Background: With increasing evidence of high HIV infection rates among transgender women (TW) worldwide, it is critical to improve their engagement in HIV primary care to achieve viral suppression. However, TW encounter numerous difficulties accessing healthcare, including stigma, provider bias, and a higher priority of seeking transgender-related care, where available.
Methods: The U.S. Department of Health and Human Services, through HRSA''s Special Projects of National Significance, funded nine demonstration sites to implement innovative interventions to engage TW living with HIV into care. The University of California, San Francisco Evaluation Center conducted key informant interviews to characterize organization-level strategies associated with successful interventions. Demonstration sites submitted information on individual-level intervention activities (screening, referrals, and services) provided to intervention participants and medical chart data on linkage, treatment, retention, and viral suppression (< 200 copies/mL) before and after intervention participation. We employed generalized estimating equations to identify intervention activities significantly associated with change in viral suppression at 24 months.
Results: Sites enrolled 858 TW into nine interventions, with 79% participating in intervention activities. TW participated in a median of 280 minutes (IQR=45-630 minutes) of activities. Viral suppression increased from 23% at baseline to 35% at 24 months. Common organization-level strategies included: transgender empowering environments and activities; TW in visible staff/mentoring roles; support for self-care of staff; and incentives to attend intervention activities and/or health services. Individual-level intervention activities associated with change in viral suppression at 24 months include: (1) screenings for: mental health diagnosis (aOR=4.15; 95% CI=1.23-13.95), substance abuse (aOR=0.41; 95% CI=0.26-0.65) or food insecurity (aOR=2.87; 95% CI=1.82-4.53); (2) referrals to: HIV primary care (aOR=2.22; 95% CI=1.17-4.20), mental health care (aOR=2.52; 95% CI=1.06-5.99) or food assistance (aOR=2.43; 95% CI=1.42-4.16); and (3) services: retention counseling (3.50; 95% CI=2.11-5.81) and employment (aOR=6.18; 95% CI=2.93-13.05).
Conclusions: Transgender-affirming care settings with TW staff and integration of HIV primary care with mental health screening and referrals; food insecurity screenings and services; HIV care referrals; and retention counseling and employment services were associated with increased viral suppression. The continued development, adaptation and scale up of integrated care interventions for this key population will be necessary to meet 90-90-90 goals.