Text Me, Girl! is a text messaging intervention that aims to improve linkage to and retention in HIV care, increase adherence to HIV medications, and improve viral suppression and other health outcomes among transgender women ages 18–34 years. Text Me, Girl! delivers automated text messages grounded in behavioral change theory and associated with all stages of the HIV care continuum. The intervention supports young transgender women with HIV, particularly those experiencing barriers to care such as periods of homelessness and/or incarceration, substance misuse, or engaging in sex work. Text Me, Girl! was developed and evaluated as part of Use of Social Media to Improve Engagement, Retention, and Health Outcomes along the HIV Care Continuum, an initiative funded by the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) program. Text Me, Girl! participation was associated with statistically significant improvements in antiretroviral therapy (ART) uptake and adherence, and self-reported viral suppression.
Los Angeles, CA
Transgender women in the United States are disproportionately impacted by HIV, due to multiple factors, including stigma, injection drug use, limited employment opportunities, and unstable housing.1 Transgender women also experience disparities in HIV care, such as delayed entry to care, poor retention in care, and lower viral suppression rates than cisgender women.2 Text messaging interventions are well suited for reaching young transgender women, since mobile technology is widely used, generally private, and inexpensive for participants and implementation sites.3
Participants received three text messages per day for 90 days. Texts were automatically delivered at 12:00 pm, 5:00 pm, and 10:00 pm, although participants could adjust the timing of their texts to better suit their schedules. They could also opt to receive the messages via email or a social media platform. No two text messages were identical, but all included content equally distributed across the stages of the HIV care continuum.
Content was divided into three main categories:
- HIV positivity/physical and emotional health
- Linkage to/retention in medical care
- Medication adherence/viral suppression
Text messages also included transgender-specific content and references to transgender culture. An example text is: “Stay on top of your numbers, now that’s Trans Pride!”
Text Me, Girl! is grounded in three theoretical frameworks:
Social support theory
Social cognitive theory
The health belief model
The text messages were equally distributed across these three frameworks.
Social support theory states that the presence of real or perceived support from trusted sources acts as a buffer to stressful and traumatic life events. An example text message is: “HIV meds work, your trans beautiful body is worth protecting.”
Social cognitive theory suggests that perceived self-efficacy plays an important role in healthy behavior change and promotes the expectation of success. An example text message is: “Make no compromise. You can protect yourself, girl.”
Health belief model texts highlight potential threats to health and promote the belief that adopting certain health behaviors can help mitigate those threats. An example text message is: “Care about your beauty? HIV care is beautiful.”
From December 2016 to May 2018, 130 transgender women participated in Text Me, Girl! Forty-three percent identified as Hispanic/Latina, 40% as Black/African American, and 12% as White/Caucasian. The average age of the participants was 29 years old.
Most participants (72%) reported reading at least some of the text messages, and 30% reported reading all of the text messages. A multivariate analysis indicated that increased exposure to the Text Me, Girl! intervention was associated with statistically significant improvements along the HIV care continuum, including ART uptake, self-reported ART adherence, and self-reported viral suppression, all of which significantly increased at the 6-month follow-up evaluation and were sustained through an 18-month follow-up evaluation.
|Evaluation data||Client data from surveys at baseline, 6, 12, and 18 months|
Text message development. Much of the planning stage was spent developing and refining the content of 270 unique text messages. To ensure a culturally competent intervention, the developers worked closely with a community advisory board (CAB) of transgender people who provided feedback and guidance on all aspects of the development, implementation, and evaluation of Text Me, Girl! The CAB helped ensure that the texts contained culturally relevant language, terminology, and topics, while maintaining fidelity to the intervention’s theoretical framework and the HIV care continuum placement. The CAB also helped develop recruitment strategies, including guidance on venue-based outreach. Eight staff members who identified as transgender participated in two pilot tests of the text messaging program, which focused on accuracy of the messages, delivery time, and functionality issues.
Text message gateway. The text messages must be distributed using a text message gateway provider. At the demonstration site, Qualtrics was used to securely store the library of 270 text messages and participant contact information, and to distribute the messages using a Health Insurance Portability and Accountability Act (HIPAA)-compliant server.
Staffing. Key staff involved in the implementation and evaluation of Text Me, Girl! included:
- A principal investigator responsible for general oversight and management of the project, including hiring staff, and coordinating all stages of planning and implementation.
- A project director who oversaw the day-to-day operation of the project, including training, ongoing monitoring, and networking with community gatekeepers.
- Research assistants who conducted outreach and recruitment in addition to eligibility screening and intake of new participants. They also tracked participants throughout the demonstration project and collected data using questionnaires and standardized assessment tools.
- A process evaluator and a data manager who worked together to conduct analysis and interpret findings for evaluation and dissemination.
Participant recruitment. The intervention team developed marketing materials, including a business card, poster, and postcard. The team considered over 100 designs, with the final design selected with input from members of the transgender community. The marketing strategies used to recruit participants included online outreach, print media, and street-and venue-based outreach at locations frequented by young transgender women. The intervention team also made use of snowball sampling and encouraged current participants to recruit up to three people. Existing participants received a small incentive, such as earrings or makeup, for each potential participant identified and brought to the clinic, and received an additional $20 gift card if an eligible participant enrolled in the intervention.
"Community-based organizations/clinics may want to vet the messages with their transgender women participants and CAB to ensure the messages are relevant to their specific local population."
- Participants can opt to continue receiving ongoing weekly text messages after the completion of the 90-day intervention period. These ongoing text messages were from HRSA’s UCARE4LIFE library, which includes an array of informational, motivational, and educational text messages in Spanish and English.
- Text messaging interventions are generally a cost-effective strategy for clinics and community-based organizations to administer. For the total 90-day Text Me, Girl! intervention duration, per participant text messaging costs were between $3 and $5, with each message costing 1–2 cents to send.
- Due to the considerable stigma experienced by young transgender women, the intervention team encountered hesitancy among potential participants due to the intervention’s association with HIV. Recruits were reluctant to disclose their HIV status to people they did not know. To counter this, the team packaged recruitment materials alongside those for a pre-exposure prophylaxis (PrEP) project focusing on transgender women without HIV, removing the assumption that recruitment efforts were only focused on people with HIV.
- The intervention team also learned through trial and error that recruitment at venues such as bars and clubs, college campuses, or via social media or other online venues was less effective. Young transgender women at bars and clubs were often engaged in commercial sex work, so did not want to be approached by members of a research team. A low number of “out” transgender women on college campuses made recruitment difficult, and social media outreach also received a low response rate.
- Additionally, consistent mobile phone access posed a challenge. Some participants experienced disruptions in service due to lack of funds or no longer having a phone. Although referrals were made for participants to obtain free phones from a government-funded program, this required a valid state ID card which many participants did not have.
- Reback CJ, Fletcher JB, Fehrenbacher AE, Kisler K. Text messaging to improve linkage, retention, and health outcomes among HIV-positive young transgender women: Protocol for a randomized controlled trial (Text Me, Girl!). JMIR Res Protoc. 2019;8(7):e12837
- Reback CJ, Fletcher JB, Kisler KA. Text messaging improves HIV care continuum outcomes among young adult trans women living with HIV: Text Me, Girl!. AIDS Behav. 2021;25(9):3011–3023.
- Reback CJ, Rünger D. Technology use to facilitate health care among young adult transgender women living with HIV. AIDS Care. 2020;32(6):785–792.
- Song W, Mulatu MS, Rao S, Wang G, Kudon HZ, O’Connor K. HIV partner service delivery among transgender women—United States, 2013–2017. MMWR Morb Mortal Wkly Rep. 2020;69(2):35–39. doi:10.15585/mmwr.mm6902a3
- Jenness SM, Myers JE, Neaigus A, Lulek J, Navejas M, Raj-Singh S. Delayed entry into HIV medical care after HIV diagnosis: Risk factors and research methods. AIDS Care. 2012;24(10):1240–1248. doi:10.1080/09540121.2012.656569
- Reback CJ, Fletcher JB, Fehrenbacher AE, Kisler K. Text messaging to improve linkage, retention, and health outcomes among HIV-positive young transgender women: Protocol for a randomized controlled trial (Text Me, Girl!). JMIR Res Protoc. 2019;8(7):e12837. doi:10.2196/12837