Improving Engagement in HIV Care for High-risk Women

Transgender women (assigned 'male' at birth but who do not identify as male) are
disproportionately impacted by HIV and have culturally unique barriers and facilitators to
engagement in HIV care. Transgender women living with HIV (TWH) are less likely than others
to take antiretroviral therapy (ART), and those who initiate ART have lower rates of ART
adherence, lower self-efficacy for integrating ART into daily routines, and report fewer
positive interactions with health care providers than non-transgender adults. As a result,
TWH have an almost three-fold higher viral load than non-transgender adults in San Francisco;
in Los Angeles, TWH are less likely to be virally suppressed than any other behavioral risk
group. In formative work, the investigators have identified culturally-specific and
modifiable barriers to HIV treatment engagement among TWH, including prioritization of
transition-related health care (i.e. hormone therapy) at the expense of HIV treatment,
avoidance of HIV care settings due to past negative health care experiences, misinformation
about ART including potential drug interactions with hormones, intensified HIV stigma, low
levels of social support, and poor coping skills. There are both individual and public health
consequences to poor engagement in care among TWH stemming from high transmission risk
factors, including substance abuse, high numbers of sex partners, engagement in sex work, and
high rates of mental illness. These findings strongly suggest that TWH face unique challenges
to engaging in and adhering to HIV treatment, and that the public health consequences for
poor engagement in this population are of grave concern. Interventions to mitigate these
barriers to engagement in care are critical in efforts to alter the pattern of HIV-related
disparities that lead to disproportionately poor health outcomes for this highly vulnerable
and marginalized population. The investigators are conducting a randomized controlled trial
of a theory-driven, population-specific, piloted intervention to improve engagement in care
for TWH. Grounded in the investigators' Models of Gender Affirmation and Health Care
Empowerment, the proposed research is the first to systematically intervene on complex
barriers to optimal engagement in HIV care for TWH. The investigators have developed and
piloted the Healthy Divas intervention to optimize engagement in HIV care for TWH at elevated
risk for treatment failure and consequential morbidity, mortality, and transmission of HIV.