San Francisco, CA
The TransAccess clinic opened in 2013 to address high HIV prevalence among transgender women of color in San Francisco, California. Located in the Tenderloin district, the clinic provides gender-affirming and comprehensive HIV care to transgender women of color who are not engaged, or not consistently engaged, in care. TransAccess provides this care onsite at the Tom Waddell Health Center and offers support services at the Asian and Pacific Islander Wellness Center. During its participation in the Special Projects of National Significance (SPNS) Transgender Women of Color Initiative, TransAccess engaged over 80 transgender women of color in care, showing improvement in antiretroviral therapy (ART) prescription and viral suppression rates among these clients through its services and harm reduction approach.
Studies have shown that 42% of transgender women of color in San Francisco have HIV, the highest prevalence for any population in the city, and African American and American Indian/Alaska Native transgender women have the highest HIV prevalence within this demographic.1 Transgender women of color face social stressors that impact health outcomes, including higher rates of substance use, unmet gender-affirming healthcare needs, lack of health care coverage, and unstable housing.2 TransAccess was created to address the structural barriers faced by these women and to advocate for their care and well-being.
“We started TransAccess with a general vision of the kind of care that HIV+ transgender women of color deserve, informed by the experiences of seasoned HIV care and transgender health providers.”
Many transgender women of color experience marginalization, trauma, HIV stigma, and culturally non-responsive care, all of which may affect their overall engagement in care. To address these challenges, TransAccess is rooted in a holistic, community-centered approach focused on core values that empower clients to stay engaged in care. These core values include creating a physically and psychologically safe environment that enhances transgender visibility, and relying on a harm reduction model that applies destigmatizing and non-judgmental approaches to care and services.
Clients can engage with TransAccess services on two levels, depending on their needs and preferences. Clients may access non-primary care services only or the full intervention (primary care plus additional services). Non-primary care services include behavioral health, psychiatry, case management, peer navigation, and drop-in services. Roughly 75% of clients opt for the full intervention (primary care plus additional services), and the other 25% of clients opt for non-primary care services only.
Non-primary care services only - The following staff members from the Asian and Pacific Islander Wellness Center provide support services to TransAccess clients:
- Peer navigators offer emotional support, help clients follow their care plans, and address social stressors that may impact retention in care (such as HIV stigma, societal racism, and transphobia). Peer navigators also run a support group.
- A case manager helps clients access housing, specialty care, health care coverage, and benefits programs. This individual also supervises the peer navigators.
- A social worker conducts mental health assessments, provides referrals to psychiatry and other behavioral health services, and assists clients with substance use disorders and other psychosocial needs.
- A psychiatrist diagnoses mental health disorders and provides treatment, such as pharmacotherapy and psychotherapy. Both the social worker and psychiatrist are available by appointment and for drop-in services.
Full intervention (primary care plus additional services) - The Tom Waddell Health Center provides HIV and primary care to TransAccess clients. A primary care provider monitors HIV care and ART adherence, addresses adherence challenges, and provides gender-related care with emphasis on assessing clients’ readiness for services. Two nurses support all aspects of HIV and gender-affirming care, including hormone therapy, lab draws, medication dispensing, and sexually transmitted infection (STI) treatments. In addition, clients may access all of the non-primary care services described above.
Every Thursday before opening, TransAccess staff members hold an hour-long meeting to discuss client updates, coordinate care, and set goals for the week. Staff members noted that these case conferencing sessions are a vital part of coordinating care for high-acuity clients with a range of psychosocial needs, for example, clients with high hospital utilization, or who experience homelessness, active sex work, or severe mental illness. Staff members also discuss individual client care plans and ensure that each plan is within the client’s capacity. A care plan reflects the client’s primary health goals and includes consideration of gender-affirming care, benefits attainment, secure living environments, and other factors that may impact the client's health.
A pre-post evaluation of 80 TransAccess clients between 2013 and 2017 found that clients had more ART prescriptions and were more likely to be virally suppressed at their 12- and 24-month follow-up appointments than at baseline.
| Category | Information |
|---|---|
| Evaluation data | Clients’ electronic health record data abstracted at baseline, 12 months, and 24 months after TransAccess enrollment |
| Measures |
|
| Results |
* statistically significant |
Note: uOR = unadjusted odds ratio, CI = confidence interval
Source: Rebchook GM, Chakravarty D, Xavier JM, Keatley JG, 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. Journal of the International AIDS Society. 2022; 25(Suppl. 5), e25991.
“This job keeps us evolving. It’s not just that you are learning, professionally, from the staff and the clients, but you evolve in your personal life: medically, spiritually, holistically.”
Peer navigation training. Peer navigators participate in extensive training to learn how to deliver trauma-informed care and to address clients with cultural sensitivity. They are also trained on HIV basics and how to safeguard personal health information. The case manager and social worker both supervise and mentor the peer navigators.
Dual-clinic partnership. TransAccess is a partnership between the Tom Waddell Health Center and the Asian and Pacific Islander Wellness Center. This partnership ensures that clients have access to a full range of services.
Clinic location. The TransAccess clinic is located in San Francisco’s Tenderloin district where many low-income transgender women of color live, making access to services easier.
While TransAccess was funded under the SPNS Transgender Women of Color Initiative, TransAccess continues to operate with existing staff members from both the Asian and Pacific Islander Wellness Center and the Tom Waddell Health Center.
- Community empowerment is vital for engaging clients in care. TransAccess fosters an environment of community and belonging through providing digital story-telling workshops, supporting programs that enhance client visibility and social justice, and supporting civic LGBTQ+ activities, such as the Transgender Day of Remembrance.
- Engaging clients in care requires intensive psychosocial and behavioral health supports. Transgender women of color face structural challenges (such as substance use, unstable housing, limited food access, and a lack of access to culturally responsive care) that may hinder them from engaging in care. The TransAccess social support team provides complex care coordination services that are vital for care engagement.
- Having HIV care and transgender care located in the same clinic positively influences client outcomes and perceptions. For many clients, gender-affirming care takes precedence over HIV care. TransAccess found that clients were attracted to a clinic with primary care providers who were well versed in both HIV and transgender care issues.
- Chiu I, Leathers M, Cano D, et al. HIV prevalence, engagement in care, and risk behavior among trans women, San Francisco: Evidence of recent successes and remaining challenges. Int J STD AIDS. 2022;33(12):1029–1037. doi:10.1177/09564624221111278
- Hsiang E, Gyamerah A, Baguso G, et al. Prevalence and correlates of substance use and associations with HIV-related outcomes among trans women in the San Francisco Bay Area. BMC Infectious Diseases. 2022;22(1):886. doi:10.1186/s12879-022-07868-4