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跨性别女性占跨性别女性的最大比例 在地球仪上，艾滋病毒感染者的数量是最多的，但在应对艾滋病毒方面却服务不足。尼泊尔是一个低收入国家， 在亚洲，跨性别妇女是受艾滋病毒影响很大的关键人群。在2019/20年度，我们进行了一项 对跨性别女性进行的探索性研究发现，11.3%的人感染了艾滋病毒，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过的反跨性别 污名化是艾滋病毒检测和艾滋病毒护理参与率低的主要驱动因素。艾滋病毒风险进一步加剧， 反跨性别者的污名化导致在教育、就业、社会支持和赋权方面的障碍。为 例如，由于大多数跨性别女性在求职时面临歧视，我们的大多数参与者都认为， 探索性工作为收入而从事性工作，无避孕套性行为的比例很高，性伴侣很多。 需要对跨性别妇女进行艾滋病毒干预，通过解决许多人的耻辱感， 对健康和保健构成障碍的水平。然而，艾滋病毒预防和治疗干预措施很少， 解决跨部门成见问题，而为低收入和中等收入国家制定的政策就更少了。 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 减少耻辱感的干预措施，在尼泊尔语中称为“接受”。主要干预结果是 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感来增加艾滋病毒检测， 一级干预的组成部分是量身定制的艾滋病毒自我检测干预。通过以下方式提高抗逆转录病毒治疗依从性 为了解决预期的和经历的耻辱，系统层面的干预组成部分是艾滋病毒治疗 送货上门为了在社区层面解决污名化问题，我们将在知情的情况下进行接触干预11 通过Photovoice 12减少经验和内在的耻辱。Photovoice将用于通知内容， * 开展社会媒体运动，减少尼泊尔社会的反跨性别现象， 这将有助于减轻内化的耻辱感。我们 这种方法是社区驱动的，非随机的，以最大限度地为急需治疗的跨性别妇女带来好处。 干预，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共同努力中建立了强大的合作关系， 为跨性别女性提供研究和服务。此外，COVID-19为以下方面创造了新的机会： 创新的艾滋病毒护理和预防，将利用在星期。如果Sweekar成功，我们将 立即使用结果数据和经验教训，制定多站点R 01提案，以测试 在尼泊尔全国范围内进行大规模干预，并与我们的尼泊尔研究和执行团队合作。

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.