Piloting a multi-level intervention to promote viral suppression among transgender women living with HIV

项目摘要/摘要： 据估计，全球范围内的变性人(跨性别)女性承受着不成比例的艾滋病毒负担 全球艾滋病毒流行率为19%。携带艾滋病毒的变性妇女也有更差的艾滋病毒护理和治疗结果 比顺性成年人，包括更低的病毒抑制率。需要多层次的反应来改进 通过同时和协同解决个人、提供者和 社区动态。跨性别女性经历了跨界别的耻辱，因为 变性人身份、艾滋病毒和性工作。这些柱头的交叉形式包括内在化的柱头，其形式为 实施消极信仰，并以排斥和歧视的形式实施污名。发展中的社会 凝聚力可以是解决污名问题的社区进程的关键第一步。我们采用了多层次的 干预，Abriendo putas(开门)，包括个人咨询、同行导航和 在多米尼加共和国为感染艾滋病毒的变性妇女进行社区动员 咨询过程。我们评估了30名患者对艾滋病毒护理和治疗行为的可行性和初步效果 携带艾滋病毒的变性妇女(无对照组)，并记录了抗逆转录病毒药物使用的积极趋势(70%至85%， P=0.03)、错过护理预约(35%至20%，P=0.39)和坚持抗逆转录病毒治疗(86%至96%，P=0.50)。 与会者强调，信任干预工作人员并在个别会议上受到尊重 让他们提高了自尊。然而，变性女性之间有限的信任和凝聚力阻碍了更多 广泛参与同行导航和社区活动。作为回应，我们确定了两个关键 对艾滋病毒携带者的变性妇女加强和进一步定制干预措施的修改：1)整合更多 性别肯定内容，包括与供应商和2)重点建立跨性别妇女之间的信任，通过 按顺序实施个人组件，然后是社区组件。拟议研究的目的 是对GAP模型进行一项试点随机试验，或性别肯定Abriendo putas。在目标1中，我们将 评估GAP干预在变性妇女中抑制病毒的初步效果 随机化的干预组与随机化的对照组进行比较。我们将随机分配TRANS 艾滋病毒感染妇女接受GAP干预(n=60)(个人咨询、同伴导航、提供者培训、 和社区支持建设)或对照组(n=60)。我们将进行基线、6个月和12个月的调查 以及病毒载量评估，以评估不同研究部门的差异。在目标2中，我们将研究 影响(例如，减少耻辱，增强凝聚力)和干预经验，以确定 具体需要改进和扩大的领域。我们将在基线上进行纵向定性采访， 6个月和12个月，20名干预参与者，并与调查一起评估差距参与如何 影响耻辱、凝聚力和艾滋病毒结果之间的途径。我们还将汲取经验和 焦点组提供者和干预人员在6个月(n=2)和12个月(n=2)时提出建议。

Project Summary/Abstract: Transgender (trans) women across the globe experience a disproportionate burden of HIV with an estimated global HIV prevalence of 19%. Trans women living with HIV also have worse HIV care and treatment outcomes than cisgender adults, including lower rates of viral suppression. Multilevel responses are needed to improve HIV outcomes among trans women by simultaneously and synergistically addressing individual, provider, and community dynamics. Trans women experience intersectional stigma due to the frequent association between trans identity, HIV, and sex work. These intersecting forms of stigma include internalized stigma in the form of applying negative beliefs and enacted stigma in the form of exclusion and discrimination. Developing social cohesion can be a critical first step in community processes to address stigma. We adapted a multilevel intervention, Abriendo Puertas (Opening Doors), including individual counseling, peer navigation, and community mobilization for trans women living with HIV in the Dominican Republic using an iterative consultation process. We assessed feasibility and initial effects on HIV care and treatment behaviors with 30 trans women living with HIV (no control group) and documented positive trends in ART use (70% to 85%, p=0.03), missed care appointments (35% to 20%, p=0.39) and ART adherence (86% to 96%, p=0.50). Participants emphasized that trusting intervention staff and being treated with respect in individual sessions allowed them to improve self-esteem. Limited trust and cohesion among trans women, however, inhibited more extensive engagement with peer navigation and community activities. In response, we identified two key modifications to strengthen and further tailor the intervention for trans women living with HIV: 1) integrate more gender affirming content, including with providers and 2) focus on building trust among trans women through sequential implementation of individual and then community components. The purpose of the proposed study is to conduct a pilot randomized trial of the GAP model, or Gender-affirming Abriendo Puertas. In Aim 1, we will assess preliminary efficacy of the GAP intervention on viral suppression among trans women randomized to the intervention compared to those randomized to control. We will randomly assign trans women living with HIV to the GAP intervention (n=60) (individual counseling, peer navigation, provider training, and community support building) or control group (n=60). We will conduct baseline, 6, and 12-month surveys and viral load assessments to assess differences across study arms. In Aim 2, we will examine pathways of influence (e.g. decreased stigma, increased cohesion) and experiences with the intervention to identify specific areas for improvement and scale up. We will conduct longitudinal qualitative interviews at baseline, 6, and 12 months with 20 intervention participants and, together with surveys, assess how GAP participation affects pathways between stigma, cohesion, and HIV outcomes. We will also elicit experiences and recommendations from providers and intervention staff in focus groups at 6 (n=2) and 12 months (n=2).