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

项目总结 在全球范围内，变性人妇女经历了极端的社会和经济边缘化，原因是 交叉污名，定义为由于社会身份的交叉而产生的污名的汇合 以及在那些倍受压迫的人中的地位。在变性女性中，基于性别的污名相交 社会地位，如从事性工作和吸毒，以及基于种族的耻辱 产生一种脆弱性和艾滋病毒感染风险增加的社会背景。在巴西，变性女性是 艾滋病毒的“最高风险”群体，估计感染艾滋病毒的几率是普通人群的55倍； 此外，变性妇女接受艾滋病毒检测和暴露前预防(PrEP)的比例明显较低 与其他高危群体不同，尽管公共部门提供了这种服务，并记录了社区的兴趣。 通过广泛的形成性工作，我们开发了一种利用艾滋病毒预防的多层次干预 已经证明了巴西变性妇女的可行性和可接受性的战略，以解决 跨部门污名和增加变性妇女在艾滋病毒预防工作中的参与度。我们建议 测试“Guerreiras”(巴西变性女性参与者所称的“勇士女性”)，由两人组成 旨在解决跨部门污名的干预组成部分：1)小组级别的、同行领导的干预和 2)个人层面的同行导航计划，以增加对艾滋病毒检测和PrEP的接受。格雷厄斯是 由描述跨部门耻辱的跨具体概念模型--性别肯定理论--提供信息 跨性别妇女面临的问题，告知调查跨界别的耻辱如何导致健康差距，以及 为干预开发和测试提供框架。我们将从以下人员中招募变性女性(N=400) 巴西圣保罗S的临床地点、外展活动和观察队列。Guerreiras将被评估 使用随机等待名单对照试验比较艾滋病毒检测吸收(自我检测和基于临床的)(目的 1)、预防和预防方案启动和持续(目标2)以及其他预防服务(如减少危害) 比较干预组和控制组的妇女，每三次收集一次数据 月份。我们将评估交叉柱头的变化(目标3)，包括内在化柱头的减少 与那些被分配到干预组的人相比，他们对预期和实施的污名具有更强的韧性 那些被分配来控制和评估柱头领域的变化如何导致预防吸收的人。结果 将通过国家药物分配系统(PrEP启动和持续)进行监测，临床 记录和自我报告(艾滋病毒检测)，并通过全面调查(跨部门污名)。这个 拟议的研究利用富有成效的多学科艾滋病毒研究伙伴关系 在巴西与跨性女性一起工作的经验、多层次干预内容以及PrEP 和HIVST是公开提供的，为评估和扩大艾滋病毒预防倡议提供了机会 在一个关键的健康差距人群中，同时促进了对跨部门耻辱的新研究。

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.