Engagement in HIV Care Among New York City Transgender Women of Color: Findings from the Peer-Led, TWEET Intervention, a SPNS Trans Women of Color Initiative

  • S. HirshfieldEmail author
  • J. Contreras
  • R. Q. Luebe
  • J. A. Swartz
  • R. Scheinmann
  • C. J. Reback
  • J. B. Fletcher
  • K. A. Kisler
  • L. M. Kuhns
  • L. F. Molano
Original Paper


Transgender women (TW) have higher HIV prevalence rates than cisgender (i.e., non-transgender) women. However, utilization of healthcare for transgender people in the U.S. is low. As part of a multisite initiative to facilitate entry and retention in HIV care for TW of color, we compared health outcomes between participants who became Peer Leaders and those who did not. From 2013 to 2016, 163 New York City, mostly Latina, TW enrolled in the Transgender Women Engagement and Entry to Care Project (TWEET). The TWEET intervention included peer-led, group-based educational sessions called Transgender Leader—Teach Back; 39% completed Peer Leadership requirements. Comparing pre-post change by Peer Leader status, Peer Leaders had a significant decrease in viral load and significant increase in CD4 at the last HIV care visit compared to the first. In multivariable logistic regression, predictors associated with Peer Leadership included having at least some college education, being in a relationship, stable housing, receiving legal assistance for political asylum, and having two or more HIV care visits during the intervention. Findings suggest that, for trans women who have completed at least secondary school education, participating in a peer-led intervention can lead to improved HIV care engagement. Understanding which program components lead to becoming a Peer Leader, and how to better engage non-Peer Leaders, are important next steps.


Transgender Peer Leader Intervention Political asylum HIV 



This publication was made possible by the US Department of Health and Human Services, Health Resources and Services Administration (HRSA; cooperative Agreement Number U90HA24973). This SPNS initiative was critical to the goal of improving health outcomes for TW of color living with HIV. Community Healthcare Network’s high level of commitment and community involvement also led to the success of this intervention. We would like to thank Ariana Beatty, Steven T. Houang, and Martin J. Downing for their assistance with research and data analysis. Note. The content is solely the responsibility of the authors and does not represent the official views of the Health Resources and Services Administration or the US Department of Health and Human Services.


  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.
    Rapues J, Wilson EC, Packer T, Colfax GN, Raymond HF. Correlates of HIV infection among transfemales, San Francisco, 2010: results from a respondent-driven sampling study. Am J Public Health. 2013;103(8):1485–92.CrossRefGoogle Scholar
  3. 3.
    Reback CJ, Fletcher JB. HIV prevalence, substance use, and sexual risk behaviors among transgender women recruited through outreach. AIDS Behav. 2014;18(7):1359–67.CrossRefGoogle Scholar
  4. 4.
    Clark H, Babu AS, Wiewel EW, Opoku J, Crepaz N. Diagnosed HIV infection in transgender adults and adolescents: results from the national HIV surveillance system, 2009–2014. AIDS Behav. 2017;21(9):2774–83.CrossRefGoogle Scholar
  5. 5.
    Grant JM, Mottet L, Tanis JE, Harrison J, Herman J, Keisling M. Injustice at every turn: a report of the national transgender discrimination survey: National Center for Transgender Equality; 2011.Google Scholar
  6. 6.
    Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis. 2013;13(3):214–22.CrossRefGoogle Scholar
  7. 7.
    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
  8. 8.
    Nuttbrock LA, Hwahng SJ. Ethnicity, sex work, and incident HIV/STI among transgender women in New York City: a three year prospective study. AIDS Behav. 2017;21(12):3328–35.CrossRefGoogle Scholar
  9. 9.
    Hill BJ, Rosentel K, Bak T, Silverman M, Crosby R, Salazar L, et al. Exploring individual and structural factors associated with employment among young transgender women of color using a no-cost transgender legal resource center. Transgend Health. 2017;2(1):29–34.CrossRefGoogle Scholar
  10. 10.
    Kuhns LM, Mimiaga MJ, Reisner SL, Biello K, Garofalo R. Project LifeSkills-a randomized controlled efficacy trial of a culturally tailored, empowerment-based, and group-delivered HIV prevention intervention for young transgender women: study protocol. BMC Public Health. 2017;17(1):713.CrossRefGoogle Scholar
  11. 11.
    Centers for Disease Control and Prevention. HIV and transgender people Atlanta, GA: Centers for Disease Control and Prevention; 2018.
  12. 12.
    Sanchez NF, Sanchez JP, Danoff A. Health care utilization, barriers to care, and hormone usage among male-to-female transgender persons in New York City. Am J Public Health. 2009;99(4):713–9.CrossRefGoogle Scholar
  13. 13.
    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
  14. 14.
    James SE, Herman J. The report of the 2015 US transgender survey: executive summary. National Center for Transgender Equality; 2017.Google Scholar
  15. 15.
    Sevelius JM, Reznick OG, Hart SL, Schwarcz S. Informing interventions: the importance of contextual factors in the prediction of sexual risk behaviors among transgender women. AIDS Educ Prev. 2009;21(2):113–27.CrossRefGoogle Scholar
  16. 16.
    Santos GM, 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;90(5):430–3.CrossRefGoogle Scholar
  17. 17.
    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
  18. 18.
    Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52(6):793–800.CrossRefGoogle Scholar
  19. 19.
    Gardner LI, Metsch LR, Anderson-Mahoney P, Loughlin AM, del Rio C, Strathdee S, et al. Efficacy of a brief case management intervention to link recently diagnosed HIV-infected persons to care. AIDS. 2005;19(4):423–31.CrossRefGoogle Scholar
  20. 20.
    Craw JA, Gardner LI, Marks G, Rapp RC, Bosshart J, Duffus WA, et al. Brief strengths-based case management promotes entry into HIV medical care: results of the antiretroviral treatment access study-II. J Acquir Immune Defic Syndr. 2008;47(5):597–606.CrossRefGoogle Scholar
  21. 21.
    Reback CJ, Shoptaw S, Downing MJ. Prevention case management improves socioeconomic standing and reduces symptoms of psychological and emotional distress among transgender women. AIDS Care. 2012;24(9):1136–44.CrossRefGoogle Scholar
  22. 22.
    Cunningham WE, Weiss RE, Nakazono T, Malek MA, Shoptaw SJ, Ettner SL, et al. Effectiveness of a peer navigation intervention to sustain viral suppression among HIV-positive men and transgender women released from jail: the LINK LA randomized clinical trial. JAMA Intern Med. 2018;178(4):542–53.CrossRefGoogle Scholar
  23. 23.
    Simoni JM, Nelson KM, Franks JC, Yard SS, Lehavot K. Are peer interventions for HIV efficacious? A systematic review. AIDS Behav. 2011;15(8):1589–95.CrossRefGoogle Scholar
  24. 24.
    Higa DH, Marks G, Crepaz N, Liau A, Lyles CM. Interventions to improve retention in HIV primary care: a systematic review of US studies. Curr HIV/AIDS Rep. 2012;9(4):313–25.CrossRefGoogle Scholar
  25. 25.
    Enriquez M, Farnan R, Neville S. What experienced HIV-infected lay peer educators working in Midwestern US HIV medical care settings think about their role and contributions to patient care. AIDS Patient Care STDs. 2013;27(8):474–80.CrossRefGoogle Scholar
  26. 26.
    Latkin CA. Outreach in natural settings: the use of Peer Leaders for HIV prevention among injecting drug users’ networks. Public Health Rep. 1998;113(Suppl 1):151–9.Google Scholar
  27. 27.
    Golub SA, Gamarel KE. The impact of anticipated HIV stigma on delays in HIV testing behaviors: findings from a community-based sample of men who have sex with men and transgender women in New York City. AIDS Patient Care STDs. 2013;27(11):621–7.CrossRefGoogle Scholar
  28. 28.
    Hughto JMW, Reisner SL, Pachankis JE. Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med. 2015;147:222.CrossRefGoogle Scholar
  29. 29.
    Kosenko K, Rintamaki L, Raney S, Maness K. Transgender patient perceptions of stigma in health care contexts. Med Care. 2013;51(9):819–22.CrossRefGoogle Scholar
  30. 30.
    White Hughto JM, Reisner SL, Mimiaga MJ. Characteristics of transgender residents of Massachusetts cities with high HIV prevalence. Am J Public Health. 2015;105(12):e14–8.CrossRefGoogle Scholar
  31. 31.
    Reisner SL, Perez-Brumer AG, McLean SA, Lama JR, Silva-Santisteban A, Huerta L, et al. Perceived barriers and facilitators to integrating HIV prevention and treatment with cross-sex hormone therapy for transgender women in Lima, Peru. AIDS Behav. 2017;21(12):3299–311.CrossRefGoogle Scholar
  32. 32.
    Bandura A. Social learning theory. Englewood Cliffs: Prentice-Hall; 1977.Google Scholar
  33. 33.
    Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs: Prentice Hall; 1986.Google Scholar
  34. 34.
    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
  35. 35.
    Bickel GW, Food US, Nutrition Service. Office of Analysis N, Evaluation. Guide to measuring household food security: Revised March, 2000: USDA, Food and Nutrition Service, Office of Analysis, Nutrition, and Evaluation; 2000.Google Scholar
  36. 36.
    AIDS Info. Guidelines for the use of antiretroviral agents in adults and adolescents living with HIV. Department of Health and Human Services; 2017.Google Scholar
  37. 37.
    Department of Health and Human Services. Panel on antiretroviral guidelines for adults and adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents living with HIV. Accessed 18 Dec 2017. p. C-7.Google Scholar
  38. 38.
    IBM Corp. IBM SPSS statistics for windows, Version 23.0. Armonk: IBM Corp; 2015.Google Scholar
  39. 39.
    Webel AR, Okonsky J, Trompeta J, Holzemer WL. A systematic review of the effectiveness of peer-based interventions on health-related behaviors in adults. Am J Public Health. 2010;100(2):247–53.CrossRefGoogle Scholar
  40. 40.
    Nemoto T, Operario D, Keatley J, Nguyen H, Sugano E. Promoting health for transgender women: transgender resources and neighborhood space (TRANS) program in San Francisco. Am J Public Health. 2005;95(3):382–4.CrossRefGoogle Scholar
  41. 41.
    Thompson MA, Mugavero MJ, Amico KR, Cargill VA, Chang LW, Gross R, et al. Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel. Ann Intern Med. 2012;156(11):817–33.CrossRefGoogle Scholar
  42. 42.
    Davidson L, Flanagan E, Roe D, Styron T. Leading a horse to water: an action perspective on mental health policy. J Clin Psychol. 2006;62(9):1141–55.CrossRefGoogle Scholar
  43. 43.
    New York City Department of Health and Mental Hygiene. HIV among people identified as transgender in New York City, 2012–2016. New York: NYC DOHMH, Program HIV Epidemiology and Field Services; 2017.Google Scholar
  44. 44.
    Braunstein SL. Select data on HIV among transgender people in New York City. New York: New York City Department of Health and Mental Hygiene, Program HEaFS; 2017.Google Scholar
  45. 45.
    Joint United Nations Programme on HIV/AIDS. 90-90-90: an ambitious treatment target to help end the AIDS epidemic. Geneva: UNAIDS; 2014.Google Scholar
  46. 46.
    Bauman LJ, Braunstein S, Calderon Y, Chhabra R, Cutler B, Leider J, et al. Barriers and facilitators of linkage to HIV primary care in New York City. J Acquir Immune Defic Syndr. 2013;64(Suppl 1):S20–6.CrossRefGoogle Scholar
  47. 47.
    Martinez O, Lopez N, Woodard T, Rodriguez-Madera S, Icard L. Transhealth information project: a peer-led HIV prevention intervention to promote HIV protection for individuals of transgender experience. Health Soc Work. 2019;44(2):104–12.CrossRefGoogle Scholar
  48. 48.
    Pearlman DN, Camberg L, Wallace LJ, Symons P, Finison L. Tapping youth as agents for change: evaluation of a Peer Leadership HIV/AIDS intervention. J Adolesc Health. 2002;31(1):31–9.CrossRefGoogle Scholar

Copyright information

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

Authors and Affiliations

  1. 1.Department of MedicineSUNY Downstate Medical CenterBrooklynUSA
  2. 2.Community Healthcare NetworkNew YorkUSA
  3. 3.AIDS Services of AustinAustinUSA
  4. 4.Jane Addams College of Social WorkUniversity of Illinois at ChicagoChicagoUSA
  5. 5.Department of Population HealthNew York University School of MedicineNew YorkUSA
  6. 6.Friends Research Institute, IncLos AngelesUSA
  7. 7.Division of Adolescent Medicine, Ann & Robert H. Lurie Children’s Hospital of ChicagoChicagoUSA
  8. 8.Department of PediatricsNorthwestern University, Feinberg School of MedicineChicagoUSA

Personalised recommendations