A qualitative description of HIV testing and healthcare experiences among trans women in Ghanaian urban slums BSGH-011

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Despite this imperative, HIV testing services as well as research in Ghana often overlook the unique experiences of transgender women in urban slums, impacting their engagement with care. Using the gender affirmative model lens, this study reports the HIV testing experiences of trans women in Ghanaian slums, highlighting how the healthcare environment, counseling, and healthcare provider attitudes shape these experiences. Methods A qualitative descriptive interview design was employed, involving 20 trans women aged 18 to 31 years living in urban slums in the Greater Accra Metropolitan Area of Ghana. Participants were recruited using purposive and snowball sampling techniques. Data were collected through face-to-face interviews, transcribed verbatim, and analyzed using NVivo. Results were presented in categories and subcategories. Results Two main categories emerged from our data analysis: 1) Positive Experiences with HIV Testing, and 2) Negative Experiences with HIV Testing. Positive experiences with HIV testing among trans women in Ghanaian slums included a welcoming environment at healthcare facilities, supportive counseling, and relatability with HIV-positive nurses. Negative experiences were characterized by fear and anxiety during testing, often intensified by healthcare worker attitudes, including unwelcoming behaviors and judgmental body language, especially in facilities that are not key population friendly. These categories provided a framework for understanding the varied experiences of trans women in Ghanaian slums regarding HIV testing. Conclusion The study emphasizes the urgent need for healthcare facilities in Ghanaian slums to address discriminatory practices and attitudes towards trans women, fostering a welcoming and affirming environment. Adopting a multifaceted approach integrating the gender-affirmative model's principles is crucial to enhancing HIV testing experiences and achieving improved health outcomes for trans women. Policymakers and healthcare providers must prioritize comprehensive training, inclusive healthcare environments, and culturally competent care to mitigate health disparities among this population. Women's studies HIV Testing ART Trans women Healthcare Urban slums Ghana Introduction In low- to middle-income countries, trans women are 77.5 times more likely to have HIV than cisgender women 1 . Ghana, a lower-middle-income country in West Africa, faces a concentrated HIV epidemic among key populations 2 . In 2017, an estimated 28.1% of trans women in Ghana were living with HIV, a prevalence rate exceeding that of all other key populations in the country and far surpassing the national average of 1.7% 3 . While HIV testing has been firmly established as a key and critical step in curbing the epidemic, the existing HIV testing coverage and frequency pose a barrier 4 . In low-and middle-income countries, less than half of people living with HIV are aware of their status 5 . In Ghana, despite a national increase in HIV status awareness from 43% in 2014 to 72% in 2023, key populations, of which trans women are a part, continue to experience low rates of HIV testing due to pervasive stigma and discrimination that permeate various aspects of their lives 3 , 6 – 9 . Within the sub-Saharan region of Africa, trans women continue to face severe societal stigmatization, reinforced by both cultural norms and legal structures 10 – 13 . Cultural norms in many sub-Saharan African societies often dictate rigid gender roles and expectations, leading to the marginalization of individuals whose gender identity do not conform to the dominant traditional norms 14 – 17 . Similar to other African nations, Ghana is deeply religious 18 , which correlates with widespread anti-LGBT sentiment 19 . Many Ghanaians perceive non-heteronormative sexual orientations and gender identities as "un-African" or as Western imports, rather than recognizing them as human rights issues 20 . As a result, physical and violent homophobic attacks against LGBT individuals are frequent and often endorsed by the media, as well as religious and political Figs. 1 4–17,21 . Additionally, legal structures in several sub-Saharan African countries, including Ghana, criminalize same-sex relationships and behaviors, contributing to the reinforcement of stigma against transgender individuals 22 – 25 . In Ghana, a recently passed anti-LGBT bill by parliament is pending presidential assent to become law, with significant international and domestic pressure urging the president to reject this discriminatory legislation 26 . The bill, otherwise known as the "Promotion of proper human sexual rights and Ghanaian Family Values Bill," imposes prison sentences for identifying as LGBTQ + and forming or funding LGBTQ + groups, with penalties of up to three years for individuals and up to five years for groups 26 , 27 . The bill also proposes harsh measures like jail terms of up to 10 years for LGBTQ + advocacy campaigns aimed at children and encourages the public to report LGBTQ + individuals to authorities for action. These legal frameworks not only seemingly perpetuate discrimination but also create barriers to accessing essential healthcare services and support for transgender women. The criminalization of homosexuality in Ghana further entrenches societal prejudices and biases against LGBTQ + individuals, including transgender women 24 , 28 , 29 Moreover, within the Ghanaian context, HIV stigma remains profoundly ingrained and fueled by misconceptions, fear, limited knowledge, and the association of HIV with sin and death 30 , 31 . Persons living with HIV often endure rejection, insults, violence, and sometimes denial of health care, resulting in social isolation, restricted healthcare access, and reluctance to seek treatment, ultimately exacerbating the HIV epidemic 30 – 32 . In healthcare settings, pervasive stigma and discrimination against trans women in Ghana persist, attributed to factors such as a lack of cultural competence among healthcare workers, absence of LGBTQI-specific training in the healthcare sector, and ingrained societal prejudices 8 , 16 , 33 . Many healthcare providers in sub-Saharan Africa lack the understanding and sensitivity required to address the unique health needs of trans women, often leading to discriminatory practices or reluctance to provide appropriate care 32 , 34 , 35 . For instance, research across Kenya, Malawi, and South Africa revealed that nearly half (45.3%) of the men who have sex with men (MSM) and transgender women (TGW) reported at least one healthcare-related stigma experience 36 . In South Africa, transgender individuals encountered stigma while accessing reproductive healthcare, while other transfeminine and gender-diverse women faced discrimination due to their gender identity and expression 37 . They described hostile health services, with unrelated health issues often linked to gender or sexual identity, causing discomfort. In Uganda, transgender women experienced various forms of stigma, including police and client violence, workplace and familial discrimination, and a lack of tailored health services 38 . These challenges faced by key populations are exacerbated, especially for those residing in urban areas, particularly within slum communities 8 , 39 – 44 , as residing in these areas, further increases the risk of HIV infection among this population 8 , 45 . Urban slums are informal settlement and pose a multitude of social and structural challenges that amplify vulnerability to HIV, which include crowded living conditions, discrimination, poverty, limited HIV knowledge, high rates of transactional sex, and limited healthcare access 46 – 49 . Notably, certain slum areas within Ghana's capital, Accra, such as Agbogboloshie (5%), Okai Koi North (8%), and Madina (7%), report a higher HIV prevalence, averaging 7% compared to the national prevalence of 1.7% 6,41 . Trans women in these areas are likely to have low HIV testing rates due to poor access to services, low HIV risk perception, lower education levels, and poverty 50 – 53 . Additionally, in low-resource settings, the impact of stigma on healthcare access is even more pronounced, presenting a significant barrier to service utilization compared to other contexts 54 . Healthcare-related stigma not only leads to avoidance of healthcare services but also adds discomfort and stress, adversely affecting health outcomes 55 – 57 . For instance, in Ghana, intersectional stigma and discrimination experienced by key populations not only deters them from seeking healthcare services, resulting in delayed diagnosis and treatment of physical health conditions, but also contributes to increased rates of depression, anxiety, and other mental health issues, as well as social exclusion and isolation 7 , 8 , 34 , 39 , 58 . Furthermore, stigma and discrimination experienced by transgender individuals in other low-income settings have been linked to adverse health effects, including depressive symptoms, anxiety, suicidality, substance abuse, condomless sex and increased HIV transmission 59 – 61 . Research specifically focused on trans women, especially those living in slum communities, in Ghana is limited, with most studies focusing on gay, bisexual, other men who have sex with men, and female sex workers 8 , 39 , 58 , 62 . This paper seeks to address this knowledge gap by offering a qualitative exploration of HIV testing and care experiences within the context of trans women living in Ghanaian urban slums, which can have significant implications for public health interventions and policy development. Identifying the unique challenges and barriers encountered by trans women can contribute to the design of more inclusive and practical strategies to combat the spread of HIV in this vulnerable population. Theoretical framework Grounded in the gender-affirmative model, we aim to highlight the nuanced landscape of HIV testing experiences among trans women living in Ghanaian slums, emphasizing both the supportive and challenging aspects of their experiences 63 . Recognizing the fundamental principles of the gender-affirmative model, which prioritize the affirmation of gender identity, empowerment, and the mitigation of stigma and discrimination 64 , this study seeks to report on the positive and negative HIV testing experiences within this marginalized community 65 . By centering the voices and lived experiences of trans women, we seek to identify the facilitators and barriers to accessing HIV testing services. The ultimate goal is to provide actionable insights that can guide policymakers, healthcare providers, and community organizations to enhance the accessibility, acceptability, and effectiveness of HIV testing services, ensuring they meet the specific needs of trans women in Ghanaian slums. Methods Research design We employed a qualitative descriptive interview design to explore HIV testing and healthcare experiences among 20 trans women living in urban slums in the Greater Accra Metropolitan Area of Ghana. This design was selected for its suitability in capturing the complex, nuanced experiences of trans women in urban slums—a population whose voices are seldom heard in traditional research. Sampling and recruitment procedure In this study, participants were recruited using purposive and snowball sampling techniques. Leveraging the established relationships with key populations, particularly transgender women in our target slum communities, research assistants from our partner community organization facilitated recruitment. The initial cohort of participants was identified through existing contacts within the transgender women community. Subsequently, a snowball sampling approach was utilized, with these initial participants referring other eligible individuals from within their social networks. Inclusion and exclusion criteria Eligibility criteria for participation required trans women to reside in an urban slum in Accra, self-identify as transgender, be aged 18 or older and have engaged in sexual activity with a male within the past year. Individuals not biologically born male or residing outside urban slum communities in the Greater Accra Metropolitan Area were excluded from the study. Data collection procedure Data collection involved face-to-face interviews with trans women participants, and were collected between the months of May 2023 and June 2023. Before the interviews, eligible individuals were provided with information sheets detailing the study and given a choice to sign consent forms, with research assistants offering additional clarification and reminders about consent during the process. All interviews occurred in secure community partner locations, with nine out of 20 conducted in Twi, a local Ghanaian language, and the remainder in English. The sample size of 20 participants was determined to be sufficient for this qualitative study as data saturation was achieved, indicating that no new significant themes was identified after the 15th interview, thus ensuring comprehensive coverage of the experiences within the target population. Nature of questions To ensure a comprehensive exploration of HIV testing experiences among transgender women in urban slums, an interview guide was developed collaboratively with experts in urban slum communities research, healthcare practice, and transgender engagement. The guide included open-ended questions and prompts aimed at eliciting narratives about positive and negative experiences encountered during HIV testing. Sample questions included: When last did you test for HIV in your community? What were your experiences like during your last HIV test? What positive experiences have you had at HIV testing sites in your community? Could you describe any challenges or negative experiences you've faced while seeking HIV testing services in your community? Analytical strategy Interviews were recorded and transcribed verbatim by research assistants, with translations from Twi to English undertaken by experienced team members who had previously performed such translations in prior studies 8 , 39 , 66 . Data analysis was conducted using NVivo, following a meticulous approach. Initially, a team of six research assistants developed a comprehensive codebook, which was refined collaboratively, and the first five transcripts were coded collectively. Subsequently, the remaining transcripts were divided, with two team members independently coding each transcript to ensure inter-coder reliability and capture nuances in the data. Coding comparisons were utilized to maintain consistency and validate decisions, with any discrepancies resolved through team discussions. This iterative process ensured the reliability and validity of the analytical findings. Throughout, diligent efforts were made to de-identify the data during transcription to adhere to ethical guidelines. After careful data comparison in NVivo, key themes representing main patterns and significant findings were identified. All monetary amounts quoted were converted using the prevailing exchange rate at the time of data collection (US$1 = GH₵12). Ethical approval and informed consent Ethical approval for this study was obtained from the Research Subjects Review Board (RSRB) at the University of Rochester University (STUDY00008151) and the Ghana Health Service Ethics Review Committee (GHS-ERC:002/03/23). In addressing the ethical considerations specific to the vulnerable population of trans women in urban slums, our study implemented several protective measures. Recognizing the heightened risks of stigma and discrimination, we ensured that all participant interactions, from recruitment through interviews, were conducted with utmost confidentiality and respect. Beyond standard informed consent procedures, we employed stringent data de-identification techniques and secure data handling practices to safeguard participant identities. Interviews were held in secure, private locations chosen by participants to ensure their comfort and safety. Additionally, research assistants were specially trained in sensitive communication and handling potentially distressing topics, ensuring that discussions did not exacerbate participants' vulnerabilities. These measures collectively aimed to uphold the dignity and safety of participants while collecting vital data on their HIV testing experiences. Results Description of participants The participants in our study consisted of 20 trans women with a mean age of 20 years, ranging from 18 to 31. Educational backgrounds varied, with 10 participants having completed secondary education, four with tertiary education, five with primary education, and one without any formal education. All were employed, earning an average monthly income of GH₵830.15 ( $ 69.2), with incomes ranging from GH₵200 ( $ 16.7) to GH₵2003 ( $ 166.91). In terms of religious affiliation, the majority were religious: 15 identified as Christians, four were non-religious, and one practiced Islam. Regarding sexual behavior, 19 participants reported having exclusively male sexual partners over the past year, and one reported having partners of both sexes. Although the study did not explicitly inquire about HIV status to avoid potential stigma, three participants voluntarily disclosed that they were living with HIV. Description of Categories and Subcategories Two main categories emerged: Positive Experiences with HIV Testing, and Negative Experiences with HIV Testing. Under Positive Experiences, subcategories included a Welcoming Environment at healthcare facilities, Counseling and Relatability with HIV-positive nurses, and Inclusive, Informative, and Supportive Counseling. Negative Experiences encompassed Fear and Anxiety in HIV Testing and Negative Health Worker Attitude. These categories provide a framework for understanding the varied experiences of trans women in Ghanaian slums regarding HIV testing. Positive Experiences with HIV Testing. Positive experiences with HIV testing were mainly characterized by welcoming environment at healthcare facilities, relatability with nurses, and inclusive, informative, and supportive counselling. Welcoming environment at the healthcare facility. Some participants reported feeling welcomed and cared for by healthcare staff during HIV testing at the health facility. One participant mentioned meeting a nurse who was welcoming and provided reassurance during their waiting period for test results. The participant highlighted the positive impact of a nurse who offered counseling during the waiting period for test results. Notably, the nurse's reassuring words, delivered by a white nurse as mentioned by the participant, not only relieved the participant's anxiety but also provided confidence to navigate potentially reactive outcomes, emphasizing the importance of supportive care. They are so welcoming. They are so nice. Yeah. And they are good too. Like they take time to take care of us. When you go there, they have patience. I met this nurse. She's White though. And then she was very welcoming. She started counseling with me while my results were pending. I was nervous and scared. But when I walked in, she was like, baby keep calm, relax, there's nothing to be afraid of. When you're reactive, there are ways to go by to live as long as you're supposed to live. And so, like her words actually calm me down and like, I am in for this and I'm okay. - (Trans woman, 23, Christian) Counseling and relatability with HIV positive nurse . In another positive encounter, a participant shared an experience with a nurse who exceeded the standard testing procedure. The nurse explained the importance of consistent medication adherence, healthy lifestyle choices, and even shared her own positive HIV status. This disclosure aimed to eliminate the social stigma surrounding HIV, emphasizing that with proper medication and care, individuals with HIV can lead fulfilling lives without facing rejection. Before I began my medications, they conducted the tests again. One of the nurses took me to a different room and told me that for HIV, if you take your medications, it won't progress. Make sure to take your medications on time, eat healthy, and drink lots of water. This is what will keep you healthy. If you miss your medications or fail to eat well, it can bring your system down. She asked if I would believe her if she told me she had HIV, and I said no. What shows she has HIV? She revealed her status as positive to me, but I didn't believe it because she looked very fine. She is a very nice woman without any visible signs of HIV. So, when it was time to check the viral load, she did it on herself before and her results were positive. This calmed me down greatly as I realized that if you have HIV, you are not rejected in society because HIV is better than some diseases. As long as you take your medications, no one would know. – (Trans woman, 19, Christian) Inclusive, informative and Supportive Counseling . Participants shared positive encounters with nurses who modeled informative and supportive counseling that went beyond the technical aspects of HIV testing. One trans woman recounted a positive interaction with a nurse who engaged in a comprehensive discussion about sexual orientation, gender identity and provided education on HIV and PrEP. This holistic approach to testing not only covered the technical aspects of the procedure but also delved into broader topics such as safe sexual relationships, highlighting the importance of comprehensive healthcare interactions for trans women in their journey through HIV testing. Another participant shared a positive account of their HIV testing experience at the health facility. The participant expressed that the atmosphere during the HIV test was serene and comfortable. The participant recounted the supportive response they received upon learning of their positive test result. The nurse provided consolation and supportive counseling, establishing a human connection beyond the clinical aspects of the test. I went there. I met a nurse and then she asked me my sexual orientation, my gender identity, and then she educated me on HIV and PrEP and then told me the outcome... um, whatever was going to come. So, we did the testing and while waiting for the results, she engaged me in conversations about safe sexual relationships. So, the results came and then I was fine. – (Trans woman, 26, Christian) When I went to test for HIV It was serene it was okay the nurse was cool with me, they did not do anything to make me feel like not going there again. because they took me through counseling first, after they counseled me and then like, we had a friendly chat. And then I did the test and after the test came out positive the nurse consoled me, and we still talk because he took my number then he will be checking on me and then when the time is due for me to take my medication, they let me know then I go for it. As for me I see them to open their door for us to come in whilst to get to check our health status without any problem. – (Trans woman, 22, Christian) Negative Experiences with HIV Testing. Negative experiences with HIV testing were mainly characterized by participant's own fear and anxiety about testing outcomes and negative healthcare worker attitude at the health facility. Fear, and anxiety in HIV testing. Fear and anxiety are prevalent among trans women seeking HIV testing services, as reported by participants in the study. They recount uncomfortable situations, experiencing terror during HIV testing, particularly when faced with delays and the need for multiple retests. These encounters led trans women to speculate about receiving a positive diagnosis, intensifying their apprehension. One participant shared her distressing experience, stating. Moreover, some trans women attributed their fear to witnessing the emotional reactions of others diagnosed with HIV at the same clinic. This communal anxiety heightened their own apprehension about undergoing testing, as expressed by another participant. Additionally, participants pointed out that interactions with healthcare providers, including intrusive questioning, often contributed to the fear and apprehension they felt during the testing process. I was very terrified. We were there, they took the test and my result wasn't coming. It was delayed and they said I had to redo the test. They did it and they were like they were not getting the result, so I had to do it again for the third time and at that point, I was scared the test was positive, and the health workers didn't want to tell me the truth. At that point, I was like, okay, let me accept the fact that I am positive till the result came out that they wanted to confirm because the first one wasn't successful, the second one was negative and they wanted to confirm it was negative so that is why they did the third one.– (Transgender Woman, 18, Christian) My experience was with the people around. Some were scared of being tested. I was also scared of being tested. Because you know, when someone has it, they come out and then cry. It's very sad, but you can't do anything about it, it has happened. So, all you need is to console the person and say something sensible to the person so that the person will be okay.– (Transgender Woman, 26, Christian) In the health facilities, sometimes they put fear in you. The nurses put fear in you. Like, ask you what have you been doing and all that. So, when the test is run, sometimes you sit down to think about the people you have sex with, looking at their bodies and wondering if they might be having HIV – (Trans woman, 31, Christian) Negative health worker attitude. Participants highlighted instances of encountering negative attitudes from healthcare staff, particularly when seeking care at hospitals based on their feminine appearance. This phenomenon was notably pronounced in healthcare facilities that were not identified as trans-friendly. In these settings, trans women reported experiences where healthcare workers exhibited unwelcoming behaviors, staring awkwardly and conveying negative body language, thereby creating a hostile environment. Participants described situations where, especially in non-trans-friendly facilities, healthcare workers made them feel unwelcome based on their feminine appearance. The body language of nurses, including prolonged stares and scrutinizing glances from top to bottom, spoke negatively without any verbal communication. Participants recounted instances where they experienced judgment and gossip from nurses in a hospital that was not trans-friendly. Despite the norm of receiving attention in the Outpatient Department, they faced reluctance and had to assert themselves before receiving any care. Mostly when I visit a health facility which is not key population oriented for testing, the workers there make you feel like you shouldn't be attended to because of the way you appear looking feminine. Sometimes too, their body language, you know, when you are at the facility, they can look at you from top to bottom. Without saying anything, their body language is speaking to you negatively.– (Trans woman, 24, Christian) There was an instance when I went to the hospital that was not key population friendly for testing, and all of a sudden, everyone was looking at me, because of the way I dressed. Everyone was looking. The nurses started gossiping. I sat there for about one hour until I approach them to tell them why I was there. But on a normal basis, you know, you go through the Out Patient Department, and a nurses will attend to you. In my case no one wanted to attend to me due to how I looked and identified myself. I had to approach them before I was attended to.– (Trans woman, 25, Muslim). Discussion The findings of this study offer valuable insights into the experiences of trans women in Ghanaian slums regarding HIV testing, contextualized within the gender-affirmative model. Our findings resonate with the principles of the gender-affirmative model, emphasizing the significance of the healthcare environment, counseling, and healthcare provider attitudes in shaping the HIV testing experiences of trans women. Consistent with existing literature and the principles of the gender-affirmative model, which emphasizes affirmation of gender identity, empowerment, and mitigation of stigma and discrimination, our findings highlight the importance of creating a welcoming environment within healthcare settings. 67 – 69 A welcoming environment serves as a practical application of these principles by affirming and validating the gender identities of trans women, alleviating anxiety, building confidence, and fostering trust during the HIV testing process, thereby encouraging regular healthcare engagement, which is essential for continuous HIV prevention and treatment. 70 – 73 The presence of supportive and empathetic healthcare providers, as mentioned by some trans women in this study has also been shown to foster trust and encourage individuals to seek HIV testing, thereby promoting HIV prevention and care 70 , 71 , 74 , 75 . The significance of counseling and peer support in healthcare settings has been widely recognized in the literature as a key factor in enhancing the HIV testing experiences of trans women and men who have sex with men. 76 , 77 Our findings corroborate this, emphasizing the importance of counseling and relatability in reducing stigma, providing emotional support, and promoting positive health outcomes. Sharing personal experiences, as demonstrated by the HIV-positive nurse in our study, can be a valuable strategy for reducing the social stigma surrounding HIV and promoting medication adherence and healthy lifestyle choices among people living with HIV. By integrating counseling and peer support within a gender-affirmative framework, healthcare providers can create a supportive and affirming environment that addresses the unique needs and challenges faced by trans women in the context of HIV testing and care. This approach not only enhances the accessibility and acceptability of HIV testing services but also contributes to improving health outcomes and reducing health disparities among this population. Our findings further highlight the value of inclusive, informative, and supportive counseling in creating a positive healthcare experience among trans women in Ghanaian slums. By fostering an environment that prioritizes affirmation of gender identity, empowerment, and the mitigation of stigma and discrimination, healthcare providers who engage in comprehensive discussions about sexual orientation, gender identity, and provide education on HIV and PrEP contribute to a more positive and empowering HIV testing experience for trans women. 78 , 79 This approach creates trust, builds rapport, and encourages open communication, promoting improved health outcomes and reducing health disparities in this population. In this study, we also found that fear and anxiety during HIV testing process, negative attitudes, and discriminatory practices of nurses were prevalent factors characterizing the negative experiences of trans women in Ghanaian slums. Fear and anxiety during the HIV testing process, as reported by the participants in our study, have been identified in previous research as common experiences across various populations and found to be significant barriers to HIV testing. 80 , 81 These findings underscore the need for healthcare facilities to improve their testing procedures and communication strategies to minimize anxiety and fear. Effective communication, transparency about the testing process, and timely delivery of results are essential to alleviate anxiety and promote a more positive testing experience. 81 , 82 Furthermore, negative attitudes and discriminatory practices within healthcare settings have been consistently reported by trans women and are considered a significant barrier to accessing healthcare services, including HIV testing, among trans women. 59 , 83 – 87 These negative experiences can lead to avoidance of healthcare services, delayed HIV testing, and reduced engagement in HIV care, which ultimately contribute to health disparities and poorer health outcomes among trans women. 59 , 83 – 87 . In line with the gender affirmative model, these findings highlight the urgent need for healthcare facilities to address and eliminate discriminatory practices and attitudes toward trans women. Healthcare providers must receive comprehensive training on key population health issues, cultural competence, and respectful communication to ensure equitable and inclusive care and promote a more positive and welcoming healthcare experience for trans women. Conclusion This study contributes to the literature on the HIV testing experiences of trans women in Ghanaian slums and highlights the need for healthcare facilities to address discriminatory practices and attitudes towards trans women and create a welcoming and affirming environment within healthcare settings to enhance HIV testing experiences and promote improved health outcomes and reduced health disparities in this population. Enhancing the accessibility, acceptability, and effectiveness of HIV testing services for trans women in Ghanaian slums requires a multifaceted approach that integrates the principles of the gender-affirmative model. These approaches include comprehensive training for healthcare providers, the creation of inclusive and affirming healthcare environments, and the provision of culturally competent, respectful care that addresses the unique needs and challenges faced by trans women. By adopting these strategies, policymakers, healthcare providers, and community organizations can contribute to reducing health disparities and improving the overall wellbeing of trans women in Ghanaian slums Strengths and Limitations This study notably contributes to the field by focusing on the often-underrepresented HIV testing experiences of trans women in urban slums within Ghana, employing the gender-affirmative model to validate and respect gender identities. The qualitative interview approach allowed for an in-depth exploration of the personal and social nuances associated with HIV testing, which quantitative methods might fail to capture. Additionally, the collaboration with local community organizations not only facilitated access to this hard-to-reach population but also ensured that our methodology was culturally sensitive and tailored to the specific needs of the participants. However, the study has limitations. It does not fully explore the intersectional factors such as ethnicity, socioeconomic status, and education level that might influence HIV testing experiences and outcomes. To address this, we acknowledge these gaps and recommend them as focal points for future research, and we have initiated discussions with community partners to integrate some of these considerations in ongoing programs. The geographical scope is also limited to the Greater Accra Metropolitan Area, which may restrict the generalizability of the findings. Future research should aim to include other regions to enhance the breadth of data and applicability of the findings. Additionally, the use of snowball sampling and a relatively small sample size may introduce selection bias and limit the diversity within the sample. Despite these potential biases, we utilized rigorous qualitative methods to ensure the reliability of our findings and plan to employ more diverse sampling techniques in future studies to improve the representativeness of the sample. References Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis . 2013;13(3):214-222. doi:10.1016/S1473-3099(12)70315-8 Ali H, Amoyaw F, Baden D, et al. Ghana’s HIV epidemic and PEPFAR’s contribution towards epidemic control. Ghana Med J . 2019;53(1):59-62. doi:10.4314/gmj.v53i1.9 Ghana AIDS Commission. Ghana Aids Commission Ghana Men ’ S Study II. Published online 2017. PAHO. PAHO urges testing as the first step towards preventing HIV and halting the AIDS epidemic. Published online 2018. Marsh K, Eaton JW, Mahy M, et al. Global, regional and country-level 90–90–90 estimates for 2018: assessing progress towards the 2020 target. AIDS . 2019;33. Ghana AIDS Commission. National HIV/AIDS strategic plan (2016 – 2020). Published online 2016. Gyamerah AO, Taylor KD, Atuahene K, et al. Stigma, discrimination, violence, and HIV testing among men who have sex with men in four major cities in Ghana. AIDS Care . 2020;32(8):1036-1044. doi:10.1080/09540121.2020.1757020 Zigah EY, Abu-Ba’are GR, Shamrock OW, et al. “For my safety and wellbeing, I always travel to seek health care in a distant facility”—the role of place and stigma in HIV testing decisions among GBMSM – BSGH 002. Health Place . 2023;83:103076. doi:https://doi.org/10.1016/j.healthplace.2023.103076 Abubakari GM, Turner D, Ni Z, et al. Community-based interventions as opportunities to increase HIV self-testing and linkage to care among men who have sex with men–lessons from Ghana, West Africa. Front Public Health . 2021;9:660256. de Villiers L, Thomas A, Jivan D, et al. Stigma and HIV service access among transfeminine and gender diverse women in South Africa - a narrative analysis of longitudinal qualitative data from the HPTN 071 (PopART) trial. BMC Public Health . 2020;20(1):1898. doi:10.1186/s12889-020-09942-5 Shabalala SB, Campbell MM. The complexities of trans women’s access to healthcare in South Africa: moving health systems beyond the gender binary towards gender equity. Int J Equity Health . 2023;22(1):231. doi:10.1186/s12939-023-02039-6 Mehta SD, Otieno FO, Kimani J, et al. Transgender women in Kenya experience greater stigma, depressive symptoms, alcohol and drug use and risky sexual practices than cis-gendered men who have sex with men. BMC Public Health . 2023;23(1):1493. doi:10.1186/s12889-023-16348-6 Snyman T. The Protection of African Transgender Women’s Rights to Dignity, Life and Health through a Teleological Reading of the Maputo Protocol . 2019. doi:10.13140/RG.2.2.29831.47525 Muwanguzi PA, Otiku PK, Nabunya R, Gausi B. Implementation and effectiveness of transgender stigma reduction interventions in sub-Saharan Africa: A scoping review. J Glob Health Rep . 2023;7:1-15. doi:10.29392/001c.72080 Banks WD. Queering Ghana: Sexuality, community, and the struggle for cultural belonging in an African nation. Published online 2013. Kushwaha S, Lalani Y, Maina G, et al. “But the moment they find out that you are MSM…”: a qualitative investigation of HIV prevention experiences among men who have sex with men (MSM) in Ghana’s health care system. BMC Public Health . 2017;17(1):1-18. Ngubane SJ. Gender Roles in the African Culture : Implications for the Spread of Hiv / Aids. Stellenbosch University . 2010;1(March):1-7. Shamrock OW. Disability, Religion and Work among Vulnerable Populations: An Inquiry of Women Experiences and Perspectives . State University of New York at Binghamton; 2022. Shamrock OW, Dakpui HD, Agbemedu GRK, et al. “I’m scared of the nurses telling other people I am a transwoman”: Disclosure and nondisclosure of gender identity among trans women in Ghana’s urban slums–BSGH010. Published online 2024. Dulani B, Sambo G, Dionne KY. Good neighbours? Africans express high levels of tolerance for many, but not for all. Published online 2016. Odoi A. Homophobic violence in Ghana: When and where it counts. Sexuality research and social policy . Published online 2021:1-10. Dada D, Abu-Ba’are GR, Turner DA, et al. Scoping review of HIV-related intersectional stigma among sexual and gender minorities in sub-Saharan Africa. BMJ Open . 2024;14(2):e078794. doi:10.1136/bmjopen-2023-078794 Hagopian A, Rao D, Katz A, Sanford S, Barnhart S. Anti-homosexual legislation and HIV-related stigma in African nations: what has been the role of PEPFAR? Glob Health Action . 2017;10(1):1306391. doi:10.1080/16549716.2017.1306391 Government of Ghana. Criminal Code, 1960 (Act 29) .; 1960. Lyons CE, Rwema JOT, Makofane K, et al. Associations between punitive policies and legal barriers to consensual same-sex sexual acts and HIV among gay men and other men who have sex with men in sub-Saharan Africa: a multicountry, respondent-driven sampling survey. Lancet HIV . Published online 2023. Coleman TE, Ako EY, Kyeremateng JG. A human rights critique of Ghana’s Anti-LGBTIQ+ Bill of 2021. African Human Rights Law Journal . 2023;23(1):96-125. Avagah R. Analysis of the Anti Gay Bill Captioned’The Promotion of Proper Human Sexual Rights and Ghanaian Family Values Bill’in Light of Kwame Nkrumah’s Philosophical Consciencism–LGQBTI Versus the African (Ghanaian) Culture. Available at SSRN 4368789 . Published online 2022. Atuguba R. Homosexuality in Ghana: Morality, Law, Human Rights. J Politics Law . 2019;12:113. doi:10.5539/jpl.v12n4p113 Osse L. Ghanaians are united and hospitable but intolerant towards same-sex relationships. Published online 2021. Asiedu GB. “Once It’s Your Sister, They Think It’s in the Bloodline”: Impact of HIV/AIDS-Related Stigma in Ghana . Kansas State University; 2010. Armstrong-Mensah E, Ofori E, Alema-Mensah E, Agyarko-Poku T. HIV destigmatization: perspectives of people living with HIV in the Kumasi Metropolis in Ghana . Frontiers in Reproductive Health . 2023;5. James P, Hayfron-Benjamine A, Abdulai M, Lasim O, Yvonne N, Obiri-Yeboah D. Predictors of HIV stigma among health workers in the Cape Coast metropolis, Ghana. J Public Health Afr . 2020;11(1):1020. doi:10.4081/jphia.2020.1020 Gyamerah AO, Kinzer E, Aidoo-Frimpong G, et al. PrEP knowledge, acceptability, and implementation in Ghana: Perspectives of HIV service providers and MSM, trans women, and gender diverse individuals living with HIV. PLOS global public health . 2023;3(6):e0001956. doi:10.1371/journal.pgph.0001956 Nelson LRE, Nyblade L, Torpey K, et al. Multi-level intersectional stigma reduction intervention to increase HIV testing among men who have sex with men in Ghana: Protocol for a cluster randomized controlled trial. PLoS One . 2021;16(11 November):1-20. doi:10.1371/journal.pone.0259324 Abubakari GM, Owusu-Dampare F, Ogunbajo A, et al. HIV Education, Empathy, and Empowerment (HIVE(3)): A Peer Support Intervention for Reducing Intersectional Stigma as a Barrier to HIV Testing among Men Who Have Sex with Men in Ghana. Int J Environ Res Public Health . 2021;18(24). doi:10.3390/ijerph182413103 Mbeda C, Ogendo A, Lando R, et al. Healthcare-related stigma among men who have sex with men and transgender women in sub-Saharan Africa participating in HIV Prevention Trials Network (HPTN) 075 study. AIDS Care . 2020;32(8):1052-1060. doi:10.1080/09540121.2020.1776824 Luvuno ZPB, Ncama B, Mchunu G. Transgender population’s experiences with regard to accessing reproductive health care in Kwazulu-Natal, South Africa: A qualitative study. Afr J Prim Health Care Fam Med . 2019;11(1):e1-e9. doi:10.4102/phcfm.v11i1.1933 Ssekamatte T, Isunju JB, Naume M, et al. Barriers to access and utilisation of HIV/STIs prevention and care services among trans-women sex workers in the greater Kampala metropolitan area, Uganda. BMC Infect Dis . 2020;20(1):932. doi:10.1186/s12879-020-05649-5 Shamrock OW, Abu-Ba’are GR, Zigah EY, et al. Community stigma, victimization, and coping strategies among gays, bisexuals, and other cis-gender men who have sex with men in slum communities in Ghana. Published online 2023. Abu-Ba’are GR, Zigah EY, Shamrock OW, et al. Qualitative description of interpersonal HIV stigma and motivations for HIV testing among gays, bisexuals, and men who have sex with men in Ghana’s slums - BSGH-005. medRxiv . Published online January 1, 2023. doi:10.1101/2023.07.29.23293357 Cassels S, Jenness SM, Biney AAE, Ampofo WK, Dodoo FNA. Migration, sexual networks, and HIV in Agbogbloshie, Ghana. Demogr Res . 2014;31(28):861-888. Abu-Ba’are GR, Torpey K, Nelson L, et al. Adaptation and feasibility of Many Men Many Voices (3MV), an HIV prevention intervention to reduce intersectional stigma and increase HIVST among YSMM residing in Ghanaian slums–A clustered pre-post pilot trial protocol. Published online 2024. Shamrock OW, Abu-Ba’are GR, Zigah EY, et al. Family rejection of non-hetero sexuality–Sexual orientation and behavior anonymity among sexual minority men in slum communities-BSGH 001. PLOS Global Public Health 3: e0001659 doi:101371/journal.pgph0001659 . Published online December 1, 2023. Abu-Ba’are GR, Shamrock OW, Apreku A, et al. Awareness and Willingness to use Condoms and Preexposure Prophylaxis among Gay, Bisexual, and Other Cisgendered Men who Have sex with men in Slum Communities in Ghana. BSGH-004. Journal of the International Association of Providers of AIDS Care (JIAPAC) . 2023;22:23259582231209650. doi:10.1177/23259582231209649 Madise NJ, Ziraba AK, Inungu J, et al. Are slum dwellers at heightened risk of HIV infection than other urban residents? Evidence from population-based HIV prevalence surveys in Kenya. Health Place . 2012;18(5):1144–1152. Jennings L, Mathai M, Linnemayr S, et al. Economic Context and HIV Vulnerability in Adolescents and Young Adults Living in Urban Slums in Kenya: A Qualitative Analysis Based on Scarcity Theory. AIDS Behav . 2017;21(9):2784-2798. doi:10.1007/s10461-017-1676-y Khan MAU, Kubra TJ, Sharmin Z, Hossen MA. Displacement and deplorable living conditions of slum dwellers: with special reference to Sylhet city. International Letters of Social and Humanistic Sciences . 2015;46:51-64. doi:https://doi.org/10.18052/www.scipress.com/ILSHS.46.51 Madise NJ, Ziraba AK, Inungu J, et al. Are slum dwellers at heightened risk of HIV infection than other urban residents? Evidence from population-based HIV prevalence surveys in Kenya. Health Place . 2012;18(5):1144-1152. Kabiru CW, Beguy D, Crichton J, Zulu EM. HIV/AIDS among youth in urban informal (slum) settlements in Kenya: What are the correlates of and motivations for HIV testing? BMC Public Health . 2011;11(1):685. doi:10.1186/1471-2458-11-685 Atinga RA, Abiiro GA, Kuganab-Lem RB. Factors influencing the decision to drop out of health insurance enrolment among urban slum dwellers in Ghana. Trop Med Int Health . 2015;20(3):312-321. doi:10.1111/tmi.12433 Darteh E, Kumi-Kyereme A, Awusabo-Asare K. Perception of Risk of HIV among Adolescents’ Living in an Urban Slum in Ghana. Afr J Reprod Health . 2016;20. doi:10.29063/ajrh2016/v20i1.6 Kaibarta S, Mandal S, Mandal P, Bhattacharya S, Paul S. Multidimensional poverty in slums: an empirical study from urban India. GeoJournal . 2022;87(4):527-549. doi:10.1007/s10708-021-10571-7 Owusu-Ansah FE, Tagbor H, Togbe MA. Access to health in city slum dwellers: The case of Sodom and Gomorrah in Accra, Ghana. Afr J Prim Health Care Fam Med . 2016;8(1):e1-7. doi:10.4102/phcfm.v8i1.822 Mekonen T, Chan GCK, Belete T, et al. Mental health service utilization in a low resource setting: A qualitative study on perspectives of health professionals in Northwest Ethiopia. PLoS One . 2022;17(11):e0278106. Abu-Ba’are GR, Aidoo-Frimpong G, Stockton M, et al. “I told myself, be bold and go and test”: Motivators and barriers to HIV testing among gay, bisexual, and other cis-gender men who have sex with men in Ghana ‒ West Africa. PLOS Global Public Health . 2024;4(1):e0002231. doi:10.1371/journal.pgph.0002231 Osman Wumpini Shamrock, Henry Delali Dakpui, George Rudolph Kofi Agbemedu, et al. “I’m Scared of the Nurses Telling Other People I Am a Transwoman”: Disclosure and Nondisclosure of Gender Identity among Trans Women in Ghana’s Urban Slums– BSGH010 .; 2024. Accessed April 19, 2024. https://doi.org/10.21203/rs.3.rs-4243840/v1 Zigah EY, Abu-Ba’are GR, Shamrock OW, et al. “For my safety and wellbeing, I always travel to seek health care in a distant facility”—the role of place and stigma in HIV testing decisions among GBMSM – BSGH 002. Health Place . 2023;83:103076. doi:10.1016/j.healthplace.2023.103076 Abu-Ba’are G, Aidoo-Frimpong G, Stockton M, et al. “I Told Myself, Be Bold and Go and Test”: Motivators and Barriers to HIV Testing among Gays, Bisexuals, and All Other Men Who Sex with Men in Ghana – West Africa .; 2023. doi:10.1101/2023.07.12.23292583 White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med . 2015;147:222-231. doi:10.1016/j.socscimed.2015.11.010 Okonkwo N, Rwema JOT, Lyons C, et al. The Relationship Between Sexual Behavior Stigma and Depression Among Men Who have Sex with Men and Transgender Women in Kigali, Rwanda: a Cross-sectional Study. Int J Ment Health Addict . 2022;20(6):3228-3243. doi:10.1007/s11469-021-00699-5 Lin Y, Xie H, Huang Z, et al. The mental health of transgender and gender non-conforming people in China : a systematic review. Lancet Public Health . 2021;6(12):e954-e969. doi:10.1016/S2468-2667(21)00236-X Ogunbajo A, Kershaw T, Kushwaha S, Boakye F, Wallace-Atiapah ND, Nelson LE. Barriers, Motivators, and Facilitators to Engagement in HIV Care Among HIV-Infected Ghanaian Men Who have Sex with Men (MSM). AIDS Behav . 2018;22(3):829-839. doi:10.1007/s10461-017-1806-6 Edwards-Leeper L, Leibowitz S, Sangganjanavanich VF. Affirmative practice with transgender and gender nonconforming youth: Expanding the model. Psychol Sex Orientat Gend Divers . 2016;3(2):165. Sevelius JM. Gender Affirmation: A Framework for Conceptualizing Risk Behavior among Transgender Women of Color. Sex Roles . 2013;68(11-12):675-689. doi:10.1007/s11199-012-0216-5 Sevelius J, Chakravarty D, Neilands TB, et al. Evidence for the Model of Gender Affirmation: The Role of Gender Affirmation and Healthcare Empowerment in Viral Suppression Among Transgender Women of Color Living with HIV. AIDS Behav . 2021;25(Suppl 1):64-71. doi:10.1007/s10461-019-02544-2 Abubakari GM, Turner D, Nelson LE, et al. An application of the ADAPT-ITT model to an evidence-based behavioral HIV prevention intervention for men who have sex with men in Ghana. International Health Trends and Perspectives . 2021;1(1):1-16. Keo-Meier CE, Ehrensaft DE. Introduction to the gender affirmative model. Published online 2018. Fauk NK, Hawke K, Mwanri L, Ward PR. Stigma and discrimination towards people living with HIV in the context of families, communities, and healthcare settings: a qualitative study in Indonesia. Int J Environ Res Public Health . 2021;18(10):5424. Sevelius JM, Patouhas E, Keatley JG, Johnson MO. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med . 2014;47(1):5-16. doi:10.1007/s12160-013-9565-8 Kwame A, Petrucka PM. A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward. BMC Nurs . 2021;20(1):158. doi:10.1186/s12912-021-00684-2 Douglas CH, Douglas MR. Patient-friendly hospital environments: exploring the patients’ perspective. Health Expect . 2004;7(1):61-73. doi:10.1046/j.1369-6513.2003.00251.x Fauk NK, Merry MS, Putra S, Sigilipoe MA, Crutzen R, Mwanri L. Perceptions among transgender women of factors associated with the access to HIV/AIDS-related health services in Yogyakarta, Indonesia. PLoS One . 2019;14(8):e0221013. Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis . 2011;52(6):793-800. doi:10.1093/cid/ciq243 Lin C, Li L, Wan D, Wu Z, Yan Z. Empathy and avoidance in treating patients living with HIV/AIDS (PLWHA) among service providers in China. AIDS Care . 2012;24(11):1341-1348. doi:10.1080/09540121.2011.648602 Gu J, Lau JTF, Wang Z, Wu AMS, Tan X. Perceived empathy of service providers mediates the association between perceived discrimination and behavioral intention to take up HIV antibody testing again among men who have sex with men. PLoS One . 2015;10(2):e0117376. doi:10.1371/journal.pone.0117376 Chen S, Fang Y, Chan PS fong, Kawuki J, Mo P, Wang Z. Counseling Supporting HIV Self-Testing and Linkage to Care Among Men Who Have Sex With Men: Systematic Review and Meta-Analysis. JMIR Public Health Surveill . 2024;10:e45647. doi:10.2196/45647 Jamil MS, Prestage G, Fairley CK, et al. Effect of availability of HIV self-testing on HIV testing frequency in gay and bisexual men at high risk of infection (FORTH): a waiting-list randomised controlled trial. Lancet HIV . 2017;4(6):e241-e250. doi:10.1016/S2352-3018(17)30023-1 McAuliffe M, Baker D, D’Aoust R. Improving healthcare quality for transgender patients in the perioperative setting: The patient’s perspective. J Perioper Pract . 2022;33(6):164-170. doi:10.1177/17504589221133937 Bass B, Nagy H. Cultural Competence in the Care of LGBTQ Patients. In: ; 2023. Rael CT, Giguere R, Lopez-Rios J, et al. Transgender Women’s Experiences Using a Home HIV-Testing Kit for Partner-Testing. AIDS Behav . 2020;24(9):2732-2741. doi:10.1007/s10461-020-02829-x Kobrak P, Remien RH, Myers JE, et al. Motivations and Barriers to Routine HIV Testing Among Men Who Have Sex with Men in New York City. AIDS Behav . 2022;26(11):3563-3575. doi:10.1007/s10461-022-03679-5 Brown L, Macintyre K, Trujillo L. Interventions to reduce HIV/AIDS stigma: what have we learned? AIDS Educ Prev . 2003;15(1):49-69. doi:10.1521/aeap.15.1.49.23844 Logie C, Lacombe-Duncan A, Brien N, et al. Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston, Jamaica: a qualitative study. J Int AIDS Soc . 2017;20. doi:10.7448/IAS.20.1.21385 Falck F, Bränström R. The significance of structural stigma towards transgender people in health care encounters across Europe: Health care access, gender identity disclosure, and discrimination in health care as a function of national legislation and public attitudes. BMC Public Health . 2023;23(1):1031. doi:10.1186/s12889-023-15856-9 Boonyapisomparn N, Manojai N, Srikummoon P, Bunyatisai W, Traisathit P, Homkham N. Healthcare discrimination and factors associated with gender-affirming healthcare avoidance by transgender women and transgender men in Thailand: findings from a cross-sectional online-survey study. Int J Equity Health . 2023;22(1):31. doi:10.1186/s12939-023-01843-4 Clark KD, Lunn MR, Bosse JD, et al. Societal stigma and mistreatment in healthcare among gender minority people: a cross-sectional study. Int J Equity Health . 2023;22(1):162. doi:10.1186/s12939-023-01975-7 Skuban-Eiseler T, Orzechowski M, Steger F. Why do transgender individuals experience discrimination in healthcare and thereby limited access to healthcare? An interview study exploring the perspective of German transgender individuals. Int J Equity Health . 2023;22(1):211. doi:10.1186/s12939-023-02023-0 Additional Declarations The authors declare no competing interests. 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interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eA qualitative description of HIV testing and healthcare experiences among trans women in Ghanaian urban slums BSGH-011\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn low- to middle-income countries, trans women are 77.5 times more likely to have HIV than cisgender women \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Ghana, a lower-middle-income country in West Africa, faces a concentrated HIV epidemic among key populations \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. In 2017, an estimated 28.1% of trans women in Ghana were living with HIV, a prevalence rate exceeding that of all other key populations in the country and far surpassing the national average of 1.7% \u003csup\u003e3\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWhile HIV testing has been firmly established as a key and critical step in curbing the epidemic, the existing HIV testing coverage and frequency pose a barrier \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. In low-and middle-income countries, less than half of people living with HIV are aware of their status \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. In Ghana, despite a national increase in HIV status awareness from 43% in 2014 to 72% in 2023, key populations, of which trans women are a part, continue to experience low rates of HIV testing due to pervasive stigma and discrimination that permeate various aspects of their lives \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWithin the sub-Saharan region of Africa, trans women continue to face severe societal stigmatization, reinforced by both cultural norms and legal structures \u003csup\u003e\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Cultural norms in many sub-Saharan African societies often dictate rigid gender roles and expectations, leading to the marginalization of individuals whose gender identity do not conform to the dominant traditional norms \u003csup\u003e\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Similar to other African nations, Ghana is deeply religious\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e, which correlates with widespread anti-LGBT sentiment\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Many Ghanaians perceive non-heteronormative sexual orientations and gender identities as \"un-African\" or as Western imports, rather than recognizing them as human rights issues\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. As a result, physical and violent homophobic attacks against LGBT individuals are frequent and often endorsed by the media, as well as religious and political Figs.\u0026nbsp;1\u003csup\u003e4\u0026ndash;17,21\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAdditionally, legal structures in several sub-Saharan African countries, including Ghana, criminalize same-sex relationships and behaviors, contributing to the reinforcement of stigma against transgender individuals \u003csup\u003e\u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. In Ghana, a recently passed anti-LGBT bill by parliament is pending presidential assent to become law, with significant international and domestic pressure urging the president to reject this discriminatory legislation \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. The bill, otherwise known as the \"Promotion of proper human sexual rights and Ghanaian Family Values Bill,\" imposes prison sentences for identifying as LGBTQ\u0026thinsp;+\u0026thinsp;and forming or funding LGBTQ\u0026thinsp;+\u0026thinsp;groups, with penalties of up to three years for individuals and up to five years for groups \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. The bill also proposes harsh measures like jail terms of up to 10 years for LGBTQ\u0026thinsp;+\u0026thinsp;advocacy campaigns aimed at children and encourages the public to report LGBTQ\u0026thinsp;+\u0026thinsp;individuals to authorities for action. These legal frameworks not only seemingly perpetuate discrimination but also create barriers to accessing essential healthcare services and support for transgender women. The criminalization of homosexuality in Ghana further entrenches societal prejudices and biases against LGBTQ\u0026thinsp;+\u0026thinsp;individuals, including transgender women \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMoreover, within the Ghanaian context, HIV stigma remains profoundly ingrained and fueled by misconceptions, fear, limited knowledge, and the association of HIV with sin and death \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Persons living with HIV often endure rejection, insults, violence, and sometimes denial of health care, resulting in social isolation, restricted healthcare access, and reluctance to seek treatment, ultimately exacerbating the HIV epidemic \u003csup\u003e\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn healthcare settings, pervasive stigma and discrimination against trans women in Ghana persist, attributed to factors such as a lack of cultural competence among healthcare workers, absence of LGBTQI-specific training in the healthcare sector, and ingrained societal prejudices \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. Many healthcare providers in sub-Saharan Africa lack the understanding and sensitivity required to address the unique health needs of trans women, often leading to discriminatory practices or reluctance to provide appropriate care \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. For instance, research across Kenya, Malawi, and South Africa revealed that nearly half (45.3%) of the men who have sex with men (MSM) and transgender women (TGW) reported at least one healthcare-related stigma experience \u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. In South Africa, transgender individuals encountered stigma while accessing reproductive healthcare, while other transfeminine and gender-diverse women faced discrimination due to their gender identity and expression\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. They described hostile health services, with unrelated health issues often linked to gender or sexual identity, causing discomfort. In Uganda, transgender women experienced various forms of stigma, including police and client violence, workplace and familial discrimination, and a lack of tailored health services\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThese challenges faced by key populations are exacerbated, especially for those residing in urban areas, particularly within slum communities \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan additionalcitationids=\"CR40 CR41 CR42 CR43\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e, as residing in these areas, further increases the risk of HIV infection among this population \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e. Urban slums are informal settlement and pose a multitude of social and structural challenges that amplify vulnerability to HIV, which include crowded living conditions, discrimination, poverty, limited HIV knowledge, high rates of transactional sex, and limited healthcare access \u003csup\u003e\u003cspan additionalcitationids=\"CR47 CR48\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e. Notably, certain slum areas within Ghana's capital, Accra, such as Agbogboloshie (5%), Okai Koi North (8%), and Madina (7%), report a higher HIV prevalence, averaging 7% compared to the national prevalence of 1.7% \u003csup\u003e6,41\u003c/sup\u003e. Trans women in these areas are likely to have low HIV testing rates due to poor access to services, low HIV risk perception, lower education levels, and poverty \u003csup\u003e\u003cspan additionalcitationids=\"CR51 CR52\" citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAdditionally, in low-resource settings, the impact of stigma on healthcare access is even more pronounced, presenting a significant barrier to service utilization compared to other contexts\u003csup\u003e\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e. Healthcare-related stigma not only leads to avoidance of healthcare services but also adds discomfort and stress, adversely affecting health outcomes\u003csup\u003e\u003cspan additionalcitationids=\"CR56\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e. For instance, in Ghana, intersectional stigma and discrimination experienced by key populations not only deters them from seeking healthcare services, resulting in delayed diagnosis and treatment of physical health conditions, but also contributes to increased rates of depression, anxiety, and other mental health issues, as well as social exclusion and isolation \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e. Furthermore, stigma and discrimination experienced by transgender individuals in other low-income settings have been linked to adverse health effects, including depressive symptoms, anxiety, suicidality, substance abuse, condomless sex and increased HIV transmission \u003csup\u003e\u003cspan additionalcitationids=\"CR60\" citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eResearch specifically focused on trans women, especially those living in slum communities, in Ghana is limited, with most studies focusing on gay, bisexual, other men who have sex with men, and female sex workers \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e,\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e. This paper seeks to address this knowledge gap by offering a qualitative exploration of HIV testing and care experiences within the context of trans women living in Ghanaian urban slums, which can have significant implications for public health interventions and policy development. Identifying the unique challenges and barriers encountered by trans women can contribute to the design of more inclusive and practical strategies to combat the spread of HIV in this vulnerable population.\u003c/p\u003e\n\u003ch3\u003eTheoretical framework\u003c/h3\u003e\n\u003cp\u003eGrounded in the gender-affirmative model, we aim to highlight the nuanced landscape of HIV testing experiences among trans women living in Ghanaian slums, emphasizing both the supportive and challenging aspects of their experiences \u003csup\u003e\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u003c/sup\u003e. Recognizing the fundamental principles of the gender-affirmative model, which prioritize the affirmation of gender identity, empowerment, and the mitigation of stigma and discrimination \u003csup\u003e\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e, this study seeks to report on the positive and negative HIV testing experiences within this marginalized community \u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e. By centering the voices and lived experiences of trans women, we seek to identify the facilitators and barriers to accessing HIV testing services. The ultimate goal is to provide actionable insights that can guide policymakers, healthcare providers, and community organizations to enhance the accessibility, acceptability, and effectiveness of HIV testing services, ensuring they meet the specific needs of trans women in Ghanaian slums.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003eResearch design\u003c/h2\u003e\n\u003cp\u003eWe employed a qualitative descriptive interview design to explore HIV testing and healthcare experiences among 20 trans women living in urban slums in the Greater Accra Metropolitan Area of Ghana. This design was selected for its suitability in capturing the complex, nuanced experiences of trans women in urban slums\u0026mdash;a population whose voices are seldom heard in traditional research.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eSampling and recruitment procedure\u003c/h2\u003e\n\u003cp\u003eIn this study, participants were recruited using purposive and snowball sampling techniques. Leveraging the established relationships with key populations, particularly transgender women in our target slum communities, research assistants from our partner community organization facilitated recruitment. The initial cohort of participants was identified through existing contacts within the transgender women community. Subsequently, a snowball sampling approach was utilized, with these initial participants referring other eligible individuals from within their social networks.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e\n\u003cp\u003eEligibility criteria for participation required trans women to reside in an urban slum in Accra, self-identify as transgender, be aged 18 or older and have engaged in sexual activity with a male within the past year. Individuals not biologically born male or residing outside urban slum communities in the Greater Accra Metropolitan Area were excluded from the study.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eData collection procedure\u003c/h2\u003e\n\u003cp\u003eData collection involved face-to-face interviews with trans women participants, and were collected between the months of May 2023 and June 2023. Before the interviews, eligible individuals were provided with information sheets detailing the study and given a choice to sign consent forms, with research assistants offering additional clarification and reminders about consent during the process. All interviews occurred in secure community partner locations, with nine out of 20 conducted in Twi, a local Ghanaian language, and the remainder in English. The sample size of 20 participants was determined to be sufficient for this qualitative study as data saturation was achieved, indicating that no new significant themes was identified after the 15th interview, thus ensuring comprehensive coverage of the experiences within the target population.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eNature of questions\u003c/h2\u003e\n\u003cp\u003eTo ensure a comprehensive exploration of HIV testing experiences among transgender women in urban slums, an interview guide was developed collaboratively with experts in urban slum communities research, healthcare practice, and transgender engagement. The guide included open-ended questions and prompts aimed at eliciting narratives about positive and negative experiences encountered during HIV testing. Sample questions included: When last did you test for HIV in your community? What were your experiences like during your last HIV test? What positive experiences have you had at HIV testing sites in your community? Could you describe any challenges or negative experiences you've faced while seeking HIV testing services in your community?\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eAnalytical strategy\u003c/h2\u003e\n\u003cp\u003eInterviews were recorded and transcribed verbatim by research assistants, with translations from Twi to English undertaken by experienced team members who had previously performed such translations in prior studies \u003csup\u003e \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e66\u003c/span\u003e \u003c/sup\u003e. Data analysis was conducted using NVivo, following a meticulous approach. Initially, a team of six research assistants developed a comprehensive codebook, which was refined collaboratively, and the first five transcripts were coded collectively. Subsequently, the remaining transcripts were divided, with two team members independently coding each transcript to ensure inter-coder reliability and capture nuances in the data. Coding comparisons were utilized to maintain consistency and validate decisions, with any discrepancies resolved through team discussions. This iterative process ensured the reliability and validity of the analytical findings. Throughout, diligent efforts were made to de-identify the data during transcription to adhere to ethical guidelines. After careful data comparison in NVivo, key themes representing main patterns and significant findings were identified. All monetary amounts quoted were converted using the prevailing exchange rate at the time of data collection (US$1\u0026thinsp;=\u0026thinsp;GH₵12).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eand informed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval\u0026nbsp;for this study was obtained from the Research Subjects Review Board (RSRB) at the University of Rochester University (STUDY00008151) and the Ghana Health Service Ethics Review Committee (GHS-ERC:002/03/23). In addressing the ethical considerations specific to the vulnerable population of trans women in urban slums, our study implemented several protective measures. Recognizing the heightened risks of stigma and discrimination, we ensured that all participant interactions, from recruitment through interviews, were conducted with utmost confidentiality and respect. Beyond standard informed consent procedures, we employed stringent data de-identification techniques and secure data handling practices to safeguard participant identities. Interviews were held in secure, private locations chosen by participants to ensure their comfort and safety. Additionally, research assistants were specially trained in sensitive communication and handling potentially distressing topics, ensuring that discussions did not exacerbate participants' vulnerabilities. These measures collectively aimed to uphold the dignity and safety of participants while collecting vital data on their HIV testing experiences.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDescription of participants\u003c/h2\u003e \u003cp\u003eThe participants in our study consisted of 20 trans women with a mean age of 20 years, ranging from 18 to 31. Educational backgrounds varied, with 10 participants having completed secondary education, four with tertiary education, five with primary education, and one without any formal education. All were employed, earning an average monthly income of GH₵830.15 (\u003cspan\u003e$\u003c/span\u003e69.2), with incomes ranging from GH₵200 (\u003cspan\u003e$\u003c/span\u003e16.7) to GH₵2003 (\u003cspan\u003e$\u003c/span\u003e166.91). In terms of religious affiliation, the majority were religious: 15 identified as Christians, four were non-religious, and one practiced Islam. Regarding sexual behavior, 19 participants reported having exclusively male sexual partners over the past year, and one reported having partners of both sexes. Although the study did not explicitly inquire about HIV status to avoid potential stigma, three participants voluntarily disclosed that they were living with HIV.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDescription of Categories and Subcategories\u003c/h2\u003e \u003cp\u003eTwo main categories emerged: Positive Experiences with HIV Testing, and Negative Experiences with HIV Testing. Under Positive Experiences, subcategories included a Welcoming Environment at healthcare facilities, Counseling and Relatability with HIV-positive nurses, and Inclusive, Informative, and Supportive Counseling. Negative Experiences encompassed Fear and Anxiety in HIV Testing and Negative Health Worker Attitude. These categories provide a framework for understanding the varied experiences of trans women in Ghanaian slums regarding HIV testing.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePositive Experiences with HIV Testing.\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePositive experiences with HIV testing were mainly characterized by welcoming environment at healthcare facilities, relatability with nurses, and inclusive, informative, and supportive counselling.\u003c/p\u003e \u003cp\u003e\u003cb\u003eWelcoming environment at the healthcare facility.\u003c/b\u003e Some participants reported feeling welcomed and cared for by healthcare staff during HIV testing at the health facility. One participant mentioned meeting a nurse who was welcoming and provided reassurance during their waiting period for test results. The participant highlighted the positive impact of a nurse who offered counseling during the waiting period for test results. Notably, the nurse's reassuring words, delivered by a white nurse as mentioned by the participant, not only relieved the participant's anxiety but also provided confidence to navigate potentially reactive outcomes, emphasizing the importance of supportive care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThey are so welcoming. They are so nice. Yeah. And they are good too. Like they take time to take care of us. When you go there, they have patience. I met this nurse. She's White though. And then she was very welcoming. She started counseling with me while my results were pending. I was nervous and scared. But when I walked in, she was like, baby keep calm, relax, there's nothing to be afraid of. When you're reactive, there are ways to go by to live as long as you're supposed to live. And so, like her words actually calm me down and like, I am in for this and I'm okay. - (Trans woman, 23, Christian)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eCounseling and relatability with HIV positive nurse\u003c/b\u003e. In another positive encounter, a participant shared an experience with a nurse who exceeded the standard testing procedure. The nurse explained the importance of consistent medication adherence, healthy lifestyle choices, and even shared her own positive HIV status. This disclosure aimed to eliminate the social stigma surrounding HIV, emphasizing that with proper medication and care, individuals with HIV can lead fulfilling lives without facing rejection.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBefore I began my medications, they conducted the tests again. One of the nurses took me to a different room and told me that for HIV, if you take your medications, it won't progress. Make sure to take your medications on time, eat healthy, and drink lots of water. This is what will keep you healthy. If you miss your medications or fail to eat well, it can bring your system down. She asked if I would believe her if she told me she had HIV, and I said no. What shows she has HIV? She revealed her status as positive to me, but I didn't believe it because she looked very fine. She is a very nice woman without any visible signs of HIV. So, when it was time to check the viral load, she did it on herself before and her results were positive. This calmed me down greatly as I realized that if you have HIV, you are not rejected in society because HIV is better than some diseases. As long as you take your medications, no one would know. \u0026ndash; (Trans woman, 19, Christian)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eInclusive, informative and Supportive Counseling\u003c/b\u003e. Participants shared positive encounters with nurses who modeled informative and supportive counseling that went beyond the technical aspects of HIV testing. One trans woman recounted a positive interaction with a nurse who engaged in a comprehensive discussion about sexual orientation, gender identity and provided education on HIV and PrEP. This holistic approach to testing not only covered the technical aspects of the procedure but also delved into broader topics such as safe sexual relationships, highlighting the importance of comprehensive healthcare interactions for trans women in their journey through HIV testing. Another participant shared a positive account of their HIV testing experience at the health facility. The participant expressed that the atmosphere during the HIV test was serene and comfortable. The participant recounted the supportive response they received upon learning of their positive test result. The nurse provided consolation and supportive counseling, establishing a human connection beyond the clinical aspects of the test.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI went there. I met a nurse and then she asked me my sexual orientation, my gender identity, and then she educated me on HIV and PrEP and then told me the outcome... um, whatever was going to come. So, we did the testing and while waiting for the results, she engaged me in conversations about safe sexual relationships. So, the results came and then I was fine. \u0026ndash; (Trans woman, 26, Christian)\u003c/p\u003e\u003cp\u003eWhen I went to test for HIV It was serene it was okay the nurse was cool with me, they did not do anything to make me feel like not going there again. because they took me through counseling first, after they counseled me and then like, we had a friendly chat. And then I did the test and after the test came out positive the nurse consoled me, and we still talk because he took my number then he will be checking on me and then when the time is due for me to take my medication, they let me know then I go for it. As for me I see them to open their door for us to come in whilst to get to check our health status without any problem. \u0026ndash; (Trans woman, 22, Christian)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eNegative Experiences with HIV Testing.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eNegative experiences with HIV testing were mainly characterized by participant's own fear and anxiety about testing outcomes and negative healthcare worker attitude at the health facility.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFear, and anxiety in HIV testing.\u003c/b\u003e Fear and anxiety are prevalent among trans women seeking HIV testing services, as reported by participants in the study. They recount uncomfortable situations, experiencing terror during HIV testing, particularly when faced with delays and the need for multiple retests. These encounters led trans women to speculate about receiving a positive diagnosis, intensifying their apprehension. One participant shared her distressing experience, stating. Moreover, some trans women attributed their fear to witnessing the emotional reactions of others diagnosed with HIV at the same clinic. This communal anxiety heightened their own apprehension about undergoing testing, as expressed by another participant. Additionally, participants pointed out that interactions with healthcare providers, including intrusive questioning, often contributed to the fear and apprehension they felt during the testing process.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI was very terrified. We were there, they took the test and my result wasn't coming. It was delayed and they said I had to redo the test. They did it and they were like they were not getting the result, so I had to do it again for the third time and at that point, I was scared the test was positive, and the health workers didn't want to tell me the truth. At that point, I was like, okay, let me accept the fact that I am positive till the result came out that they wanted to confirm because the first one wasn't successful, the second one was negative and they wanted to confirm it was negative so that is why they did the third one.\u0026ndash; (Transgender Woman, 18, Christian)\u003c/p\u003e\u003cp\u003eMy experience was with the people around. Some were scared of being tested. I was also scared of being tested. Because you know, when someone has it, they come out and then cry. It's very sad, but you can't do anything about it, it has happened. So, all you need is to console the person and say something sensible to the person so that the person will be okay.\u0026ndash; (Transgender Woman, 26, Christian)\u003c/p\u003e\u003cp\u003eIn the health facilities, sometimes they put fear in you. The nurses put fear in you. Like, ask you what have you been doing and all that. So, when the test is run, sometimes you sit down to think about the people you have sex with, looking at their bodies and wondering if they might be having HIV \u0026ndash; (Trans woman, 31, Christian)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eNegative health worker attitude.\u003c/b\u003e Participants highlighted instances of encountering negative attitudes from healthcare staff, particularly when seeking care at hospitals based on their feminine appearance. This phenomenon was notably pronounced in healthcare facilities that were not identified as trans-friendly. In these settings, trans women reported experiences where healthcare workers exhibited unwelcoming behaviors, staring awkwardly and conveying negative body language, thereby creating a hostile environment. Participants described situations where, especially in non-trans-friendly facilities, healthcare workers made them feel unwelcome based on their feminine appearance. The body language of nurses, including prolonged stares and scrutinizing glances from top to bottom, spoke negatively without any verbal communication. Participants recounted instances where they experienced judgment and gossip from nurses in a hospital that was not trans-friendly. Despite the norm of receiving attention in the Outpatient Department, they faced reluctance and had to assert themselves before receiving any care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMostly when I visit a health facility which is not key population oriented for testing, the workers there make you feel like you shouldn't be attended to because of the way you appear looking feminine. Sometimes too, their body language, you know, when you are at the facility, they can look at you from top to bottom. Without saying anything, their body language is speaking to you negatively.\u0026ndash; (Trans woman, 24, Christian)\u003c/p\u003e\u003cp\u003eThere was an instance when I went to the hospital that was not key population friendly for testing, and all of a sudden, everyone was looking at me, because of the way I dressed. Everyone was looking. The nurses started gossiping. I sat there for about one hour until I approach them to tell them why I was there. But on a normal basis, you know, you go through the Out Patient Department, and a nurses will attend to you. In my case no one wanted to attend to me due to how I looked and identified myself. I had to approach them before I was attended to.\u0026ndash; (Trans woman, 25, Muslim).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study offer valuable insights into the experiences of trans women in Ghanaian slums regarding HIV testing, contextualized within the gender-affirmative model. Our findings resonate with the principles of the gender-affirmative model, emphasizing the significance of the healthcare environment, counseling, and healthcare provider attitudes in shaping the HIV testing experiences of trans women.\u003c/p\u003e \u003cp\u003eConsistent with existing literature and the principles of the gender-affirmative model, which emphasizes affirmation of gender identity, empowerment, and mitigation of stigma and discrimination, our findings highlight the importance of creating a welcoming environment within healthcare settings. \u003csup\u003e\u003cspan additionalcitationids=\"CR68\" citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e A welcoming environment serves as a practical application of these principles by affirming and validating the gender identities of trans women, alleviating anxiety, building confidence, and fostering trust during the HIV testing process, thereby encouraging regular healthcare engagement, which is essential for continuous HIV prevention and treatment. \u003csup\u003e\u003cspan additionalcitationids=\"CR71 CR72\" citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e The presence of supportive and empathetic healthcare providers, as mentioned by some trans women in this study has also been shown to foster trust and encourage individuals to seek HIV testing, thereby promoting HIV prevention and care \u003csup\u003e\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e,\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e,\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe significance of counseling and peer support in healthcare settings has been widely recognized in the literature as a key factor in enhancing the HIV testing experiences of trans women and men who have sex with men. \u003csup\u003e\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e,\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e\u003c/sup\u003e Our findings corroborate this, emphasizing the importance of counseling and relatability in reducing stigma, providing emotional support, and promoting positive health outcomes. Sharing personal experiences, as demonstrated by the HIV-positive nurse in our study, can be a valuable strategy for reducing the social stigma surrounding HIV and promoting medication adherence and healthy lifestyle choices among people living with HIV. By integrating counseling and peer support within a gender-affirmative framework, healthcare providers can create a supportive and affirming environment that addresses the unique needs and challenges faced by trans women in the context of HIV testing and care. This approach not only enhances the accessibility and acceptability of HIV testing services but also contributes to improving health outcomes and reducing health disparities among this population.\u003c/p\u003e \u003cp\u003eOur findings further highlight the value of inclusive, informative, and supportive counseling in creating a positive healthcare experience among trans women in Ghanaian slums. By fostering an environment that prioritizes affirmation of gender identity, empowerment, and the mitigation of stigma and discrimination, healthcare providers who engage in comprehensive discussions about sexual orientation, gender identity, and provide education on HIV and PrEP contribute to a more positive and empowering HIV testing experience for trans women. \u003csup\u003e\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e\u003c/sup\u003e This approach creates trust, builds rapport, and encourages open communication, promoting improved health outcomes and reducing health disparities in this population.\u003c/p\u003e \u003cp\u003eIn this study, we also found that fear and anxiety during HIV testing process, negative attitudes, and discriminatory practices of nurses were prevalent factors characterizing the negative experiences of trans women in Ghanaian slums. Fear and anxiety during the HIV testing process, as reported by the participants in our study, have been identified in previous research as common experiences across various populations and found to be significant barriers to HIV testing. \u003csup\u003e\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e,\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e\u003c/sup\u003e These findings underscore the need for healthcare facilities to improve their testing procedures and communication strategies to minimize anxiety and fear. Effective communication, transparency about the testing process, and timely delivery of results are essential to alleviate anxiety and promote a more positive testing experience. \u003csup\u003e\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e,\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFurthermore, negative attitudes and discriminatory practices within healthcare settings have been consistently reported by trans women and are considered a significant barrier to accessing healthcare services, including HIV testing, among trans women. \u003csup\u003e\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e,\u003cspan additionalcitationids=\"CR84 CR85 CR86\" citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e\u003c/sup\u003e These negative experiences can lead to avoidance of healthcare services, delayed HIV testing, and reduced engagement in HIV care, which ultimately contribute to health disparities and poorer health outcomes among trans women. \u003csup\u003e\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e,\u003cspan additionalcitationids=\"CR84 CR85 CR86\" citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e\u003c/sup\u003e. In line with the gender affirmative model, these findings highlight the urgent need for healthcare facilities to address and eliminate discriminatory practices and attitudes toward trans women. Healthcare providers must receive comprehensive training on key population health issues, cultural competence, and respectful communication to ensure equitable and inclusive care and promote a more positive and welcoming healthcare experience for trans women.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study contributes to the literature on the HIV testing experiences of trans women in Ghanaian slums and highlights the need for healthcare facilities to address discriminatory practices and attitudes towards trans women and create a welcoming and affirming environment within healthcare settings to enhance HIV testing experiences and promote improved health outcomes and reduced health disparities in this population. Enhancing the accessibility, acceptability, and effectiveness of HIV testing services for trans women in Ghanaian slums requires a multifaceted approach that integrates the principles of the gender-affirmative model. These approaches include comprehensive training for healthcare providers, the creation of inclusive and affirming healthcare environments, and the provision of culturally competent, respectful care that addresses the unique needs and challenges faced by trans women. By adopting these strategies, policymakers, healthcare providers, and community organizations can contribute to reducing health disparities and improving the overall wellbeing of trans women in Ghanaian slums\u003c/p\u003e "},{"header":"Strengths and Limitations","content":"\u003cp\u003eThis study notably contributes to the field by focusing on the often-underrepresented HIV testing experiences of trans women in urban slums within Ghana, employing the gender-affirmative model to validate and respect gender identities. The qualitative interview approach allowed for an in-depth exploration of the personal and social nuances associated with HIV testing, which quantitative methods might fail to capture. Additionally, the collaboration with local community organizations not only facilitated access to this hard-to-reach population but also ensured that our methodology was culturally sensitive and tailored to the specific needs of the participants. However, the study has limitations. It does not fully explore the intersectional factors such as ethnicity, socioeconomic status, and education level that might influence HIV testing experiences and outcomes. To address this, we acknowledge these gaps and recommend them as focal points for future research, and we have initiated discussions with community partners to integrate some of these considerations in ongoing programs. The geographical scope is also limited to the Greater Accra Metropolitan Area, which may restrict the generalizability of the findings. Future research should aim to include other regions to enhance the breadth of data and applicability of the findings. Additionally, the use of snowball sampling and a relatively small sample size may introduce selection bias and limit the diversity within the sample. Despite these potential biases, we utilized rigorous qualitative methods to ensure the reliability of our findings and plan to employ more diverse sampling techniques in future studies to improve the representativeness of the sample.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBaral SD, Poteat T, Str\u0026ouml;mdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. \u003cem\u003eLancet Infect Dis\u003c/em\u003e. 2013;13(3):214-222. doi:10.1016/S1473-3099(12)70315-8\u003c/li\u003e\n\u003cli\u003eAli H, Amoyaw F, Baden D, et al. Ghana\u0026rsquo;s HIV epidemic and PEPFAR\u0026rsquo;s contribution towards epidemic control. \u003cem\u003eGhana Med J\u003c/em\u003e. 2019;53(1):59-62. doi:10.4314/gmj.v53i1.9\u003c/li\u003e\n\u003cli\u003eGhana AIDS Commission. Ghana Aids Commission Ghana Men \u0026rsquo; S Study II. Published online 2017.\u003c/li\u003e\n\u003cli\u003ePAHO. PAHO urges testing as the first step towards preventing HIV and halting the AIDS epidemic. Published online 2018.\u003c/li\u003e\n\u003cli\u003eMarsh K, Eaton JW, Mahy M, et al. Global, regional and country-level 90\u0026ndash;90\u0026ndash;90 estimates for 2018: assessing progress towards the 2020 target. \u003cem\u003eAIDS\u003c/em\u003e. 2019;33.\u003c/li\u003e\n\u003cli\u003eGhana AIDS Commission. National HIV/AIDS strategic plan (2016 \u0026ndash; 2020). Published online 2016.\u003c/li\u003e\n\u003cli\u003eGyamerah AO, Taylor KD, Atuahene K, et al. Stigma, discrimination, violence, and HIV testing among men who have sex with men in four major cities in Ghana. \u003cem\u003eAIDS Care\u003c/em\u003e. 2020;32(8):1036-1044. doi:10.1080/09540121.2020.1757020\u003c/li\u003e\n\u003cli\u003eZigah EY, Abu-Ba\u0026rsquo;are GR, Shamrock OW, et al. \u0026ldquo;For my safety and wellbeing, I always travel to seek health care in a distant facility\u0026rdquo;\u0026mdash;the role of place and stigma in HIV testing decisions among GBMSM \u0026ndash; BSGH 002. \u003cem\u003eHealth Place\u003c/em\u003e. 2023;83:103076. doi:https://doi.org/10.1016/j.healthplace.2023.103076\u003c/li\u003e\n\u003cli\u003eAbubakari GM, Turner D, Ni Z, et al. Community-based interventions as opportunities to increase HIV self-testing and linkage to care among men who have sex with men\u0026ndash;lessons from Ghana, West Africa. \u003cem\u003eFront Public Health\u003c/em\u003e. 2021;9:660256.\u003c/li\u003e\n\u003cli\u003ede Villiers L, Thomas A, Jivan D, et al. Stigma and HIV service access among transfeminine and gender diverse women in South Africa - a narrative analysis of longitudinal qualitative data from the HPTN 071 (PopART) trial. \u003cem\u003eBMC Public Health\u003c/em\u003e. 2020;20(1):1898. doi:10.1186/s12889-020-09942-5\u003c/li\u003e\n\u003cli\u003eShabalala SB, Campbell MM. The complexities of trans women\u0026rsquo;s access to healthcare in South Africa: moving health systems beyond the gender binary towards gender equity. \u003cem\u003eInt J Equity Health\u003c/em\u003e. 2023;22(1):231. doi:10.1186/s12939-023-02039-6\u003c/li\u003e\n\u003cli\u003eMehta SD, Otieno FO, Kimani J, et al. Transgender women in Kenya experience greater stigma, depressive symptoms, alcohol and drug use and risky sexual practices than cis-gendered men who have sex with men. \u003cem\u003eBMC Public Health\u003c/em\u003e. 2023;23(1):1493. doi:10.1186/s12889-023-16348-6\u003c/li\u003e\n\u003cli\u003eSnyman T. \u003cem\u003eThe Protection of African Transgender Women\u0026rsquo;s Rights to Dignity, Life and Health through a Teleological Reading of the Maputo Protocol\u003c/em\u003e. 2019. doi:10.13140/RG.2.2.29831.47525\u003c/li\u003e\n\u003cli\u003eMuwanguzi PA, Otiku PK, Nabunya R, Gausi B. Implementation and effectiveness of transgender stigma reduction interventions in sub-Saharan Africa: A scoping review. \u003cem\u003eJ Glob Health Rep\u003c/em\u003e. 2023;7:1-15. doi:10.29392/001c.72080\u003c/li\u003e\n\u003cli\u003eBanks WD. Queering Ghana: Sexuality, community, and the struggle for cultural belonging in an African nation. Published online 2013.\u003c/li\u003e\n\u003cli\u003eKushwaha S, Lalani Y, Maina G, et al. \u0026ldquo;But the moment they find out that you are MSM\u0026hellip;\u0026rdquo;: a qualitative investigation of HIV prevention experiences among men who have sex with men (MSM) in Ghana\u0026rsquo;s health care system. \u003cem\u003eBMC Public Health\u003c/em\u003e. 2017;17(1):1-18.\u003c/li\u003e\n\u003cli\u003eNgubane SJ. Gender Roles in the African Culture : Implications for the Spread of Hiv / Aids. \u003cem\u003eStellenbosch University\u003c/em\u003e. 2010;1(March):1-7.\u003c/li\u003e\n\u003cli\u003eShamrock OW. \u003cem\u003eDisability, Religion and Work among Vulnerable Populations: An Inquiry of Women Experiences and Perspectives\u003c/em\u003e. State University of New York at Binghamton; 2022.\u003c/li\u003e\n\u003cli\u003eShamrock OW, Dakpui HD, Agbemedu GRK, et al. \u0026ldquo;I\u0026rsquo;m scared of the nurses telling other people I am a transwoman\u0026rdquo;: Disclosure and nondisclosure of gender identity among trans women in Ghana\u0026rsquo;s urban slums\u0026ndash;BSGH010. Published online 2024.\u003c/li\u003e\n\u003cli\u003eDulani B, Sambo G, Dionne KY. Good neighbours? Africans express high levels of tolerance for many, but not for all. Published online 2016.\u003c/li\u003e\n\u003cli\u003eOdoi A. Homophobic violence in Ghana: When and where it counts. \u003cem\u003eSexuality research and social policy\u003c/em\u003e. Published online 2021:1-10.\u003c/li\u003e\n\u003cli\u003eDada D, Abu-Ba\u0026rsquo;are GR, Turner DA, et al. Scoping review of HIV-related intersectional stigma among sexual and gender minorities in sub-Saharan Africa. \u003cem\u003eBMJ Open\u003c/em\u003e. 2024;14(2):e078794. doi:10.1136/bmjopen-2023-078794\u003c/li\u003e\n\u003cli\u003eHagopian A, Rao D, Katz A, Sanford S, Barnhart S. Anti-homosexual legislation and HIV-related stigma in African nations: what has been the role of PEPFAR? \u003cem\u003eGlob Health Action\u003c/em\u003e. 2017;10(1):1306391. doi:10.1080/16549716.2017.1306391\u003c/li\u003e\n\u003cli\u003eGovernment of Ghana. \u003cem\u003eCriminal Code, 1960 (Act 29)\u003c/em\u003e.; 1960.\u003c/li\u003e\n\u003cli\u003eLyons CE, Rwema JOT, Makofane K, et al. Associations between punitive policies and legal barriers to consensual same-sex sexual acts and HIV among gay men and other men who have sex with men in sub-Saharan Africa: a multicountry, respondent-driven sampling survey. \u003cem\u003eLancet HIV\u003c/em\u003e. Published online 2023.\u003c/li\u003e\n\u003cli\u003eColeman TE, Ako EY, Kyeremateng JG. A human rights critique of Ghana\u0026rsquo;s Anti-LGBTIQ+ Bill of 2021. \u003cem\u003eAfrican Human Rights Law Journal\u003c/em\u003e. 2023;23(1):96-125.\u003c/li\u003e\n\u003cli\u003eAvagah R. Analysis of the Anti Gay Bill Captioned\u0026rsquo;The Promotion of Proper Human Sexual Rights and Ghanaian Family Values Bill\u0026rsquo;in Light of Kwame Nkrumah\u0026rsquo;s Philosophical Consciencism\u0026ndash;LGQBTI Versus the African (Ghanaian) Culture. \u003cem\u003eAvailable at SSRN 4368789\u003c/em\u003e. Published online 2022.\u003c/li\u003e\n\u003cli\u003eAtuguba R. Homosexuality in Ghana: Morality, Law, Human Rights. \u003cem\u003eJ Politics Law\u003c/em\u003e. 2019;12:113. doi:10.5539/jpl.v12n4p113\u003c/li\u003e\n\u003cli\u003eOsse L. Ghanaians are united and hospitable but intolerant towards same-sex relationships. Published online 2021.\u003c/li\u003e\n\u003cli\u003eAsiedu GB. \u003cem\u003e\u0026ldquo;Once It\u0026rsquo;s Your Sister, They Think It\u0026rsquo;s in the Bloodline\u0026rdquo;: Impact of HIV/AIDS-Related Stigma in Ghana\u003c/em\u003e. Kansas State University; 2010.\u003c/li\u003e\n\u003cli\u003eArmstrong-Mensah E, Ofori E, Alema-Mensah E, Agyarko-Poku T. HIV destigmatization: perspectives of people living with HIV in the Kumasi Metropolis in Ghana . \u003cem\u003eFrontiers in Reproductive Health \u003c/em\u003e. 2023;5.\u003c/li\u003e\n\u003cli\u003eJames P, Hayfron-Benjamine A, Abdulai M, Lasim O, Yvonne N, Obiri-Yeboah D. Predictors of HIV stigma among health workers in the Cape Coast metropolis, Ghana. \u003cem\u003eJ Public Health Afr\u003c/em\u003e. 2020;11(1):1020. doi:10.4081/jphia.2020.1020\u003c/li\u003e\n\u003cli\u003eGyamerah AO, Kinzer E, Aidoo-Frimpong G, et al. PrEP knowledge, acceptability, and implementation in Ghana: Perspectives of HIV service providers and MSM, trans women, and gender diverse individuals living with HIV. \u003cem\u003ePLOS global public health\u003c/em\u003e. 2023;3(6):e0001956. doi:10.1371/journal.pgph.0001956\u003c/li\u003e\n\u003cli\u003eNelson LRE, Nyblade L, Torpey K, et al. Multi-level intersectional stigma reduction intervention to increase HIV testing among men who have sex with men in Ghana: Protocol for a cluster randomized controlled trial. \u003cem\u003ePLoS One\u003c/em\u003e. 2021;16(11 November):1-20. doi:10.1371/journal.pone.0259324\u003c/li\u003e\n\u003cli\u003eAbubakari GM, Owusu-Dampare F, Ogunbajo A, et al. HIV Education, Empathy, and Empowerment (HIVE(3)): A Peer Support Intervention for Reducing Intersectional Stigma as a Barrier to HIV Testing among Men Who Have Sex with Men in Ghana. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e. 2021;18(24). doi:10.3390/ijerph182413103\u003c/li\u003e\n\u003cli\u003eMbeda C, Ogendo A, Lando R, et al. Healthcare-related stigma among men who have sex with men and transgender women in sub-Saharan Africa participating in HIV Prevention Trials Network (HPTN) 075 study. \u003cem\u003eAIDS Care\u003c/em\u003e. 2020;32(8):1052-1060. doi:10.1080/09540121.2020.1776824\u003c/li\u003e\n\u003cli\u003eLuvuno ZPB, Ncama B, Mchunu G. Transgender population\u0026rsquo;s experiences with regard to accessing reproductive health care in Kwazulu-Natal, South Africa: A qualitative study. \u003cem\u003eAfr J Prim Health Care Fam Med\u003c/em\u003e. 2019;11(1):e1-e9. doi:10.4102/phcfm.v11i1.1933\u003c/li\u003e\n\u003cli\u003eSsekamatte T, Isunju JB, Naume M, et al. Barriers to access and utilisation of HIV/STIs prevention and care services among trans-women sex workers in the greater Kampala metropolitan area, Uganda. \u003cem\u003eBMC Infect Dis\u003c/em\u003e. 2020;20(1):932. doi:10.1186/s12879-020-05649-5\u003c/li\u003e\n\u003cli\u003eShamrock OW, Abu-Ba\u0026rsquo;are GR, Zigah EY, et al. Community stigma, victimization, and coping strategies among gays, bisexuals, and other cis-gender men who have sex with men in slum communities in Ghana. Published online 2023.\u003c/li\u003e\n\u003cli\u003eAbu-Ba\u0026rsquo;are GR, Zigah EY, Shamrock OW, et al. Qualitative description of interpersonal HIV stigma and motivations for HIV testing among gays, bisexuals, and men who have sex with men in Ghana\u0026rsquo;s slums - BSGH-005. \u003cem\u003emedRxiv\u003c/em\u003e. Published online January 1, 2023. doi:10.1101/2023.07.29.23293357\u003c/li\u003e\n\u003cli\u003eCassels S, Jenness SM, Biney AAE, Ampofo WK, Dodoo FNA. Migration, sexual networks, and HIV in Agbogbloshie, Ghana. \u003cem\u003eDemogr Res\u003c/em\u003e. 2014;31(28):861-888.\u003c/li\u003e\n\u003cli\u003eAbu-Ba\u0026rsquo;are GR, Torpey K, Nelson L, et al. Adaptation and feasibility of Many Men Many Voices (3MV), an HIV prevention intervention to reduce intersectional stigma and increase HIVST among YSMM residing in Ghanaian slums\u0026ndash;A clustered pre-post pilot trial protocol. Published online 2024.\u003c/li\u003e\n\u003cli\u003eShamrock OW, Abu-Ba\u0026rsquo;are GR, Zigah EY, et al. Family rejection of non-hetero sexuality\u0026ndash;Sexual orientation and behavior anonymity among sexual minority men in slum communities-BSGH 001. \u003cem\u003ePLOS Global Public Health 3: e0001659 doi:101371/journal.pgph0001659\u003c/em\u003e. Published online December 1, 2023.\u003c/li\u003e\n\u003cli\u003eAbu-Ba\u0026rsquo;are GR, Shamrock OW, Apreku A, et al. Awareness and Willingness to use Condoms and Preexposure Prophylaxis among Gay, Bisexual, and Other Cisgendered Men who Have sex with men in Slum Communities in Ghana. BSGH-004. \u003cem\u003eJournal of the International Association of Providers of AIDS Care (JIAPAC)\u003c/em\u003e. 2023;22:23259582231209650. doi:10.1177/23259582231209649\u003c/li\u003e\n\u003cli\u003eMadise NJ, Ziraba AK, Inungu J, et al. Are slum dwellers at heightened risk of HIV infection than other urban residents? Evidence from population-based HIV prevalence surveys in Kenya. \u003cem\u003eHealth Place\u003c/em\u003e. 2012;18(5):1144\u0026ndash;1152.\u003c/li\u003e\n\u003cli\u003eJennings L, Mathai M, Linnemayr S, et al. Economic Context and HIV Vulnerability in Adolescents and Young Adults Living in Urban Slums in Kenya: A Qualitative Analysis Based on Scarcity Theory. \u003cem\u003eAIDS Behav\u003c/em\u003e. 2017;21(9):2784-2798. doi:10.1007/s10461-017-1676-y\u003c/li\u003e\n\u003cli\u003eKhan MAU, Kubra TJ, Sharmin Z, Hossen MA. Displacement and deplorable living conditions of slum dwellers: with special reference to Sylhet city. \u003cem\u003eInternational Letters of Social and Humanistic Sciences\u003c/em\u003e. 2015;46:51-64. doi:https://doi.org/10.18052/www.scipress.com/ILSHS.46.51\u003c/li\u003e\n\u003cli\u003eMadise NJ, Ziraba AK, Inungu J, et al. Are slum dwellers at heightened risk of HIV infection than other urban residents? Evidence from population-based HIV prevalence surveys in Kenya. \u003cem\u003eHealth Place\u003c/em\u003e. 2012;18(5):1144-1152.\u003c/li\u003e\n\u003cli\u003eKabiru CW, Beguy D, Crichton J, Zulu EM. HIV/AIDS among youth in urban informal (slum) settlements in Kenya: What are the correlates of and motivations for HIV testing? \u003cem\u003eBMC Public Health\u003c/em\u003e. 2011;11(1):685. doi:10.1186/1471-2458-11-685\u003c/li\u003e\n\u003cli\u003eAtinga RA, Abiiro GA, Kuganab-Lem RB. Factors influencing the decision to drop out of health insurance enrolment among urban slum dwellers in Ghana. \u003cem\u003eTrop Med Int Health\u003c/em\u003e. 2015;20(3):312-321. doi:10.1111/tmi.12433\u003c/li\u003e\n\u003cli\u003eDarteh E, Kumi-Kyereme A, Awusabo-Asare K. Perception of Risk of HIV among Adolescents\u0026rsquo; Living in an Urban Slum in Ghana. \u003cem\u003eAfr J Reprod Health\u003c/em\u003e. 2016;20. doi:10.29063/ajrh2016/v20i1.6\u003c/li\u003e\n\u003cli\u003eKaibarta S, Mandal S, Mandal P, Bhattacharya S, Paul S. Multidimensional poverty in slums: an empirical study from urban India. \u003cem\u003eGeoJournal\u003c/em\u003e. 2022;87(4):527-549. doi:10.1007/s10708-021-10571-7\u003c/li\u003e\n\u003cli\u003eOwusu-Ansah FE, Tagbor H, Togbe MA. Access to health in city slum dwellers: The case of Sodom and Gomorrah in Accra, Ghana. \u003cem\u003eAfr J Prim Health Care Fam Med\u003c/em\u003e. 2016;8(1):e1-7. doi:10.4102/phcfm.v8i1.822\u003c/li\u003e\n\u003cli\u003eMekonen T, Chan GCK, Belete T, et al. Mental health service utilization in a low resource setting: A qualitative study on perspectives of health professionals in Northwest Ethiopia. \u003cem\u003ePLoS One\u003c/em\u003e. 2022;17(11):e0278106.\u003c/li\u003e\n\u003cli\u003eAbu-Ba\u0026rsquo;are GR, Aidoo-Frimpong G, Stockton M, et al. \u0026ldquo;I told myself, be bold and go and test\u0026rdquo;: Motivators and barriers to HIV testing among gay, bisexual, and other cis-gender men who have sex with men in Ghana ‒ West Africa. \u003cem\u003ePLOS Global Public Health\u003c/em\u003e. 2024;4(1):e0002231. doi:10.1371/journal.pgph.0002231\u003c/li\u003e\n\u003cli\u003eOsman Wumpini Shamrock, Henry Delali Dakpui, George Rudolph Kofi Agbemedu, et al. \u003cem\u003e\u0026ldquo;I\u0026rsquo;m Scared of the Nurses Telling Other People I Am a Transwoman\u0026rdquo;: Disclosure and Nondisclosure of Gender Identity among Trans Women in Ghana\u0026rsquo;s Urban Slums\u0026ndash; BSGH010\u003c/em\u003e.; 2024. Accessed April 19, 2024. https://doi.org/10.21203/rs.3.rs-4243840/v1\u003c/li\u003e\n\u003cli\u003eZigah EY, Abu-Ba\u0026rsquo;are GR, Shamrock OW, et al. \u0026ldquo;For my safety and wellbeing, I always travel to seek health care in a distant facility\u0026rdquo;\u0026mdash;the role of place and stigma in HIV testing decisions among GBMSM \u0026ndash; BSGH 002. \u003cem\u003eHealth Place\u003c/em\u003e. 2023;83:103076. doi:10.1016/j.healthplace.2023.103076\u003c/li\u003e\n\u003cli\u003eAbu-Ba\u0026rsquo;are G, Aidoo-Frimpong G, Stockton M, et al. \u003cem\u003e\u0026ldquo;I Told Myself, Be Bold and Go and Test\u0026rdquo;: Motivators and Barriers to HIV Testing among Gays, Bisexuals, and All Other Men Who Sex with Men in Ghana \u0026ndash; West Africa\u003c/em\u003e.; 2023. doi:10.1101/2023.07.12.23292583\u003c/li\u003e\n\u003cli\u003eWhite Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. \u003cem\u003eSoc Sci Med\u003c/em\u003e. 2015;147:222-231. doi:10.1016/j.socscimed.2015.11.010\u003c/li\u003e\n\u003cli\u003eOkonkwo N, Rwema JOT, Lyons C, et al. The Relationship Between Sexual Behavior Stigma and Depression Among Men Who have Sex with Men and Transgender Women in Kigali, Rwanda: a Cross-sectional Study. \u003cem\u003eInt J Ment Health Addict\u003c/em\u003e. 2022;20(6):3228-3243. doi:10.1007/s11469-021-00699-5\u003c/li\u003e\n\u003cli\u003eLin Y, Xie H, Huang Z, et al. The mental health of transgender and gender non-conforming people in China : a systematic review. \u003cem\u003eLancet Public Health\u003c/em\u003e. 2021;6(12):e954-e969. doi:10.1016/S2468-2667(21)00236-X\u003c/li\u003e\n\u003cli\u003eOgunbajo A, Kershaw T, Kushwaha S, Boakye F, Wallace-Atiapah ND, Nelson LE. Barriers, Motivators, and Facilitators to Engagement in HIV Care Among HIV-Infected Ghanaian Men Who have Sex with Men (MSM). \u003cem\u003eAIDS Behav\u003c/em\u003e. 2018;22(3):829-839. doi:10.1007/s10461-017-1806-6\u003c/li\u003e\n\u003cli\u003eEdwards-Leeper L, Leibowitz S, Sangganjanavanich VF. Affirmative practice with transgender and gender nonconforming youth: Expanding the model. \u003cem\u003ePsychol Sex Orientat Gend Divers\u003c/em\u003e. 2016;3(2):165.\u003c/li\u003e\n\u003cli\u003eSevelius JM. Gender Affirmation: A Framework for Conceptualizing Risk Behavior among Transgender Women of Color. \u003cem\u003eSex Roles\u003c/em\u003e. 2013;68(11-12):675-689. doi:10.1007/s11199-012-0216-5\u003c/li\u003e\n\u003cli\u003eSevelius J, Chakravarty D, Neilands TB, et al. Evidence for the Model of Gender Affirmation: The Role of Gender Affirmation and Healthcare Empowerment in Viral Suppression Among Transgender Women of Color Living with HIV. \u003cem\u003eAIDS Behav\u003c/em\u003e. 2021;25(Suppl 1):64-71. doi:10.1007/s10461-019-02544-2\u003c/li\u003e\n\u003cli\u003eAbubakari GM, Turner D, Nelson LE, et al. An application of the ADAPT-ITT model to an evidence-based behavioral HIV prevention intervention for men who have sex with men in Ghana. \u003cem\u003eInternational Health Trends and Perspectives\u003c/em\u003e. 2021;1(1):1-16.\u003c/li\u003e\n\u003cli\u003eKeo-Meier CE, Ehrensaft DE. Introduction to the gender affirmative model. Published online 2018.\u003c/li\u003e\n\u003cli\u003eFauk NK, Hawke K, Mwanri L, Ward PR. Stigma and discrimination towards people living with HIV in the context of families, communities, and healthcare settings: a qualitative study in Indonesia. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e. 2021;18(10):5424.\u003c/li\u003e\n\u003cli\u003eSevelius JM, Patouhas E, Keatley JG, Johnson MO. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. \u003cem\u003eAnn Behav Med\u003c/em\u003e. 2014;47(1):5-16. doi:10.1007/s12160-013-9565-8\u003c/li\u003e\n\u003cli\u003eKwame A, Petrucka PM. A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward. \u003cem\u003eBMC Nurs\u003c/em\u003e. 2021;20(1):158. doi:10.1186/s12912-021-00684-2\u003c/li\u003e\n\u003cli\u003eDouglas CH, Douglas MR. Patient-friendly hospital environments: exploring the patients\u0026rsquo; perspective. \u003cem\u003eHealth Expect\u003c/em\u003e. 2004;7(1):61-73. doi:10.1046/j.1369-6513.2003.00251.x\u003c/li\u003e\n\u003cli\u003eFauk NK, Merry MS, Putra S, Sigilipoe MA, Crutzen R, Mwanri L. Perceptions among transgender women of factors associated with the access to HIV/AIDS-related health services in Yogyakarta, Indonesia. \u003cem\u003ePLoS One\u003c/em\u003e. 2019;14(8):e0221013.\u003c/li\u003e\n\u003cli\u003eGardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. \u003cem\u003eClin Infect Dis\u003c/em\u003e. 2011;52(6):793-800. doi:10.1093/cid/ciq243\u003c/li\u003e\n\u003cli\u003eLin C, Li L, Wan D, Wu Z, Yan Z. Empathy and avoidance in treating patients living with HIV/AIDS (PLWHA) among service providers in China. \u003cem\u003eAIDS Care\u003c/em\u003e. 2012;24(11):1341-1348. doi:10.1080/09540121.2011.648602\u003c/li\u003e\n\u003cli\u003eGu J, Lau JTF, Wang Z, Wu AMS, Tan X. Perceived empathy of service providers mediates the association between perceived discrimination and behavioral intention to take up HIV antibody testing again among men who have sex with men. \u003cem\u003ePLoS One\u003c/em\u003e. 2015;10(2):e0117376. doi:10.1371/journal.pone.0117376\u003c/li\u003e\n\u003cli\u003eChen S, Fang Y, Chan PS fong, Kawuki J, Mo P, Wang Z. Counseling Supporting HIV Self-Testing and Linkage to Care Among Men Who Have Sex With Men: Systematic Review and Meta-Analysis. \u003cem\u003eJMIR Public Health Surveill\u003c/em\u003e. 2024;10:e45647. doi:10.2196/45647\u003c/li\u003e\n\u003cli\u003eJamil MS, Prestage G, Fairley CK, et al. Effect of availability of HIV self-testing on HIV testing frequency in gay and bisexual men at high risk of infection (FORTH): a waiting-list randomised controlled trial. \u003cem\u003eLancet HIV\u003c/em\u003e. 2017;4(6):e241-e250. doi:10.1016/S2352-3018(17)30023-1\u003c/li\u003e\n\u003cli\u003eMcAuliffe M, Baker D, D\u0026rsquo;Aoust R. Improving healthcare quality for transgender patients in the perioperative setting: The patient\u0026rsquo;s perspective. \u003cem\u003eJ Perioper Pract\u003c/em\u003e. 2022;33(6):164-170. doi:10.1177/17504589221133937\u003c/li\u003e\n\u003cli\u003eBass B, Nagy H. Cultural Competence in the Care of LGBTQ Patients. In: ; 2023.\u003c/li\u003e\n\u003cli\u003eRael CT, Giguere R, Lopez-Rios J, et al. Transgender Women\u0026rsquo;s Experiences Using a Home HIV-Testing Kit for Partner-Testing. \u003cem\u003eAIDS Behav\u003c/em\u003e. 2020;24(9):2732-2741. doi:10.1007/s10461-020-02829-x\u003c/li\u003e\n\u003cli\u003eKobrak P, Remien RH, Myers JE, et al. Motivations and Barriers to Routine HIV Testing Among Men Who Have Sex with Men in New York City. \u003cem\u003eAIDS Behav\u003c/em\u003e. 2022;26(11):3563-3575. doi:10.1007/s10461-022-03679-5\u003c/li\u003e\n\u003cli\u003eBrown L, Macintyre K, Trujillo L. Interventions to reduce HIV/AIDS stigma: what have we learned? \u003cem\u003eAIDS Educ Prev\u003c/em\u003e. 2003;15(1):49-69. doi:10.1521/aeap.15.1.49.23844\u003c/li\u003e\n\u003cli\u003eLogie C, Lacombe-Duncan A, Brien N, et al. Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston, Jamaica: a qualitative study. \u003cem\u003eJ Int AIDS Soc\u003c/em\u003e. 2017;20. doi:10.7448/IAS.20.1.21385\u003c/li\u003e\n\u003cli\u003eFalck F, Br\u0026auml;nstr\u0026ouml;m R. The significance of structural stigma towards transgender people in health care encounters across Europe: Health care access, gender identity disclosure, and discrimination in health care as a function of national legislation and public attitudes. \u003cem\u003eBMC Public Health\u003c/em\u003e. 2023;23(1):1031. doi:10.1186/s12889-023-15856-9\u003c/li\u003e\n\u003cli\u003eBoonyapisomparn N, Manojai N, Srikummoon P, Bunyatisai W, Traisathit P, Homkham N. Healthcare discrimination and factors associated with gender-affirming healthcare avoidance by transgender women and transgender men in Thailand: findings from a cross-sectional online-survey study. \u003cem\u003eInt J Equity Health\u003c/em\u003e. 2023;22(1):31. doi:10.1186/s12939-023-01843-4\u003c/li\u003e\n\u003cli\u003eClark KD, Lunn MR, Bosse JD, et al. Societal stigma and mistreatment in healthcare among gender minority people: a cross-sectional study. \u003cem\u003eInt J Equity Health\u003c/em\u003e. 2023;22(1):162. doi:10.1186/s12939-023-01975-7\u003c/li\u003e\n\u003cli\u003eSkuban-Eiseler T, Orzechowski M, Steger F. Why do transgender individuals experience discrimination in healthcare and thereby limited access to healthcare? An interview study exploring the perspective of German transgender individuals. \u003cem\u003eInt J Equity Health\u003c/em\u003e. 2023;22(1):211. doi:10.1186/s12939-023-02023-0\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Rochester","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"HIV, Testing, ART, Trans women, Healthcare, Urban slums, Ghana ","lastPublishedDoi":"10.21203/rs.3.rs-4390892/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4390892/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAchieving the UNAIDS 90\u0026ndash;90\u0026ndash;90 targets hinges on identifying and engaging individuals with HIV in care, requiring 90% of those infected to be diagnosed, initiated on ART, and achieving viral suppression. Despite this imperative, HIV testing services as well as research in Ghana often overlook the unique experiences of transgender women in urban slums, impacting their engagement with care. Using the gender affirmative model lens, this study reports the HIV testing experiences of trans women in Ghanaian slums, highlighting how the healthcare environment, counseling, and healthcare provider attitudes shape these experiences.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative descriptive interview design was employed, involving 20 trans women aged 18 to 31 years living in urban slums in the Greater Accra Metropolitan Area of Ghana. Participants were recruited using purposive and snowball sampling techniques. Data were collected through face-to-face interviews, transcribed verbatim, and analyzed using NVivo. Results were presented in categories and subcategories.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwo main categories emerged from our data analysis: 1) Positive Experiences with HIV Testing, and 2) Negative Experiences with HIV Testing. Positive experiences with HIV testing among trans women in Ghanaian slums included a welcoming environment at healthcare facilities, supportive counseling, and relatability with HIV-positive nurses. Negative experiences were characterized by fear and anxiety during testing, often intensified by healthcare worker attitudes, including unwelcoming behaviors and judgmental body language, especially in facilities that are not key population friendly. These categories provided a framework for understanding the varied experiences of trans women in Ghanaian slums regarding HIV testing.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe study emphasizes the urgent need for healthcare facilities in Ghanaian slums to address discriminatory practices and attitudes towards trans women, fostering a welcoming and affirming environment. Adopting a multifaceted approach integrating the gender-affirmative model's principles is crucial to enhancing HIV testing experiences and achieving improved health outcomes for trans women. Policymakers and healthcare providers must prioritize comprehensive training, inclusive healthcare environments, and culturally competent care to mitigate health disparities among this population.\u003c/p\u003e","manuscriptTitle":"A qualitative description of HIV testing and healthcare experiences among trans women in Ghanaian urban slums BSGH-011","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-09 08:01:00","doi":"10.21203/rs.3.rs-4390892/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7d573235-4bc4-4eb9-8cdc-b46b8cdda1a7","owner":[],"postedDate":"May 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":31690007,"name":"Women's studies"}],"tags":[],"updatedAt":"2024-05-09T08:21:57+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-09 08:01:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4390892","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4390892","identity":"rs-4390892","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}