Gender-Affirmative Medical Care to Improve HIV Treatment Cascade Among Transgender Women

A three-phase sequential implementation science study that culturally tailored an informed consent model of transgender care integrating routine HIV prevention and treatment as part of cross-sex hormone therapy supported by peer health navigators for transgender women was implemented in Lima, Peru.

Adult individuals, ages ≥18 years, assigned a male sex at birth, who identified as male-to-female transgender or on the trans-feminine continuum, regardless of initiation or completion of gender enhancement procedures, were eligible to participate. The study target population was transgender women who were unaware of their HIV serostatus or were living with HIV but not engaged in routine HIV care.

Phase 1. Formative research.

Community Engagement and Education. Following principles of Good Participatory Practice to ensure ethical and scientific integrity, based on the specific needs of the target population and to enhance community engagement, a Task Force composed of transgender women community representatives was convened for the study. The Task Force informed the investigators on community issues, advised on study design, supported development of educational programs and campaigns, and facilitated collaborations with the study population. Tailored annual community engagement and education plans were designed in advance of study implementation to include: (1) formative research for stakeholder identification and educational material validation; (2) community awareness activities; and (3) study communication, including development of educational materials, community consultations, and communication of study results.

Mixed-Methods Formative Research. Formative research was conducted among transgender women to assess: (1) experiences accessing HIV prevention services and engagement in HIV primary care, including facilitators and barriers to medical access; (2) attitudes toward a peer navigation system to increase engagement in HIV care; (3) gender-affirmative procedures (experiences with previous and current use of hormone therapy, both personal experiences and community perspectives); (4) assessment of health care needs related to HIV care and gender-affirmation; and (5) attitudes toward having a dedicated facility to receive gender-affirmative care. Formative research also included healthcare professionals (including medical providers and administrators) to assess: (1) knowledge of and experience providing feminization hormone therapy for transgender woman patients; (2) feasibility and acceptability of providing cross-hormone therapy with the existing public health system; (3) acceptability and willingness to provide cross-sex hormone therapy; and (4) perceptions of stigma and discrimination resulting from providing hormone therapy to transgender women. Both transgender women and healthcare professionals were queried about: (1) perceived acceptability of intervention components; and (2) potential barriers to intervention success.