Ssimusango: Multi-level intervention for intersectional stigma reduction to improve HIV outcomes for transgender women

西穆桑戈：多层次干预减少交叉耻辱，以改善跨性别女性的艾滋病毒结果

• 批准号: 10755926
• 负责人: Andrew Mujugira
• 金额: $ 18.62万
• 依托单位: INFECTIOUS DISEASES INSTITUTE
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-07-15 至 2026-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10755926
• 关键词: AIDS prevention; Address; Adherence; Adoption; Adult; Africa South of the Sahara; African; Caring; Catchment Area; Clinic; Clinical; Clinical Trials; Communities; Consolidated Framework for Implementation Research; Consultations; Data; Disclosure; Discrimination; Education; Effectiveness; Empathy; Enrollment; Equity; Evaluation; Face; Feedback; Focus Groups; Fright; Gender Identity; General Population; HIV; HIV Infections; Health Personnel; Health Policy; Health Services; Health Status; Health care facility; Healthcare; High Risk Woman; Human immunodeficiency virus test; Hybrids; Incidence; Individual; Institution; Intervention; Interview; Manuals; Measures; Modeling; Outcome; Population; Prevalence; Prevention; Qualitative Methods; RNA; Randomized; Research; Risk; Sampling; Services; Sex Orientation; Stigmatization; Surveys; Tenofovir; Testing; Training; Uganda; Urine; Viral; Waiting Lists; Well in self; Woman; Work; acceptability and feasibility; aged; antiretroviral therapy; effectiveness evaluation; effectiveness/implementation trial; empowerment; evidence base; experience; gender minority; health assessment; health care settings; health training; implementation evaluation; implementation intervention; implementation outcomes; improved; informant; internalized stigma; intersectionality; intervention delivery; marginalized population; men; men who have sex with men; multidisciplinary; peer; perceived discrimination; pilot test; post intervention; pre-exposure prophylaxis; prevention service; primary outcome; programs; residence; response; scale up; secondary outcome; sex; social stigma; standard of care; synergism; therapy adherence; therapy design; transgender; transgender women; treatment services; uptake

PROJECT SUMMARY/ABSTRACT Transgender women (TGW) are at high risk for HIV infection, and are an important, under-researched key population in sub-Saharan Africa. Globally, HIV acquisition risk among TGW is 14 times higher than other adults aged 15-49 years. Intersectional stigma and discrimination (ISD) experienced by TGW at the intersections of HIV, sexual orientation, gender minority identity and sex work results in poor engagement in care and suboptimal adherence to HIV pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART). Much work remains in addressing HIV-related ISD and scaling up treatment and prevention coverage for TGW. Two evidence-based ISD-reduction interventions are available -- (1) Health Policy Plus (HP+) Total Facility Approach (TFA) to Stigma Reduction (a clinic-level intervention) and (2) HIV Education, Empathy and Empowerment (HIVE3) (an individual- level intervention) -- but these have not been adapted and implemented for TGW in sub-Saharan Africa. HP+ and HIVE3 are complementary interventions that could be combined to reduce health facility- and individual-level stigma. However, research is needed to show if the adapted multi-level HP+/HIVE3 intervention, Ssimusango (means “no self-blame or blaming others” in Luganda), decreases HIV-related stigma and improves HIV outcomes for TGW. To address these questions, we will conduct a randomized wait-list controlled trial to test the preliminary effectiveness of Ssimusango on PrEP adherence and viral suppression, compared with standard of care, using a status-neutral approach i.e., engagement in care regardless of HIV status. We will also use qualitative methods to assess mechanisms and synergies of intervention delivery. Leveraging the multi- disciplinary expertise of our multi-national research team, and working at four health facilities in Kampala ranked lowest on the PEPFAR Uganda stigma scorecard, we propose the following specific aims: (1) adapt the HP+ and HIVE3 stigma-reduction interventions to address ISD for TGW in Uganda (intervention adaptation); (2) conduct a hybrid type 1 effectiveness-implementation trial with 120 TGW to pilot test the preliminary effectiveness of Ssimusango on (a) PrEP adherence and (b) viral suppression (intervention implementation); and (3) evaluate Ssimusango using qualitative methods and the Intersectionality-Enhanced Consolidated Framework for Implementation Research (intervention evaluation). Clinic-level implementation outcomes are adoption, fidelity, and sustainability assessed using key informant interviews, training attendance sheets, observation checklists, and rapid feedback surveys. Individual-level outcomes: (1) PrEP adherence at 3 and 6 months post-intervention, measured by urine tenofovir levels (primary outcome) and (2) viral suppression (HIV RNA <50 copies/mL) and (3) ISD reduction 6 months post-intervention (secondary outcomes). This multi-level approach to implementing ISD interventions will improve PrEP and ART adherence outcomes among TGW - “the most vulnerable of the vulnerable” -, build stigma research capacity in Uganda, and generate actionable data for scale-up and program implementation in Uganda and sub-Saharan Africa.

项目概要/摘要 跨性别女性 (TGW) 感染艾滋病毒的风险很高，是一个重要的、尚未得到充分研究的关键人群 在全球范围内，撒哈拉以南非洲地区的 TGW 感染艾滋病毒的风险比其他成年人高 14 倍。 TGW 在 15-49 岁的交叉点经历过交叉耻辱和歧视 (ISD)。 艾滋病毒、性取向、性别少数群体身份和性工作导致护理参与度低且不理想 坚持艾滋病毒暴露前预防 (PrEP) 和抗逆转录病毒治疗 (ART) 仍有许多工作要做。 解决与艾滋病毒相关的 ISD 问题并扩大 TGW 的治疗和预防覆盖范围 两项基于证据的研究。 可以采取减少 ISD 的干预措施 -- (1) 针对耻辱的健康政策加 (HP+) 总体设施方法 (TFA) 减少（临床层面的干预）和（2）艾滋病毒教育、同理心和赋权（HIVE3）（个人- 级干预）——但这些尚未在撒哈拉以南非洲 HP+ 的 TGW 中进行调整和实施。 和 HIVE3 是补充干预措施，可以结合起来减少卫生机构和个人层面的 然而，需要研究来证明多层次 HP+/HIVE3 干预措施 Ssimusango 是否有效。 （卢干达语的意思是“不自责或责怪他人”），减少与艾滋病毒相关的耻辱并改善艾滋病毒 为了解决这些问题，我们将进行一项随机等待名单对照试验来测试 TGW 的结果。 与标准相比，Ssimusango 对 PrEP 依从性和病毒抑制的初步效果 我们还将采用状态中立的方法，即无论艾滋病毒感染状况如何，都参与护理。 利用多方评估干预措施的机制和协同作用的定性方法。 我们的跨国研究团队的学科专业知识，以及在坎帕拉的四个卫生机构的工作排名 在 PEPFAR 乌干达污名记分卡上最低，我们提出以下具体目标： (1) 调整 HP+ 减少 HIVE3 耻辱感的干预措施，以解决乌干达 TGW 的 ISD问题（干预措施调整）（2）； 与 120 个 TGW 进行混合类型 1 有效性实施试验，以试点测试初步效果 Ssimusango 对 (a) PrEP 依从性和 (b) 病毒抑制（干预实施）的有效性； (3) 使用定性方法和交叉性增强综合评估 Ssimusango 实施研究框架（干预评估）。 通过关键知情人访谈、培训出勤表、 观察清单和快速反馈调查：(1) 3 岁和 6 岁的 PrEP 依从性。 干预后几个月，通过尿液替诺福韦水平（主要结果）和（2）病毒抑制（HIV RNA <50 拷贝/mL）和 (3) 干预后 6 个月 ISD 减少（次要结果）。 实施 ISD 干预措施的方法将改善 TGW 中的 PrEP 和 ART 依从性结果 - “弱势群体中的最弱势群体”——在乌干达建立耻辱研究能力，并产生可采取行动的 乌干达和撒哈拉以南非洲地区扩大规模和计划实施的数据。