Improving HIV testing and PrEP for transgender women through mHealth

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Abstract Despite decades of evidence-based interventions, including the 90/90/90 strategy, the HIV epidemic in Malaysia remains volatile. With over 100,000 cumulative HIV cases, Malaysia's rapidly expanding HIV epidemic is the fifth largest in the Asia-Pacific region and is concentrated within the most-at-risk populations. Originally driven by people who inject drugs, the majority of new infections today (>90%) are attributed to sexual transmission, many of which occur among transgender women (TGW). TGW are disproportionately impacted by HIV worldwide, with an estimated global prevalence of 19%. In Malaysia, an estimated 12.4% of TGW are living with HIV. TGW experience multi-level vulnerabilities to HIV, including discrimination in employment and economic opportunities, steering many TGW into high-risk occupations, such as sex work. High levels of stigma and discrimination against TGW by healthcare providers can foster a hostile environment toward TGW, complicating efforts to scale-up of HIV testing and prevention services among trans women, including pre-exposure prophylaxis (PrEP). Modeling studies suggest increased HIV testing and uptake of PrEP is the most impactful and cost-effective strategy for reducing new infections. Despite this, only 37% of TGW in Malaysia have ever been HIV tested. Similarly, while PrEP is recommended in Malaysia's National Strategic Plan to End AIDS (2016-2030), only 1 in 5 TGW has ever heard of PrEP. However, after learning about PrEP, more than 80% of TGW in Malaysia say they would take it. To scale-up of HIV testing and PrEP among TGW, innovative strategies are needed to rapidly overcome the complex barriers preventing uptake. In settings where anti-trans stigma is pervasive, such as Malaysia, mHealth may provide an empowering alternative approach to service delivery for TGW. An effective platform for reaching vulnerable and hidden populations, mHealth can overcome barriers associated with traditional clinic-based care by designing customized models of care tailored to the needs of vulnerable populations. Through confidential screening, rapid referrals to trans-friendly providers, and tools that facilitate access to gender-affirming health care needs, mHealth is a promising platform that can be leveraged for intervening around HIV prevention. Thus, we propose to develop and test a new clinic-affiliated app, called MyLink2care, to deliver an integrated HIV prevention intervention for TGW in Malaysia. Specifically, we propose to: 1) adapt, expand, and refine an existing mobile application by conducting formative research with TGW and clinical stakeholders to develop a prototype of the MyLink2Care app to undergo usability testing, followed by development of the beta version of the app; 2) conduct “beta testing” of the MyLink2Care app to assess its usability and acceptability; and 3) assess preliminary feasibility and acceptability of the MyLink2care app within a pilot, randomized-controlled trial, compared with treatment-as-usual for engagement in HIV prevention.