The "Cycle" of HIV: Limits of Personal Responsibility in HIV Vulnerability Among Transgender Adolescents and Young Women in Lima, Peru.

Globally, transgender women (TW) face a high burden of the HIV epidemic. In Peru, HIV prevalence among TW rises at age 25, indicating a need to understand HIV vulnerability as adolescents reach adulthood. The life course of TW is often marked by abuse, discrimination and poverty fueled by transphobic stigma. Approaches to the HIV epidemic among TW and adolescents emphasize problem behaviors such as unprotected sex and substance. However, there has been a call for HIV research and interventions to understand and leverage community strengths. This qualitative study utilized a transgender-oriented, strength-based, intersectional and feminist approach to understand the strengths and protective health behaviors among 17 transgender adolescents and young women (TAYW) age 16-24 in Lima, Peru. Most participants re-located to Lima from the Amazon due to familial rejection, and engaged in obligatory sex work. TAYW demonstrated self-knowledge, motivation for education, efforts to secure employment, strong community networks, legal advocacy, avoiding problem substance use, HIV knowledge and condom use. However, strengths were impeded by multi-level barriers such as familial physical abuse, educational discrimination, and sexual assault which led to increased HIV vulnerability. We created a conceptual model of the "cycle" of HIV to describe the limits of personal responsibility within a vulnerable community denied access to family, education, employment and human rights. We recommend researchers, clinicians and public health workers follow the lead of TAYW at the frontlines of the HIV epidemic, and support beloved communities and enabling environments which may permit protective behaviors to mitigate HIV vulnerability.

RESUMEN: A nivel mundial, las mujeres transgénero (MT) enfrentan una alta carga de la epidemia del VIH. En Perú, la prevalencia del VIH entre las MT aumenta a los 25 años, lo que indica la necesidad de comprender la vulnerabilidad al VIH a medida que las adolescentes llegan a la edad adulta. El curso de vida de las MT suele estar marcado por el abuso, la discriminación y la pobreza por culpa del estigma transfóbico. Los enfoques sobre la epidemia del VIH entre las MT y los adolescentes enfatizan conductas problemáticas como el sexo sin protección o el uso de sustancias. Sin embargo, existe un llamado a realizar investigaciones e intervenciones sobre el VIH para comprender y aprovechar las fortalezas de la comunidad. Este estudio cualitativo utilizó un enfoque feminista, interseccional, basado en fortalezas y orientado a las personas transgénero para comprender las fortalezas y los comportamientos protectores de la salud entre 17 adolescentes y mujeres jóvenes transgénero de 16 a 24 años en Lima, Perú. La mayoría de las participantes migraron a Lima desde la Amazonía debido al rechazo familiar y se dedicaron al trabajo sexual obligatorio. Las adolescentes y mujeres jóvenes transgénero demostraron autoconocimiento, motivación para la educación, esfuerzos para conseguir empleo, redes comunitarias sólidas, defensa legal, evitar el uso problemático de sustancias, conocimiento sobre el VIH y uso de condones. Sin embargo, las fortalezas se vieron obstaculizadas por barreras de múltiples niveles, como el abuso físico familiar, la discriminación educativa y la agresión sexual, que llevaron a una mayor vulnerabilidad al VIH. Desarrollamos un modelo conceptual del "ciclo" del VIH para describir los límites de la responsabilidad personal dentro de una comunidad vulnerable a la que se le niega el acceso a la familia, la educación, el empleo y los derechos humanos. Recomendamos que los investigadores, médicos y trabajadores de la salud pública sigan el ejemplo de adolescentes y mujeres jóvenes transgénero en la primera línea de la epidemia del VIH y apoyen a comunidades queridas y entornos propicios que puedan permitir conductas protectoras para mitigar la vulnerabilidad al VIH.

Intersectional stigma and the arc of intranational migration: experiences of transgender adolescents and women who migrate within Peru.

BACKGROUND: Migration is recognized as a key determinant of health. Yet, limited research addresses the arc of intranational migration and, even less, the experiences of transgender (trans) adolescents and women migrants and the associated health vulnerabilities. Using intersectional stigma as a theoretical frame, this study seeks to better understand the sexual health vulnerabilities and needs of trans women migrants in Peru. METHODS: Between October and November 2016, in-depth interviews (n = 14) and two focus groups (n = 20) were conducted in Spanish with trans women in three Peruvian cities. To explore pre- and during migration experiences, focus groups were conducted in Pucallpa and Iquitos, key cities in the Amazon where trajectories often originate. To assess during migration and post-migration experiences, we conducted interviews in Pucallpa, Iquitos, and Lima to better understand processes of relocation. Audio files were transcribed verbatim and analysed via an immersion crystallization approach, an inductive and iterative process, using Dedoose (v.6.1.18). RESULTS: Participants described migration as an arc and, thus, results are presented in three phases: pre-migration; during migration; and post-migration. Intersectional stigma was identified as a transversal theme throughout the three stages of migration. The pre-migration stage was characterized by poverty, transphobia, and violence frequently motivating the decision to migrate to a larger city. Exploitation was also described as pervasive during migration and in relocation. Many participants spoke of their introduction to sex work during migration, as key to economic earning and associated violence (police, clients). CONCLUSION: Findings advance understandings of intranational migration and forced displacement as key determinants of trans women's health. Dimensions of violence at the intersection of classism and cisgenderism render trans women highly vulnerable at every step of their migratory journeys. Experiences of intranational mobility and relocation were described as uniquely tied to age, intersectional transphobic stigma, engagement in sex work, and multiple forms of violence, which impact and can magnify sexual health vulnerabilities for transgender women in Peru who migrated intranationally.

Decision-Making at the Intersection of Risk and Pleasure: A Qualitative Inquiry with Trans Women Engaged in Sex Work in Lima, Peru.

To inform culturally relevant HIV prevention interventions, we explore the complexity of sex work among Peruvian transgender women. In 2015, we conducted twenty in-depth interviews and demographic surveys with transgender women in Lima, Peru to examine how transgender women enact individual- and community-level resistance strategies within a context of pervasive marginalization. Although 40% self-identified as "sex workers," 70% recently exchanged sex for money. Participants described nuanced risk-benefit analyses surrounding paid sexual encounters. Classification of clients as "risky" or "rewarding" incorporated issues of health, violence, and pleasure. Interviews highlighted context-informed decision-making (rejecting disrespectful clients, asserting condom use with specific partner types) demonstrating that motivations were not limited to HIV prevention or economic renumeration, but considered safety, health, attraction, gender validation, hygiene, and convenience. These findings underscore the complex risk assessments employed by Peruvian trans women. These individual-level decision-making and context-specific health promotion strategies represent critical frameworks for HIV prevention efforts.

TransPrEP: Results from the Pilot Study of a Social Network-Based Intervention to Support PrEP Adherence Among Transgender Women in Lima, Peru.

We conducted a pilot randomized controlled trial of a social network-based intervention to promote PrEP adherence among transgender women (TW) in Lima, Peru. We enrolled 89 TW from six social networks and cluster-randomized them 1:1 to standard of care (n = 44) or the TransPrEP intervention (n = 45). Core workshops discussed strategies to support PrEP adherence and defined group adherence objectives. Maintenance workshops discussed participants' experiences taking PrEP and collective adherence goals. At 3-month follow-up, we evaluated 40 participants and obtained 29 hair samples for tenofovir level measurements. Though no significant differences were observed, 36.4% (4/11) of participants of TransPrEP participants and 10.0% (1/10) of control participants had tenofovir levels > 0.023 ng/mg, consistent with ≥ 4 doses per week. 81.8% (9/11) of intervention and 40.0% (4/10) of control participants had any detectable tenofovir in their hair. Pilot assessment of our network-based intervention suggested a trend towards improved PrEP adherence, measured objectively, for TW in Peru.

RESUMEN: Realizamos un estudio piloto controlado y aleatorizado de una intervención basada en redes sociales para promover la adherencia al PrEP en mujeres transgénero (MT) de Lima, Perú. Enrolamos a 89 MT de 6 redes sociales y las aleatorizamos por grupos a razón 1:1 al estándar de atención como control (n = 44) o a la intervención TransPrEP (n = 45). En los talleres centrales se discutieron estrategias para respaldar la adherencia al PrEP y se definieron los objetivos de adherencia del grupo. En los talleres de mantenimiento se discutieron las experiencias de los participantes al tomar PrEP y los objetivos de adherencia colectiva. A los 3 meses de seguimiento, evaluamos a 40 participantes y obtuvimos 29 muestras de cabello para medir el nivel de tenofovir. Aunque no se observaron diferencias significativas, el 36.4% (4/11) de los participantes de TransPrEP y el 10.0% (1/10) de los participantes del grupo control tenían niveles de tenofovir> 0.023 ng/mg, congruente con 4 o más dosis por semana. El 81.8% (9/11) del grupo de intervención y el 40.0% (4/10) de los participantes de control tenían tenofovir detectable en el cabello. La evaluación piloto de nuestra intervención basada en redes sugiere una tendencia hacia una mejor adherencia al PrEP, medida objetivamente, para las MT en Perú.

Transcervical Foley Balloon Plus Vaginal Misoprostol versus Vaginal Misoprostol Alone for Cervical Ripening in Nulliparous Obese Women: A Multicenter, Randomized, Comparative-Effectiveness Trial.

OBJECTIVE: Nulliparous obese women are at increased risk of labor induction and cesarean delivery (CD). We sought to determine whether the combination of a transvaginal Foley balloon plus misoprostol prostaglandin E1 (PGE1) is superior to misoprostol alone in reducing the risk for CD. STUDY DESIGN: We undertook a multicenter, open-label, comparative-effectiveness randomized clinical trial of nulliparous obese women with unfavorable cervix (Bishop's score ≤ 6) undergoing labor induction from January 2016 to June 2018 at three tertiary centers. Those at <32 weeks' gestation, premature rupture of membranes, stillbirth, and major fetal anomalies were excluded. Women were randomized 1:1 to either a combination of Foley balloon and misoprostol or misoprostol alone. Once Bishop's score was >6, further management was deferred to treating physicians. Primary outcome was the rate of CD. Secondary maternal outcomes included duration of induction-to-delivery interval, occurrence of tachysystole, clinical chorioamnionitis, need for operative vaginal delivery, as well as a composite of maternal morbidity (postpartum endometritis, surgical-site infection, venous thromboembolism, need for transfusion, intensive care unit admission, and maternal death). Secondary neonatal outcomes included need for neonatal intensive care unit admission, transient tachypnea of the newborn, respiratory distress syndrome, meconium aspiration syndrome, culture-proven sepsis, neonatal seizures, and a composite of neonatal morbidity (Apgar's score ≤7 at 5 minutes, umbilical artery cord pH ≤7.10, birth injury, perinatal death). With the rate of CD rate being 53% at Children's Memorial Herman Hospital among nulliparous obese women who underwent induction of labor at ≥32 weeks and met our inclusion criteria; 250 women (125 women per group) were required to answer the study question. All analyses were by intention to treat. RESULTS: Of the 236 women randomized, 113 (48%) were allocated to group 1 (combined Foley and PGE1) and 123 (52%) to group 2 (PGE1 alone). The rate of CD was similar between the groups (45 vs. 43%, p = 0.84, relative risk [RR]: 1.03, 95% CI: 0.75-1.42). There was no difference in the occurrence of tachysystole that resulted in fetal heart rate abnormalities between the groups (8.8 vs. 16.2%, p = 0.09, RR: 0.54, 95% CI: 0.27-1.11). The total duration of the induction-to-delivery interval was also similar between the groups (24.8 ± 13.8 vs. 24.5 ± 14.0 hours, p = 0.87) regardless of the mode of delivery. No differences were seen in the indications for CD and secondary maternal or neonatal outcomes. CONCLUSION: In this trial of nulliparous obese women undergoing labor induction, cervical ripening with combined Foley balloon and PGE1 resulted in similar CD rates than ripening with vaginal PGE1 alone. KEY POINTS: · Nulliparous obese women are at increased risk for cesarean delivery.. · Combined intravaginal misoprostol-Foley balloon versus misoprostol alone resulted in similar rates of cesarean delivery.. · Further research is warranted to determine the optimal cervical ripening strategy in this population..

HIV Status Communication with Sex Partners and Associated Factors Among High-Risk MSM and Transgender Women in Lima, Peru.

Men who have sex with men (MSM) and transgender women (TW) are key populations in the HIV epidemic. HIV status communication between sex partners can inform decisions regarding sexual behavior. MSM and TW were asked about HIV status communication with sex partners at baseline, 9- and 18-months. GEE models assessed associations with HIV status communication at baseline using prevalence ratios (PRs) and longitudinally using odds ratios (ORs). At baseline, those who had previously had an HIV test, disclosed their HIV status to 42 % of their sex partners. HIV status communication was associated with knowing their sex partner's HIV status at baseline (aPR 5.20) and longitudinally (aOR 1.86). HIV positivity at baseline was negatively associated with HIV status communication during follow-up (aOR 0.55). All reported aPRs and aORs have p < 0.05. Interventions promoting HIV status communication and more frequent HIV testing should be explored as current efforts are insufficient.

"Manejar la Situacion": Partner Notification, Partner Management, and Conceptual Frameworks for HIV/STI Control Among MSM in Peru.

Previous analyses of partner notification (PN) have addressed individual, interpersonal, social, and structural issues influencing PN outcomes but have paid less attention to the conceptual framework of PN itself. We conducted 18 individual interviews and 8 group discussions, in a two-stage qualitative research process, to explore the meanings and contexts of PN for sexually transmitted infections (STI) among men who have sex with men (MSM) and men who have sex with men and women (MSMW) in Lima, Peru. Participants described PN as the open disclosure of private, potentially stigmatizing information that could strengthen or disrupt a partnership, structured by the tension between concealment and revelation. In addition to informing partners of an STI diagnosis, the act of PN was believed to reveal other potentially stigmatizing information related to sexual identity and practices such as homosexuality, promiscuity, and HIV co-infection. In this context, the potential development of visible, biological STI symptoms represented a risk for disruption of the boundary between secrecy and disclosure that could result in involuntary disclosure of STI status. To address the conflict between concealment and disclosure, participants cited efforts to "manejar la situacion" (manage the situation) by controlling the biological risks of STI exposure without openly disclosing STI status. We use this concept of "managing the situation" as a practical and theoretical framework for comprehensive Partner Management for HIV/STI control systems among MSM in Latin America.

Design and pilot evaluation of a brief intervention to reduce transphobia and improve attitudes of government officials to address legal gender affirmation needs of transgender people in Peru.

Legal gender affirmation - legal name and gender marker change - is an important health-promoting health determinant for transgender people. In Peru, the state's failure to universally recognize transgender people's legal identity limits standardized legal affirmation procedures, including the paucity of government officials trained in gender affirmation strategies. This project, in partnership with Registro Nacional de Identificación y Estado Civil (RENIEC) and transgender communities, designed and piloted a group-based intervention to sensitize government officers to the importance of gender-concordant identity documents. Between August 2017 and February 2018, three in-person group intervention sessions were held (each 3-4 hours) with 51 government officers. Guided by Gender Affirmation and Structural Violence Frameworks, the intervention utilized Adult Learning Theory and applied storytelling and testimonials as pedagogy. Pre-/post-test surveys were administered (19 true/false items, summed to create an index score measuring knowledge and attitudes toward transgender people). Within-person changes in pre-/post-intervention scores were evaluated using paired t-tests. Pre-/post-test data were available for 41 participants. After the intervention, there were improvements in knowledge and more favorable attitudes toward transgender people (pre-test mean = 14.09, SD = 2.33 vs. post-test mean = 15.62, SD = 1.82; difference = 1.53, 95% CL = 0.60, 2.67; t-test = 3.30 [df = 46]; p = 0.002). The intervention was feasible to conduct and garnered high acceptability. The results suggest the promise of this brief intervention for future research and testing before potential later implementation and scale-up to increase the capacity of government officers to address legal gender affirmation for transgender people in Peru.

Main findings: A brief group-based theoretically informed intervention designed and piloted by a multidisciplinary cross-sector team in partnership with transgender communities was feasible to conduct, garnered high levels of acceptability, and significantly increased knowledge and favorable attitudes toward transgender people for government officers responsible for identity documents in Peru.Added knowledge: Legal gender affirmation is an important determinant of mental health and wellbeing for transgender people; this evidence-based intervention increased the capacity of government officers to meet health-harming legal gender affirmation needs, specifically legal name and gender marker change, addressing a structural barrier to legal gender affirmation for transgender people in Peru.Global health impact for policy and action: Findings underscore the promise of this intervention for future research and testing before potential later implementation and scale-up in Peru, and for adaptation in other countries and contexts to address the training and capacity of government officials to effectively process and implement legal gender affirmation, a structural barrier to legal gender affirmation for transgender people.

Moderno love: sexual role-based identities and HIV/STI prevention among men who have sex with men in Lima, Peru.

Role-based sexual identities structure male same-sex partnerships and influence HIV/STI epidemiology among MSM in Latin America. We explored shifting relationships between sexual roles, identities and practices among MSM in Lima, Peru, and implications for HIV/STI prevention. Patterns of HIV/STI epidemiology reflected differential risks for transmission within role-based partnerships with relatively low prevalences of HIV, syphilis, and HSV-2 but higher prevalences of urethral gonorrhea/chlamydia among activo MSM compared with moderno and pasivo participants. Qualitative analysis of how MSM in Peru integrate sexual identities, roles, and practices identified four key themes: pasivo role as a gay approximation of cultural femininity; activo role as a heterosexual consolidation of masculinity; moderno role as a masculine reconceptualization of gay identity; and role-based identities as social determinants of partnership, network, and community formation. The concept of role-based sexual identities provides a framework for HIV prevention for Latin American MSM that integrates sexual identities, practices, partnerships, and networks.

Frequency, patterns, and preferences of lubricant use during anal intercourse within male sexual partnerships in Lima, Peru: implications for a rectal microbicide HIV prevention intervention.

Understanding current practices of lubricant use during anal intercourse can help to assess the contexts for the introduction of topical rectal microbicides as an HIV prevention tool for men who have sex with men (MSM). We used quantitative and qualitative methods to assess: current patterns of lubricant use; preferred characteristics of commercial lubricant formulations; and social and behavioral contexts of lubricant use within male sexual partnerships in Lima, Peru. Between 2007 and 2008, we conducted a quantitative behavioral survey with 547 MSM followed by qualitative individual and group interviews with 36 MSM from Lima, Peru. Approximately half of all participants in the quantitative survey (50.3%) reported using commercial lubricant during intercourse occasionally or consistently during the preceding two months, with lack of availability at the time of intercourse the most commonly reported reason for non-use. No clear preferences regarding the color, smell, taste, or viscosity of commercial lubricants were identified, and all participants who reported using a commercial lubricant used the same product ("Love-Lub"). In the qualitative analysis, participants characterized lubricant use as a sexual practice consistently controlled by the receptive partner, who typically obtained and applied lubricant independently, with or without the consent of the insertive partner. Quantitative findings supported this differential pattern of lubricant use, with men who reported sexual identities or roles consistent with receptive anal intercourse, including unprotected receptive intercourse, more likely to report lubricant use than MSM who claimed an exclusively insertive sexual role. Given the social, behavioral, and biological factors contributing to increased vulnerability for HIV and STI acquisition by the receptive partner in anal intercourse, delivery of a topical rectal microbicide as a lubricant formulation could provide an important HIV prevention resource for at-risk MSM in Lima, Peru.

Quality of life, self-reported outcomes and impact of education among people with moderate and severe hemophilia A: An integrated perspective from a Latin American country.

Collecting and interpreting self-reported outcomes among people with hemophilia A supports the understanding of the burden of the disease and its treatment to improve holistic care. However, in Colombia, this information is limited. Therefore, this study aimed to describe the knowledge, perception and burden of hemophilia A from the patients' perspective. A cross-sectional study was conducted in the context of a hemophilia educational bootcamp held from November 29th to December 1st, 2019, in Medellin, Colombia. The bootcamp was organized by a hemophilia patient association responsible for contacting and inviting patients with hemophilia A (PwHA). Information on patients' health beliefs, treatment experiences, and health-related quality of life (HRQoL) was obtained through focus groups, individual interviews and the Patient Reported Outcomes, Burdens and Experiences (PROBE) questionnaire. A total of 25 moderate or severe PwHA were enrolled in this study and completed the PROBE questionnaire. Acute pain was the most frequently reported symptom, with 88% of the patients reporting the use of pain medication. Difficulty with activities of daily living was reported by 48%. Furthermore, 52% reported having more than 2 spontaneous bleeding events in the last year. Treatment was administered at home for 72% of patients, with regular prophylaxis as the most common treatment regimen. In terms of overall HRQoL, the median EQ-5D VAS score was 80 (IQR: 50-100). PwHA in Colombia still suffer from disease complications related to bleeding events, pain and disability that affect their HRQoL, which highlights the need to develop patient-centered initiatives to improve the wellness of this population.

A life course health development model of HIV vulnerabilities and resiliencies in young transgender women in Peru.

BACKGROUND: Globally transgender women (TW) are at heightened vulnerability for HIV infection. In Lima Peru, sharp increases in HIV prevalence are seen among TW ages 25 years and older highlighting the need for early HIV prevention efforts for young TW. This study conducted in-depth qualitative interviews to elucidate the social and developmental contexts of HIV vulnerability for young TW in Lima Peru. METHODS: Between November 2019 and February 2020, young TW ages 16-24 years (n = 21) in Lima Peru were purposively sampled using in-person (e.g., face-to-face outreach) and online (e.g., social media, networking websites) social network-based methods. Interviews were conducted in Spanish and a rapid qualitative analysis was conducted using a modified immersion crystallization methodology to identify themes. RESULTS: Five themes emerged, informing the conceptualization of a Life Course Health Development Model of HIV Vulnerabilities and Resiliencies: (1) interpersonal contexts (family, school, partners, sexual debut, trans mothers); (2) structural vulnerabilities (poverty, educational constraints, migration, hostile environments, sex work, police violence); (3) concomitant mental health and psychosocial factors (discrimination, violence, depression, suicidality, substance use, life hopes/dreams/future expectations); (4) gender affirmation processes (gender identity development, hormones, surgery, legal name/gender marker change); (5) HIV prevention and treatment barriers (PrEP uptake, HIV care, condom use, risk reduction). CONCLUSIONS: Young TW experience formidable developmental challenges associated with transphobia, violence, and pre-maturely facing accelerated milestones. Developmentally and culturally appropriate interventions to mitigate HIV vulnerability in Peru are needed, including those that consider co-occurring stigma-related conditions in adolescence and young adulthood.

Understanding the HIV/AIDS epidemic in transgender women of Lima, Peru: results from a sero-epidemiologic study using respondent driven sampling.

In Latin America, transgender women (transwomen or male to female transgenders) have been included in MSM research but without addressing their specific needs in terms of the HIV/AIDS. We present results of the first seroepidemiologic study designed for transwomen in Peru. We conducted a study using respondent driven sampling to recruit transwomen from Lima. Our survey explored sociodemographic characteristics, gender enhancement procedures and sexual behavior. In addition, we conducted laboratory based HIV, genital herpes (HSV2) and syphilis testing. A total of 450 transwomen were recruited between April and July 2009. HIV prevalence was 30%, HSV2: 79% and syphilis: 23%. Sex-work was the main economic activity (64%). Gender enhancement procedures were reported by 70% of the population. Multivariable analysis showed HIV infection to be associated with being older than 35 recent, syphilis infection and HSV2 infection. Transwomen are the group most vulnerable to HIV/AIDS in Peru.

Effect of a community popular opinion leader HIV/STI intervention on stigma in urban, coastal Peru.

Evaluating interventions that reduce HIV stigma may help to craft effective stigma-reduction programs. This study evaluates the effects of a community popular opinion leader HIV/STI intervention on stigma in urban, coastal Peru. Mixed effects modeling was used to analyze data on 3,049 participants from the Peru site of the NIHM collaborative trial. Analyses looked at differences between the comparison and intervention groups on a stigma index from baseline to 12- and 24-month follow-up. Sub-analyses were conducted on heterosexual-identified men (esquineros), homosexual-identified men (homosexuales), and socially marginalized women (movidas). Compared to participants in the comparison group, intervention participants reported lower levels of stigma at 12- and 24-month follow-up. Similar results were found within esquineros and homosexuales. No significant differences were found within movidas. Findings suggest that interventions designed to normalize HIV prevention behaviors and HIV communication can reduce HIV-related stigma and change community norms.

"Existimos": Health and social needs of transgender men in Lima, Peru.

BACKGROUND: The health of transgender men (trans men)-individuals who identify as men and were assigned a female sex assigned at birth-is overlooked globally. This mixed-methods exploratory study sought to understand the lived experiences, health, and social needs of trans men in Lima, Peru to bring visibility to specific health needs and inform responsive and holistic public health efforts. METHODS: Between July 2016-January 2017, 46 trans men in Lima, Peru participated in a mixed-methods study. Four focus group discussions were conducted, complemented with 10 one-on-one interviews to explore in-depth issues that arose in groups. Two individuals participated in both a focus group and an interview. All participants completed a brief survey assessing sociodemographic characteristics and experiences with healthcare, mental health, and stigma. Audio files were transcribed verbatim and analyzed using an immersion crystallization approach to identify themes. RESULTS: Participants had a mean age of 24 years (range 18-48). Trans men reported a lack of awareness and information among medical providers, avoidance of healthcare due to discrimination and maltreatment, an absence of public services for medical gender affirmation (hormones, surgeries), and unmet mental health needs. Trans men described health as multidimensional and influenced by social, economic, and legal contexts including family, school, employment and work, legal identity recognition, discrimination in public spaces, and peer support. Violence, stigma, and intersecting forms of oppression were described as limiting social and legal recognition of trans identity a central dimension of health. Peer support, often in an online environment, was described as important to resistance and well-being. CONCLUSIONS: Findings demonstrate that the physical and mental health of trans men, as well as unmet needs for healthcare services, are influenced by a complex set of social, economic, and legal challenges due to the social exclusion of trans people in Peruvian society. Results are a call to action for stakeholders in Peru to guarantee the rights, health, and wellbeing of this community.

The wisdom of mistrust: qualitative insights from transgender women who participated in PrEP research in Lima, Peru.

INTRODUCTION: Although pre-exposure prophylaxis (PrEP) is a remarkable biomedical advance to prevent HIV, ongoing research on PrEP contributes to and interacts with a legacy of HIV experimentation on marginalized communities in resource-limited settings. This paper explores the complexity of PrEP research mistrust among Peruvian transgender (trans) women who completed a PrEP adherence intervention and those who refused participation (i.e. declined to enrol, voluntarily withdrew, and/or were lost to follow-up). METHODS: Data were derived from 86 trans women (mean age 29 years) participants in the formative (four focus groups (n = 32), 20 interviews) and the evaluation stages (34 interviews) of a social network-based PrEP intervention for trans women in Lima, Peru. The formative stage took place from May to July 2015, while the evaluative stage took place from April to May 2018. Audio files were transcribed verbatim and analysed via an immersion crystallization approach using Dedoose (v.6.1.18). RESULTS: Three paradoxes of trans women's participation in PrEP science as a "key" population emerged as amplifying mistrust: (1) increases in PrEP research targeting trans women but limited perceived improvements in HIV outcomes; (2) routine dismissal by research physicians and staff of PrEP-related side effects and the social realities of taking PrEP, resulting in questions about who PrEP research is really for and (3) persistent limitations on PrEP access for trans women despite increasing involvement in clinical trials, fostering feelings of being a "guinea pig" to advance PrEP science. CONCLUSIONS: Findings highlight the wisdom inherent in PrEP mistrust as a reflection of trans women's experiences that underscore the broken bonds of trust between communities, researchers and the research enterprise. PrEP mistrust is amplified through perceived paradoxes that suggest to trans women that they are key experimental participants but not target PrEP users outside of research settings. Findings highlight the urgent need to reframe mistrust not as a characteristic of trans women to be addressed through education and outreach, but as a systemic institutional- and industry-level problem replicated, manifested and ultimately to be corrected, through global HIV science.

Confluent paths: Research and community participation to protect the right to health among transgender women in Peru.

The recognition of transgender women (TGW) as the most vulnerable population to HIV/AIDS in Peru and their inclusion as a specific key affected population in health research was the outcome of an extended process that culminated when TGW community organisations succeeded in articulating themselves as a population separate from men who have sex with men (MSM) and, in alliance with some academic research groups, documented their HIV prevalence and vulnerability factors. Prior to that process, TGW remained subsumed under the epidemiological category of men who have sex with men (MSM), invisible in the context of public health policies. Based on a growing body of academic research evidence, coupled with the increasing number and capacities of TGW representatives in technical and policy-related gatherings, a consensus emerged for the establishment of TGW health statistics separate from MSM by 2010. During the past decade, social and health research has contributed conclusive evidence on the living conditions of TGW and the structural barriers they face, beyond the focus of HIV/AIDS research. Despite such progress, pervasive barriers in public policies continue to hinder the use of existing research evidence and community experience in the development of sensitive HIV prevention and care strategies as part of a comprehensive health model for TGW in Peru.

The impact and cost-effectiveness of combined HIV prevention scenarios among transgender women sex-workers in Lima, Peru: a mathematical modelling study.

BACKGROUND: HIV incidence remains high among transgender women in Lima, Peru, most of whom report sex work. On the basis of a stakeholder analysis and health system capacity assessment, we designed a mathematical model to guide HIV programmatic planning among transgender women sex workers (TWSW) in Lima. METHODS: Using a deterministic compartmental model, we modelled HIV transmission among TWSW, their stable partners, and their clients to estimate the impact and cost-effectiveness of combinations of interventions compared with the standard of care on reducing HIV incidence over a 10-year period. We simulated HIV transmission accounting for differences in sexual positioning in anal intercourse and condom use by partner type and fitted the model to HIV surveillance data using Latin hypercube sampling. The interventions we considered were 15% relative increase in condom use with clients and 10% relative increase with stable partners; increase in antiretroviral treatment (ART) coverage at CD4 count lower than 500 cells per mm3 and greater than or equal to 500 cells per mm3; and 15% pre-exposure prophylaxis (PrEP) coverage using generic and branded formulations. We considered a basic scenario accounting for current limitations in the Peruvian HIV services and an enhanced scenario assuming achievement of the UNAIDS 90-90-90 targets and general improvements in HIV services. The 50 best fits according to log-likelihood were used to give the minimum and maximum values of intervention effect for each combination. We used disability-adjusted life-years (DALYs) to measure the negative health outcomes associated with HIV infection that could be averted through the interventions investigated and calculated incremental cost-effectiveness ratios to compare their cost-effectiveness. FINDINGS: Under the basic scenario, combining the four interventions of increasing condom use with clients and stable partners, extending ART to people with CD4 count greater than or equal to 500 cells per mm3, and 15% PrEP coverage with generic drugs would avert 47% (range 27-51) of new infections in TWSW, their clients, and their stable partners over 10 years, with an incremental cost-effectiveness ratio of US$509 per DALY averted. Under the enhanced scenario, this strategy would avert 61% (44-64) of new infections among this population with an incremental cost-effectiveness ratio of $1003 per DALY averted. Under both scenarios, implementation of this strategy approaches or surpasses the 50% incidence reduction goal and would represent a cost-effective use of country resources if generic PrEP drugs are used. The total cost of implementing this strategy under the enhanced scenario would be approximately $1·2 million per year over 10 years, corresponding to 10% of the current Global Fund's yearly contribution in Peru. INTERPRETATION: Investments in HIV services among TWSW in Lima would be cost-effective, even under stringent cost-effectiveness criteria when accounting for setting-specific resource constraints. Notable improvements in HIV testing rates, innovative interventions to increase condom use, and reduced PrEP costs will be key to achieving the 50% incidence reduction goal. Modelling studies incorporating stakeholders' perspectives and health system assessments can bring added value to HIV policy making. FUNDING: National Institutes of Health.

Compensated Sex and Sexual Risk: Sexual, Social and Economic Interactions between Homosexually- and Heterosexually-Identified Men of Low Income in Two Cities of Peru.

This study describes the complex dynamics of the sexual, economic and social interactions between a group of feminized homosexual men and men who have sex with men and self-identify as heterosexual ('mostaceros'), in lower-income peripheral urban areas of Lima and Trujillo, Peru. The study examined sexual risk between these two groups of men, and the significance of the economic exchanges involved in their sexual interactions. Using a Grounded Theory approach, 23 individual interviews and 7 focus groups were analyzed. The results reveal that cultural, economic and gender factors mold sexual and social relations among a group of men who have sex with men in Peru. Compensated sex is part of the behaviors of these men, reflecting a complicated construction of sexuality based on traditional conceptions of gender roles, sexual identity and masculinity. Several factors (e.g. difficulty in negotiating condom use, low self-esteem, low risk perception, alcohol and drug consumption), in the context of compensated sex, play a role in risk-taking for HIV infection.