Ssimusango: Multi-level intervention for intersectional stigma reduction to improve HIV outcomes for transgender women

西穆桑戈：多层次干预减少交叉耻辱，以改善跨性别女性的艾滋病毒结果

• 批准号: 10755926
• 负责人: Andrew Mujugira
• 金额: $ 18.62万
• 依托单位: INFECTIOUS DISEASES INSTITUTE
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-07-15 至 2026-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10755926
• 关键词: AIDS prevention; Address; Adherence; Adoption; Adult; Africa South of the Sahara; African; Caring; Catchment Area; Clinic; Clinical; Clinical Trials; Communities; Consolidated Framework for Implementation Research; Consultations; Data; Disclosure; Discrimination; Education; Effectiveness; Empathy; Enrollment; Equity; Evaluation; Face; Feedback; Focus Groups; Fright; Gender Identity; General Population; HIV; HIV Infections; Health Personnel; Health Policy; Health Services; Health Status; Health care facility; Healthcare; High Risk Woman; Human immunodeficiency virus test; Hybrids; Incidence; Individual; Institution; Intervention; Interview; Manuals; Measures; Modeling; Outcome; Population; Prevalence; Prevention; Qualitative Methods; RNA; Randomized; Research; Risk; Sampling; Services; Sex Orientation; Stigmatization; Surveys; Tenofovir; Testing; Training; Uganda; Urine; Viral; Waiting Lists; Well in self; Woman; Work; acceptability and feasibility; aged; antiretroviral therapy; effectiveness evaluation; effectiveness/implementation trial; empowerment; evidence base; experience; gender minority; health assessment; health care settings; health training; implementation evaluation; implementation intervention; implementation outcomes; improved; informant; internalized stigma; intersectionality; intervention delivery; marginalized population; men; men who have sex with men; multidisciplinary; peer; perceived discrimination; pilot test; post intervention; pre-exposure prophylaxis; prevention service; primary outcome; programs; residence; response; scale up; secondary outcome; sex; social stigma; standard of care; synergism; therapy adherence; therapy design; transgender; transgender women; treatment services; uptake

PROJECT SUMMARY/ABSTRACT Transgender women (TGW) are at high risk for HIV infection, and are an important, under-researched key population in sub-Saharan Africa. Globally, HIV acquisition risk among TGW is 14 times higher than other adults aged 15-49 years. Intersectional stigma and discrimination (ISD) experienced by TGW at the intersections of HIV, sexual orientation, gender minority identity and sex work results in poor engagement in care and suboptimal adherence to HIV pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART). Much work remains in addressing HIV-related ISD and scaling up treatment and prevention coverage for TGW. Two evidence-based ISD-reduction interventions are available -- (1) Health Policy Plus (HP+) Total Facility Approach (TFA) to Stigma Reduction (a clinic-level intervention) and (2) HIV Education, Empathy and Empowerment (HIVE3) (an individual- level intervention) -- but these have not been adapted and implemented for TGW in sub-Saharan Africa. HP+ and HIVE3 are complementary interventions that could be combined to reduce health facility- and individual-level stigma. However, research is needed to show if the adapted multi-level HP+/HIVE3 intervention, Ssimusango (means “no self-blame or blaming others” in Luganda), decreases HIV-related stigma and improves HIV outcomes for TGW. To address these questions, we will conduct a randomized wait-list controlled trial to test the preliminary effectiveness of Ssimusango on PrEP adherence and viral suppression, compared with standard of care, using a status-neutral approach i.e., engagement in care regardless of HIV status. We will also use qualitative methods to assess mechanisms and synergies of intervention delivery. Leveraging the multi- disciplinary expertise of our multi-national research team, and working at four health facilities in Kampala ranked lowest on the PEPFAR Uganda stigma scorecard, we propose the following specific aims: (1) adapt the HP+ and HIVE3 stigma-reduction interventions to address ISD for TGW in Uganda (intervention adaptation); (2) conduct a hybrid type 1 effectiveness-implementation trial with 120 TGW to pilot test the preliminary effectiveness of Ssimusango on (a) PrEP adherence and (b) viral suppression (intervention implementation); and (3) evaluate Ssimusango using qualitative methods and the Intersectionality-Enhanced Consolidated Framework for Implementation Research (intervention evaluation). Clinic-level implementation outcomes are adoption, fidelity, and sustainability assessed using key informant interviews, training attendance sheets, observation checklists, and rapid feedback surveys. Individual-level outcomes: (1) PrEP adherence at 3 and 6 months post-intervention, measured by urine tenofovir levels (primary outcome) and (2) viral suppression (HIV RNA <50 copies/mL) and (3) ISD reduction 6 months post-intervention (secondary outcomes). This multi-level approach to implementing ISD interventions will improve PrEP and ART adherence outcomes among TGW - “the most vulnerable of the vulnerable” -, build stigma research capacity in Uganda, and generate actionable data for scale-up and program implementation in Uganda and sub-Saharan Africa.

项目总结/摘要 跨性别妇女（TGW）是艾滋病毒感染的高风险，是一个重要的，研究不足的关键 撒哈拉以南非洲的人口。在全球范围内，TGW感染艾滋病毒的风险是其他成年人的14倍 年龄15-49岁。TGW在以下交叉点经历的交叉羞辱和歧视： 艾滋病毒、性取向、性别少数认同和性工作导致护理参与不足， 坚持艾滋病毒暴露前预防（PrEP）和抗逆转录病毒治疗（ART）。还有很多工作要做， 解决与艾滋病毒相关的ISD问题并扩大TGW的治疗和预防覆盖范围。两个基于证据的 （1）“卫生政策+”（HP+）消除成见的“全面设施办法”（TFA） 减少（诊所一级的干预）和（2）艾滋病毒教育、同情和赋权（艾滋病毒3）（个人- 在撒哈拉以南非洲，这些措施尚未得到调整和实施。HP+ 和艾滋病毒3是互补的干预措施，可以结合起来，以减少卫生设施和个人层面的 耻辱然而，需要进行研究，以表明经调整的多层次HP+/HIV-3干预，Ssimusango， （在卢甘达语中的意思是“不自责或责怪他人”），减少与艾滋病毒有关的耻辱感， TGW的结果。为了解决这些问题，我们将进行一项随机等待名单对照试验，以测试 Ssimusango对PrEP依从性和病毒抑制的初步有效性，与 护理，使用地位中立的方法，即，无论艾滋病毒状况如何，都要参与护理。我们还将使用 采用定性方法评估干预措施交付的机制和协同作用。利用多- 我们的多国研究团队的学科专业知识，并在坎帕拉的四个卫生设施的工作排名 在PEPFAR乌干达耻辱记分卡上排名最低，我们提出以下具体目标：（1）调整HP+ 和艾滋病毒3减少耻辱干预措施，以解决乌干达过渡期妇女的综合性服务障碍问题（干预措施适应）;（2） 利用120个TGW进行混合1型有效性实施试验，对初步的 Ssimusango对（a）PrEP依从性和（B）病毒抑制（实施干预）的有效性; 和（3）评价Ssimusango使用定性方法和交叉增强综合 实施研究框架（干预评估）。临床层面的实施结果是 采用，忠诚度和可持续性评估使用关键线人访谈，培训出勤表， 观察清单和快速反馈调查。个体水平的结果：（1）3岁和6岁时的PrEP依从性 干预后3个月，通过尿液替诺福韦水平（主要结局）和（2）病毒抑制（HIV RNA <50拷贝/mL）和（3）干预后6个月ISD减少（次要结局）。该多电平 实施ISD干预措施的方法将改善TGW中的PrEP和ART依从性结果- “弱势群体中最弱势的群体”-在乌干达建立污名化研究能力， 在乌干达和撒哈拉以南非洲扩大规模和实施方案的数据。