"Stigma Is Still There": Healthcare Providers' Accounts of Multilevel Stigma Affecting Transgender Women's HIV Service Access in Ghana. BSGH 019

Abstract Background. Transgender women experience substantial barriers to HIV prevention, testing, treatment, and other healthcare services, with stigma operating across healthcare and broader social contexts. Although previous research has documented transgender women's experiences of stigma in Ghana and other settings, less is known about how healthcare providers perceive and describe the forms, sources, and consequences of stigma affecting transgender women's HIV-related healthcare access. This study examines healthcare providers' accounts of stigma affecting transgender women in Ghana. Methods. A qualitative study was conducted among 20 healthcare providers working in healthcare facilities in the Greater Accra Metropolitan Area of Ghana. Participants included nurses, midwives, laboratory personnel, a counselor, and a physician working across HIV-focused and general clinical services. Semi-structured in-depth interviews were conducted between May and June 2023. Interviews were audio-recorded, transcribed verbatim, translated into English where applicable, and analyzed thematically using NVivo. The Ecological Systems Framework guided the organization and interpretation of providers' accounts across individual, healthcare facility, community, and structural levels. Results. Healthcare providers described stigma affecting transgender women across four interconnected levels: individual, healthcare facility, community, and structural. At the individual level, providers described anticipated stigma, self-stigma, fear of disclosure, identity concealment, and fear of recognition as barriers to healthcare-seeking. At the healthcare facility level, providers reported ridicule, derogatory language, gossip, neglect, refusal of care, and healthcare arrangements that could increase the visibility of patients seeking HIV-related services. At the community level, providers described social rejection, surveillance, fear of exposure, and concerns about being recognized by relatives or acquaintances. At the structural level, providers linked the persistence of stigma to broader religious beliefs, cultural expectations, and sociocultural norms. Across these levels, providers perceived stigma as contributing to nondisclosure, delayed or avoided healthcare-seeking, interrupted engagement with HIV services, and discontinuity of care. Conclusions. Healthcare providers described stigma affecting transgender women as a multilevel phenomenon extending across individual, healthcare facility, community, and structural contexts. Their accounts suggest that anticipated judgment, discriminatory healthcare encounters, social exposure, and broader sociocultural conditions may interact to influence disclosure, healthcare-seeking, engagement with HIV-related services, and continuity of care. These findings provide a provider-centered perspective on how stigma is perceived to shape HIV-related healthcare access for transgender women in Ghana.