Testing Community-Level Effects of a Crowdsourcing and Peer-Actuated Network Intervention on Internalized Homophobia and Transphobia and Psychological Distress Among Sexual and Gender Expansive Men in Kazakhstan

BACKGROUND & PURPOSE: Sexual and gender expansive people (e.g., gay, bisexual, and other men who have sex with men; transgender and gender non-binary individuals) in Kazakhstan experience high stigma and face discrimination stemming from cultural and religious traditions, which in turn are shaped by a profound legacy of Soviet colonization, Earlier research found that internalized homophobia and transphobia compromise psychosocial wellbeing, and these issues have been associated with lower rates of HIV testing among sexual and gender diverse men in Kazakhstan. An efficacy trial of the Peer Reach and Influencer-Driven Engagement in HIV Care Continuum (PRIDE in HIV Care)—a crowdsourcing and peer-actuated network intervention—indicated that the intervention was efficacious in exerting a community-wide effect of increasing HIV testing among sexual and gender expansive men in Kazakhstan. We sought to test whether the intervention was efficacious addressing secondary outcomes of: (1) internalized homophobia and transphobia, and (2) psychological distress.

METHODS: The intervention was tested in a NIDA-funded stepped-wedge, cluster-randomized controlled trial (clinicaltrials.gov #NCT02786615) conducted from 2018-2022 across three cities in Kazakhstan. Intervention implementation by city was randomly set in 6-month increments. Self-reported social and behavioral data in combination with biological assay of sexually transmitted infections (STIs) were collected from 629 sexual and gender diverse men in these cities. Internalized homophobia and transphobia was assessed using the Internalized Homophobia Scale (Herek, 2009) that was adapted and translated for sexual and gender expansive men in Kazakhstan; higher scores indicate greater internalized homophobia and transphobia. Psychological distress was assessed using a translated Short-form of Depression Anxiety Stress Scales (Henry & Crawford, 2005); higher scores indicate greater psychological distress. We used multilevel regression to test the hypothesis that the internalized homophobia and psychological distress would decrease as a function of time (measured in months) since the intervention began to be implemented in a respondent’s city.

RESULTS: As PRIDE in HIV Care was sequentially implemented across cities in accordance with the stepped-wedge design, 213 of these individuals received the intervention that prompted them to use social marketing principles to promote well-being and HIV testing, care, and prevention among their networks and communities of sexual and gender diverse men in Kazakhstan. After controlling for sociodemographics, STIs, and secular trends in the outcome measures, for every additional month that the intervention was implemented in a respondent’s city, we found a statistically significant decrease in internalized homophobia (b=-0.3; p<.001) and psychological distress (b=-0.6; p<.01) among the study sample of sexual and gender expansive men in Kazakhstan. Additional analyses support the specificity of the intervention’s effect with these particular outcomes.

CONCLUSIONS & IMPLICATIONS: The PRIDE in HIV Care intervention appears to be efficacious in reducing stigma and psychological distress among sexual and gender expansive men in Kazakhstan. Given the crowdsourcing and social marketing/network aspect of the intervention, this study supports the use of community-sourced solutions and community-driven health promotion, which not only offloads the burden and challenges of researcher and “expert” driven approaches (e.g., medical models of psychosocial interventions), but also fosters empowerment of marginalized and stigmatized populations.