Background: Over 2.6 million children aged 0-15 years are living with HIV globally, with the majority living in low and middle income countries in sub-Saharan Africa. Addressing stigma associated with HIV is key given the significant harm that may be experienced in the form of negative health and social outcomes, reduced access to HIV prevention services, and increased vulnerability to infection. Previous research among young people in Uganda showed that stigma is meted out in the form of verbal and physical abuse from teachers and peers (bullying), leading to social isolation, school drop-out, depression and suicidal ideation. Given the limited evidence available in support of effective stigma reduction among young people, efforts to help those affected constitute a major gap in the HIV prevention literature.

Purpose: The overall aim of the proposed study is to implement and evaluate an arts-based intervention rooted in local cultural knowledge to reduce stigma and improve HIV prevention outcomes among HIV positive and HIV- affected young people.

Methods: The study will employ a stepped-wedge, cluster randomized design involving crossover of clusters from the control to the intervention arm. The stepped-wedge design will consist of three groups (Group 1, Group 2, Group 3), each comprised of two primary and two secondary schools. Each time period will be 8 weeks in duration. Group 1 will receive the intervention for three time periods (24 weeks). Group 2 will receive the intervention over two time periods (16 weeks). Group 3 will receive the intervention over one time period (8 weeks). Formative qualitative interviews will also inform the arts-based HIV-stigma intervention and obtain additional data for research objectives. We will conduct at 50 qualitative semi-structured interviews, lasting between 30 minutes to 45 minutes, with purposively selected students, Elders, and teachers at participating schools. A community advisory committee (CAC) will inform all design elements and supervise implementation. Team members will collaborate to develop, implement, evaluate and disseminate results of the proposed study. Primary endpoints will include: 1) HIV stigma reduction; and, 2) knowledge increase. Secondary endpoints will include: 1) HIV testing frequency among sexually active participants; 2) linkage to care among HIV+ participants; 3) ART initiation among HIV+ participants; 4) ART adherence among HIV+ participants; and 5) viral suppression among HIV+ participants. Secondary endpoints will be measured through a local AIDS non-governmental organization (TASO) and the community health clinics who have agreed to provide access to their medical files. No blood samples will be drawn. Ages 10+ will participate in the study with parental consent.

Survey Data Analysis: Descriptive analyses will be used to describe clusters relative to their size at each time point (planned sample size and achieved sample size), key demographics and outcomes, and comparison of randomization groups. Main analyses will follow an intention-to-treat approach, with clusters analyzed as per original treatment assignment. Main analyses will use Linear Mixed Effect Models (LMEM) or Generalized Linear Mixed Effect Models (GLMEM) to assess the intervention effect. LMEM will be used for continuous outcomes that approach normality and GLMEM for binary and other types of outcomes. Normality will be assessed by the model residuals and outliers by Cook's Distance, Leverage and Residuals. Calendar time and school semester will be entered as fixed effects. The multilevel structure will be defined by participants as level 1 and clusters as level 2. All clustering levels will be specified as random effects. Sensitivity analyses will be performed of drop-outs and completers to better understand possible biases arising from attrition. A significance level of 0.05 will be used in all statistical tests.

Interview Data Analysis: Interviews will be coded using a constant-comparative and concept-development approach based on emergent themes that evolve throughout the course of the research. Initial coding will be done jointly by two researchers, and consensus negotiated. Matrix methodology techniques described by Miles, Huberman and Saldana will also be used in the analysis. First level analysis will be used to assign a descriptive code (label) to a segment of the data to give it meaning. As the researchers become more familiar with the data, pattern coding will be used to label emerging themes. An inductive approach will be used to analyze the data by iteratively coding and identifying themes and relationships between themes. Memos will be used to record methodological decisions and analytic insights. Validity will be assessed by convening focus groups for member checking the interpretation of data.

Significance: The study it will fill this evidence gap in HIV stigma intervention research and practice by creating and evaluating a transformative education and arts-based intervention using a participatory approach. The method of transforming cultural knowledge to an arts-based intervention may be a reproducible method for locally acceptable intervention design to improve HIV outcomes among young people.