Best Practices for Trans HIV Prevention and Care: Addressing Social Determinants of Health

On April 6, 2017, the California HIV/AIDS Policy Research Centers (CHPRC) convened a statewide group of stakeholders to discuss best practices for HIV prevention and care within transgenderⁱ communities in California. Presentations by leading experts from academic medical centers and community-based organizations focused on utilizing an intersectionality perspective to identify best practices for serving transgender populations throughout the state. The overall purpose of the day’s meeting was threefold:

1. To identify HIV prevention and care best practices for transgender individuals in California that address social determinants of health;
2. To identify barriers and facilitators to statewide implementation of those best practices; and
3. To identify important policy research needs that CHPRC can address in order to complement and/or aid the work others are already doing to develop and implement culturally appropriate interventions to improve the health and well-being of transgender populations in California.

Studies have shown that transgender people experience marginalization, both social and economic, which impacts their ability to access appropriate health care services.ⁱⁱ A recent survey of the health status of transgender individuals taken from a probability sample found that transgender individuals were more likely than cisgender individuals to not have healthcare coverage or a personal health care provider and were more likely to have been unable to afford a doctor visit when they needed it.ⁱⁱⁱ Thus, experts agree HIV prevention efforts for transgender people must be comprehensive to be effective.^iv

The convening was designed to identify existing efforts to address social determinants of health in the lives of transgender persons. We note that healthcare providers have made conscious efforts to design health promotion practices focused specifically on the health of transgender individuals.^v Additionally, local efforts have targeted the provision of safety net services to address particular needs of the transgender community.^vi Other social services organizations have dedicated resources to develop employment programs for transgender clients and patients.^vii Community-based training focused on leadership development led by and for transgender people was an additional practice mentioned both in the literature and by participants during this day-long think tank.^viii Finally, researchers discussed leveraging opportunities to train, hire and retain trans- identified research staff.^ix

Much time was devoted to discussing barriers to implementation of transgender-specific health services and programs to address transgender people’s unique psychosocial needs, including challenges to scaling up projects that have proven to be effective. This included a list of challenges specific to gaps in data collection, funding, transportation, gender-affirming education, sex positivity in sexual health education, employment opportunities, leadership development, and bureaucratic efficiency. Participants in the day-long think tank emphasized the importance of tackling implementation-related barriers to the delivery of HIV prevention and treatment programs for transgender people across the state.

In an effort to develop more diverse and innovative approaches to HIV prevention and treatment efforts for transgender people in California, participants engaged in an exercise to design solutions to identified problems. Small groups focused on strategies identified by transgender, gender-queer, gender non-conforming, and gender non- binary-identified individuals and topical groups focused on transgender youth, incarcerated, criminalized and detained transgender individuals, economic empowerment, funding support, and the specific need for supportive housing. Throughout the day, a standing group of transgender-identified participants were invited to discuss a range of topics based on their experiences. This opportunity allowed for honest discussions within and among transgender and gender non-conforming individuals.

While the robust nature of these day-long discussions yielded bountiful suggestions, several key recommendations appeared most promising. These included the following:

1. Create a hub or community at multiple geographic centers placing the needs of the most impacted transgender people: Cluster around this population myriad services and social support, addressing a range of needs such as housing, transportation, leadership development, employment opportunities, re-entry services, and intergenerational programming. This strategy could address bureaucratic inefficiencies and the need to co-locate and bundle social services.
2. Expand existing efforts to increase economic empowerment of transgender individuals: Leverage knowledge and experiences of leaders already engaged in economic empowerment activities, and leverage efforts to establish more and more effective interventions through identifying best practices. Partner with the labor community, private sector businesses and corporations at the local level to increase employment opportunities. Increase financial and emotional support to facilitate educational attainment as a strategy to ensure that not all employment opportunities focus on entry-level positions.
3. Reimagine Funding: Ensure deliberate incorporation of transgender voices at all stages of any given funding process—from the Request For Proposals to proposal review, through to the evaluation and funding-decision phase. Address cultural humility within the funding institutions themselves while also monitoring for cultural humility among those institutions funded to conduct HIV prevention and treatment research and programs for transgender people. Tie funding to mandates (e.g. establishing priorities, ongoing training, use of gender affirming language) to increase the use of best practices in addressing the continued needs of the most vulnerable transgender individuals.

The mission of the CHPRC is to work in partnership with consumers, advocates, and policymakers to conduct policy-relevant research that strengthen local, state, and national HIV prevention and care services for affected persons and populations. Below is a list of next steps that CHPRC will pursue during the remainder of the current funding cycle and beyond:

1. Given the need to center transgender people in policymaking, CHPRC will convene, staff, and incentivize participation for a statewide multidisciplinary panel of transgender and allied experts committed to exploring policymaking that addresses HIV prevention and care for and by transgender individuals;
2. Given CHRPC’s mandate to conduct policy research that is responsive to current policymaking efforts, we will identify specific research opportunities raised by the planning body and utilize the rapid response research mechanism to conduct such research;
3. Given the need to scale up strategies focused on economic empowerment, CHRPC will engage existing economic empowerment programs that specifically serve transgender people to understand best-practices for transgender economic empowerment programs and to identify future rapid response research opportunities to document best practices, including facilitators and barriers to implementing economic empowerment strategies; and
4. Given CHRPC’s strong ties to its funder, the California HIV/AIDS Research Program, CHPRC and its planning body will engage in continued conversation with the funder to establish recommendations for future funding mechanisms that may address the needs and concerns raised in the course of the proceedings.

These proposed activities scarcely address the many promising ideas and thoughtful reflections provided throughout the course of the convening. We thank all participants and presenters who dedicated their time and energy to this work. We look forward to implementing practices that include the meaningful inclusion of transgender individuals, developing relevant policy research which addresses the needs of transgender people, and continued engagement in honest conversation across communities.