Improving engagement in HIV care for high-risk women

 描述(由申请人提供)：变性妇女(出生时被指定为“男性”，但不认为自己是男性)受艾滋病毒的影响不成比例，在参与艾滋病毒护理方面有独特的文化障碍和促进者。携带艾滋病毒(TWh)的变性人妇女比其他人更不可能接受抗逆转录病毒疗法(ART)，那些开始抗逆转录病毒疗法的人ART依从率更低，将ART纳入日常生活的自我效能更低，与医疗保健提供者的积极互动报告比非变性人成年人更少。因此，在旧金山，TWh的病毒载量几乎是非变性人成年人的三倍；在洛杉矶，TWh受到病毒抑制的可能性低于其他任何行为风险群体。在我们的形成性工作中，我们确定了特定于文化的和可修改的 TWH参与艾滋病毒治疗的障碍，包括以艾滋病毒治疗为代价优先考虑与过渡相关的保健(即激素疗法)，由于过去的负面保健经历而避免艾滋病毒护理环境，关于抗逆转录病毒治疗的错误信息，包括潜在的药物与激素的相互作用，艾滋病毒污名加剧，社会支持水平低，以及应对技能差。由于高传播风险因素，包括药物滥用、性伴侣数量多、从事性工作和精神疾病的高比率，TWH对护理的投入不足对个人和公共健康都有影响。这些发现有力地表明，TWH在从事和坚持艾滋病毒治疗方面面临着独特的挑战，这一人群参与不良的公共卫生后果令人严重关切。减少参与护理的这些障碍的干预措施对于努力改变艾滋病毒相关差距的模式至关重要，这种差距导致这一高度脆弱和边缘化人口的健康结果不成比例地差。我们建议进行一项理论驱动、特定人群、试点干预的随机对照试验，以提高TWH护理的参与度。基于研究人员的性别肯定和卫生保健授权模型，拟议的研究首次系统地干预了TWH在艾滋病毒护理方面最佳参与的复杂障碍。我们已经开发和试点了健康的Divas干预措施，以优化TWH在治疗失败和相应的艾滋病毒发病率、死亡率和传播风险增加的艾滋病毒护理方面的参与。

 DESCRIPTION (provided by applicant): Transgender women (assigned `male' at birth but who do not identify as male) are disproportionately impacted by HIV and have culturally unique barriers and facilitators to engagement in HIV care. Transgender women living with HIV (TWH) are less likely than others to take antiretroviral therapy (ART), and those who initiate ART have lower rates of ART adherence, lower self-efficacy for integrating ART into daily routines, and report fewer positive interactions with health care providers than non-transgender adults. As a result, TWH have an almost three-fold higher viral load than non-transgender adults in San Francisco; in Los Angeles, TWH are less likely to be virally suppressed than any other behavioral risk group. In our formative work, we have identified culturally-specific and modifiable barriers to HIV treatment engagement among TWH, including prioritization of transition-related health care (i.e. hormone therapy) at the expense of HIV treatment, avoidance of HIV care settings due to past negative health care experiences, misinformation about ART including potential drug interactions with hormones, intensified HIV stigma, low levels of social support, and poor coping skills. There are both individual and public health consequences to poor engagement in care among TWH stemming from high transmission risk factors, including substance abuse, high numbers of sex partners, engagement in sex work, and high rates of mental illness. These findings strongly suggest that TWH face unique challenges to engaging in and adhering to HIV treatment, and that the public health consequences for poor engagement in this population are of grave concern. Interventions to mitigate these barriers to engagement in care are critical in efforts to alter the pattern of HIV-related disparities that lead to disproportionately poor health outcomes for this highly vulnerable and marginalized population. We propose a randomized controlled trial of a theory- driven, population-specific, piloted intervention to improve engagement in care for TWH. Grounded in the investigators' Models of Gender Affirmation and Health Care Empowerment, the proposed research is the first to systematically intervene on complex barriers to optimal engagement in HIV care for TWH. We have developed and piloted the Healthy Divas intervention to optimize engagement in HIV care for TWH at elevated risk for treatment failure and consequential morbidity, mortality, and transmission of HIV.