Bienestar Human Services is a community-based organization that provides HIV services to the Latina(o/x) community across Los Angeles (LA) County. The organization has been working with the transgender community for over 20 years and has several bilingual staff members who identify as transgender women. With funding from a Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance initiative, Bienestar developed TransActivate to improve timely engagement and retention in HIV care among Latina transgender women. Linkage coordinators/peer navigators use a strengths-based approach to help clients reach their goals of entering and staying in medical care.
Los Angeles, CA
Data consistently show that transgender women are disproportionately impacted by HIV1 and often face multiple barriers to HIV care, gender-affirming care, and other essential services2. To help address these access issues, Bienestar developed an intervention aimed at improving engagement and retention in HIV care among Latina transgender women. TransActivate uses peer navigation services to encourage engagement in HIV care. Services include accompanying clients to medical and supportive service appointments, modeling helpful coping behaviors and interactions with medical staff, increasing knowledge and health literacy, and coordinating referrals for other beneficial services. There is also an important social network and outreach component to TransActivate, which is central to the program’s recruitment strategy.
“We have a diverse staff that meets clients with understanding and acceptance, building trust and fostering a unique sense of community for those who use our services.”
TransActivate uses ‘social network testing’, a method that engages people with HIV and those at increased risk for HIV, to recruit individuals from their own social, sexual, and drug use networks for HIV testing. Bienestar identified potential peer recruiters from their own client population of transgender Latina clients. Recruiters were trained on the purposes and benefits of the intervention, and on how to approach people in their social networks about getting tested, disclosing (or not) their own HIV status, how to provide HIV risk reduction education, and how to connect people to testing at Bienestar locations.
Although clients can be tested for HIV at one of the agency’s six locations, the intervention also made use of mobile testing. This allowed outreach and testing personnel to provide services at times and locations that best meet the needs of the transgender population. Testing is provided into the late evening at venues frequented by Latina transgender women.
Similar to social network testing, social network engagement deploys people with HIV—and those at increased risk of HIV—to identify people with HIV in their social, sexual, or drug use networks who may have fallen out of HIV care, or access care infrequently. Using the same recruiters engaged in social network HIV testing, individuals were trained on how to discuss and encourage linkage and engagement in care with people in their networks who have HIV.
Grounded in the transtheoretical model of behavior change, motivational interviewing helps people modify their attitudes and behaviors and can be used to address a range of issues. TransActivate staff were trained in motivational interviewing to help clients resolve their ambivalence about accessing or remaining engaged in care.
Upon testing positive for HIV, transgender clients were immediately connected to a linkage coordinator/peer navigator who assessed their emotional state and readiness to enter medical care. The linkage coordinator/peer navigator prioritized whatever clients needed at that time, while also encouraging them to enter HIV care as soon as possible.
After successful linkage to care for individuals with a new diagnosis of HIV, or reengagement for those returning to care, a team of peer navigators guided clients through the county’s complex health care system to support their continued engagement and retention in care. The navigators helped transgender clients set up their own medical and other social services appointments, accompanied them to appointments, and provided education and interpretation assistance.
“When my life has felt tough, coming to Bienestar has given me the strength I needed to keep going.”
Between 2014 and 2016, Bienestar enrolled 150 clients in TransActivate. At the time of enrollment, 9% of clients had a new diagnosis of HIV, 14% were HIV positive but out of care, and 78% were in care but needed more support. Of those enrolled, 76% of clients were ages 40 or older.
|Evaluation data||Client demographic data, client medical record data|
|Measures||Number of HIV tests performed, Timely linkage to HIV care|
Source: HRSA SPNS webinar: Improving Health Outcomes: Moving Patients Along the HIV Care Continuum (2018)
Pre-intervention planning. Bienestar dedicated 12 months to the planning and development of TransActivate. During this period, Bienestar hired and trained key staff, developed evaluation tools and standard protocols, identified and solidified community partnerships, developed promotional materials, and gathered feedback from its community advisory board (CAB).
Community referral partnerships. The success of TransActivate relied on the strength of community partnerships that Bienestar fostered to expand client recruitment and to provide a range of clinical and supportive services. Multiple clinical partners ensured that clients had access to medical services close to where they lived, and that met their specific needs. Linkage coordinators/peer navigators helped select the right clinics based on clients’ needs.
Involvement of people with lived experience. In addition to input from the CAB, the involvement of people with HIV and other community stakeholders was key to the planning and implementation of TransActivate. Peer recruiters and peer navigators play central roles in the day-to-day activities of the intervention.
Staffing. The following staff members helped plan and implement TransActivate at Bienestar:
- Program Director: Recruited staff, monitored the program, and conducted financial oversight.
- Program Manager: Oversaw daily coordination documentation of TransActivate activities and served as the liaison with community partners, including clinicians.
- Linkage Coordinator/Peer Navigator: Conducted HIV testing and outreach for new clients and worked directly with clients to link and maintain their engagement in care.
- HIV Testing Counselor: Provided HIV testing and counseling in a variety of settings.
“To promote our program [among community partners], Bienestar clearly communicates the purpose of the program and creates [an] MOU [memorandum of understanding] with our partners to define the specific roles of each agency.”
The majority of costs were tied to personnel and associated fringe benefits. Other costs included overhead, such as rent, utilities, and vehicle costs including insurance, and various office and program supplies. Many of the services that are part of TransActivate, such as peer navigation, HIV testing, and linkage to care, can be supported using RWHAP funding.
- Bienestar staff realized that many of the clients participating in TransActivate were experiencing substance use disorders, legal issues, and housing instability. To implement TransActivate, providers should consider establishing memoranda of understanding with substance use providers, providers of legal services, and housing services to address these needs among their clients.
- Few referrals were made to TransActivate by partnering clinical providers. The development of data sharing agreements prior to implementation of the intervention might have facilitated referrals of clients who had fallen out of care.
- Bienestar identified three clinical partners at TransActivate’s inception but quickly realized more were needed to fully accommodate participating clients’ medical needs. Sites considering this intervention should put adequate resources into place to meet the needs of the clients they intend to serve.
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
- Los Angeles County Commission on HIV and the Los Angeles County Department, of Public Health Division of HIV and STD Programs. Los Angeles County Comprehensive HIV Plan (2017–2021) publichealth.lacounty.gov/dhsp/Reports/Publications/LAC-Comprehensive-HIV-Plan2017-2021.pdf
- Jefferson KB, Neilands T, Sevelius J. Transgender women of color: discrimination and depression symptoms. In: Mutch C and Marlowe JD, eds. Ethnicity and Inequalities in Health and Social Care. 2013;6(4):121–136. doi:10.1108/EIHSC-08-2013-0013