Globally, transgender (`trans') women experience extreme social and economic marginalization due to intersectional stigma, defined as the confluence of stigma that results from the intersection of social identities and positions among those who are multiply oppressed. 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, despite availability in the public sector and documented interest in the community. Through extensive formative work, we have developed a multi-level intervention utilizing HIV prevention strategies which have demonstrated feasibility and acceptability by trans women in Brazil, to address intersectional stigma and increase engagement of trans women in the HIV prevention continuum. We propose to test `Guerreiras' (`warrior women', as named by trans women participants in Brazil), comprised of two intervention components designed to address intersectional stigma: 1) a group-level, peer-led intervention and 2) an individual-level peer navigation program to increase uptake of HIV testing and PrEP. Guerreiras is informed by a trans-specific conceptual model, gender affirmation theory, that describes intersectional stigma faced by trans women, informs investigations of how intersectional stigma results in health disparities, and provides a framework for intervention development and testing. We will recruit trans women (N=400) from clinical sites, outreach events, and an observational cohort in So Paulo, Brazil. Guerreiras will be evaluated using a randomized wait-list controlled trial to compare HIV testing uptake (self-testing and clinic-based) (Aim 1), PrEP initiation and persistence (Aim 2), and other prevention services (e.g. harm reduction) among trans women in the intervention arm compared to those in the control arm with data collection scheduled every three months. We will assess changes in intersectional stigma (Aim 3), including reductions in internalized stigma and increased resilience to anticipated and enacted stigma, among those assigned to intervention compared to those assigned to control, and assess how changes in stigma domains result in prevention uptake. Outcomes will be monitored through the national medications dispensing system (PrEP initiation and persistence), clinical records and self-report (HIV testing), and through comprehensive surveys (intersectional stigma). The proposed research leverages a productive multi-disciplinary HIV research partnership with extensive experience working with trans women in Brazil, multi-level intervention components, and a context where PrEP and HIVST are available publicly, providing an opportunity to evaluate and scale-up an HIV prevention initiative in a key health disparity population, while contributing to nascent research in intersectional stigma.
The proposed trial is grounded in a novel transgender-specific conceptual framework and is the culmination of decades of research in a population at high risk for HIV acquisition. Together, our investigative team has developed and piloted multiple, complementary intervention components to address intersectional stigma and increase engagement in the HIV prevention continuum among trans women in So Paulo, Brazil. The proposed intervention approach has the potential to optimize health outcomes in a population where intersectional stigma results in extreme health disparities and few proven effective interventions exist to date.
