Impact of multiple stigmas on HIV care continuum outcomes for key populations

背景：在全球范围内，耻辱仍然是参与和保留PLWH护理的主要障碍。这个 这项建议的目标是了解多重污名对抗逆转录病毒(ART)的影响。 男男性行为者(MSM)和跨性别者(TW)的开始和保持护理 在印度感染艾滋病毒(MSM/TW+H)。印度的艾滋病毒负担位居世界第三，而这种流行病 对MSM/TW的影响不成比例。像MSM/TW+H这样的关键(污名化)人群更有可能 艾滋病毒治疗结果不佳，导致抗逆转录病毒治疗开始/保留和病毒感染的比率 达到艾滋病规划署90-90-90目标的压抑率低到令人无法接受的程度。在印度，MSM和TW 妇女虽然是两个不同的群体，但面临着相似的性别或性认同和艾滋病毒相关问题 耻辱，这可能：(1)直接阻碍艾滋病毒护理工作，(2)间接降低能力 通过心理健康状况不佳(抑郁/焦虑)等媒介参与艾滋病毒护理， 心理资源(如应对能力差)和人际因素(如缺乏社交能力 支持)。 有必要研究耻辱及其导致艾滋病毒结果的中介途径。 方法：这项R21研究，响应PA 18-277《与服务合作设计的研究》 供应商..。要了解影响艺术萌芽的因素……留存是一种创新 与印度最大的基于社区的艾滋病毒服务机构建立合作社区研究伙伴关系 提供商。它旨在利用该机构强大的服务和跟踪基础设施来 对污名、相关临床结果进行纵向前瞻性队列研究(ART 启动和保留6个月)，以及370个MSM-TW+H(各185个MSM/TW)的潜在介体。 在艾滋病毒污名框架的指导下，我们的目标是：1)描述流行率和 在新诊断的印度MSM/TW+H队列中出现多个耻辱的时间。这也将涉及 探索男男性接触者和TW之间在污名程度和类型上的潜在差异，以告知未来 干预性发展。2)检查纵向的直接和间接(通过心理健康， 人际因素和心理资源)污名对a)艺术启蒙的影响 B)保留6个月的艺术护理。我们还将探索震级上的差异 对每种结果的不同污名的影响，以更好地了解哪些是最强的 未来干预的目标。我们还将进行探索性分析，以进行a)检查 男男性接触者与台湾妇女在这些影响上的差异；以及 B)确定如何调整未来的干预措施以满足每个群体的需要。 潜在的影响。虽然全球卫生机构呼吁减少艾滋病毒和男男性接触者/TW的耻辱，但没有 存在有效和可扩展的干预措施，解决MSM/TW+H之间的多重耻辱，以改善 艾滋病毒护理连续不断的成果。这项研究将提供所需的关于倍数的经验数据 MSM/TW+H面临的耻辱，这些耻辱对ART启动/保留的影响，以及潜在的 可能破坏污名对艾滋病毒护理和信息的影响的可修改因素(即调解人) 干预措施。

Background: Globally, stigma continues to be a major barrier to engage and retain PLWH in care. The goal of this proposal is to understand the impact of multiple stigmas on antiretroviral (ART) initiation and retention in care among men who have sex with men (MSM) and transwomen (TW) living with HIV (MSM/TW+H) in India. India has the third largest HIV burden in the world, and the epidemic disproportionately impacts MSM/TW. Key (stigmatized) populations such as MSM/TW+H, are more likely to have poor HIV treatment outcomes, resulting in rates of ART initiation/retention and viral suppression that are unacceptably low to achieve UNAIDS 90-90- 90 goals. In India, MSM and TW women, though two distinct populations, face similar gender or sexual-identity and HIV-related stigmas, which may: (1) directly discourage HIV care engagement and (2) indirectly reduce capacity for HIV care engagement via mediators such as poor mental health (depression/anxiety), psychological resources (e.g. poor coping skills), and interpersonal factors (e.g. lack of social support). Studying stigma and its mediational paths to HIV outcomes are needed. Methods: This R21 study, responsive to PA 18-277,"studies designed in partnership with service providers ... to understand factors impacting ART initiation... retention," is an innovative collaborative community research partnership with India's largest community-based HIV service provider. It is designed to leverage the agency's robust service and tracking infrastructure to conduct a longitudinal prospective cohort study of stigma, associated clinical outcomes (ART initiation and retention at 6 months), and potential mediators in 370 MSM­-TW+H (185 MSM/TW each). Guided by the HIV Stigma Framework, our Aims are to: 1) Characterize the prevalence and change over time of multiple stigmas in a cohort of newly diagnosed Indian MSM/TW+H. This will also involve exploring potential differences in levels and types of stigmas between MSM and TW to inform future intervention development. 2) Examine the longitudinal direct and indirect (via mental health, interpersonal factors, and psychological resources) effects of stigmas on a) ART initiation by 3 months and b) retention in ART care at 6 months. We will also explore differences in the magnitude of effects across different stigmas for each outcome to better understand which are the strongest targets for future interventions. We will additionally conduct exploratory analyses to a) examine differences in these effects for MSM versus TW; and b) identify how future interventions can be tailored to meet the needs of each group. Potential Impact. While global health agencies are calling to reduce HIV and MSM/TW stigma, no effective and scalable interventions exist that address multiple stigmas among MSM/TW+H to improve HIV care continuum outcomes. This study will provide the needed empirical data about the multiple stigmas faced by MSM/TW+H, these stigmas' influence on ART initiation/retention, and potential modifiable factors (i.e. mediators) that could disrupt the impact of stigmas on HIV care and inform interventions.