title: Leveraging social capital: multilevel stigma, associated HIV vulnerabilities, and social resilience strategies among transgender women in Lima, Peru.
abstract: In Peru, transgender women (TW) experience unique vulnerabilities for HIV infection due to factors that limit access to, and quality of, HIV prevention, treatment and care services. Yet, despite recent advances in understanding factors associated with HIV vulnerability among TW globally, limited scholarship has examined how Peruvian TW cope with this reality and how existing community-level resilience strategies are enacted despite pervasive social and economic exclusion facing the community. Addressing this need, our study applies the understanding of social capital as a social determinant of health and examines its relationship to HIV vulnerabilities to TW in Peru.
  
  
  
  Using qualitative methodology to provide an in-depth portrait, we assessed (1) intersections between social marginalization, social capital and HIV vulnerabilities; and (2) community-level resilience strategies employed by TW to buffer against social marginalization and to link to needed HIV-related services in Peru. Between January and February 2015, 48 TW participated (mean age = 29, range = 18-44) in this study that included focus group discussions and demographic surveys. Analyses were guided by an immersion crystallization approach and all coding was conducted using Dedoose Version 6.1.18.
  
  
  
  Themes associated with HIV vulnerability included experiences of multilevel stigma and limited occupational opportunities that placed TW at risk for, and limited their engagement with, existing HIV services. Emergent resiliency-based strategies included peer-to-peer and intergenerational knowledge sharing, supportive clinical services (e.g. group-based clinic attendance) and emotional support through social cohesion (i.e. feeling part of a community).
  
  
  
  This study highlights the importance of TW communities as support structures that create and deploy social resiliency-based strategies aimed at deterring and mitigating the impact of social vulnerabilities to discrimination, marginalization and HIV risk for individual TW in Peru. Public health strategies seeking to provide HIV prevention, treatment and care for this population will benefit from recognizing existing social capital within TW communities and incorporating its strengths within HIV prevention interventions. At the intersection of HIV vulnerabilities and collective agency, dimensions of bridging and bonding social capital emerged as resiliency strategies used by TW to access needed healthcare services in Peru. Fostering TW solidarity and peer support are key components to ensure acceptability and sustainability of HIV prevention and promotion efforts.
authors.affiliation: Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY, USA.
authors.forename: Amaya G
authors.initials: AG
authors.lastname: Perez-Brumer
authors.affiliation: The Fenway Institute, Fenway Health, Boston, MA, USA.|Division of General Pediatrics, Boston Children's Hospital/Harvard Medical School, Boston, MA, USA.|Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
authors.forename: Sari L
authors.initials: SL
authors.lastname: Reisner
authors.affiliation: The Fenway Institute, Fenway Health, Boston, MA, USA.
authors.forename: Sarah A
authors.initials: SA
authors.lastname: McLean
authors.affiliation: Universidad Peruana Cayetano Heredia, Lima, Peru.
authors.forename: Alfonso
authors.initials: A
authors.lastname: Silva-Santisteban
authors.affiliation: Epicentro, Lima, Peru.
authors.forename: Leyla
authors.initials: L
authors.lastname: Huerta
authors.affiliation: The Fenway Institute, Fenway Health, Boston, MA, USA.
authors.forename: Kenneth H
authors.initials: KH
authors.lastname: Mayer
authors.affiliation: Asociación Civil Impacta Salud y Educación, Lima, Peru.|Department of Global Health, University of Washington, Seattle, WA, USA.|Centro de Investigaciones Tecnologicas, Biomedicas y Medioambientales, Lima, Peru.
authors.forename: Jorge
authors.initials: J
authors.lastname: Sanchez
authors.affiliation: Department of Medicine, Division of Infectious Diseases, University of California Los Angeles, Los Angeles, CA, USA.
authors.forename: Jesse L
authors.initials: JL
authors.lastname: Clark
authors.affiliation: The Fenway Institute, Fenway Health, Boston, MA, USA.|The Institute for Community Health Promotion, Brown University School of Public Health, Providence, RI, USA.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Mimiaga
authors.affiliation: Asociación Civil Impacta Salud y Educación, Lima, Peru.|Department of Global Health, University of Washington, Seattle, WA, USA.
authors.forename: Javier R
authors.initials: JR
authors.lastname: Lama
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D017144:Focus Groups; D015658:HIV Infections / Q000188:drug therapy / Q000628:therapy; D006801:Humans; D010568:Peru; D066270:Social Capital; D062487:Social Marginalization; D057545:Social Stigma; D063106:Transgender Persons / Q000523:psychology; D055815:Young Adult; D008297:Male
keywords: HIV vulnerability; Peru; Transgender women; community strategies; resiliency; social capital