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Background Transgender (trans) women are overrepresented among people living with HIV, yet trans women living with HIV (WLWH) experience lower access to HIV care. Access to medical transition may facilitate access to HIV care among trans WLWH. This study sought to describe barriers and facilitators to access to medical transition among trans WLWH. Methods: This convergent parallel mixed-methods study drew on cross-sectional quantitative data from 48 trans WLWH analysed using descriptive and bivariate analyses, as well as qualitative semistructured interview data from a subsample of 11 participants analysed using framework analysis. The primary outcome was self-reported transition experience (completed or in the process of medical transition vs planning to but have not begun medical transition). Quantitative and qualitative results were merged and analysed for convergence, divergence and/or expansion of understanding. Results: Just over half the participants reported being fully completed medical transition or in the process of medical transition (52.1% (25/48); 95% confidence interval (CI) 37.5–67.6%), with one-fifth reporting planning to but not having begun medical transition (18.8% (9/48); 95% CI 8.3–29.2%). Factors significantly associated with not having begun one’s medical transition included housing instability, transphobia, HIV-related stigma and barriers in access to care. Qualitative findings revealed varied transition experiences, influenced by community norms, passing and class privilege, HIV and structural barriers. Mixed-methods results showed positive relationships between trans WLWH and HIV care providers in terms of trans and HIV health care. Conclusions: HIV-related stigma and social determinants of health limit access to medical transition for trans WLWH. Stigma must be addressed in a broad range of healthcare settings, in addition to structural barriers, to increase access to gender-affirming HIV care and medical transition for trans WLWH.

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).

Transgender (trans) women experience barriers to access to HIV care, which result in their lower engagement in HIV prevention, treatment and support relative to cisgender people living with HIV. Studies of trans women's barriers to HIV care have predominantly focused on perspectives of trans women, while barriers are most often described at provider, organisation and/or systems levels. Comparing perspectives of trans women and service providers may promote a shared vision for achieving health equity. Thus, this qualitative study utilised focus groups and semi-structured interviews conducted 2018-2019 to understand barriers and facilitators to HIV care from the perspectives of trans women (n = 26) and service providers (n = 10). Barriers endorsed by both groups included: (a) anticipated and enacted stigma and discrimination in the provision of direct care, (b) lack of provider knowledge of HIV care needs for trans women, (c) absence of trans-specific services/organisations and (d) cisnormativity in sexual healthcare. Facilitators included: (a) provision of transpositive trauma-informed care, (b) autonomy and choice for trans women in selecting sexual health services and (c) models for trans-affirming systems change. Each theme had significant overlap, yet nuanced perspective, between trans women and service providers. Specific recommendations to improve HIV care access for trans women e34 | LACOMBE-DUNCAN Et AL.

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IntroductionEducational workshops are a promising strategy to increase healthcare providers’ ability to provide gender-affirming care for transgender (trans) people. This strategy may also reduce healthcare providers’ stigma towards trans people and people living with HIV. There is less evidence, however, of educational workshops that address HIV prevention and care among trans women. This protocol details development and pilot testing of the Transgender Education for Affirmative and Competent HIV and Healthcare intervention that aims to increase gender-affirming HIV care knowledge and perceived competency, and to reduce negative attitudes/biases, among providers.Methods and analysisThis community-based research (CBR) project involves intervention development and implementation of a non-randomised multisite pilot study with pre–post test design. First, we conducted a qualitative formative phase involving focus groups with 30 trans women and individual interviews with 12 providers to understand HIV care access barriers for trans women and elicit feedback on a proposed workshop. Second, we will pilot test the intervention with 90–150 providers (n=30–50×3 in-person settings). For pilot studies, primary outcomes include feasibility (eg, completion rate) and acceptability (eg, workshop satisfaction). Secondary preintervention and postintervention outcomes, assessed directly preceding and following the workshop, include perceived competency, attitudes/biases towards trans women with HIV, and knowledge needed to provide gender-affirming HIV care. Primary outcomes will be summarised as frequencies and proportions (categorical variables). We will conduct paired-sample t-tests to explore the direction of preintervention and postintervention differences for secondary outcomes.Ethics and disseminationThis study has been approved by the University of Toronto HIV Research Ethics Board (Protocol Number: 00036238). Study findings will be disseminated through community forums with trans women and service providers; manuscripts submitted to peer reviewed journals; and conferences. Findings will inform a larger CBR research agenda to remove barriers to engagement in HIV prevention/care among trans women across Canada.Trial registration numberNCT04096053; Pre-results.

Purpose: Transgender (trans) women of color's HIV vulnerabilities are shaped by social exclusion and intersectional stigma. There is a dearth of tailored HIV prevention interventions with trans women of color in Canada. The objective of the study was to explore trans women of color's HIV prevention priorities and to pilot test an intervention developed from these priorities.Methods: We conducted a qualitative implementation science study to develop HIV intervention strategies with trans women of color in Toronto, Canada. First, we conducted a focus group with trans women of color (n=8) to explore HIV prevention priorities. Second, we held a consultation with trans women of color community leaders (n=2). Findings informed the development of the TRANScending Love (T-Love) arts-based workshop that we pilot tested with three groups of trans women of color (n=18). Workshops were directly followed by focus groups to examine T-Love products and processes.Results: Focus group participants called for researchers to shift the focus away from trans women's bodies and HIV risks to address low self-acceptance produced by intersecting forms of stigma. The community leader consultation articulated the potential for strengths-focused arts-based approaches to address self-worth. T-Love participants described how workshops fostered self-acceptance and built connections between trans women of color.Conclusions: Findings demonstrate the feasibility and acceptability of an arts-based strategy with trans women of color to elicit group-based sharing of journeys to self-acceptance, fostering feelings of solidarity and connection. Providing opportunities for dialogue and reflection about individual and collective strengths may reduce internalized stigma among trans women of color.

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