Healthy Divas: Improving Engagement in HIV Care for High-risk Transgender Women

Abstract: Trans women are disproportionately impacted by HIV and have culturally unique barriers and facilitators to engagement in HIV care. Trans women living with HIV (hereafter:  TWH) are less likely than other populations 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; TWH are less likely to be virally suppressed than any other behavioral risk group. 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. Healthy Divas is a randomized controlled trial, grounded in Models of Gender Affirmation and Health Care Empowerment, that compares the Healthy Divas intervention to a treatment as usual (TAU) control condition. The Healthy Divas intervention is a combination of 6 individual sessions, completed within 3 months, with a peer counselor and a peer-led group workshop with other TWH, a HIV primary care provider, and a transgender health care provider. TWH (N=286) who are confirmed HIV-positive and show evidence of suboptimal engagement in care, defined as meeting one or more of the following three indicators: a) not on ART, b) on ART but reporting non-adherence, c) reporting no HIV care appointments in the prior 6 months, are enrolled at either the San Francisco site or the Los Angeles site (n=143/site). The primary outcome is virologic control. The specific aims are: 1) To evaluate rates of virologic control for TWH in response to the Healthy Divas intervention; 2) To evaluate the efficacy of the intervention on HIV treatment engagement among TWH; and, 3) To explore the effect of the intervention on hypothesized mechanisms of action. The randomized two-group design uses repeated assessments at baseline and at 3-, 6-, 9-, and 12-month post-randomization follow-up.