First HIV prevention trial targeting young transgender women reduces unprotected sex

LifeSkills program reduces condomless sex acts 40% compared to standard of care HIV and STD counseling and testing, new research shows.

Matthew Mimiaga
Matthew Mimiaga

PROVIDENCE, R.I. [Brown University] — Young transgender women are at high risk of acquiring HIV, yet no randomized clinical efficacy trials focused on reducing risks targeting this group have been published.

Until now.

A new study by researchers from Brown University, Northwestern University, Harvard University and The Fenway Institute is the first HIV prevention trial to focus on the transgender community and specifically on transgender women between 16 and 29 years old. The research was published Aug. 13 in JAMA Pediatrics.

The senior author was Matthew Mimiaga, a professor of behavioral and social health sciences and epidemiology in the Brown University School of Public Health, a professor of psychiatry and human behavior at the Alpert Medical School and affiliated Senior Research Scientist at The Fenway Institute, Fenway Health.

We asked Mimiaga about the new JAMA Pediatrics paper.

Q: This study was the first transgender-specific, HIV-prevention efficacy trial, correct? What were the major results?

Yes, that’s correct. This study was the first HIV-prevention efficacy trial specifically for transgender women funded by the National Institutes of Health. An efficacy trial tests if the intervention works to improve health under controlled circumstances after a pilot study has determined if the intervention is feasible and acceptable. We’re excited that Project LifeSkills is now the first evidence-based, behavioral risk-reduction intervention for HIV prevention among young transgender women with demonstrated efficacy. The main finding is that the young transgender women randomly assigned to the LifeSkills intervention had 40% fewer condomless sex acts compared to those who received standard care, even after 12 months.

Q: Why do you think the LifeSkills program was so much more effective than standard STD testing and counseling? 

I believe this is true for many reasons. At the initial stage of intervention development and pilot testing, researchers at Howard Brown Health Center in Chicago — led by co-authors Professors Robert Garofalo and Lisa Kuhns — engaged the local transgender community at all levels, including hiring transgender staff to conduct the formative work and draft the intervention manual, be the face of the project both in terms of community activities, participant recruitment and retention events, and deliver the group-based intervention sessions to other transgender women in the community. For the current efficacy trial, we mirrored this approach in Boston and Chicago.

LifeSkills is grounded in the contextual realities faced by young transgender women. This means we carefully considered the potential impact of discrimination, violence and stigma on HIV risk behaviors, as well as the related structural challenges of securing housing, employment, accessing health care and systemic barriers to legal recognition, while taking into account other factors that increase HIV risk, such as engaging in transactional sex, incarceration, substance use and depression.

Q: Why are these kind of clinical trials important?

Because worldwide, transgender women contend with exceptionally high risks for HIV acquisition and transmission. Despite consistently documented social, health and HIV-related inequities, inclusion of transgender women in HIV prevention trials has been limited, and the Centers for Disease Control’s Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention currently includes no evidence-based interventions based off of an efficacy trial designed to reduce sexual risk for HIV infection for these women. We believe that the LifeSkills intervention will be the first of its kind to be included in the CDC’s compendium.

Q: What are the next steps for this research? Are there any plans to expand the use of this prevention program?

Yes, absolutely! We have already applied for more funding to adapt the LifeSkills intervention to an app to get it into the hands of individuals. Mobile devices have the advantage of simple interface for users, accessibility anywhere internet access is available, relative affordability and have been promoted specifically to reach stigmatized and disenfranchised populations. We hope to receive funding to do this important work.

Q: Why are young transgender women at such high risk of acquiring HIV?

For young transgender women, discrimination, mistreatment and adversity in the form of rejection from friends, family and others, can become a central part of young adulthood, affecting the ability to secure housing, employment, social services and healthcare. This basic struggle for survival undermines young transgender women’s ability to prioritize and avoid HIV risk. In addition, young transgender women are disproportionately represented among homeless people, often a result of estrangement from their families. They experience discrimination in seeking housing and have trouble finding a job. This socioeconomic marginalization may force young transgender women to earn money to support themselves through sex work. Transactional sex is significantly related to sexual risk behavior and HIV infection in transgender women because economic pressures often result in compromising safer sex practices for monetary incentives. And related issues such as depression, trauma, intimate partner violence, substance use and many others drive high levels of HIV-related risk behaviors among this group.