BACKGROUND: Transgender women (TGW) have high HIV risk but low engagement in care. Peer delivery is an effective strategy for increasing HIV and sexually transmitted infection (STI) testing, but it has not been evaluated for TGW in Uganda.

METHODS: We conducted formative research for a randomized trial of peer delivered HIV self-testing (HIVST), STI self-sampling and oral pre-exposure prophylaxis (PrEP) for TGW in Uganda (NCT04328025) between October 2019 and April 2020. Twenty in-depth interviews with TGW peers explored (a) barriers and facilitators of peer delivered combination HIV prevention, and (b) preferences for HIV/STI testing approaches and PrEP refills. Interviews were conducted in Luganda (local language) at a location convenient for the interviewee. They were audio recorded and transcribed verbatim to English by the interviewer. We used an inductive content analytic approach centering on descriptive category development to analyze the data and identify themes representing TGW preferences for HIV prevention delivery.
RESULTS: Four key themes that explain TGW preferences within a peer delivery system emerged from the qualitative data: (1) Peer training. TGW peers needed to be knowledgeable about the use and interpretation of HIV self-tests, PrEP adherence counseling and the correct way to self-collect samples for STI testing; (2) Confidentiality. Trust in peers to keep personal health information private was essential for successful delivery of HIV self-tests and PrEP refills, and for returning self-collected STI samples for laboratory testing; (3) Trans-friendly care. TGW peers and transgender-led drop-in-centers were perceived to be the most effective ways of distributing HIVST and PrEP refills and improving access to STI testing; (4) Stigma reduction. Peer delivered HIV services were seen as desirable because they would enable TGW to avoid stigma and discrimination experienced at health facilities from providers and other clients. Overall, the desired peer attributes for facilitating HIV/STI testing and PrEP use were confidentiality, trustworthiness, and practical knowledge of biomedical HIV prevention tools.
CONCLUSIONS: Peer delivery and trans-friendly care may help to overcome barriers to HIV/STI testing and PrEP use among TGW. Community-based strategies such as peer delivery and drop-in-centers may improve testing and PrEP outcomes and decrease HIV burden in this population.

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