Addressing violence and HIV cascade of care outcomes among transgender women

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PROJECT SUMMARY Transgender (`trans') women of color experience violence in a variety of contexts, including from partners, strangers, law enforcement, healthcare providers, and in public accommodations. Violence is consistently linked with avoiding care, suboptimal ART adherence, and lower odds of viral suppression via pathways including chronic stress, immune inflammatory response, posttraumatic stress disorder (PTSD) symptoms, and substance use. These epidemics are concurrent and mutually reinforcing, constituting a “syndemic” or synergistic interaction that contributes to documented inequities in HIV continuum of care outcomes. In Detroit, Michigan, trans women of color are one of the `most-at-risk' groups for HIV, with significant disparities in engagement in HIV care. In this R21 exploratory/developmental research application, we propose to adapt and pilot test a culturally-responsive, evidence-based, and trauma-informed intervention to improve engagement in HIV care (primary outcome), reduce PTSD symptoms (secondary outcome), and increase sustained viral suppression (tertiary outcome) among trans women of color living with HIV. Guided by the ADAPT-ITT model, our first aim seeks to conduct a systematic adaptation of the intervention, with a focus on the unique aspects of violence, gender affirmation needs, and engagement in HIV care by conducting interviews with trans women of color and key stakeholders to inform the adaptation. Our community advisory board consisting of trans women of color will review all adapted materials. The second aim seeks to examine the feasibility, acceptability, and preliminary efficacy of the adapted intervention in a one-arm pilot with follow-ups immediate and 3-month post- intervention. The third aim seeks to gather qualitative data from one-arm pilot participants to identify strategies to overcome barriers to implementing rigorous randomized controlled trial research designs with trans women of color within limited-resources settings. Study findings will provide the necessary groundwork for a subsequent community-engaged large-scale randomized controlled trial. Findings also have the potential to provide a blueprint to guide future research efforts with trans women of color who are often embedded in close- knit communities with few existing culturally-responsive services.