There is no HIV prevention intervention for transwomen (TW) with evidence of efficacy outside the US. The largest burden of HIV among TW rests on those outside the US where intersectional stigma is a driver of HIV. No research in South Asia has examined the impact of intersectional stigma on HIV risk and care among TW. TW's unique vulnerabilities related to stigma are different from those of MSM and other key populations, and it is past time that their specific risks and intervention needs are explored. Consistent with the goals of the PA-17-474, we propose to explore the impact of anti-trans, HIV and sex worker stigma among TW in Nepal, one of the poorest countries in the world and South Asia. We propose to conduct the first population-based Respondent Driven Sampling (RDS) study of HIV risk among TW in Nepal to disaggregate TW from MSM in behavioral surveillance. Disaggregation is essential as TW sexual networks are different from MSM and approaches to prevention and care are not the same. We will also collect data to examine the impact of anti-trans, HIV, and sex worker stigma on HIV-risk and health seeking behaviors, which has not been done in prior research. Our proposed study will also examine the impact of social cohesion and social participation on HIV-related health seeking behaviors of TW in Nepal to lay the groundwork for a future R34 proposal. Results from this study have the potential for applicability across South Asia where similar sexual and gender identities exist, such as India, one of the most populous countries in the world, and Pakistan, Bangladesh, and Sri Lanka. This study aligns with WHO's 2016-2021 Global Health Sector Strategy on HIV which calls for attention to: (1) TW, MSM and sex workers; (2) LMICs; and (3) facilitators to HIV testing & care. The final pillar of this proposal is to build and expand an equitable stigma research partnership called the Nepalese Stigma Research Initiative (NSRI) with the Blue Diamond Society in Nepal. The Blue Diamond is the first the largest non- governmental organization in Nepal to serve the LGBT population and is a leader is building collaborations in the region for the purposes of HIV prevention and care. This proposal will embed a stigma research initiative within the organization through capacity building efforts and engagement of a multi-sector group of stakeholders interested in addressing stigma and HIV. This proposal will result in the first HIV point estimate for transwomen in Nepal to be used as a benchmark for future success of a social cohesion and social participation intervention to increase HIV-related health seeking behaviors and reduce the impact of HIV on TW in Nepal. Capacity building efforts will increase local research capabilities to conduct research on stigma and HIV and create an ongoing initiative to address the effects of stigma towards sexual and gender minorities in the region.
PROJECT NARATIVE There is not one study with proven efficacy for reducing HIV risk among transwomen and little research with transwomen in low and middle income countries. We propose to determine the HIV prevalence and to examine the effects of stigma on HIV-related health seeking behaviors among transwomen in Nepal. This study will provide epidemiological data and build capacity for future interventions to address stigma in Nepal and other regions of the world where transwomen are disproportionately impacted by HIV.
