Stigma, Cohesion and HIV Outcomes Among Vulnerable Women Across Epidemic Settings

 描述(由申请人提供)：在流行环境中的弱势妇女中的耻辱、凝聚力和艾滋病毒结果女性性工作者(FSW)感染艾滋病毒的风险显著增加。在全球范围内，女性同性恋者感染艾滋病毒的几率是非性工作者的13.5倍。尽管有这样的负担，只有不到一半的FSW能够获得抗逆转录病毒治疗(ART)。艾滋病毒污名是已知对艾滋病毒结果产生负面影响的关键社会决定因素，包括获得治疗和遵守抗逆转录病毒疗法。对于携带艾滋病毒的妇女来说，艾滋病毒污名的影响可能会因与其职业、性别和/或社会经济地位有关的其他形式的污名而进一步加剧。为了应对这种耻辱，妇女地位委员会在许多环境中团结一致，解决其艾滋病毒相关风险的社会结构背景。性工作者社区内的社会凝聚力一直是以社区为基础的艾滋病毒应对措施的核心要素，并与保护性行为密切相关。然而，社会凝聚力的作用及其对艾滋病毒和性工作污名的潜在调解影响，尚未在艾滋病毒治疗结果方面进行探讨。虽然在过去的研究中对艾滋病毒污名的测量给予了极大的关注，但对其他相互交织的社会污名，包括性工作污名的测量，重视的要少得多。利用位于不同社会和流行环境中的两个正在进行的队列的现有研究基础设施，我们建议纵向检查艾滋病毒和性工作污名和社会凝聚力作为坦桑尼亚感染艾滋病毒的女性妇女和医生中艾滋病毒结果的关键社会决定因素的作用。我们的具体目标是：(1)根据不同社会和流行环境中女性工作人员感染艾滋病毒的现实，制定与性工作相关的污名的有效和可靠的综合衡量标准；(2)确定艾滋病毒和性工作污名和社会凝聚力作为跨环境生物艾滋病毒结果(例如血液中的ART、病毒抑制)的预测因素的作用；以及(3)定性地探讨与艾滋病毒服务和结果相关的艾滋病毒和性工作相关的耻辱和社会凝聚力的动态背景。对于目标1，我们将使用定性方法来为测量发展提供信息，包括深度访谈和认知访谈(n=40)。然后，我们将使用IRT以及因素和可靠性分析来建立与每个背景下的性工作污名领域相关的共同和独特的项目。在目标2中，我们将进行纵向结构方程建模，以考察艾滋病毒与性工作耻辱、社会凝聚力和病毒抑制之间的预测因素和途径，以及在坦桑尼亚和DR(n=400)感染艾滋病毒的FSW人群中病毒抑制的其他已知相关因素。在目标3中，将通过对每个国家的队列参与者(n=40)进行纵向、定性的深入访谈，探讨艾滋病毒和性工作耻辱和社会凝聚力的动态社会背景。这些发现将使FSW在不同地理和疫情背景下作为预防干预措施进行量身定制的治疗。

 DESCRIPTION (provided by applicant): Stigma, cohesion and HIV outcomes among vulnerable women across epidemic settings Female sex workers (FSW) are at significantly heightened risk for HIV. Globally, FSW have a 13.5 times greater odds of being HIV-infected compared to women who are not sex workers. Despite this burden, less than half of FSW have access to antiretroviral therapy (ART). HIV stigma is a critical social determinant known to negatively influence HIV outcomes including access to treatment and ART adherence. For FSW living with HIV, the impact of HIV stigma may be further compounded by other forms of stigma related to their occupation, gender, and/or socioeconomic position. In response to such stigmas, FSW in many settings have come together in solidarity to address the socio-structural context of their HIV-related risk. Social cohesion within the sex worker community has been a central element of community-based responses to HIV and is significantly associated with protective behaviors. However, the role of social cohesion, and its potential mediating influence on HIV and sex work stigma, has yet to be explored in relation to HIV treatment outcomes. While significant attention has been paid to the measurement of HIV stigma in past studies, much less emphasis has been placed on other intersecting social stigmas, including the measurement of sex work stigma. Utilizing the existing research infrastructure of two ongoing cohorts located within distinct social and epidemic settings, we propose to longitudinally examine the role of HIV and sex work stigma and social cohesion as key social determinants of HIV outcomes among FSW living with HIV in Tanzania and the DR. Our specific aims are to: (1) Develop a valid and reliable aggregate measure of sex work-related stigma tailored to the realities of FSW living with HIV in distinct social and epidemic contexts; (2) Determine the roles of HIV and sex work stigma and social cohesion as predictors of biologic HIV outcomes (e.g. ART in the blood, viral suppression) across settings; and (3) Qualitatively explore the dynamic context of HIV and sex work- related stigma and social cohesion among FSW in relation to HIV services and outcomes. For Aim 1 we will use qualitative methods to inform measurement development including both in-depth and cognitive interviews (n=40). We will then employ IRT and factor and reliability analysis to establish shared and distinct items related to the domain of sex work stigma per context. In Aim 2, we will conduct longitudinal structural equation modeling to examine predictors and pathways between HIV and sex work stigma, social cohesion and viral suppression in the context of other known correlates of viral suppression among cohorts of FSW living with HIV in Tanzania and the DR (n=400). In Aim 3 will explore the dynamic social context of HIV and sex work stigma and social cohesion through longitudinal qualitative in-depth interviews among a subset of cohort participants in each country (n=40). Findings will inform tailored treatment as prevention interventions among FSW across geographic and epidemic settings.