that information, motivation, and behavioural skills are critical to fostering and sustaining health-promoting behaviours [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. During the intervention, participants were equipped with knowledge about the health implications of ART adherence and the risks associated with non-adherence. The intervention also provided an opportunity for participants to explore and adopt alternative, healthier coping mechanisms.\u003c/p\u003e \u003cp\u003eAlcohol abuse is a critical barrier to ART adherence among people living with HIV as it impairs judgment and disrupts the consistency required for optimum adherence, ultimately compromising treatment efficacy and increasing the risk of viral resistance [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The intervention provided a space for participants to explore and adopt alternative, healthier coping mechanisms leading to a decrease in alcohol abuse and risky sexual behaviours. For instance, participants shared the transition from reliance on alcohol and sexual activity to listening to music, adoption of mindfulness techniques, engaging in social activities, and practicing self-control as stress-relief strategies. These positive behaviours underscore the potential for people centred interventions to not only address immediate alcohol abuse concerns but also foster sustainable lifestyle changes.\u003c/p\u003e \u003cp\u003eThe disclosure of HIV status and aspects of one's SOGI remains a deeply personal and complex decision influenced by various factors, including the fear of stigma, anticipated negative consequences, and social context [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Findings suggest that targeted strategies to support disclosure can be effective in helping individuals navigate the complexities of revealing their HIV status and SOGI. The intervention equipped participants with some skills to improve their confidence and self-esteem, enabling them to feel more empowered to disclose in contexts where they previously felt vulnerable. Improved confidence contributed to overall well-being among participants by reducing the psychological burden associated with concealing their HIV status or sexual identity. The participant's experience illustrates how disclosure, when managed more effectively, can lead to positive health outcomes and enhanced social relationships [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThrough the promotion of peer interaction and self-acceptance, participants appeared to recognise the importance of social connection in sustaining mental well-being [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The intervention seemed to help participants connect with their peers, which may have fostered a sense of belonging and support. Participants learned strategies to handle negative societal responses, such as walking away from stigmatizing encounters, seeking social support and embracing affirmations of self-worth. This finding is in line with findings from a study by Bridge et al. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] which showed that sexual minority young adults utilised positive coping responses such as relying on social relationships for support and noting their own successes or positive qualities.\u003c/p\u003e \u003cp\u003eThe empowerment potentially fostered through the provision of knowledge, emotional support, and coping strategies enabled participants to begin confronting and mitigating the impact of stigma (including internalised, anticipated and experienced stigma). However, despite these improvements because of participating in the intervention, some participants expressed ongoing struggles. Internalized stigma, particularly related to SOGI and living with HIV, remained a source of compounded emotional distress for certain individuals. This may stem from deeply rooted heteronormative norms, religious condemnation, and the criminalisation of same-sex relationships in the countries where participants reside [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], all of which reinforce feelings of shame and self-stigma. While the intervention offered tools such as knowledge, emotional support, and coping strategies to manage these challenges, it became clear that some deeper issues, such as societal stigma and the complexities of living with a chronic illness, may require more prolonged or specialized support. This suggests that while the intervention was effective in many ways, it may not have been sufficient to fully address the mental health needs of all participants in group settings.\u003c/p\u003e \u003cp\u003eThe quantitative findings and interview data collectively demonstrate that the intervention had a significant positive effect on participants\u0026rsquo; mental health and overall wellbeing. Recurring themes such as enhanced emotional stability and the adoption of positive coping strategies, particularly mindfulness underscore its effectiveness in addressing mental health challenges, aligning with evidence that mindfulness reduces depression and anxiety while improving cognitive and social outcomes [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The findings further show that improved mental health played a central role in supporting adherence to ART, as participants reported that the intervention helped them manage depression, anxiety, and stigma in ways that strengthened their commitment to treatment. Although it did not fully resolve these challenges, the intervention helped to foster self-acceptance and introduced coping skills that mitigated the negative effects of stigma on adherence. Grounded in the IMB model, the intervention sought to combine essential ART education with motivation to confront stigma and develop disclosure strategies, while reinforcing behavioral practices such as using reminders and engaging social support [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Together, these elements created conditions that enabled effective treatment management and equipped participants with the knowledge, skills, and confidence necessary for sustained adherence.\u003c/p\u003e \u003cp\u003eThe use of peer facilitators to deliver the intervention significantly contributed to the acceptability of the intervention. Peer-facilitated interventions appear to enhance medication adherence as well as other healthful behaviours, such as exercise [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Participants reported feeling more comfortable and engaged when interacting with facilitators and fellow participants who shared their experiences. This relatability between peer facilitators and the participants created an environment where participants felt understood, leading to a more meaningful experience. The structure of the intervention, characterized by short, interactive sessions, also contributed to its acceptability. Participants appreciated the collaborative atmosphere fostered through group work, where they could share personal stories and learn from one another. This aligns with educational theories that advocate for active participation to enhance retention and understanding of complex topics [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the overall positive feedback of the pilot intervention, some study limitations are noted.\u003c/p\u003e \u003cp\u003eParticipants voiced concerns regarding the overall length of the intervention. Some participants felt that the sessions were a bit rushed. The 4-week timeframe may have limited deeper exploration and reflection on the covered topics. Participants' preference for longer interventions underscores the need to extend future programs, allowing deeper topic exploration and fuller engagement. Data was also collected by trained peer research assistants, some of whom were themselves members of the study population. Respondents might have responded to questions in a way they think is more socially acceptable or favourable rather than reflecting their true thoughts to avoid judgment from peer research assistants. However, because of the sensitive nature of the study, we felt that peer facilitators and researcher assistants were better positioned to facilitate the intervention and collect data due to their shared background, lived experience, and ability to foster trust within these communities. Lastly, while the preliminary findings are promising, the sustained impact of the intervention over time is yet to be established and warrants further longitudinal research to assess its long-term effectiveness and durability.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe findings highlight the potential of a peer facilitator intervention in managing intersectional stigma and improving mental health outcomes and ART adherence for HIV-positive young MSM and TGW in Malawi, Zambia, and Zimbabwe. Using the IMB model, the intervention showed promise in addressing the complexities of disclosure, intersectional stigma, and mental health challenges that influence ART adherence. By providing essential information on HIV and ART, fostering motivation through peer support and empowerment, and reinforcing practical adherence strategies such as mindfulness techniques and coping mechanisms, the intervention seemed to support the development of personal agency and emotional resilience, which may have contributed to improved overall well-being. However, the study also revealed that some participants continued to struggle with internalized stigma and emotional distress, underscoring the need for more prolonged and specialized support in future interventions. Overall, this intervention represents a meaningful step toward supporting ART adherence and mental health in a highly stigmatized and vulnerable population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eART\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntiretroviral therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAUDIT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAlcohol use disorders identification test\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCES-D\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCenter for epidemiological studies-depression 10 item\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIMB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInformation\u0026ndash;motivation-behavioural skills model\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMSM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emen who have sex with men (MSM)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSOGI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSexual orientation or gender identity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTGW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTransgender women\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e This study was conducted in accordance with the Declaration of Helsinki. The study received ethical approval from the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (BREC/00001655/2020), and the research ethics committees of Kamuzu University of Health Sciences (P.04/24\u0026ndash;0654), University of Zambia (REF. NO. 1070\u0026ndash;2020), and the Medical Research Council of Zimbabwe (MRCZ/A/3185). All participants provided informed consent for participation and for the inclusion of anonymised data in this manuscript.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e All participants provided written informed consent before participating in the study, which included consent to publish anonymous quotes from individual participants.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe study was funded under HIV Special Fund Round III managed by the Southern African Development Community (CON7932 1/10/2020\u0026ndash;30/9/2023).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eStudy and concept design: RA, PN, KG, JZ, NM, VJ, AM. Data analysis and interpretation: PN, JZ, NM, VJ, AM. Additional quantitative analysis: SB, KG. Drafting of the manuscript: PN, KG, JZ. Review and revision of the manuscript: PN, KG, JZ, NM, VJ, AM. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe acknowledge the young individuals who volunteered to share their experiences as gender and/or sexuality minorities and as individuals living with HIV in a challenging environment. Special thanks go to the organisation working with young key populations in Malawi, Zambia and Zimbabwe that helped promote the study and provided safe and secure spaces for the data collection.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Please note that all data have been carefully anonymized to protect privacy and ensure compliance with ethical standards. Access will only be granted for legitimate research purposes after appropriate review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e\u0026zwnj;UNAIDS. Global HIV statistics [Internet]. 2025. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unaids.org/sites/default/files/2025-07/2025_Global_HIV_Factsheet_en.pdf\u003c/span\u003e\u003cspan address=\"https://www.unaids.org/sites/default/files/2025-07/2025_Global_HIV_Factsheet_en.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindsay BR, Mwango L, Toeque M\u0026ndash;G, Malupande SL, Nkhuwa E, Moonga CN, et al. Peer community health workers improve HIV testing and ART linkage among key populations in Zambia: retrospective observational results from the Z\u0026ndash;CHECK project, 2019\u0026ndash;2020. 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High Educ Res Dev. 2018;37(1):58\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/07294360.2017.1344197\u003c/span\u003e\u003cspan address=\"10.1080/07294360.2017.1344197\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Intersectional stigma, mental health, peer-led intervention, information–motivation–behavioural skills (IMB) model","lastPublishedDoi":"10.21203/rs.3.rs-8826781/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8826781/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eYoung men who have sex with men (MSM) and transgender women (TGW) in Southern Africa experience a disproportionate burden of HIV, compounded by intersecting stigma related to HIV status and sexual orientation or gender identity (SOGI). These stigmas undermine mental health and antiretroviral therapy (ART) adherence, yet few integrated, community-informed interventions exist in low-resource settings. This study assessed the feasibility, acceptability, and preliminary impact of a peer-led pilot intervention to reduce stigma, improve mental health, and strengthen ART adherence among young MSM and TGW living with HIV in Malawi, Zambia, and Zimbabwe.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-methods parallel design was used, combining quantitative self-administered questionnaires with qualitative in-depth interviews. Seventy-two participants aged 18\u0026ndash;24 years were recruited through community-based organisations, with 64 completing baseline and endline assessments. The 8-week intervention, grounded in the information\u0026ndash;motivation-behavioural skills (IMB) model, was delivered by trained peer facilitators under clinical supervision. Quantitative outcomes included measures of HIV-related stigma, SOGI stigma, depressive symptoms (CES-D-10), alcohol use (AUDIT), and ART adherence self-efficacy. Descriptive statistics were generated, paired sample t-tests were used for continuous variables, and McNemar\u0026rsquo;s tests assessed changes in categorical outcomes. Qualitative data were analysed thematically to explore participant experiences and perceptions of the intervention.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eStatistically significant improvements were observed from baseline to endline, including reductions in internalised HIV stigma (p\u0026thinsp;=\u0026thinsp;0.01), anticipated HIV stigma (p\u0026thinsp;=\u0026thinsp;0.01), healthcare-related stigma (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), SOGI-related harassment (p\u0026thinsp;=\u0026thinsp;0.02), and depressive symptoms (p\u0026thinsp;=\u0026thinsp;0.01). ART adherence self-efficacy increased significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Although changes in sexual risk behaviours were not statistically significant, trends suggested increased condom use and reduced substance use before sex. Qualitative findings indicated enhanced self-acceptance, improved coping strategies (including reduced reliance on alcohol), increased confidence around disclosure, and strong acceptability of the peer-led, group-based intervention, despite some concerns about session pacing.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis pilot peer-led intervention was feasible, acceptable, and showed promising improvements in stigma, mental health, and ART adherence self-efficacy among young MSM and TGW in three Southern African countries. The findings support the potential value of theory-informed, peer-delivered interventions to address intersecting stigma and adherence challenges in highly marginalised populations, warranting further evaluation through larger and longer-term studies.\u003c/p\u003e","manuscriptTitle":"Assessing the feasibility and acceptability of a pilot peer led intervention to reduce stigma and improve ART adherence among young men having sex with men and transgender women living with HIV in low resource settings in Southern Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-18 17:04:35","doi":"10.21203/rs.3.rs-8826781/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-09T08:43:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-30T07:05:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-17T17:20:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33520681406715141877310069753185741488","date":"2026-03-09T10:28:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"212779041741038460048729780851672471221","date":"2026-03-08T12:46:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75546774914974771805040033148004101478","date":"2026-02-21T05:22:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-13T00:16:25+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-11T12:13:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-10T23:55:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-10T23:55:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-02-09T06:34:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"72f50dfb-cf57-47bf-aee4-17c7a30e4f88","owner":[],"postedDate":"February 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-19T08:53:33+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-18 17:04:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8826781","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8826781","identity":"rs-8826781","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}