Transgender Status-Neutral Community-to-Clinic Models to End the HIV Epidemic

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TG persons, especially transgender women (TGW), have a high prevalence of HIV and lifetime risk of acquiring HIV. In 2019, 625 TGW and 45 transgender men (TGM) were diagnosed with HIV in the United States and 6 dependent areas.1 About half (51%) of these diagnoses were in persons aged 20-29 years. In the 2019-2020 National HIV Behavioral Surveillance Trans cycle, 42% of TGW tested positive for HIV.2 Racial/ethnic disparities in positivity were also found, with positivity rates of 62% among Black/African American (Black) TGW and 35% among Hispanic/Latina (Hispanic) TGW compared to 17% among White TGW.Despite the disproportionate burden of HIV among TGW, receipt of HIV prevention and care services have been suboptimal. Among TG persons, 92% reported that they were aware of PrEP but only 32% that they have used it.2 In 2019, viral suppression among persons with diagnosed HIV was 67% among TGW.3 Large proportions of TG persons were living at or below the poverty level, experienced homelessness, or exchanged sex for money or drugs.2 Large proportions of TGW also reported verbal or physical abuse, including by a sexual partner, and suicidal ideation and behavior.2 Substance use is prevalent in TG populations.4 All of these factors have an impact on access to and utilization of HIV prevention and care services. In addition, some clinical staff might lack TG cultural awareness, and this can be a barrier to TG persons remaining engaged in health care.Feminizing or masculinizing gender-affirming hormone therapy was reported by 72% of TGW, with an additional 20% wanting to take hormones.2 Many TG persons seek hormone therapy at TG clinics that serve as centers of excellence for TG health and well-being. These encounters provide opportunities for HIV education and counseling, HIV testing and risk assessment, status-neutral HIV services, sexually transmitted infection (STI) testing, and other health care services. HIV testing identifies HIV-negative persons who should be assessed for preexposure prophylaxis (PrEP) and nonoccupational postexposure prophylaxis (nPEP) indications,5,6 and if indicated, offered and prescribed PrEP or nPEP. Patients who seek care in TG clinics for gender-affirming services such as hormone therapy can be assessed for PrEP indications and offered PrEP. HIV testing can also identify persons with HIV for rapid antiretroviral therapy (ART) initiation. Some TG health care providers might lack experience with HIV prevention and treatment; conversely, some health care and CBO staff might not be familiar with transgender specific health needs such as gender-affirming services.TG CBOs might be better poised than TG clinics to reach TG persons who are not already engaged in HIV prevention or care services for HIV education and counseling, HIV testing, and referral to clinical services for PrEP, nPEP, ART, and gender-affirming services. TG CBOs can provide this critical connection with TG persons for HIV prevention services and help link them to TG clinics for community-to-clinic comprehensive health care services.In the proposed demonstration project, TG clinics and TG CBOs will work collaboratively to develop holistic models to provide health care and well-being services for TG men and women that include co-located HIV prevention and care, gender-affirming services including hormone therapy and other procedures, STI testing, hepatitis testing, preventive health care, and chronic disease care, and to ensure access to mental health and substance use disorder services and social support services. These services will be developed with trans-specific cultural awareness to ensure that TG persons feel welcomed, heard, and cared for.The recipients will also participate in a national learning collaborative to share lessons learned and best practices for TG clinic and TG CBO partnerships to provide status-neutral, community-to-clinic services for TG persons.

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