Sweekar - multi-level intersectional stigma reduction to increase HIV testing and care engagement among trans women in nepal - trans women in low- and middle- income countries make up the largest…

Sweekar - multi-level intersectional stigma reduction to increase HIV testing and care engagement among trans women in nepal - trans women in low- and middle- income countries make up the largest proportion of trans women around the globe but are underserved in the response to HIV. Nepal is a lower income country in south asia where trans women are a key population highly impacted by HIV. In 2019/20, we conducted an exploratory study with trans women finding that 11.3% were living with HIV, and only 70% were engaged in HIV care and virally suppressed. Discrimination resulting in anticipated HIV stigma and experienced anti-trans stigma was a main driver of low HIV testing and HIV care engagement. HIV risk was further exacerbated by anti-trans stigma resulting in barriers to education, employment, social support and empowerment. For example, because most trans women faced discrimination in job seeking, the majority of participants in our exploratory work did SEX work for income and had high rates of condomless SEX and many sexual partners. HIV interventions for trans women are needed that will have sustained impact by addressing stigma at many levels that present barriers to health and wellness. However, few HIV prevention and treatment interventions tackle intersectional stigma, and even fewer are developed for low- and middle-income country settings. Building on evidence from our exploratory study, we propose to test a multi-level, HIV serostatus-neutral stigma reduction intervention called sweekar, or acceptance in nepali. The primary intervention outcomes are HIV testing and HIV care engagement. To increase HIV testing by addressing anticipated stigma, the individual level intervention component is a tailored HIV self-testing intervention. To increase art adherence by addressing anticipated and experiences stigma, the systems level intervention component is HIV treatment home delivery. To address stigma at the community level, we will conduct a contact INTERVENTION11 informed by PHOTOVOICE12 to reduce experienced and internalized stigma. Photovoice will be used to inform content and delivery of a social media campaign to reduce anti-trans in nepali society, with benefits for increasing social support and empowerment among trans women in nepal, which will help mitigate internalized stigma. Our approach is community-driven and non-randomized to maximize benefit for trans women in immediate need of intervention, which is an essential practice to reduce health disparities. Feasibility is high as the US and nepali researchers have forged a strong collaboration over the course of more than a decade working together to serve trans women in research and services. Furthermore, covid-19 has created new opportunities for innovations HIV care and prevention that will be leveraged in sweekar. If sweekar is successful, we will immediately use the outcome data and lessons learned to develop multi-site R01 proposal to test the intervention at scale throughout nepal and in partnership with our nepali research and implementation team.