Claudia Kazmirak

Nominated From: University of Washington

Research Site: IMPACTA

Research Area: HIV Transmission among Partners of Transgender Women (PTW)

Primary Mentors: Dr. Ann Duerr and Dr. Alexander Lankowski

Research Project

Development of a Discrete Choice Experiment (DCE) to assess access to and formats of care delivery among Partners of Transgender Women (PTW) who are living with, or at risk for, HIV infection in Lima, Peru

This project will aim to address the disproportionately high levels of HIV among partners of transgender women (PTW), in Lima, Peru. The ultimate driver of HIV transmission among these populations is condomless anal intercourse (CAI). Behaviors such as sexual concurrency (overlapping sexual partnerships where sexual intercourse with one partner occurs between two acts of intercourse with another partner), drug or alcohol use/dependence, sex work, housing insecurity, and reluctance to seek testing or healthcare services for HIV/STIs are known to increase risk for HIV. These behaviors are influenced by psychosocial determinants of disease burden, notably interpersonal stigma and self-perceived risk. Exploring factors that increase vulnerability for acquiring HIV is imperative to gaining a more holistic understanding of the persistently elevated HIV burden among these populations and developing sustainable interventions. Efforts must be made to elucidate the barriers to care for PTW and factors that may increase their willingness to participate in HIV prevention programs. A recent qualitative study found that cisgender men in partnerships with transgender women did not want to be linked to or engage in HIV prevention programs that were designed for sexual and gender minority communities. The low HIV testing uptake among MSM and TW may stem from stigmatizing attitudes towards people living with HIV, which may generate fear of HIV stigma and being labeled as HIV positive, thereby preventing people from seeking out their HIV status. Systematic discrimination and stigma within the healthcare setting can also deter marginalized communities from visiting healthcare providers and getting tested. Understanding the barriers to care within this community is important in developing HIV prevention strategies that will successfully reach them. Intersectional approaches to guide health promotion efforts are needed to understand the needs of the target populations and the unique drivers of HIV risk among them, and to mitigate the effects of interpersonal stigma that prevents them from engaging in health-seeking behaviors. For this study, we are building upon information gathered in a study our team conducted last year, which aimed to understand the social determinants of health among TW and PTW, particularly how stigma and self-perceived risk of HIV impact likelihood of engaging in behaviors that increase HIV risk among transgender women and their sexual partners, and to explore relationships of transgender women and their partners with the healthcare system, their understanding of HIV, and identify factors that may promote development of targeted sexual health education and tailored resources for testing, treatment and other support services. The data collected in this study was designed to inform the development of a future Discrete Choice Experiment (DCE) which will gather data on access to care and desired formats of care delivery among men who have sex with transgender women who are living with, or at risk for, HIV infection. DCEs are a qualitative method for gathering preference data, by asking individuals to choose between or among hypothetical scenarios. DCEs are based on the following assumptions: that goods or services can be described by their characteristics; that the extent to which any individual values the good or service depends on the nature and level of these characteristics; and that individuals will choose between alternative goods or services by weighing the characteristics and opting for the good/service with the highest utility – that is, the highest benefit to that individual. We will conduct a DCE to elicit preferences for HIV testing and treatment services for men who have sex with TW in order to inform the development of an HIV testing/treatment program in Lima. DCEs are typically presented as a series of choice tasks consisting of sets of hypothetical scenarios describing the good or service under study. Respondents are asked to choose between the scenarios and indicate their preferred scenario out of each set. These sets are called choice sets. Each scenario is described by a set of attributes, or characteristics, with each attribute having multiple potential levels. For example, in a comparison between two different scenarios describing an HIV testing/treatment program, one attribute may be “cost,” with levels for 0 soles (the national currency in Peru), 10 soles, and 20 soles. We have already begun the groundwork of selecting attributes that may be meaningful to our target population. In designing our current data collection, which was planned to support a future DCE, we considered several published DCEs that were related to our area of interest (Montgomery et al, 2021; Dommaraju et al, 2021). We have selected several attributes, such as location, convenience, confidentiality/privacy, and cost, and included them in the survey we are conducting currently. We have included several levels for each attribute and are gauging the relative importance of each level and attribute to the participants of our current study. The findings from this survey will inform the development of our DCE by giving us an idea of the importance of each attribute, and an appropriate range of levels. In addition, we will use data from the one-on-one interviews we are conducting with a subset of survey participants to inform us of any other attributes or levels that may be significant. DCEs are usually presented to participants as surveys that cycle through several different choice sets. Respondents indicate their preferred scenario out of each choice set, requiring them to weigh trade-offs between attributes. In our DCE, we plan to use illustrations for each attribute and level to help participants understand the characteristics of each scenario. Once the DCE has been designed, we will use cognitive interviews to pilot test it with 10 participants to ensure that it is understandable to the study population, and to solicit any attributes or levels we may have missed. All aspects of the proposed research will be developed in close collaboration with our Peruvian co-investigator, Hugo Sanchez, who has substantial experience interacting with the populations involved in this study and has worked with us this past year on our survey and qualitative interview data collection. Mr. Sanchez will coordinate and carry out the recruitment of participants for the DCE. Recruitment will be conducted in a similar manner to our current study, with Mr. Sanchez traveling to “casas travesti,” local safehouses for TW in Lima, where he will recruit PTW indirectly from TW. Given the stigma associated with partnership with transgender women, PTW are considered to be a “hidden” population and thus very difficult to recruit directly. TW participants who agree to recruit partners will be asked to recruit a maximum of 5 partners with whom they have had sexual contact in the last 6 months. TW will be asked to include a variety of partner types, including client/transactional partners, casual partners, and stable partners, in the recruitment. TW will be compensated for every partner they successfully recruit, up to a total of five partners. Each TW “seed” participant will be given a list of five unique online DCE links set to expire after a single use. The TW participants will be instructed to distribute these links to five different partners. PTW who successfully complete the DCE will be compensated for their participation in the study.

Research Significance

This research is important because current HIV prevention activities may not be reaching PTW, resulting in less frequent HIV testing, condom use, and treatment among those already infected. Evidence from recent studies suggests that PTW may be difficult to reach through traditional community-targeted HIV-prevention approaches. In Peru, outreach and prevention is largely targeted to gay communities, and therefore may underserve TW and their partners, who identify primarily as hetero- or bisexual. These findings are not exclusive to Peru; a recent meta-analysis in the United States found that none of the studies included assessed HIV services utilization among PTW. Understanding the psychosocial determinants of health and barriers to accessing healthcare services is integral to developing HIV prevention strategies that reach these populations. Research is warranted to better understand whether and how TW and PTW appraise HIV risk and define sexual health goals to prevent HIV acquisition or transmission in their relationships. A cross-sectional study in Thailand found that future HIV prevention strategies need to fill the gap between self-perceived risk and actual risk in order to help HIV-vulnerable populations understand their risk better and proactively seek HIV prevention services. Furthermore, understanding access to care and desired formats of care delivery among PTW who are at risk for or have acquired HIV infection is imperative for the development of sustainable, effective interventions among this population. 


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