Reducing Intersectional Stigma among High-Risk Women in Brazil to Promote Uptake of HIV Testing and PrEP

项目摘要 在全球范围内，跨性别妇女经历了极端的社会和经济边缘化， 交叉污名，定义为社会身份交叉导致的污名的汇合 而在那些被压迫的人中，在跨性别女性中，基于性别的耻辱感 社会地位，如从事性工作和药物使用，以及基于种族的耻辱， 造成脆弱的社会环境，增加感染艾滋病毒的风险。在巴西，跨性别女性是 艾滋病毒“高危”群体，估计感染艾滋病毒的几率比一般人群高55倍; 此外，跨性别女性接受艾滋病毒检测和暴露前预防（PrEP）的比例明显较低 尽管公共部门提供了这些服务，而且有文件证明社区对这些服务感兴趣，但这些服务的数量仍然多于其他高危群体。 通过广泛的形成性工作，我们制定了利用艾滋病毒预防的多层次干预措施， 已证明可行性和为巴西跨性别妇女所接受的战略， 跨性别妇女在艾滋病毒预防连续性中的参与。我们提出 为了测试“Guerreiras”（巴西跨性别女性参与者命名的“女战士”）， 旨在解决交叉污名问题的干预组成部分：1）群体一级的同行领导的干预， 2)一个个人层面的同行导航计划，以增加艾滋病毒检测和PrEP的吸收。 由跨特定的概念模型，性别肯定理论，描述交叉污名通知 跨性别妇女面临的问题，为调查跨部门耻辱如何导致健康差异提供了信息， 提供了干预开发和测试的框架。我们将招募跨性别女性（N=400）， 巴西圣保罗的临床研究中心、外展活动和观察队列。将对Guerreiras进行评估 使用随机等待列表对照试验比较HIV检测摄取（自我检测和基于诊所）（目的 1），PrEP启动和持续（目标2），以及跨性别者的其他预防服务（例如减少伤害） 干预组的妇女与对照组的妇女相比，每三个月收集一次数据。 个月我们将评估交叉污名（目标3）的变化，包括减少内化污名 在那些被分配到干预组的人中， 这些人被分配到控制，并评估污名领域的变化如何导致预防的吸收。成果 将通过国家药物分配系统（PrEP启动和持续性）、临床 记录和自我报告（艾滋病毒检测），并通过全面调查（交叉污名）。的 拟议的研究利用了富有成效的多学科艾滋病毒研究伙伴关系， 在巴西与跨性别妇女合作的经验，多层次的干预成分，以及PrEP 和艾滋病毒/艾滋病防治措施的信息公开，为评估和扩大艾滋病毒预防举措提供了机会 在一个关键的健康差距人口，同时有助于交叉耻辱的新生研究。

PROJECT SUMMARY Globally, transgender (`trans') women experience extreme social and economic marginalization due to intersectional stigma, defined as the confluence of stigma that results from the intersection of social identities and positions among those who are multiply oppressed. Among trans women, gender-based stigma intersects with social positions such as engagement in sex work and substance use, as well as race-based stigma to generate a social context of vulnerability and increased risk of HIV acquisition. In Brazil, trans women are the `most-at-risk' group for HIV, with 55 times higher estimated odds of HIV infection than the general population; further, uptake of HIV testing and pre-exposure prophylaxis (PrEP) among trans women is significantly lower than other at-risk groups, despite availability in the public sector and documented interest in the community. Through extensive formative work, we have developed a multi-level intervention utilizing HIV prevention strategies which have demonstrated feasibility and acceptability by trans women in Brazil, to address intersectional stigma and increase engagement of trans women in the HIV prevention continuum. We propose to test `Guerreiras' (`warrior women', as named by trans women participants in Brazil), comprised of two intervention components designed to address intersectional stigma: 1) a group-level, peer-led intervention and 2) an individual-level peer navigation program to increase uptake of HIV testing and PrEP. Guerreiras is informed by a trans-specific conceptual model, gender affirmation theory, that describes intersectional stigma faced by trans women, informs investigations of how intersectional stigma results in health disparities, and provides a framework for intervention development and testing. We will recruit trans women (N=400) from clinical sites, outreach events, and an observational cohort in São Paulo, Brazil. Guerreiras will be evaluated using a randomized wait-list controlled trial to compare HIV testing uptake (self-testing and clinic-based) (Aim 1), PrEP initiation and persistence (Aim 2), and other prevention services (e.g. harm reduction) among trans women in the intervention arm compared to those in the control arm with data collection scheduled every three months. We will assess changes in intersectional stigma (Aim 3), including reductions in internalized stigma and increased resilience to anticipated and enacted stigma, among those assigned to intervention compared to those assigned to control, and assess how changes in stigma domains result in prevention uptake. Outcomes will be monitored through the national medications dispensing system (PrEP initiation and persistence), clinical records and self-report (HIV testing), and through comprehensive surveys (intersectional stigma). The proposed research leverages a productive multi-disciplinary HIV research partnership with extensive experience working with trans women in Brazil, multi-level intervention components, and a context where PrEP and HIVST are available publicly, providing an opportunity to evaluate and scale-up an HIV prevention initiative in a key health disparity population, while contributing to nascent research in intersectional stigma.