Insights from Black Women of Transgender Experience on Improving Engagement In HIV Prevention Continuum

Background and Purpose: Black transgender women are disproportionately impacted by HIV in the US. While effective HIV prevention strategies have blossomed in the last decade, including pre-exposure prophylaxis (PrEP), uptake among Black transgender women has been slow. Existing literature suggests gaps remain in initiation, linkage, and sustained engagement in HIV prevention, particularly PrEP. An analysis of PrEP use among transgender women found that only 32% of transgender women used PrEP in 2020. Low use of PrEP among Black transgender women has been linked to psychological conditions (e.g., depression, anxiety, post-traumatic stress disorder [PTSD], and substance use), social determinants (i.e., social inequities, stigma, transphobia), and structural determinants (e.g., health care discrimination, experiences of homelessness). Project Transcendence is a longitudinal mixed methods study that sought to understand factors that influenced Black transgender women’s HIV prevention behaviors and better contextualize women’s considerations for PrEP as an HIV prevention tool. This presentation focuses on the qualitative phase of Project Transcendence.

Methods: Project Transcendence is an explanatory mixed-methods HIV prevention study of HIV-negative Black transgender women living in the US Ending the HIV Epidemic (EHE) priority jurisdictions (n=75). Participants were recruited via a multi-method strategy from April 2023 to February 2026. In the qualitative, we conducted semi-structured phenomenological interviews over Zoom (n = 30). These interviews examined women’s experiences related to gender identity, consideration for engaging in HIV prevention strategies, and their preferences related to PrEP products and use. We used rapid qualitative analysis using thematic analysis based on a priori codes based on the literature and key constructs of the quantitative findings.

Results: The interviews resulted in four main themes: HIV prevention strategies, PrEP awareness, considerations, and modality preferences, community awareness and attitudes, and strategies to improve PrEP uptake. The first theme illustrated the multitude of HIV prevention strategies being used by Black transgender women based on their perceived HIV vulnerability. The second theme described gaps existing in subgroups of Black transgender women in terms of awareness and knowledge of PrEP. Furthermore, women reported openness to using PrEP, whereas others communicated skepticism on its long-term health impacts or potential interactions with gender affirming hormones. Additionally, women provided examples for future PrEP modalities for consideration to engage Black transgender women. The last two themes focused on community perceptions about using PrEP and community awareness, and strategies to improve PrEP uptake which stressed the need for holistic and affirming group level community-engaged educational workshops, representativeness in marketing of PrEP products, and integrated of HIV prevention in primary care settings.

Conclusions and Implications: Findings from Project Transcendence suggest additional psychoeducation may be warranted to address the unique concerns of Black transgender women related to PrEP use and its impact on the health of that community. Such interventions should incorporate psychosocial PrEP education as part of a holistic and affirming program that addresses socio-structural and behavioral health needs of the community. Social workers serving Black transgender women clients should educate themselves on PrEP as HIV intervention strategy and identify resources to connect clients in need.