Reducing intersectional stigma among transgender women in Brazil to promote uptake of HIV testing and PrEP: study protocol for a randomised controlled trial of Manas por Manas

Background and rationale

Transgender (‘trans’) women in Brazil experience multiple stigmas that complicate their access to and adherence to healthcare, resulting in intersectional stigma and negative health outcomes. Stigma is a social process enacted through social structures and interpersonal interactions that devalues human difference, marginalises stigmatised individuals and creates a social hierarchy that reinforces social inequality.1 Stigma is a fundamental cause of health disparities.2 Intersectionality is a theoretical approach that highlights how multiple types of oppression intersect to create and reinforce social inequalities.3 Thus, intersectional stigma is defined here as the confluence of multiple stigmatised identities, social positions and stigma-related barriers that result in structural inequalities and health disparities.
3 Due to gender-based stigma, trans women face extreme social and economic marginalisation that lead to additional stigmas based on social positions, such as engagement in sex work and substance use,4 5 which also intersect with race-based stigma. Further, these identity-based and social position-based stigmas intersect with stigma-related barriers such as pre-exposure prophylaxis (PrEP) stigma6 and HIV stigma7 to drive low rates of HIV testing, PrEP uptake and PrEP persistence among trans women. Experiences of enacted stigma (experiences of being stigmatised and/or discriminated against) often lead trans women to anticipate stigma (expectations of experiencing stigma) from healthcare providers, which in turn leads to healthcare avoidance and the internalisation of stigma8 (adopting stigmatising attitudes toward oneself; see figure 1 for conceptual framework). Stigma resilience is the ability to cope with and/or challenge enacted stigma, seek healthcare despite anticipated stigma and resist internalisation of stigmatising beliefs,9–11 which includes being empowered in one’s healthcare12 despite the context of stigma.

Figure 1

Conceptual framework for intersectional stigma reduction intervention

Largely driven by stigma, trans women have some of the highest rates of HIV in the world and are at the highest risk of HIV in Brazil. A recent meta-analysis of pooled data among trans women from 10 low-income countries found 50 times increased odds of HIV compared with other adults and an HIV prevalence of 18%.13 In South America, HIV prevalence estimates as high as 30% have been documented in population-based studies among trans women.14 In Rio de Janeiro, 31% of trans women recruited through respondent-driven sampling were living with HIV, 7% were new diagnoses; almost one-third (29%) of their participants had not been previously tested.15 Additional data corroborate that trans women are the ‘most at-risk’ group in Brazil,16 with estimated odds of HIV diagnosis among trans women over 55 times higher than the general Brazilian population,17 placing Brazil among countries with the greatest HIV disparities.13

Despite high rates of HIV, HIV testing and uptake of PrEP among trans women are significantly lower than other groups. Trans women report activities that increase risk of HIV exposure, including condomless anal sex with multiple partners,18 19 high number of sex partners,20 sex while using drugs and alcohol,21 and sex work,22 23 yet they frequently underestimate their risk of acquiring HIV18 and have low rates of HIV testing.24 Oral PrEP has been shown to reduce risk of acquiring HIV by 92% among adherent users.25 However, one study of PrEP uptake and adherence among trans women found that although they had high uptake (48%) and retention (85.4%) in the study, adherence was relatively low—only 48.6% had high PrEP adherence.26 In Brazil, awareness of PrEP is low among trans women despite its free availability through the Brazilian universal health system or Sistema Único de Saúde (SUS).27 One study in Rio de Janeiro found that among 345 participants offered HIV testing, 204 (59.1%) were not living with HIV, 101 (29.3%) had previously been diagnosed with HIV and 40 (11.6%) were newly diagnosed with HIV. Of those who were not living with HIV, 131 (38.0%) had heard of PrEP at the time of the survey, 76% were willing to use PrEP once they were aware of it and 67% met PrEP behavioural eligibility criteria.28 Despite eligibility and willingness to use PrEP, as of August 2018, only 74 Brazilian trans women had initiated PrEP through SUS nationally.29 The São Paulo state PrEP monitoring report notes a need for new strategies to promote PrEP uptake among trans people.30

Multilevel interventions that address intersectional stigma to increase uptake of HIV testing and PrEP are urgently needed to improve health outcomes among trans women in Brazil. Working at both the group and individual levels, we have developed Manas por Manas, a trans-specific, gender-affirming group empowerment and peer navigation intervention to address intersectional stigma, thereby improving the HIV prevention continuum, namely HIV testing and PrEP uptake, among trans women in Brazil. While structural interventions are crucial for long-term social change, it is also critical to increase stigma resilience among trans women through support and empowerment that are urgently necessary to navigate existing systems that cannot be immediately reformed and where stigma is pervasively enacted against transgender people31 32 and continues to fuel HIV transmission.33 To have an immediate impact on the lives of trans women, we must work to increase stigma resilience to support trans women in navigating current systems of care.1 34

This study is a randomised wait-list controlled trial testing Manas por Manas, designed to address intersectional stigma among transgender women in São Paulo, Brazil. Manas por Manas is comprised of two intervention components: (1) a group-level, peer-led intervention and (2) an individual-level peer navigation programme to increase uptake of HIV testing and PrEP. Manas por Manas is informed by our team’s trans-specific conceptual model, Gender Affirmation,35 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.

Objectives

This randomised controlled trial had the following aims:

Aim 1, HIV testing: to determine whether uptake of regular HIV testing, including both self-testing and clinic-based testing, is higher among trans women randomised to an intersectional stigma intervention compared with those assigned to the control condition. Aim 1a (exploratory): to explore persistence of gains in regular HIV testing among intervention arm participants following the conclusion of their participation in the intervention.

Aim 2, HIV prevention: to determine whether PrEP initiation and persistence are higher among trans women randomised to an intersectional stigma intervention compared with those assigned to the control condition. Secondary prevention outcomes include PrEP adherence, condom use, and utilisation of sexual health and harm reduction. Aim 2a (exploratory): to explore persistence of prevention gains post-intervention.

Aim 3, mechanisms: to explore changes in intersectional stigma, including reductions in internalised stigma and increased resilience to anticipated and enacted stigma, among those assigned to intervention compared with those assigned to the control arm, and assess how changes in stigma result in prevention uptake.