Transgender women (TGW), particularly young TGW (ages 18-29), are among the fastest growing HIV+ populations worldwide, with HIV prevalence rates of 15-28%. Thailand has the highest adult HIV seroprevalence in Asia, with high rates of HIV infection among TGW (18%). Pre-exposure prophylaxis (PrEP) is an efficacious HIV prevention strategy recommended for all persons at substantial risk for HIV. PrEP is highly effective when taken as prescribed, but uptake and adherence have been low, particularly among TGW. Key barriers include stigma related to gender identity, limited employment, and high-risk behaviors (e.g., sex work, substance use). TGW experience intersectional stigma that may have a synergistic influence on engagement in HIV prevention, including PrEP use and HIV testing. To address these challenges, we propose to develop and pilot a mHealth intervention to overcome stigma and promote use of PrEP. We will adapt the 4-session, Healthy Choices (HC) intervention for mHealth (mHC) to increase access and delivery of HC in our target population. We will also culturally translate select modules of the FRESH intervention into a client focused, digitized abbreviate package to address HIV, trans-, and intersectional stigmas that harm TGW, drawing on our successful protocols tested in prior projects. Intervention development will be guided by ADAPT-ITT and informed by two conceptual models. These intervention components will be integrated to enhance the impact of mHC through FRESH content and will be delivered via an innovative intervention platform. Our primary aim is to develop mHC and FRESH content and assess their preliminary efficacy. We will use a Multiphase Optimization Strategy (MOST) to identify the most effective intervention component or combination of components to address intersectional stigma and PrEP use in this population. The proposed study will have 3 phases. Phase I includes focus groups with Thai young TGW and healthcare providers to explore intersectional stigma, and barriers and facilitators of the use of HIV prevention services through thematic analysis to inform intervention adaptation. Phase II consists of adapting and beta testing mHC and FRESH content, leveraging a community advisory board. In Phase III, we will conduct a MOST design-based trial to assess feasibility, acceptability, and preliminary efficacy of intervention components (mHC and FEESH content). One hundred and eight TGW will be randomized to one of four experimental conditions: (1) Standard PrEP Counseling (SPC, control), (2) mHC + SPC, (3) FRESH content + SPC, and (4) mHC + FRESH content + SPC. Feasibility and acceptability of the intervention will be assessed through intervention engagement data and the System Usability Scale. Preliminary outcomes will be assessed by evaluating stigma reduction, PrEP use, and HIV testing. TGW will complete assessments at baseline and at 3- and 6-months post-intervention. Upon R34 completion, we will have a highly innovative mHealth intervention designed specifically to address HIV and related stigmas to promote PrEP use in Thai TGW which will be ready for efficacy trial testing.

Young transgender women (TGW) in Thailand face widespread stigma and discrimination. This discrimination may result from multiple marginalized identities including gender and sexual identity and perception of HIV status. “Intersectional stigma” may be one key barrier to HIV prevention and care (PrEP use, HIV testing). This project will develop and test a technology-delivered program designed to reduce HIV-related stigma and improve the use of HIV prevention services . If successful, the program could help young TGW in Thailand to live healthier lives and reduce risk for HIV.