Transgender Women Engagement and Entry to Care (T.W.E.E.T.) aims to engage transgender women in HIV care by combining weekly peer-based education and discussion groups, leadership training, community building, and the provision of supportive services. Three sites implemented T.W.E.E.T. as part of Using Evidence-Informed Interventions to Improve Health Outcomes among People Living with HIV (E2i), an initiative funded by the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) program from 2017–2021. Clients had improved outcomes across the HIV care continuum 12 months after enrollment in T.W.E.E.T.
New Orleans, LA
Detroit, MI
San Juan, PR
Transgender women, and particularly transgender women of color, are disproportionately impacted by HIV. A recent Centers for Disease Control and Prevention study found that 42% of transgender women surveyed had HIV, and this rate was 62% among African American transgender women.1
Many transgender women also face multiple barriers to HIV care, gender-affirming care, and other essential services as a result of pervasive discrimination in housing, employment, health care, and education.2 When transgender women do receive HIV care, they are often less likely to receive antiretroviral treatment (ART), less likely to adhere to medications, and less likely to reach and maintain viral suppression.3
T.W.E.E.T. is intended for transgender women with HIV who either have a new diagnosis of HIV, are not engaged in HIV care, or are at risk of falling out of care. T.W.E.E.T. is an evidence-informed intervention developed by HIV experts in collaboration with community members to improve health outcomes among transgender women with HIV. The intervention integrates two theoretical frameworks: Social Cognitive Theory, a learning approach that focuses on the importance of observation, imitation, reward, interaction, sharing in learning, and adopting new behaviors modeled by peers, and the Transtheoretical Model, which helps explain behavior change and the maintenance of healthy behaviors.
“T.W.E.E.T. has been lifesaving. The women feel like for the first time they belong somewhere. They are validated.”
Peer leaders are central to the success of T.W.E.E.T. and lead many of the intervention’s activities. These people are T.W.E.E.T. clients who have completed at least five Transgender Leader (TL)-Teach Back group sessions and have received coaching from peer specialists on facilitating group sessions themselves. After receiving coaching, they can lead up to three sessions on one of the five core topics listed below. Peer leaders also help recruit new participants, provide supportive services, and inspire others to adopt healthy behaviors. Although not a paid position, peer leaders could receive incentives and may be encouraged to apply for paid positions at the agency.
T.W.E.E.T. runs five cycles of weekly TL-Teach Back sessions, each lasting 90–120 minutes. Sessions may be repeated and attended in any order. They are typically attended by 8–12 participants but can be attended by up to 25 participants per session if space allows. During these peer-led group education and discussion sessions, participants focus on five health and wellness topics relevant to transgender women:
- HIV and sexually transmitted infections
- Sexual health
- Gender affirmation
- Mental health
- Wellness
T.W.E.E.T. helps build strong communities by forging partnerships with local organizations that support transgender people. Participants and facilitators also create support networks that are formed during the TL-Teach Back sessions.
T.W.E.E.T. clients receive supportive services such as mental health counseling, housing, food, financial assistance, and legal aid to help support linkage to and engagement in care. These services are provided in conjunction with one-on-one support from a peer specialist.
During a 12- to 18-month period, 96 transgender women with HIV enrolled in T.W.E.E.T. across the three E2i sites. The participants were between the ages of 25–34 and 82% identified as Black or African American. There were improvements in engagement in HIV care (statistically significant), retention in HIV care, and viral suppression. Receipt of ART was 100% at baseline and 12 months after enrollment. Across the sites, only 18% of participants completed T.W.E.E.T. within 12 months.
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Source: T.W.E.E.T. (Transgender Women Engagement and Entry to Care): E2i Implementation Guide. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau; 2021.
“I’m a member of the community, but I didn’t know so many trans women would gravitate toward us. T.W.E.E.T. has really changed and benefited people. Younger and older gravitate together.”
Settings. T.W.E.E.T. can take place in a variety of clinical or non-clinical settings. For example, the intervention was evaluated at a RWHAP-funded clinic in Puerto Rico, a large FQHC in New Orleans, and a social services agency in Michigan. Regardless of the venue, spaces to conduct group sessions should be private and comfortable and conveniently located near public transportation routes, or close to where transgender people receive other services.
Staffing. Implementation sites should allow sufficient time and resources to identify, recruit, and train staff members who will support T.W.E.E.T. activities. All staff should be trained in cultural humility, reducing stigma, and providing culturally responsive care to transgender people. In addition to staff who can help support clients such as case managers or community health workers, core staff should include:
- Peer specialists
- These positions should be filled by transgender women whose roles include recruitment and outreach, organizing and facilitating the TL-Teach Back group sessions, and providing coaching to peer leaders.
- As paid staff members and non-participants in T.W.E.E.T., peer specialists are distinct from the peer leader role discussed earlier.
- Peer specialists also provides supportive services to clients to help facilitate linkage and retention in care.
- Peer specialist candidates should have knowledge of HIV and be able to effectively communicate and engage with clients. They should receive training on the core elements of T.W.E.E.T., including group facilitation and the teach-back method.
- The number of peer specialists required will depend on the agency and size of the population to be served.
- Program coordinator
- This staff member trains and supervises peer specialists, supports the development of group sessions, helps track client enrollment and outcomes, and builds community partnerships with local organizations that support transgender women.
Recruitment of clients. Potential T.W.E.E.T. clients may be identified through inreach activities, identifying existing clients at the organization who meet enrollment criteria. Incorporating peer specialists into high-visibility daily activities may help identify potential clients. Programs can also recruit T.W.E.E.T. clients through outreach activities like hosting or attending community events, posting flyers at local venues or community agencies, or posting on websites or social media platforms that local transgender people may visit.
Community partnerships. Strong community partnerships can help recruit and support T.W.E.E.T. clients by developing bidirectional referral relationships. Community partners may range from mental health providers to bars and nightclubs, but they should all provide services in a way that supports and affirms the transgender community.
“Professional development and training are important for peers, as this may be their first professional work experience.”
Three sites implemented T.W.E.E.T. as part of E2i implementation sites. Learn more about their implementations below.
Centro Ararat (San Juan, PR)
CrescentCare (New Orleans, LA)
Ruth Ellis Center (Detroit, MI)
- In some states, Medicaid covers peer support services, although there is wide variation in certifications and other requirements.
- RWHAP providers may also support T.W.E.E.T. activities using RWHAP funds under the non-medical case management or health education/risk reduction service categories.
- The costs associated with T.W.E.E.T. were related to planning, recruitment, implementation, and supervision and management. See the implementation guide for more information.
“One of the sites trained their peer specialists in early intervention services, so they could provide direct services.”
- Sites found it difficult to recruit peer leaders. In these circumstances, staff members, including the peer specialist, assumed more of a direct role in facilitating group sessions, recruitment, and providing supportive services. Once recruited, the sites found that peer leaders often required more coaching and support than expected.
- Two of the sites struggled with client recruitment, having identified only a small number of participants. Multiple social and personal stressors, such as substance use and mental health issues, or work demands, made participation difficult for some transgender women.
- At two of the sites, T.W.E.E.T. activities were integrated into clinical settings, allowing for better coordination of care and supportive services needed by T.W.E.E.T. clients.
- All the sites widened the scope of T.W.E.E.T. to include transgender women without HIV. They found the content applicable to participants without HIV, but it also helped reduce stigma and encourage participation of transgender women with HIV, who may have otherwise stayed away from group sessions due to fear of disclosure.
"To reduce stigma and hesitancy from engaging in T.W.E.E.T., the E2i sites opened the TL-Teach Back groups to transgender women of any HIV status."
- Hirshfield S, Contreras J, Luebe RQ, et al. Engagement in HIV care among New York City transgender women of color: Findings from the peer-led, T.W.E.E.T. intervention, a SPNS Trans Women of Color Initiative. AIDS Behav. 2021 Jul;25(Suppl 1):20-30. doi:10.1007/s10461-019-02667-6
- 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. doi:10.1002/jia2.25991
- 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. Centers for Disease Control and Prevention (CDC); 2021.
- Jefferson KB, Neilands T, Sevelius J. Transgender women of color: discrimination and depression symptoms. In: Mutch C and Marlowe JD, ed. Ethnicity and Inequalities in Health and Social Care. 2013;6(4):121–136. doi:10.1108/EIHSC-08-2013-0013
- Sevelius JM, Patouhas E, Keatley JG, Johnson MO. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med. 2014;47(1):5–16. doi:10.1007/s12160-013-9565-8
