INFINI-T

INFINI-T is a peer mentoring program for young transgender women of color implemented by the Health & Education Alternatives for Teens (HEAT) Program of the State University of New York (SUNY) Downstate Medical Center in 2012. HEAT broadened its existing partnership with the Hetrick-Martin Institute, the largest New York City agency that provides comprehensive HIV care for LGBTQ+ youth (ages 13–24) of color. INFINI-T aimed to reach young transgender women of color with HIV and retain them in care through peer advocates who provided case management. In addition, these peer advocates facilitated social support sessions with the goal of alleviating the negative impacts of psychosocial factors like history of trauma, stigma, and discrimination. Clients were more likely to be virally suppressed and retained in care after 12 months of participating in the intervention. 

Brooklyn, NY

Implementation Guide
True
Evidence-informed intervention
Evidence-informed intervention
Icon for Intervention Type
Outreach and reengagement activities
Icon for HIV Care Continuum
Retention in HIV medical care; Viral suppression
Icon for Focus Population
Transgender women; Women of color; Youth ages 13 to 24
Icon for Priority Funding
RWHAP Part F - SPNS
Icon for Setting
Community health center, including Federally Qualified Health Centers (FQHCs)
Need Addressed

Transgender women of color are disproportionately affected by HIV; in 2019, 81% of new HIV diagnoses among transgender women were among women of color.1 The high rates of HIV are compounded by substance use, incarceration, mental health diagnoses, and unstable housing. Stigma and institutionalized racism have also made it difficult for transgender women of color to access HIV care.2

Core Elements
Multidisciplinary team approach

INFINI-T aimed to address the psychosocial factors that affect many young transgender women of color by using a multidisciplinary approach, including HIV counseling and testing, peer advocacy, case management, and mental health treatment. By providing services that address factors beyond HIV, INFINI-T helped reduce the stigma often associated with receiving HIV clinical care.

Peer advocacy

Peer youth advocates were recruited and hired to engage, or reengage, young transgender women of color in care and provide support to help mitigate barriers to care. The peer advocates connected clients to services, including transgender healthcare, support services, and mental health supports. However, their role extended beyond linkage to care; they provided culturally appropriate support tailored to each client with the goal of retaining them in care over time.

Outcomes

INFINI-T recruited 23 transgender women from 2012 to 2017, and the evaluation found that participants were more likely to be virally suppressed and retained in care after 12 months of participating in the intervention.

CategoryInformation
Evaluation dataElectronic health record data and client self-administered computer surveys  
Measures
  • Retention in HIV care was defined as having an HIV care visit during the current and previous six-month periods with 60 days in between
  • Viral suppression rates
Results
  • Retention in HIV care improved among INFINI-T participants as compared to baseline (12-month uOR = 11.93, CI: 2.58 - 55.20; 24-month uOR = 24.98, CI: 3.22 - 93.47)*
  • INFINI-T participants were more likely to be virally suppressed as compared to baseline (uOR = 2.39, CI: 1.03 - 5.51)*

* statistically significant

Notes: CI = confidence interval, uOR = unadjusted odds ratio

Source: Rebchook GM, Chakravarty D, Xavier JM, et al. An evaluation of nine culturally tailored interventions designed to enhance engagement in HIV care among transgender women of colour in the United States. J Int AIDS Soc. 2022;25 Suppl 5(Suppl 5):e25991.

Planning & Implementation
  • Singer’s Syndemic Theory. This theory hypothesizes that adverse social circumstances (e.g., trauma, homelessness) have compounding effects that lead to increased risk of HIV acquisition. It provided the framework for INFINI-T, helping the program better understand and address the physical and social environments in which many transgender women of color reside, the interconnectedness of the multifaceted, adverse conditions they face, and how those issues affect care engagement.
  • Hiring staff. The Hetrick-Martin Institute and HEAT hired staff with extensive knowledge of, and relationships with, the transgender community, including a youth services specialist. Other staff roles included a transgender coordinator/case manager/social worker,  peer youth advocate, and an LGBTQ+ outreach coordinator. Additionally, staff contracted with a transgender health consultant to collaborate on implementation of a group level psychosocial intervention  in support of INFINI-T.
  • Staff training. Staff were trained on hormone therapy, transphobia, stigma, legal issues faced by transgender people (e.g., identity documents), mental health and substance use, and disclosure of HIV and transgender status.
  • Interagency collaboration. The Hetrick-Martin Institute engaged with young transgender women of color in the community and guided them to HEAT for services. The agencies set up a system to monitor, reintegrate, and guide clients back to HEAT if they disconnected from care at INFINI-T. This collaboration, which was essential in the implementation of INFINI-T, was facilitated by monthly meetings, intensive coordination between the HEAT program coordinator and the Hetrick-Martin onsite supervisor, and high levels of administrative and direct service provider staff buy-in.
  • Referral partnerships. To increase program enrollment, HEAT partnered with multiple organizations to receive referrals. They included STAR Health Center, Callen Lorde, Project STAY, Housing Works, and Community and Kinship Life.

“Given the overlapping programmatic goals of HEAT and HMI [the Hetrick-Martin Institute], both programs had a strong level of administrative and provider buy-in for INFINI-T from the outset.”

Sustainability

INFINI-T was funded through the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) Transgender Women of Color initiative. The annual cost of the intervention was approximately $256,000, including direct costs and personnel. 

Lessons Learned

High staff turnover at the Hetrick-Martin Institute compromised INFINI-T’s ability to engage young transgender women of color. This turnover led to a lower-than-expected enrollment in the intervention.

Some peer staff had limited professional experience, especially in a hospital setting. Strong supervision, training on boundary setting (e.g., “turn the job off”), and praise and encouragement helped to support and enhance the peer advocacy model.  

Originally, INFINI-T included Just One of the Girls (JOG), a group-level psycho-educational intervention, adapted from the evidence-based intervention, Sisters Informing Sisters about Topics on AIDS, which focused on Black women. JOG aimed to build community relationships and provide educational sessions that addressed needs specific to transgender people, such as hormone usage and safe injections. After several cycles of this intervention, JOG was stopped due to recruitment and staffing challenges.

The INFINI-T team analyzed data, and in monthly meetings, reviewed enrollment, and client retention with all staff. Findings showed that recruitment requires a multifaceted approach to engage clients in care. To this end, staff continued to engage with clients in person at the Hetrick-Martin Institute and HEAT but also through phone calls and texts, Facebook messaging, and other social media outreach.

Contact
SUNY Downstate Medical Center
Jeffrey M. Birnbaum, MD, MPH
University of California San Francisco
Gregory Rebchook, PhD
Center for AIDS Prevention Studies (CAPS) & UCSF Prevention Research Center

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