Healthy Divas focuses on empowering transgender women with HIV to achieve their personal health goals. Three sites implemented the intervention as part of the Using Evidence-Informed Interventions to Improve Health Outcomes among People Living with HIV (E2i) initiative funded through the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) program from 2017 through 2021. Both engagement in HIV care and having an antiretroviral therapy (ART) prescription improved significantly for clients 12 months after enrollment in Healthy Divas.
Transgender women are disproportionately impacted by HIV.1 They experience many individual, structural, and societal barriers to care and often encounter stigma and discrimination which can prevent them from reaching their desired health goals.2 The Healthy Divas evidence-informed intervention is designed to address these barriers by providing transgender women with the support and resources they need to make empowered and informed decisions regarding their gender-affirming care and HIV medical care. Originally funded by the National Institutes of Health and developed by the Center of Excellence for Transgender Health at the University of California San Francisco, Healthy Divas was developed with input from the transgender community, and was initially found to be effective in achieving its outlined goals among Black and Latina transgender women with HIV.
"Organizations may choose to focus recruitment efforts on transgender women who need support in becoming or staying engaged in care, or who struggle with taking ART as prescribed."
Transgender women serve as peer counselors and engage other women in Healthy Divas sessions. These peer counselors may also provide health care navigation, referrals and linkage to other services, and recruitment and outreach services.
The trans-identified peer counselor leads six one-on-one sessions with clients focusing on:
- A personal health care plan
- Individual strengths
- Assertive communication
- Support networks
- Successes and challenges
- Future health goals
Clients participate in a single group workshop with other transgender women. An HIV clinician and a gender-affirming care clinician also attend, which allows clients the opportunity to ask questions and receive advice from medical experts.
Clients in the Healthy Divas initiative also receive support in accessing and remaining engaged in HIV medical and supportive services that welcome and include transgender people. Implementation sites are encouraged to develop and maintain an up-to-date directory of such resources. This list should include:
- HIV medical care programs and services
- Gender-affirming care programs and services
- Supportive services—such as housing assistance, employment agencies, legal services, food banks, mental health counseling, and substance use disorder treatment
During the two-year implementation period, 73 transgender women enrolled in Healthy Divas across the three sites. Most identified as Black (82%) and Latina (11%). Among the clients enrolled in Healthy Divas, both engagement in HIV care and prescription of ART improved significantly. Other measures included the percentage of clients who completed the program in 12 months (59%), the percentage who received supportive services (78%), and the percentage who attended at least one individual or group session (96%).
* statistically significant
Source: Healthy Divas: E2i Implementation Guide. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau; 2021.
“Through Healthy Divas, we have increased our direct support to clients, and clients have become more active advocates for their own health and well-being.”
Identify and train staff. Involvement of people with lived experience is critical to the initiative. Identify existing staff or hire new staff to serve as peer counselors. These peers should be transgender women who have excellent communication and community engagement skills, knowledge of HIV care, and the capacity to facilitate individual and group sessions. The implementation sites carefully selected peer counselor candidates, understanding that leadership and trust in the community should be considered alongside relevant experience and education. Roles and responsibilities for key staff include:
- Peer counselors offer shared experience of being a transgender woman with HIV. This component is critical to the success of the intervention. Not only do the peer counselors facilitate the individual sessions and group workshop, but they also engage in outreach, navigation, and linkage services.
- HIV clinicians answer questions regarding HIV care during the group workshop.
- Gender-affirming care clinicians guide clients and answer questions regarding gender-affirming care, including hormone therapy. This could be the same individual as the HIV clinician, if they have expertise in both fields.
- Other key staff may include the clinic supervisor, case managers, and/or community health workers.
Develop an outreach and recruitment plan. Having an outreach and recruitment plan is important in developing mechanisms for reaching new or existing clients who could benefit from Healthy Divas. This could include “in-reach”, identifying existing clients, or outreach by promoting at events or using social media.
Customize materials. Adapt or create new Healthy Divas outreach and recruitment materials, and customize materials from the Peer Facilitator’s Manual as needed including the session worksheets and client feedback forms.
Three sites participated in the Healthy Divas E2i initiative. Learn more about their implementations below.
Birmingham AIDS Outreach (Birmingham, AL)
California Prostitutes Education Project (Oakland, CA)
Rutgers New Jersey Medical School Infectious Disease Practice (Newark, NJ)
- Healthy Divas offers considerable flexibility to service providers. For example, the intervention can be offered in clinical or non-clinical settings and individual sessions and group workshops can be in person or via virtual platforms. The intervention can benefit transgender women who are either struggling to stay engaged in HIV care, or those who are having difficulty adhering to daily medications.
- Different funding sources may be available to agencies wishing to implement a Healthy Divas program. Many state Medicaid programs cover peer counseling and navigation services, and many of the activities that are part of Healthy Divas, such as non-medical case management, health education, risk reduction, and treatment adherence, are eligible RWHAP service categories.
- Integration of Healthy Divas into standard of care for transgender women with HIV helps ensure that all those who may benefit have an opportunity to participate.
- Integration and sustainability will require administrative buy-in from agency leadership. One way to achieve this is providing training for all agency staff, preferably by Healthy Divas program staff.
- The costs associated with Healthy Divas are related to planning, recruitment, implementation, and supervision and management. See the implementation guide for more information.
“Having someone who looks like them, talks like them, and understands their ambitions gives the clients a role model and gives them hope.”
- To achieve engagement in Healthy Divas across the organization, it is important to build staff awareness of transgender women and their health needs. An effective way to grow awareness is for Healthy Divas program staff to organize and run trainings on transgender health for all agency staff.
- Recruiting and retaining transgender women into Healthy Divas can be challenging for several reasons. Transgender women often face competing work demands, housing instability, and behavioral health issues that impact their capacity to enroll in Healthy Divas or complete all sessions. HIV stigma, mistrust of health care providers, and fear of disclosing their HIV status can also keep transgender women from wanting to participate. Small populations of transgender women with HIV in the local area may limit recruitment numbers. For the E2i sites, low recruitment led to difficulties with organizing and scheduling group workshops with enough participants.
- Busy medical providers may have difficulty fitting group workshops into their schedules. Organizations should try to schedule groups as far in advance as possible to accommodate provider schedules.
- Expect and plan for barriers to session attendance. Clients may face several barriers that make participation difficult. Plan ahead to provide transportation, flexible hours, or other adjustments to make participation easier and more appealing to potential clients.
“Professional development and training are important for peers, as this may be their first professional work experience.”
- 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. cdc.gov/hiv/library/reports/hiv-surveillance.html. Published April 2021.
- Sevelius J, Chakravarty D, Neilands TB, et al. Evidence for the model of gender affirmation: The role of gender affirmation and healthcare empowerment in viral suppression among transgender women of color living with HIV. AIDS Behav. 2021;25(Suppl 1):64-71.