The Landscape of Gender Affirmative Care in Community-Based HIV Service Organizations in the U.S. South

Background: Black and Brown Transgender and Gender Non-Conforming (TGNC) individuals living in the U.S. South are disproportionately impacted by the HIV epidemic (CDC, 2020). These health inequities are exacerbated by intersectional stigma and discriminatory policies, as evidenced by the acceleration of systemic racism (Blackstock, 2021; CDC, 2019) and over 200 pieces of anti-trans legislation (mostly in the U.S. South; ACLU, 2022). These policies and practices impede TGNC individuals’ access to and engagement in healthcare (Baral, Beyrer, & Poteat, 2011). Gender Affirmative Care (GAC) is a person-centered approach that provides social and structural recognition, validation, psychological safety, and support of a person’s gender identity or expression (Sevelius, 2013; Wagner et al., 2019). Though GAC improves individuals’ health outcomes (Glynn et al., 2016; Reisner et al., 2015), little is known about HIV service organizations’ (HSO) capacity around GAC. Understanding the landscape of GAC implementation is essential to developing structural change interventions to increase the practice of GAC. Study aims are to understand: 1) the extent to which HSOs in the U.S. South practice GAC, and 2) barriers to utilizing GAC.

Methods: Survey data were collected online with HSO in the U.S. South (n=207; AL, FL, GA, LA, MS, NC, SC, TN, TX) to identify service needs related to HIV healthcare, including GAC. Survey participants were identified using the National Prevention Information Network (NPIN) and Substance Abuse and Mental Health Services Association (SAMHSA) databases. Analysis consisted of frequency distributions of questions related to GAC and binary logistic regressions investigating the relationship between GAC training and the implementation of GAC organizational strategies, controlling for potential covariates.

Results: Only 33% (n=69) of organizations had ever received GAC training. Regarding specific GAC organizational strategies, 70% (n=144) of organizations reported using clients’ asserted pronouns on documentation, 59% (n=123) engaged with TGNC community groups, and 52% (n=108) provided gender affirmative spaces. Compared to organizations that did not receive GAC training, GAC-trained organizations were: 2.9 times more likely to include pronouns on their organizational documentation (p<.000), 2.5 times more likely to engage with TGNC community groups (p<.000), and 2.5 times more likely to have a gender affirming space in their organization (p<.000). Reported barriers to implementing GAC included funding (61%), expertise/knowledge (59%), capacity/staffing (52%), and political climate (23%).

Conclusion and Implications: To our knowledge, this study is the largest survey of HSOs in the U.S. South that includes GAC data. Our study finds significant gaps in the training and implementation of GAC in Southern HSOs. Structural barriers, such as lack of funding and training, impede the uptake of this social justice centered, evidence-based approach. The study underscores the need for intentional funding and capacity building that centers the implementation of GAC across Southern HSOs. Authors have used this research to inform GAC training and capacity building efforts with HSOs in the U.S South, and will share the impact of this work during the presentation.