Project Summary/Abstract:
Transgender (trans) women across the globe experience a disproportionate burden of HIV with an estimated
global HIV prevalence of 19%. Trans women living with HIV also have worse HIV care and treatment outcomes
than cisgender adults, including lower rates of viral suppression. Multilevel responses are needed to improve
HIV outcomes among trans women by simultaneously and synergistically addressing individual, provider, and
community dynamics. Trans women experience intersectional stigma due to the frequent association between
trans identity, HIV, and sex work. These intersecting forms of stigma include internalized stigma in the form of
applying negative beliefs and enacted stigma in the form of exclusion and discrimination. Developing social
cohesion can be a critical first step in community processes to address stigma. We adapted a multilevel
intervention, Abriendo Puertas (Opening Doors), including individual counseling, peer navigation, and
community mobilization for trans women living with HIV in the Dominican Republic using an iterative
consultation process. We assessed feasibility and initial effects on HIV care and treatment behaviors with 30
trans women living with HIV (no control group) and documented positive trends in ART use (70% to 85%,
p=0.03), missed care appointments (35% to 20%, p=0.39) and ART adherence (86% to 96%, p=0.50).
Participants emphasized that trusting intervention staff and being treated with respect in individual sessions
allowed them to improve self-esteem. Limited trust and cohesion among trans women, however, inhibited more
extensive engagement with peer navigation and community activities. In response, we identified two key
modifications to strengthen and further tailor the intervention for trans women living with HIV: 1) integrate more
gender affirming content, including with providers and 2) focus on building trust among trans women through
sequential implementation of individual and then community components. The purpose of the proposed study
is to conduct a pilot randomized trial of the GAP model, or Gender-affirming Abriendo Puertas. In Aim 1, we will
assess preliminary efficacy of the GAP intervention on viral suppression among trans women
randomized to the intervention compared to those randomized to control. We will randomly assign trans
women living with HIV to the GAP intervention (n=60) (individual counseling, peer navigation, provider training,
and community support building) or control group (n=60). We will conduct baseline, 6, and 12-month surveys
and viral load assessments to assess differences across study arms. In Aim 2, we will examine pathways of
influence (e.g. decreased stigma, increased cohesion) and experiences with the intervention to identify
specific areas for improvement and scale up. We will conduct longitudinal qualitative interviews at baseline,
6, and 12 months with 20 intervention participants and, together with surveys, assess how GAP participation
affects pathways between stigma, cohesion, and HIV outcomes. We will also elicit experiences and
recommendations from providers and intervention staff in focus groups at 6 (n=2) and 12 months (n=2).