RESUMEN
INTRODUCTION: Globally, transgender ('trans') women experience extreme social and economic marginalisation due to intersectional stigma, defined as the confluence of stigma that results from the intersection of social identities and positions among those who are oppressed multiple times. Among trans women, gender-based stigma intersects with social positions such as engagement in sex work and substance use, as well as race-based stigma to generate a social context of vulnerability and increased risk of HIV acquisition. In Brazil, trans women are the 'most at-risk' group for HIV, with 55 times higher estimated odds of HIV infection than the general population; further, uptake of HIV testing and pre-exposure prophylaxis (PrEP) among trans women is significantly lower than other at-risk groups. Through extensive formative work, we developed Manas por Manas, a multilevel intervention using HIV prevention strategies with demonstrated feasibility and acceptability by trans women in Brazil, to address intersectional stigma and increase engagement in the HIV prevention continuum. METHODS AND ANALYSIS: We are conducting a two-arm randomised wait-list controlled trial of the intervention's efficacy in São Paulo, Brazil, to improve uptake of HIV testing and PrEP among transgender women (N=400). The primary outcomes are changes in HIV testing (self-testing and clinic based), changes in PrEP uptake and changes in PrEP persistence at baseline and follow-up assessment for 12 months at 3-month intervals. ETHICS AND DISSEMINATION: This study was approved by University of California, San Francisco Institutional Review Board (15-17910) and Comissão Nacional de Ética em Pesquisa (Research Ethics National Commission, CAAE: 25215219.8.0000.5479) in Brazil. Participants provided informed consent before enrolment. We are committed to collaboration with National Institutes of Health officials, other researchers, and health and social services communities for rapid dissemination of data and sharing of materials. The results will be published in peer-reviewed academic journals and scientific presentations. TRIAL REGISTRATION NUMBER: NCT03081559.
Asunto(s)
Infecciones por VIH , Profilaxis Pre-Exposición , Estigma Social , Personas Transgénero , Humanos , Personas Transgénero/psicología , Brasil/epidemiología , Femenino , Infecciones por VIH/prevención & control , Infecciones por VIH/diagnóstico , Masculino , Adulto , Prueba de VIH , Ensayos Clínicos Controlados Aleatorios como Asunto , Adulto Joven , Adolescente , Aceptación de la Atención de Salud/psicologíaRESUMEN
BACKGROUND: Transgender women are disproportionately affected by both HIV and gender-based violence (GBV), defined as physical, sexual, or emotional violence perpetrated against an individual based on their gender identity/expression. While a growing body of evidence demonstrates that GBV leads to poor HIV care and treatment outcomes among cisgender women, less research has examined this association among transgender women. We assessed the impact of lifetime experiences of GBV on subsequent retention in HIV care and laboratory confirmed viral suppression among a sample of transgender women living with HIV (TWH) in Brazil. METHODS: A pilot trial of a peer navigation intervention to improve HIV care and treatment among TWH was conducted in São Paulo, Brazil between 2018 and 2019. TWH were recruited and randomized into the intervention or control arm and participated in a baseline and 9-month follow-up survey and ongoing extraction of clinical visit, prescribing, and laboratory data. Generalized linear model regressions with a Poisson distribution estimated the relative risk (RR) for the association of lifetime physical and sexual violence reported at baseline with treatment outcomes (retention in HIV care and viral suppression) at follow-up, adjusting for baseline sociodemographic characteristics. RESULTS: A total of 113 TWH participated in the study. At baseline, median age was 30 years, and the prevalence of lifetime physical and sexual violence was 62% and 45%, respectively. At follow-up, 58% (n = 66/113) were retained in care and 35% (n = 40/113) had evidence of viral suppression. In adjusted models, lifetime physical violence was non-significantly associated with a 10% reduction in retention in care (aRR: 0.90, 95% CI: 0.67, 1.22) and a 31% reduction in viral suppression (aRR: 0.69; 95% CI: 0.43, 1.11). Lifetime sexual violence was non-significantly associated with a 28% reduction in retention in HIV care (aRR: 0.72, 95% CI: 0.52, 1.00) and significantly associated with a 56% reduction in viral suppression (aRR: 0.44; 95% CI: 0.24, 0.79). CONCLUSION: Our findings are among the first to demonstrate that lifetime experiences with physical and sexual violence are associated with poor HIV outcomes over time among transgender women. Interventions seeking to improve HIV treatment outcomes should assess and address experiences of GBV among this population. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03525340.
Asunto(s)
Violencia de Género , Infecciones por VIH , Personas Transgénero , Adulto , Femenino , Humanos , Masculino , Brasil/epidemiología , Identidad de Género , Violencia de Género/psicología , Infecciones por VIH/terapia , Infecciones por VIH/tratamiento farmacológico , Personas Transgénero/psicología , Resultado del TratamientoRESUMEN
Purpose: We assessed whether anticipated stigma (i.e., fear of public mistreatment due to gender identity) impacts communication between transgender women (TGW) living with HIV and health care providers. Methods: This is a secondary analysis of baseline data from Trans Amigas, a study conducted in Brazil, 2018. The study population consisted of TGW living with HIV, older than 18 years, residing in the São Paulo metropolitan area. We used multivariable logistic regression (α = 0.05), mediation, and bootstrapping for the analysis. Results: One hundred and thirteen participants completed the study. Fear of public mistreatment had an adjusted odds ratio (aOR) of 7.42 (p = 0.003) for difficulty reporting new symptoms to providers. Concerning fear of public mistreatment, we found that unemployment had an aOR of 3.62 (p = 0.036); sex work, an aOR of 2.95 (p = 0.041); and issues related to name change in documents, an aOR of 2.71 (p = 0.033). For the indirect effect on difficulty reporting new symptoms, mediated by fear of public mistreatment, unemployment had an aOR of 1.52 (confidence interval [CI] = 0.88-2.24); sex work, an aOR of 1.48 (CI = 0.81-2.52); and name change issues, an aOR of 1.47 (CI = 0.96-2.43). Conclusions: Anticipated stigma was associated with communication difficulties between TGW living with HIV and providers. Our data suggest that structural factors associated with anticipated stigma could indirectly impact on difficulty reporting new symptoms. These findings indicate the importance of considering social contexts that intersect with individual experiences when analyzing communication barriers between providers and patients, and the need to strengthen social policies for TGW in Brazil. Clinical Trial Registration number: R34MH112177.
Asunto(s)
Infecciones por VIH , Personas Transgénero , Humanos , Masculino , Femenino , Infecciones por VIH/epidemiología , Análisis de Mediación , Identidad de Género , Brasil , Homosexualidad Masculina , Estigma Social , Comunicación , Personal de SaludRESUMEN
Travestis and transgender women (TrTGW) constitute the groups with the highest HIV prevalence in the world, with higher probability of infection compared with the general population and lower adherence to prevention and treatment strategies than other vulnerable groups. Considering these challenges, this study describes the factors associated with the retention of TrTGW with HIV to the TransAmigas project. Participants were recruited from April 2018 to September 2019 in a public health service in São Paulo, Brazil. A total of 113 TrTGW were randomly assigned to either a peer navigation intervention (75) or a control group (38) and followed up for nine months. To analyze the association between the selected variables and the outcome ("retention at nine months", regardless of contact at three months, defined by the "full completion of the final questionnaire"), bivariate and multivariate logistic regression models were used. Peer contact forms were qualitatively assessed to validate and complement the previous selection of quantitative component variables. Of the 113 participants, 79 (69.9%) participated in the interview after nine months, of which 54 (72%) were from the intervention group and 25 (66%) from the control group. In the final multivariate model, contact at three months (adjusted odds ratio - aOR = 6.15; 95% confidence interval - 95%CI: 2.16-17.51) and higher schooling level (≥ 12 years) (aOR = 3.26; 95%CI: 1.02-10.42) remained associated with the outcome, adjusted by race/skin color, age ≤ 35 years, and HIV serostatus disclosure. Future studies with TrTGW should include contact at regular intervals, with additional efforts aimed at participants with lower schooling level.
Travestis e mulheres trans (TrMT) pertencem aos grupos com mais alta prevalência do HIV no mundo, com maior probabilidade de infecção em relação à população geral e menor adesão a estratégias de prevenção e tratamento do que outros grupos vulneráveis. Considerando esses desafios, descrevemos os fatores associados à retenção de TrMT com HIV no projeto TransAmigas. O recrutamento ocorreu entre abril de 2018 e setembro de 2019, em um serviço público de saúde em São Paulo, Brasil. Foram inscritas 113 TrMT, atribuídas aleatoriamente para uma intervenção com navegadora de pares (75) ou um grupo controle (38) e seguidas durante nove meses. Para analisar a associação entre as variáveis selecionadas e o desfecho ("retenção aos nove meses" independentemente do contato aos três meses, definido pela "resposta completa ao questionário final"), foram empregados modelos de regressão logística bi e multivariados. Uma exploração qualitativa dos formulários de contato de pares foi realizada para validar e complementar a seleção prévia de variáveis do componente quantitativo. Das 113 participantes, 79 (69,9%) responderam à entrevista de nove meses, sendo 54 (72%) do grupo intervenção e 25 (66%) do grupo controle. No modelo multivariado final, o contato aos três meses (odds ratio ajustado - ORa = 6,15; intervalo de 95% de confiança - 95%CI: 2,16-17,51) e a maior escolaridade (≥ 12 anos) (ORa = 3,26; IC95%: 1,02-10,42) permaneceram associados ao desfecho, ajustados por raça/cor, idade < 35 anos e revelação do status sorológico para HIV. Pesquisas futuras com TrMT devem incluir contato em intervalos regulares, com esforços adicionais voltados a participantes com menor escolaridade.
La población de travestis y mujeres trans (TrMT) está en los grupos con mayor prevalencia de VIH en el mundo, con mayor probabilidad de infección en comparación con la población general y menor adherencia a las estrategias de prevención y tratamiento que otros grupos vulnerables. Ante estos desafíos, describimos los factores asociados a la retención de TrMT con VIH en el proyecto TransAmigas. La selección ocurrió entre abril de 2018 y septiembre de 2019, en un servicio público de salud de São Paulo, Brasil. Se inscribieron 113 TrMT, a las cuales se asignaron aleatoriamente a una intervención de navegador de pares (75) o a un grupo control (38) y se les dio seguimiento durante 9 meses. Para analizar la asociación entre las variables seleccionadas y el resultado ("retención a los nueve meses" independientemente del contacto a los 3 meses, definido por "respuesta completa al cuestionario final"), se utilizaron modelos de regresión logística bi- y multivariante. Se realizó una exploración cualitativa de los formularios de contacto de pares para validar y complementar la selección previa de las variables en el componente cuantitativo. De las 113 participantes, 79 (69,9%) respondieron a la entrevista de los 9 meses, de las cuales 54 (72%) pertenecían al grupo intervención y 25 (66%) al grupo control. En el modelo multivariante final, el contacto a los 3 meses (odds ratio ajustado - ORa = 6,15; intervalo de 95% de confianza - IC95%: 2,16-17,51) y un alto nivel de instrucción (≥ 12 años) (ORa = 3,26; IC95%: 1,02-10,42) permanecieron asociados con el resultado, ajustado por etnia/color, edad < 35 años y divulgación del estado serológico respecto al VIH. Los futuros estudios con la población TrMT deberán incluir contacto a intervalos regulares, con esfuerzos adicionales dirigidos a las participantes con menor nivel de instrucción.
Asunto(s)
Infecciones por VIH , Personas Transgénero , Adulto , Femenino , Humanos , Brasil/epidemiología , Infecciones por VIH/epidemiología , Infecciones por VIH/prevención & control , Prevalencia , Encuestas y CuestionariosRESUMEN
Travestis e mulheres trans (TrMT) pertencem aos grupos com mais alta prevalência do HIV no mundo, com maior probabilidade de infecção em relação à população geral e menor adesão a estratégias de prevenção e tratamento do que outros grupos vulneráveis. Considerando esses desafios, descrevemos os fatores associados à retenção de TrMT com HIV no projeto TransAmigas. O recrutamento ocorreu entre abril de 2018 e setembro de 2019, em um serviço público de saúde em São Paulo, Brasil. Foram inscritas 113 TrMT, atribuídas aleatoriamente para uma intervenção com navegadora de pares (75) ou um grupo controle (38) e seguidas durante nove meses. Para analisar a associação entre as variáveis selecionadas e o desfecho ("retenção aos nove meses" independentemente do contato aos três meses, definido pela "resposta completa ao questionário final"), foram empregados modelos de regressão logística bi e multivariados. Uma exploração qualitativa dos formulários de contato de pares foi realizada para validar e complementar a seleção prévia de variáveis do componente quantitativo. Das 113 participantes, 79 (69,9%) responderam à entrevista de nove meses, sendo 54 (72%) do grupo intervenção e 25 (66%) do grupo controle. No modelo multivariado final, o contato aos três meses (odds ratio ajustado - ORa = 6,15; intervalo de 95% de confiança - 95%CI: 2,16-17,51) e a maior escolaridade (≥ 12 anos) (ORa = 3,26; IC95%: 1,02-10,42) permaneceram associados ao desfecho, ajustados por raça/cor, idade < 35 anos e revelação do status sorológico para HIV. Pesquisas futuras com TrMT devem incluir contato em intervalos regulares, com esforços adicionais voltados a participantes com menor escolaridade.
La población de travestis y mujeres trans (TrMT) está en los grupos con mayor prevalencia de VIH en el mundo, con mayor probabilidad de infección en comparación con la población general y menor adherencia a las estrategias de prevención y tratamiento que otros grupos vulnerables. Ante estos desafíos, describimos los factores asociados a la retención de TrMT con VIH en el proyecto TransAmigas. La selección ocurrió entre abril de 2018 y septiembre de 2019, en un servicio público de salud de São Paulo, Brasil. Se inscribieron 113 TrMT, a las cuales se asignaron aleatoriamente a una intervención de navegador de pares (75) o a un grupo control (38) y se les dio seguimiento durante 9 meses. Para analizar la asociación entre las variables seleccionadas y el resultado ("retención a los nueve meses" independientemente del contacto a los 3 meses, definido por "respuesta completa al cuestionario final"), se utilizaron modelos de regresión logística bi- y multivariante. Se realizó una exploración cualitativa de los formularios de contacto de pares para validar y complementar la selección previa de las variables en el componente cuantitativo. De las 113 participantes, 79 (69,9%) respondieron a la entrevista de los 9 meses, de las cuales 54 (72%) pertenecían al grupo intervención y 25 (66%) al grupo control. En el modelo multivariante final, el contacto a los 3 meses (odds ratio ajustado - ORa = 6,15; intervalo de 95% de confianza - IC95%: 2,16-17,51) y un alto nivel de instrucción (≥ 12 años) (ORa = 3,26; IC95%: 1,02-10,42) permanecieron asociados con el resultado, ajustado por etnia/color, edad < 35 años y divulgación del estado serológico respecto al VIH. Los futuros estudios con la población TrMT deberán incluir contacto a intervalos regulares, con esfuerzos adicionales dirigidos a las participantes con menor nivel de instrucción.
Travestis and transgender women (TrTGW) constitute the groups with the highest HIV prevalence in the world, with higher probability of infection compared with the general population and lower adherence to prevention and treatment strategies than other vulnerable groups. Considering these challenges, this study describes the factors associated with the retention of TrTGW with HIV to the TransAmigas project. Participants were recruited from April 2018 to September 2019 in a public health service in São Paulo, Brazil. A total of 113 TrTGW were randomly assigned to either a peer navigation intervention (75) or a control group (38) and followed up for nine months. To analyze the association between the selected variables and the outcome ("retention at nine months", regardless of contact at three months, defined by the "full completion of the final questionnaire"), bivariate and multivariate logistic regression models were used. Peer contact forms were qualitatively assessed to validate and complement the previous selection of quantitative component variables. Of the 113 participants, 79 (69.9%) participated in the interview after nine months, of which 54 (72%) were from the intervention group and 25 (66%) from the control group. In the final multivariate model, contact at three months (adjusted odds ratio - aOR = 6.15; 95% confidence interval - 95%CI: 2.16-17.51) and higher schooling level (≥ 12 years) (aOR = 3.26; 95%CI: 1.02-10.42) remained associated with the outcome, adjusted by race/skin color, age ≤ 35 years, and HIV serostatus disclosure. Future studies with TrTGW should include contact at regular intervals, with additional efforts aimed at participants with lower schooling level.
RESUMEN
Trans women living with HIV (TWH) have suboptimal HIV care engagement. We pilot tested Trans Amigas, a theory-based, trans-specific peer navigation (PN) intervention to address barriers to care in São Paulo, Brazil. TWH were randomized to the PN intervention (n = 75) or control (n = 38) condition. Control participants were referred to trans-friendly HIV care. Intervention participants were assigned a navigator who conducted nine in-person one-on-one sessions and bi-weekly phone or text check-ins to help participants overcome barriers to care and work towards gender affirmation and healthcare goals. We followed participants for 9 months to determine intervention feasibility, acceptability, and preliminary efficacy in improving retention in care. Analyses were intention to treat (ITT). Intervention acceptability was high: at end line, 85.2% of PN participants said they would continue receiving services and 94.4% would recommend peer navigation to a friend. A priori feasibility criteria were met: 92% of eligible participants enrolled and 70% were retained at 9 months; however, only 47% achieved moderate or better adherence to both in-person and phone/text program components. Though the pilot was not powered for efficacy, ITT findings trended toward significance, with intervention participants 40% more likely to be retained in care at the end of the study. Population-specific peer programming to support care engagement is acceptable, feasible, and can improve HIV outcomes for Trans women living with HIV.
RESUMEN: Las mujeres transgénero que viven con VIH (MTV) tienen una participación subóptima en la atención del VIH. Nosotros evaluamos el programa piloto "Trans Amigas", una intervención de navegación (o acompañamiento) de pares (NP) basada en un marco teórico, diseñado específicamente para mujeres transgénero, para abordar las dificultades de acceso a la salud en São Paulo, Brasil. MTV fueron asignadas de manera aleatoria a la intervención (n = 75) o a la condición de control (n = 38). Las participantes del grupo control fueron referidas a una unidad con servicios especializados para MTV. Las participantes en la intervención fueron asignadas a una navegadora, quien realizó nueve sesiones individuales en persona, así como llamadas telefónicas o mensajes de texto cada dos semanas para ayudar a las participantes a superar las barreras de acceso a la atención médica y avanzar hacia sus metas de afirmación de género y de salud. Seguimos a las participantes durante nueve meses para determinar factibilidad, aceptabilidad y eficacia preliminar en la retención en los servicios médicos. Usamos análisis por intención de tratar (AIT). La aceptabilidad de la intervención fue alta: 85.2% de las participantes NP dijeron que les gustaría seguir recibiendo los servicios NP, y 94.4% recomendarían NP a una amiga. El criterio de factibilidad a priori fue alcanzado: 92% de las participantes eligibles se inscribió y el 70% continuó por nueve meses. Sin embargo, solo el 47% alcanzó una adherencia moderada o alta tanto a las visitas en persona como a los mensajes de texto/llamadas telefónicas. Aunque el estudio piloto no tuvo el poder necesario para evaluar eficacia, el AIT reveló una tendencia hacia la significancia de que las participantes de la intervención tuvieran uma retención en la atención médica un 40% mayor. Los programas NP que apoyan el la participación en la atención del VIH, diseñados especificamente para la población, son aceptables, factibles, y pueden mejorar la situación de salud de las mujeres transgénero que viven con VIH.
Asunto(s)
Infecciones por VIH , Aceptación de la Atención de Salud , Navegación de Pacientes , Personas Transgénero , Transexualidad , Brasil/epidemiología , Femenino , Infecciones por VIH/prevención & control , Humanos , Grupo Paritario , Proyectos PilotoRESUMEN
In Brazil, little data is available to inform HIV prevention programming for travestis and transgender ('trans') women, despite the existence of a social movement that has gained strength in recent years. We conducted formative research in Rio de Janeiro to gather trans women's perspectives on combination HIV prevention approaches. Framing the analysis within the model of gender affirmation, we found that several social and contextual factors inhibited participants' access to HIV prevention and treatment. Experienced and anticipated gender-related discrimination and HIV stigma were linked to the avoidance of HIV testing, health services and HIV status disclosure. Participants recommended HIV prevention interventions which combined socio-structural interventions, such as peer-based empowerment and social support, with biomedical interventions such as pre-exposure prophylaxis (PrEP). Participants expressed a preference for programmes and interventions that emphasised a gender-affirmative approach, promoted autonomy and aimed to reduce stigma and discrimination in public health services.
Asunto(s)
Infecciones por VIH , Accesibilidad a los Servicios de Salud , Profilaxis Pre-Exposición , Sexismo , Estigma Social , Personas Transgénero/estadística & datos numéricos , Adulto , Femenino , Grupos Focales , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/prevención & control , Humanos , Masculino , Tamizaje Masivo , Investigación Cualitativa , Apoyo SocialAsunto(s)
Infecciones por VIH , Profilaxis Pre-Exposición , Fármacos Anti-VIH , Brasil , Femenino , Humanos , Cumplimiento de la MedicaciónRESUMEN
Transgender women in Lima, Peru have, until recently, been grouped together with gay and bisexual men in the category MSM, or men who have sex with men, with little consideration of their unique situation and needs. Transgender women, self-identified in Peru as travesti, are a socially vulnerable population with many unmet health needs, including an HIV prevalence of 30%. Understanding specific transgender identities and their contexts will contribute to the improvement and development of HIV prevention programs. Through qualitative open-ended interviews with trans-identified women in Lima, Peru, this study found that the non-normative travesti identity is constructed within a conservative homophobic and heteronormative social context. Participants strive towards appearances and relationships perceived as feminine, seeking out silicone injections and abusive men as social markers of this femininity. Sex work is the primary economic activity available and travestis are often alienated from their families and communities. Work is needed to increase self-esteem and decrease violence, stigma, and discrimination. There is a need for multilevel HIV prevention campaigns prioritising travesti in Lima, utilising a human rights framework.
Asunto(s)
Infecciones por VIH/prevención & control , Disparidades en Atención de Salud , Homosexualidad Masculina/psicología , Discriminación Social , Estigma Social , Personas Transgénero/psicología , Adolescente , Adulto , Femenino , Identidad de Género , Infecciones por VIH/epidemiología , Infecciones por VIH/transmisión , Homosexualidad Masculina/estadística & datos numéricos , Humanos , Entrevistas como Asunto , Masculino , Perú/epidemiología , Prevalencia , Investigación Cualitativa , Autoimagen , Personas Transgénero/clasificación , Personas Transgénero/estadística & datos numéricos , Adulto JovenRESUMEN
BACKGROUND: Pre-exposure prophylaxis (PrEP) with oral emtricitabine and tenofovir disoproxil fumarate is used to prevent the sexual acquisition of HIV in groups at high risk such as transgender women. We used data from the iPrEx study to assess PrEP efficacy, effectiveness, and adherence in transgender women. METHODS: The iPrEx trial was a randomised controlled trial of PrEP with oral emtricitabine plus tenofovir disoproxil fumarate compared with placebo in men who have sex with men (MSM) and transgender women, followed by an open-label extension. Drug concentrations were measured in blood by liquid chromatography and tandem mass spectroscopy. We did unplanned exploratory analyses to investigate differences in PrEP outcomes among transgender women and between transgender women and MSM. FINDINGS: Of the 2499 participants enrolled in the randomised controlled trial, 29 (1%) identified as women, 296 (12%) identified as trans, 14 (1%) identified as men but reported use of feminising hormones, such that 339 (14%) reported one or more characteristics and are classified as transgender women for the purpose of this study. Compared with MSM, transgender women more frequently reported transactional sex, receptive anal intercourse without a condom, or more than five partners in the past 3 months. Among transgender women, there were 11 HIV infections in the PrEP group and ten in the placebo group (hazard ratio 1·1, 95% CI 0·5-2·7). In the PrEP group, drug was detected in none of the transgender women at the seroconversion visit, six (18%) of 33 seronegative transgender women (p=0·31), and 58 (52%) of 111 seronegative MSM (p<0·0001). PrEP use was not linked to behavioural indicators of HIV risk among transgender women, whereas MSM at highest risk were more adherent. INTERPRETATION: PrEP seems to be effective in preventing HIV acquisition in transgender women when taken, but there seem to be barriers to adherence, particularly among those at the most risk. Studies of PrEP use in transgender women populations should be designed and tailored specifically for this population, rather than adapted from or subsumed into studies of MSM. FUNDING: US National Institutes of Health and the Bill & Melinda Gates Foundation.