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Background Transgender (trans) women face constrained access to gender-affirming HIV prevention and care. This is fueled in part by the convergence of limited trans knowledge and competency with anti-trans and HIV-related stigmas among social and healthcare providers. To advance gender-affirming HIV service delivery we implemented and evaluated ‘Transgender Education for Affirmative and Competent HIV and Healthcare (TEACHH)’. This theoretically-informed community-developed intervention aimed to increase providers’ gender-affirming HIV prevention and care knowledge and competency and reduce negative attitudes and biases among providers towards trans women living with and/or affected by HIV. Methods Healthcare and social service providers and providers in-training (e.g., physicians, nurses, social workers) working with trans women living with and/or affected by HIV (n = 78) participated in a non-randomized multi-site pilot study evaluating TEACHH with a pre-post-test design. Pre- and post-intervention surveys assessed participant characteristics, intervention feasibility (e.g., workshop completion rate) and acceptability (e.g., willingness to attend another training). Paired sample t-tests were conducted to assess pre-post intervention differences in perceived competency, attitudes/biases, and knowledge to provide gender-affirming HIV care to trans women living with HIV and trans persons. Results The intervention was feasible (100% workshop completion) and acceptable (91.9% indicated interest in future gender-affirming HIV care trainings). Post-intervention scores indicated significant improvement in: 1) knowledge, attitudes/biases and perceived competency in gender-affirming HIV care (score mean difference (MD) 8.49 (95% CI of MD: 6.12–10.86, p < 0.001, possible score range: 16–96), and 2) knowledge, attitudes/biases and perceived competency in gender-affirming healthcare (MD = 3.21; 95% CI of MD: 1.90–4.90, p < 0.001, possible score range: 9–63). Greater change in outcome measures from pre- to post-intervention was experienced by those with fewer trans and transfeminine clients served in the past year, in indirect service roles, and having received less prior training. Conclusions This brief healthcare and social service provider intervention showed promise in improving gender-affirming provider knowledge, perceived competency, and attitudes/biases, particularly among those with less trans and HIV experience. Scale-up of TEACHH may increase access to gender-affirming health services and HIV prevention and care, increase healthcare access, and reduce HIV disparities among trans women. Trial registration ClinicalTrials.gov (NCT04096053).

Violence is a known driver of HIV vulnerability among transgender (trans) women, who are disproportionately impacted by HIV globally. Violence is also a barrier to accessing HIV prevention, treatment, and support. Yet, little is known about the everyday experiences of violence faced by trans women living with HIV, who live at the intersection of a marginalized gender identity and physical health condition. To address this gap, this study draws on semi-structured, individual interviews conducted 2017–2018 with a purposive sample (selected based on diverse identities) of trans women living with HIV ( n = 11) participating in a large, community-based cohort study in three Canadian provinces. Framework analysis was used to identify key themes, patterns within themes between participants, and patterns across themes among participants. Findings showed that trans women living with HIV experience specific contexts of violence shaped at the intersection of stigma based on gender identity, gender expression, and HIV status, among other identities/experiences. Violence experienced in childhood (e.g., familial rejection, bullying) increased trans women’s likelihood of being exposed to a violent social context in young adulthood (e.g., state violence perpetuated by the police, interpersonal violence perpetuated by sexual partners, and community violence perpetuated by society-at-large/the general public), which increased trans women’s HIV vulnerability; once living with HIV trans women were subjected to discursive violence from healthcare providers. These multiple forms of violence have serious consequences for trans women living with HIV’s ongoing social, mental, and physical well-being. The findings suggest that interventions are urgently needed to reduce violence against trans women in childhood and young adulthood, in addition to reducing violence against trans women living with HIV perpetuated by healthcare providers in adulthood, to both proactively and responsively promote their safety, health, and well-being.

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