A Novel Adaptation of Peer Health Navigation and Contingency Management for Advancement Along the HIV Care Continuum Among Transgender Women of Color

  • Cathy J. RebackEmail author
  • Kimberly A. Kisler
  • Jesse B. Fletcher
Original Paper


Transgender women, particularly racial/ethnic minority transgender women, evidence disproportionately high rates of untreated HIV infection and disproportionately low rates of HIV viral suppression. The Alexis Project was a combined peer health navigation (PHN) and contingency management (CM) intervention that targeted HIV milestones associated with advancement along the HIV care continuum. From February 2014 through August 2016, 139 transgender women of color (TWOC) enrolled and received unlimited PHN sessions and an escalating CM rewards schedule for confirmed achievement of both behavioral (e.g., HIV care visits) and biomedical (e.g., viral load reductions and achieved/sustained viral suppression) HIV milestones. Results demonstrated that increased attendance to PHN sessions was associated with significant achievement of both behavioral (coef. range 0.12–0.38) and biomedical (coef. = 0.10) HIV milestones (all p ≤ 0.01); 85% were linked to HIV care, and 83% who enrolled detectable and achieved the minimum 1 log viral load reduction advanced to full viral suppression. The combined PHN and CM intervention successfully promoted advancement along the HIV Care Continuum, with particularly robust effects for behavioral HIV milestones.


Transgender HIV Contingency management Peer health navigation HIV care continuum 



This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under Grant Number H97HA24968 in the last annual award amount of $285,757 awarded to Friends Research Institute (PI: C. Reback). No percentage of this project was financed with non-governmental sources. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. Dr. Reback acknowledges additional support from the National Institute of Mental Health (P30 MH58107). The authors would like to thank the Peer Health Navigators, Angelina Alamilla and Miranda Ramirez, for their sincere commitment to improve the health outcomes of The Alexis Project participants.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Poteat T, Reisner SL, Radix A. HIV epidemics among transgender women. Curr Opin HIV AIDS. 2014;9(2):168–73.CrossRefGoogle Scholar
  2. 2.
    Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav. 2008;12(1):1–17.CrossRefGoogle Scholar
  3. 3.
    Operario D, Nemoto T, Iwamoto M, Moore T. Risk for HIV and unprotected sexual behavior in male primary partners of transgender women. Arch Sex Behav. 2011;40(6):1255–61.CrossRefGoogle Scholar
  4. 4.
    Sevelius JM, Keatley J, Gutierrez-Mock L. HIV/AIDS programming in the United States: considerations affecting transgender women and girls. Women’s Health Issues. 2011;21(6):S278–82.CrossRefGoogle Scholar
  5. 5.
    Centers for Disease Control and Prevention. HIV Among Transgender People in the United States:–2013 November 2013.Google Scholar
  6. 6.
    Institute of Medicine. The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. Washington, D.C.: National Institute of Health; 2011.Google Scholar
  7. 7.
    Santos G-M, Wilson EC, Rapues J, Macias O, Packer T, Raymond HF. HIV treatment cascade among transgender women in a San Francisco respondent driven sampling study. Sex Transm Infect. 2014;8:2014.Google Scholar
  8. 8.
    Radix A, Sevelius J, Deutsch MB. Transgender women, hormonal therapy and HIV treatment: a comprehensive review of the literature and recommendations for best practices. J Int AIDS Soc. 2016;19(3Suppl 2):20810.Google Scholar
  9. 9.
    Kalichman SC, Hernandez D, Finneran S, Price D, Driver R. Transgender women and HIV-related health disparities: falling off the HIV treatment cascade. Sex Health. 2017;14(5):469–76.CrossRefGoogle Scholar
  10. 10.
    Doshi RK, Milberg J, Isenberg D, Matthews T, Malitz F, Matosky M, et al. High rates of retention and viral suppression in the US HIV safety net system: HIV care continuum in the Ryan White HIV/AIDS Program, 2011. Clin Infect Dis. 2014;60(1):117–25.CrossRefGoogle Scholar
  11. 11.
    Mizuno Y, Frazier EL, Huang P, Skarbinski J. Characteristics of transgender women living with HIV receiving medical care in the United States. LGBT Health. 2015;2(3):228–34.CrossRefGoogle Scholar
  12. 12.
    Melendez RM, Exner TA, Ehrhardt AA, Dodge B, Remien RH, Rotheram-Borus M-J, et al. Health and health care among male-to-female transgender persons who are HIV positive. Am J Public Health. 2006;96(6):1034–7.CrossRefGoogle Scholar
  13. 13.
    Sevelius JM, Carrico A, Johnson MO. Antiretroviral therapy adherence among transgender women living with HIV. J Assoc Nurses AIDS Care. 2010;21(3):256–64.CrossRefGoogle Scholar
  14. 14.
    Baguso GN, Gay CL, Lee KA. Medication adherence among transgender women living with HIV. AIDS Care. 2016;28(8):976–81. Scholar
  15. 15.
    Lombardi E. Varieties of transgender/transsexual lives and their relationship with transphobia. J Homosex. 2009;56(8):977–92.CrossRefGoogle Scholar
  16. 16.
    de Vries KM. Transgender people of color at the center: conceptualizing a new intersectional model. Ethnicities. 2015;15(1):3–27.CrossRefGoogle Scholar
  17. 17.
    Reback CJ, Larkins S. HIV risk behaviors among a sample of heterosexually identified men who occasionally have sex with another male and/or a transwoman. J Sex Res. 2011;50(2):151–63.CrossRefGoogle Scholar
  18. 18.
    De Santis JP. HIV infection risk factors among male-to-female transgender persons: a review of the literature. J Assoc Nurses AIDS Care. 2009;20(5):362–72.CrossRefGoogle Scholar
  19. 19.
    Norton AT, Herek GM. Heterosexuals’ attitudes toward transgender people: Findings from a national probability sample of US adults. Sex Roles. 2013;68(11–12):738–53.CrossRefGoogle Scholar
  20. 20.
    Bockting WO, Robinson BE, Rosser BR. Transgender HIV prevention: a qualitative needs assessment. AIDS Care. 1998;10:505–25.CrossRefGoogle Scholar
  21. 21.
    Nemoto T, Sausa LA, Operario D, Keatley J. Need for HIV/AIDS education and intervention for MTF transgenders. J Homosex. 2006;51(1):183–201.CrossRefGoogle Scholar
  22. 22.
    Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey. Washington, D.C: National Center for Transgender Equality, and the National Gay and Lesbian Task Force; 2011.Google Scholar
  23. 23.
    Poteat T, German D, Kerrigan D. Managing uncertainty: a grounded theory of stigma in transgender health care encounters. Soc Sci Med. 2013;84:22–9.CrossRefGoogle Scholar
  24. 24.
    Bradford J, Reisner SL, Honnold JA, Xavier J. Experiences of transgender-related discrimination and implications for health: results from the Virginia Transgender Health Initiative Study. Am J Public Health. 2013;103(10):1820–9.CrossRefGoogle Scholar
  25. 25.
    Grossman AH, D’Augelli AR. Transgender youth: Invisible and vulnerable. J Homosex. 2006;51(1):111–28.CrossRefGoogle Scholar
  26. 26.
    Feldman J, Bockting W. Transgender health. Minn Med. 2003;86(7):25–32.Google Scholar
  27. 27.
    Reback CJ, Clark K, Holloway IW, Fletcher JB. Health disparities, risk behaviors and healthcare utilization among transgender women in Los Angeles county: a comparison from 1998-1999 to 2015-2016. AIDS Behav. 2018;22(8):2524–33.CrossRefGoogle Scholar
  28. 28.
    Hede K. Agencies look to patient navigators to reduce cancer care disparities. J Natl Cancer Inst. 2006;98(3):157–9.CrossRefGoogle Scholar
  29. 29.
    Vargas RB, Cunningham WE. Evolving trends in medical care-coordination for patients with HIV and AIDS. Curr HIV/AIDS Rep. 2006;3(4):149–53.CrossRefGoogle Scholar
  30. 30.
    Bandura A. Social cognitive theory and exercise of control over HIV infection. Preventing AIDS. New York: Springer; 1994. p. 25–59.Google Scholar
  31. 31.
    Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 2001;52(1):1–26.CrossRefGoogle Scholar
  32. 32.
    Safren SA, Traeger L, Skeer MR, O’Cleirigh C, Meade CS, Covahey C, et al. Testing a social-cognitive model of HIV transmission risk behaviors in HIV-infected MSM with and without depression. Health Psychol. 2010;29(2):215.CrossRefGoogle Scholar
  33. 33.
    Sugano E, Nemoto T, Operario D. The impact of exposure to transphobia on HIV risk behavior in a sample of transgendered women of color in San Francisco. AIDS Behav. 2006;10(2):217–25.CrossRefGoogle Scholar
  34. 34.
    De Walque D, Dow WH, Nathan R, Abdul R, Abilahi F, Gong E, et al. Incentivising safe sex: a randomised trial of conditional cash transfers for HIV and sexually transmitted infection prevention in rural Tanzania. BMJ Open. 2012;2(1):e000747.CrossRefGoogle Scholar
  35. 35.
    Loewenstein G, Volpp KG, Asch DA. Incentives in health: different prescriptions for physicians and patients. JAMA. 2012;307(13):1375–6.CrossRefGoogle Scholar
  36. 36.
    Baird SJ, Garfein RS, McIntosh CT, Özler B. Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial. Lancet. 2012;379(9823):1320–9.CrossRefGoogle Scholar
  37. 37.
    Sorensen JL, Haug NA, Delucchi KL, Gruber V, Kletter E, Batki SL, et al. Voucher reinforcement improves medication adherence in HIV-positive methadone patients: a randomized trial. Drug Alcohol Depend. 2007;88(1):54–63.CrossRefGoogle Scholar
  38. 38.
    Volpp KG, Troxel AB, Pauly MV, Glick HA, Puig A, Asch DA, et al. A randomized, controlled trial of financial incentives for smoking cessation. N Engld J Med. 2009;360(7):699–709.CrossRefGoogle Scholar
  39. 39.
    John LK, Loewenstein G, Volpp KG. Empirical observations on longer-term use of incentives for weight loss. Prev Med. 2012;55:S68–74.CrossRefGoogle Scholar
  40. 40.
    Volpp KG, Loewenstein G, Troxel AB, Doshi J, Price M, Laskin M, et al. A test of financial incentives to improve warfarin adherence. BMC Health Serv Res. 2008;8(1):272.CrossRefGoogle Scholar
  41. 41.
    Marcus AC, Kaplan CP, Crane LA, Berek JS, Bernstein G, Gunning JE, et al. Reducing loss-to-follow-up among women with abnormal Pap smears: results from a randomized trial testing an intensive follow-up protocol and economic incentives. Med Care. 1998;36(3):397–410.CrossRefGoogle Scholar
  42. 42.
    Reback CJ, Peck JA, Dierst-Davies R, Nuno M, Kamien JB, Amass L. Contingency management among homeless, out-of-treatment men who have sex with men. J Sub Abuse Treat. 2010;39:255–63.CrossRefGoogle Scholar
  43. 43.
    Shoptaw S, Klausner JD, Reback CJ, Tierney S, Stansell J, Hare CB, et al. A public health response to the methamphetamine epidemic: the implementation of contingency management to treat methamphetamine dependence. BMC Public Health. 2006;6:214.CrossRefGoogle Scholar
  44. 44.
    Reback CJ, Shoptaw S, Peck JA, Larkins S, Freese TE, Rawson RA. Getting off: a behavioral treatment intervention for gay and bisexual male methamphetamine users. Los Angeles, CA: Friends Research Institute, Inc.; 2005.Google Scholar
  45. 45.
    Seal KH, Kral AH, Lorvick J, McNees A, Gee L, Edlin BR. A randomized controlled trial of monetary incentives vs. outreach to enhance adherence to the hepatitis B vaccine series among injection drug users. Drug Alcohol Depend. 2003;71(2):127–31.CrossRefGoogle Scholar
  46. 46.
    Malotte CK, Hollingshead JR, Larro M. Incentives vs outreach workers for latent tuberculosis treatment in drug users. Am J Prev Med. 2001;20(2):103–7.CrossRefGoogle Scholar
  47. 47.
    Silverman K, Wong CJ, Needham M, Diemer KN, Knealing T, Crone-Todd D, et al. A randomized trial of employment-based reinforcement of cocaine abstinence in injection drug users. J Appl Behav Anal. 2007;40(3):387–410.CrossRefGoogle Scholar
  48. 48.
    Kirby KC, Carpenedo CM, Stitzer ML, Dugosh KL, Petry NM, Roll JM, et al. Is exposure to an effective contingency management intervention associated with more positive provider beliefs? J Subst Abuse Treat. 2012;42(4):356–65.CrossRefGoogle Scholar
  49. 49.
    Riccio J, Dechausay N, Greenberg D, Miller C, Rucks Z, Verma N. Toward reduced poverty across generations: early findings from New York City’s conditional cash transfer program. 2010.Google Scholar
  50. 50.
    Reback CJ, Ferlito D, Kisler KA, Fletcher JB. Recruiting, linking, and retaining high-risk transgender women into HIV prevention and care services: an overview of barriers, strategies, and lessons learned. Int J Transgend. 2015;16(4):209–21.CrossRefGoogle Scholar
  51. 51.
    Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81.CrossRefGoogle Scholar
  52. 52.
    May MT, Costagliola D, Sabin CA, Phillips AN, Justice AC, Dabis F, et al. HIV treatment response and prognosis in Europe and North America in the first decade of highly active antiretroviral therapy: a collaborative analysis. Lancet. 2006;368(9534):451–8.CrossRefGoogle Scholar
  53. 53.
    Brennan AT, Maskew M, Sanne I, Fox MP. The importance of clinic attendance in the first six months on antiretroviral treatment: a retrospective analysis at a large public sector HIV clinic in South Africa. J Int AIDS Soc. 2010;13(1):49.CrossRefGoogle Scholar
  54. 54.
    Sevelius J, Patouhas E, Keatley J, Johnson M. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med. 2014;47(1):5–16.CrossRefGoogle Scholar
  55. 55.
    Reisner SL, Radix A, Deutsch MB. Integrated and gender-affirming transgender clinical care and research. J Acquir Immune Defic Syndr. 1999;72(Suppl 3):S235.Google Scholar
  56. 56.
    Sindelar J, Elbel B, Petry NM. What do we get for our money? Cost-effectiveness of adding contingency management. Addiction. 2007;102(2):309–16.CrossRefGoogle Scholar
  57. 57.
    Jaccard J, McDonald R, Wan CK, Guilamo-Ramos V, Dittus P, Quinlan S. Recalling sexual partners: the accuracy of self-reports. J Health Psychol. 2004;9(6):699–712.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Friends Research Institute, IncLos AngelesUSA
  2. 2.Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human BehaviorUniversity of California, Los AngelesLos AngelesUSA
  3. 3.Center for HIV Identification, Prevention and Treatment ServicesUniversity of California, Los AngelesLos AngelesUSA

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