The BeT intervention to reduce HIV prevention and care disparities among young transwomen in Rio De Janeiro

摘要 我们最近的研究发现，在巴西以人口为基础的年轻跨性别者样本中，近25% 艾滋病毒检测呈阳性。这一发现与研究表明跨性别者是 全球受艾滋病毒影响最严重的人口，在有效获取艾滋病毒方面面临重大障碍 预防和护理方案。没有针对年轻变性妇女的艾滋病毒预防干预措施，证据表明 在美国以外的功效。我们提出了两阶段联合预防干预措施，以解决主要的 在资源有限的情况下，我们的研究发现了艾滋病毒预防和护理方面的障碍。耻辱可以防止 年轻的变性妇女无法获得艾滋病毒预防和护理服务，尽管这些服务 公共卫生系统保健系统(即SUS)中的所有巴西人都可以免费获得。年轻人的艾滋病毒检测 水平和护理机会参差不齐。我们研究的数据显示，几乎没有年轻的跨性别女性经常 由于进行了艾滋病毒检测，而且检测水平较低，年轻人不太可能获得艾滋病毒护理。对NICHD的回应 RFA-HD-18-032，我们建议为年轻人提供Brilho e Transcend(Bit，或Shine and Transcend)干预 巴西18-24岁的跨性别女性。我们提议的干预使用了从美国收集的专业知识 基于年轻跨性别妇女的队列研究和我们横断面跨性别妇女艾滋病毒风险研究的知识 在巴西。我们的研究包括两个阶段，以解决公共卫生系统中的耻辱，干预 通过医疗保健系统导航克服青年挑战，并在证明属实的情况下广泛推广干预措施 很有效。在为期两年的UG3阶段，我们建议开发、实施和测量高度可见的、 社区知情的社会营销活动，以减少目前在四个SUS诊所的反跨性污名 实施国家PrEP准入努力，这也是ImPrEP的一部分，ImPrEP是一个3国PrEP 实施项目的重点是变性人和男男性接触者。在UG3阶段，我们还将 收集形成性数据以使我们基于Artas的系统导航干预适应文化背景和 巴西年轻变性妇女的艾滋病毒预防和护理需求。在适应之后，我们将进行一次小型试点 对20名青年参与者进行干预，以确定初步疗效并展示我们的能力 在这群人中招募年轻人。在UG3阶段从RCT收集的初步数据将用于改进 干预并证明移动到UH3阶段和更大的RCT以测试干预的有效性。 在UH3阶段，我们将对150名年轻跨性别者随机进行随机对照试验 干预或控制。该干预将是利用对等设备进行的数字系统导航干预 解决青年在艾滋病毒预防和护理方面的障碍--即风险感知、系统导航技能 和健康素养。干预措施将在三个月内密集实施，并对12个月进行跟踪 月份。控制臂将在同一时期接收单向教育文本消息。我们将测试 干预组参与者是否增加了艾滋病毒检测频率、PrEP摄入量和艾滋病毒护理 与控制臂中的参与者相比，链接。我们干预的一个关键创新是，它将是 由训练有素的变性女性同龄人以数字方式提供。需要参与者在以下时间进行交互的干预 特定的日程安排和面对面给年轻的跨性别女性带来了许多问题，她们面临着大量的 相互竞争的需求和参与的障碍。我们的干预是私下进行的，可以按方便的时间表进行 对参与者而言，并且不需要面对面的交互。后一种优势在年轻人中尤为突出。 在公共场合，尤其是在交通工具上面临威胁和虐待风险的跨性别女性。系统-导航 与需要亲自到场的现有干预措施相比，干预措施承诺具有多种优势， 包括更频繁的参与和更低的数字干预成本，与年轻人的方式保持一致 跨性别女性在社交和互动中，以及在应对跨性别者在参与 以放置为基础的干预。有了有效性的证明，干预可以作为一种 与ImPrEP合作，为年轻跨性别者提供可复制、可持续的循证干预 研究和巴西卫生部努力增加跨性别妇女获得预防和护理的机会， 包括年轻人。

ABSTRACT Our recent research discovered that almost 25% of a population-based sample of young transwomen in Brazil tested positive for HIV. This finding is consistent with research demonstrating that transwomen are the population most severely affected by HIV worldwide and face important barriers to accessing effective prevention and care programs. There is no HIV prevention intervention for young transwomen with evidence of efficacy outside the US. We propose a two-phase combination prevention intervention to address the main barriers to HIV prevention and care found in our research in this resource constrained setting. Stigma prevents young transwomen from accessing HIV prevention and care services, despite the fact that such services are freely available to all Brazilians in the public health system care system (i.e., SUS). Young people's HIV testing levels and care access is uneven. Data from our study show that almost no young transwomen regularly got tested for HIV, and given low testing levels, it is unlikely youth are accessing HIV care. In response to NICHD RFA-HD-18-032, we propose the Brilho e Transcender (BeT, or Shine and Transcend) intervention for young transwomen ages 18-24 years old in Brazil. Our proposed intervention uses expertise gleaned from a US based cohort study of young transwomen and knowledge from our cross-sectional transwomen HIV risk study in Brazil. Our study is comprised of two phases to address stigma in the public health system, intervene to overcome youth challenges with health care systems navigation and to scale the intervention widely if proven efficacious. During the 2-year UG3 phase, we propose to develop, implement and measure a highly visible, community-informed social marketing campaign to reduce anti-trans stigma in four SUS clinics currently implementing national PrEP access efforts that are also part of ImPrEP, which is a 3-country PrEP implementation project focused on transgender individuals and MSM. During the UG3 phase, we will also collect formative data to adapt our ARTAS-based system navigation intervention to the cultural context and HIV prevention and care needs of young transwomen in Brazil. After adaptation, we will conduct a small pilot intervention with 20 youth participants to determine preliminary efficacy and demonstrate our ability to recruit youth in this population. Preliminary data gathered from the RCT in the UG3 phase will be used to refine the intervention and justify movement to the UH3 phase and larger RCT to test efficacy of the intervention. During the UH3 phase, we will conduct a RCT with 150 young transwomen randomized to the BeT intervention or control. The intervention will be a digital systems navigation intervention utilizing peers to address youth-specific barriers to HIV prevention and care- namely, risk perception, system navigation skills and health literacy. The intervention will be intensively implemented over three months with follow-up to twelve months. The control arm will receive unidirectional educational text messages for the same period. We will test whether intervention arm participants have an increase in HIV testing frequency, PrEP uptake and HIV care linkage compared to participants in the control arm. A key innovation of our intervention is that it will be delivered digitally by trained transwomen peers. Interventions that require participants to interact on a particular schedule and in-person present a number of problems for young transwomen who face substantial competing needs and barriers to participation. Our intervention is private, can occur on a schedule convenient to participants, and does not require in-person interaction. The latter advantage is particularly salient for young transwomen who risk threats and abuse in public, especially on transportation. The system-navigation intervention promises multiple advantages over existing interventions that require in-person attendance, including more frequent engagement and lower cost of a digital intervention, alignment with the ways young transwomen socialize and interact, and in addressing safety challenges trans people face with participation in placed-based interventions. With proof of efficacy, the intervention can be rapidly brought to scale as a replicable, sustainable, evidence-based intervention for young transwomen in collaboration with the ImPrEP study and the Brazilian Ministry of Health efforts to increase prevention and care access for transwomen, including youth.