Howard Brown Health (Howard Brown), is a Chicago-based Federally Qualified Health Center that provides clinical and supportive services focused on meeting the needs of the gay, lesbian, bisexual, transgender, non-binary, and queer communities (LGBTQ+), including people with HIV. In 2012, Howard Brown launched an intervention that complements and leverages its existing clinical, behavioral health, and supportive services by creating unique “community-based entry points” for transgender and non-binary people. As part of a Ryan White HIV/AIDS Program (RWHAP) Part F Special Project of National Significance (SPNS) initiative, Howard Brown established a specialized drop-in clinic and support groups, and implemented organizational initiatives to provide culturally relevant and gender-affirming services for transgender and non-binary people, including transgender women of color. The goal of this intervention was to optimize engagement and retention in HIV services and primary care. From 2012-2016, the number of transgender and non-binary people served in primary care at Howard Brown more than tripled.
As in much of the United States, people of color in Chicago are disproportionately impacted by HIV.1 This burden is most striking among transgender women of color who are more likely to test positive for HIV than any other population.2 Howard Brown aimed to improve its capacity for providing gender-affirming care to the transgender and non-binary community by creating a specialized drop-in clinic offering full primary care services using an informed consent hormone protocol, in conjunction with peer services, support groups, and other community programming.
Although the new services were available to all transgender and non-binary individuals, an explicit focus of the intervention was on the recruitment, engagement, and retention of people with HIV. This open and welcoming approach built trust within the transgender and non-binary community and facilitated the provision of status-neutral services in a setting where networks of people could receive care together, regardless of HIV status. Additionally, this approach helped ensure privacy and reduced stigma often associated with HIV prevention and care.
“Our intervention is predicated on the value of community-tailored health intervention programs that create safe spaces for transgender women to comfortably discuss issues related to health, gender history, depression, sexual risk, and substance use.”
Staff facilitated “After Hours,” a biweekly Friday evening drop-in clinic, and provided clinical, pharmacy, behavioral health, and other supportive services designed exclusively for transgender and non-binary people. The drop-in clinic consisted of an entire first floor of one Howard Brown location and provided services on a first-come, first-served basis from the hours of 6–9 PM. Clients were allowed to stay as long as they liked, and access the services they wanted or needed. Additionally, clients had access to no-cost clothing, hot meals, personal hygiene products, and medical care and prevention benefits navigation.
Staff facilitated “TYRA,” a weekly support group for transgender and non-binary youth ages 14–24, held at a Howard Brown location specifically designed for youth services. Attendees could access other services while onsite for the support groups, including medical and behavioral health care, housing services, meals, and laundry. The structure of the support group was flexible to allow for discussion and changes in topic, and the group was delivered in a relaxed, informal format over dinner. Topics discussed included PrEP, hormone therapy, job searching and resume writing, relationships, and personal safety.
Staff facilitated “T-Time,” a biweekly two-hour support group for transgender adults, aged 25 and older. As with the youth support groups, the structure was flexible to allow for open conversation and included topics such as current events, personal aesthetics (e.g., makeup and beauty), hormone therapy, dating and relationships, and self-care.
Staff provided outreach services to transgender and non-binary people at strategic locations within their community and at Howard Brown locations. Some outreach activities were coordinated alongside community events such as Black Pride, Transgender Day of Remembrance, or other LGBTQ+ holidays. Outreach activities also occurred online via various Facebook groups, email, and other platforms. Staff promoted Howard Brown’s services for transgender and non-binary people, and encouraged community members to access HIV care and other services at the health center.
Howard Brown trained staff across the health center to improve their capacity and competency in providing gender-affirming care and inclusive supportive services. Frontline staff received education and support on how to interact and communicate with transgender and non-binary patients respectfully, including gender-inclusive language and culturally responsive training. Health center resources and policies were also expanded to better align with culturally relevant services and to improve working conditions for transgender and non-binary staff. For example, five choices of pronoun buttons were made available to staff and patients, the use of name and gender pronouns was normalized at meetings and events, employee health coverage was expanded to cover hormones and gender-affirming surgery, and a tailored patient satisfaction survey was placed in all clinics. Transgender and non-binary-specific organizational goals were also incorporated into the health center’s strategic plan.
“SHINE” is a needle exchange program service developed by—and specifically intended for—the transgender and non-binary community with a special focus on providing supplies for injectable hormone use. It is offered at each After Hours clinic and coordinated by one staff member and two volunteers. A safer injection presentation is given and syringe/needle options are coordinated with medical providers. The service was not federally funded and not part of the SPNS-funded programming.
Howard Brown evaluated the After Hours intervention between 2012 and 2016 as part of the SPNS initiative and has continued to monitor progress post-SPNS funding. The evaluation found that the number of transgender and non-binary people who accessed primary care increased three-fold during this time period. Use of the After Hours drop-in clinic increased each year, as did the TYRA and T-Time support group attendance.
|Evaluation data||Service utilization data|
|Measures||Number of transgender and non-binary people with HIV receiving clinical and supportive services|
Source: The SPNS Transgender Women of Color Initiative Interventions Manual (for 2012-2016 data), and communication with Howard Brown (for 2021 data)
“…the implementation of After Hours, in combination with the in-house initiatives, created a repeating cycle of deepening community trust and continually improving affirmative care.”
Community feedback and system-wide review. Although Howard Brown is considered a national leader in the provision of LGBTQ+ services, staff recognized that there were opportunities for improvement in their approach to delivering services to the transgender and non-binary community. Community members told staff that services were not always delivered in sensitive or respectful ways. In response to this feedback, Howard Brown embarked on a comprehensive, system-wide review to pinpoint opportunities for improving its provision of care and services to the transgender and non-binary community and its affirmative and respectful treatment of transgender and non-binary staff. Initiatives included developing an agency-wide training on gender-affirming language, hiring more diverse staff, and placing these services at the forefront of Howard Brown’s mission and vision. Transgender and non-binary community members contributed to this review, and services and institutional policies were adjusted to better meet the community’s needs.
Expanded staff recruitment and hiring. During implementation of the intervention, Howard Brown expanded and modified staffing for outreach, clinical, and supportive services, recruiting an increasingly diverse staff that more closely represented the community they served. This included transgender women and transgender men, and Spanish-speaking staff that could better engage with the Hispanic/Latina(o/x) community.
Staffing. Several key staff supported intervention activities. The After Hours drop-in clinic was staffed by four primary care providers, a behavioral health provider, a nurse and two medical assistants, a benefits navigator, a transgender and non-binary health manager, three transgender and non-binary health staff, and community volunteers. A team of three outreach workers led all outreach activities, and support groups were facilitated by a combination of staff and volunteers.
“The agency made an inaccurate assumption that because we provided care that was more trans affirmative than other places, the care we provided was already excellent and as trans affirmative as it needed to be.”
- Howard Brown created the After Hours drop-in clinic to include a full range of primary care and behavioral health services rather than positioning it as a program with limited, stereotypical population-specific care options. The drop-in clinic was also presented to staff as a structured clinical shift rather than as an optional volunteer rotation. Full integration of gender-affirming services into clinic operations supports quality and consistency of care, sustainability, and acceptance.
- Equipping staff with the skills they need to fully serve the transgender and non-binary community also helped sustain the initiative. Gender-affirming training should become part of standard onboarding and staff training for all employees, regardless of their role.
- The drop-in clinic, support groups, and organizational initiatives were so successful that Howard Brown continued them for years after grant funding with transgender and non-binary services being expanded to include gender-affirming surgical navigation. The drop-in clinic and support groups were interrupted by COVID-19; Howard Brown is currently exploring how to restart them.
- Many of the services provided as part of the intervention, including targeted outreach, testing, linkage to and provision of clinical care and supportive service for people with HIV, are allowable uses of RWHAP funding.
“Throughout the project, the team kept a list of lessons learned. Lessons that were hard won in the early years of the project became second nature as our workflow, staffing and program structures evolved.”
- Leadership support was critical to the success of the initiative at Howard Brown. Leaders were actively involved in the development and implementation of transgender and non-binary services and their visible support of the programming as a priority encouraged broader agency support and investment.
- Representation matters. Howard Brown hired transgender and non-binary staff to facilitate and support program activities. Hiring representative staff who are known and respected in the community can help establish trust and engage transgender and non-binary communities and participants. A diverse staff with a range of gender identities projects an environment of trust and safety to the transgender and non-binary community.
- Transgender and non-binary staff engaged in significant emotional labor when developing community trust and creating a bridge between the community and Howard Brown, especially as Howard Brown was better understanding and addressing gaps in the care it was offering.
- It is important to assess organizational readiness in honest and transparent ways. Howard Brown took a series of intentional steps to evaluate and improve its capacity for providing respectful and competent gender-affirming services to the community.
“Most systems, even systems that consider themselves affirmative, have a fair amount of agency evolution and growth that must occur before outreach staff will be able to authentically represent your services as truly affirmative in the transgender community.”
Rebchook G, Keatley J, Contreras R, et al. The Transgender Women of Color Initiative: Implementing and Evaluating Innovative Interventions to Enhance Engagement and Retention in HIV Care. Am J Public Health. 2017;107(2):224–229. doi:10.2105/AJPH.2016.303582
- Chicago Department of Public Health. HIV/STI Surveillance Report, 2019. Chicago, IL: City of Chicago; December 2020
- Centers for Disease Control and Prevention. HIV Infection, Risk, Prevention, and Testing Behaviors among Transgender Women National HIV Behavioral Surveillance, 7 U.S. Cities, 2019–2020. HIV Surveillance Special Report 27. Centers for Disease Control and Prevention (CDC); 2021