Sweekar - Multi-level intersectional stigma reduction to increase HIV testing and care engagement among trans women in Nepal

低收入和中等收入国家的变性妇女占变性妇女的最大比例 但在应对艾滋病毒方面却没有得到足够的服务。尼泊尔是南部收入较低的国家 在亚洲，变性妇女是受艾滋病毒高度影响的关键人群。在2019/20年度，我们进行了 对变性妇女的探索性研究发现，11.3%的人携带艾滋病毒，只有70%的人从事 艾滋病毒护理和病毒抑制。歧视导致预期的艾滋病毒污名和经历的反性行为 耻辱是艾滋病毒检测和艾滋病毒护理参与度低的主要驱动因素。艾滋病毒风险进一步加剧的原因是 反对导致教育、就业、社会支持和赋权障碍的跨性污名。为 由于大多数跨性女性在求职时面临歧视，我们的大多数参与者 探索性工作是为了赚取收入，没有公寓的性行为比率很高，性伴侣也很多。 需要对变性妇女进行艾滋病毒干预，通过解决许多人的耻辱问题产生持久的影响 对健康和健康构成障碍的水平。然而，很少有艾滋病毒预防和治疗干预措施 解决跨部门污名问题，为低收入和中等收入国家环境制定的更少。 基于我们探索性研究的证据，我们建议测试一种多水平的、HIV血清状态中性的 减少污名的干预措施在尼泊尔被称为“接受”或“接受”。主要的干预结果是 艾滋病毒检测和艾滋病毒护理参与。为了通过解决预期的耻辱来增加艾滋病毒检测，个人 水平干预部分是一种量身定做的艾滋病毒自我检测干预措施。通过以下方式提高艺术的忠诚度 针对预期和经历的耻辱，系统一级的干预组成部分是艾滋病毒治疗 送货上门。为了解决社区一级的污名问题，我们将进行一次接触干预。 通过PhotoVoice12减少经验污名和内化污名。PhotoVoice将用于通知内容和 开展一项社交媒体运动，以减少尼泊尔社会中的反变性现象，并为增加社会 尼泊尔跨性别妇女的支持和赋权，这将有助于减轻内在化的耻辱。我们的 方法是社区驱动和非随机的，以最大限度地提高迫切需要的跨性别妇女的利益 干预措施，这是减少健康差距的基本做法。可行性很高，因为美国和尼泊尔 研究人员在十多年的时间里建立了强大的合作关系，共同努力 在研究和服务方面为变性女性提供服务。此外，新冠肺炎为以下领域创造了新的机遇 创新艾滋病毒护理和预防，将在斯威格发挥杠杆作用。如果斯威格成功了，我们会 立即使用结果数据和吸取的经验教训来制定多站点R01提案，以测试 与我们的尼泊尔研究和实施团队合作，在尼泊尔全境进行大规模干预。

Trans women in low- and middle- income countries make up the largest proportion of trans women around the globe but are underserved in the response to HIV. Nepal is a lower income country in South Asia where trans women are a key population highly impacted by HIV. In 2019/20, we conducted an exploratory study with trans women finding that 11.3% were living with HIV, and only 70% were engaged in HIV care and virally suppressed. Discrimination resulting in anticipated HIV stigma and experienced anti-trans stigma was a main driver of low HIV testing and HIV care engagement. HIV risk was further exacerbated by anti-trans stigma resulting in barriers to education, employment, social support and empowerment. For example, because most trans women faced discrimination in job seeking, the majority of participants in our exploratory work did sex work for income and had high rates of condomless sex and many sexual partners. HIV Interventions for trans women are needed that will have sustained impact by addressing stigma at many levels that present barriers to health and wellness. However, few HIV prevention and treatment interventions tackle intersectional stigma, and even fewer are developed for low- and middle-income country settings. Building on evidence from our exploratory study, we propose to test a multi-level, HIV serostatus-neutral stigma reduction intervention called Sweekar, or acceptance in Nepali. The primary intervention outcomes are HIV testing and HIV care engagement. To increase HIV testing by addressing anticipated stigma, the individual level intervention component is a tailored HIV self-testing intervention. To increase ART adherence by addressing anticipated and experiences stigma, the systems level intervention component is HIV treatment home delivery. To address stigma at the community level, we will conduct a contact intervention11 informed by Photovoice12 to reduce experienced and internalized stigma. Photovoice will be used to inform content and delivery of a social media campaign to reduce anti-trans in Nepali society, with benefits for increasing social support and empowerment among trans women in Nepal, which will help mitigate internalized stigma. Our approach is community-driven and non-randomized to maximize benefit for trans women in immediate need of intervention, which is an essential practice to reduce health disparities. Feasibility is high as the US and Nepali researchers have forged a strong collaboration over the course of more than a decade working together to serve trans women in research and services. Furthermore, Covid-19 has created new opportunities for innovations HIV care and prevention that will be leveraged in Sweekar. If Sweekar is successful, we will immediately use the outcome data and lessons learned to develop multi-site R01 proposal to test the intervention at scale throughout Nepal and in partnership with our Nepali research and implementation team.