Recommendations to Advance Equitable Access to HIV Prevention, Treatment, and Support: A Qualitative Study of the Experiences of Transgender Women and Service Providers

Background and Purpose: Transgender (trans) women experience a disproportionate prevalence of HIV due to social and structural inequality (e.g., anti-trans stigma), and multiple barriers to HIV prevention, treatment, and support, relative to cisgender (cis) people. The vast majority of research has focused only on the perspectives of trans women, despite that barriers are most often described at provider (e.g., provider stigma), organizational (e.g., lack of trans-inclusive policies), and/or systems levels (e.g., lack of research focused on the needs of trans women). Thus, this study sought to compare perspectives of trans women and service providers to promote a shared vision for addressing healthcare barriers and achieving equitable access to HIV care among trans women. Social workers may utilize these findings to identify barriers and facilitators to HIV care access within their organizations, and to promote the adoption of recommendations grounded in community and provider perspectives.

Methods: In this community-based participatory qualitative study, 60-90-minute focus groups were conducted with trans women (n=26) and 30-70-minute semi-structured individual interviews were conducted with health and social service providers (n=10) 2018-2019 to understand barriers and facilitators to HIV prevention, treatment, and support experienced by trans women. A team comprised of cis and trans authors utilized a thematic approach to data analysis and identified six high-level themes (four barriers and three facilitators). After completion of data analysis, the team generated recommendations to improve access to HIV prevention, treatment, and support.

Results: Barriers to HIV prevention, treatment, and support 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/organizations and (d) cisnormativity in sexual healthcare. Facilitators included: (a) provision of trans-positive 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. Within each theme, intersectional considerations were captured, such as how barriers and facilitators were experienced by trans women impacted by intersecting stigmas (e.g., racism, sex work stigma).

Conclusions and Implications: Results informed the development of specific recommendations to improve HIV care access for trans women, mapped specifically onto barriers and facilitators. For example, recommendations to address anticipated and enacted stigma in the provision of direct care included implementing trans-affirming HIV/STI screening and mandating provider training to reduce biases/attitudes and increase care competency. Another critical recommendation was to increase hours dedicated to trans health and HIV in medical and allied health (e.g., social work), programs, to address a lack of provider knowledge and experience. Importantly, increased funding to newly develop trans-specific services and organizations, led by trans people and trans leadership of existing services, were recommended to truly disrupt cisnormativity in sexual healthcare provision. These recommendations can be used by social workers in administrative and direct practice to work collaboratively with trans women to reduce barriers and facilitators to HIV care and ultimately to achieve health equity.