Advancing Sexual Health Equity: A Mixed Methods Study of Barriers and Facilitators to Integrated Gender-Affirming and HIV/STBBI Services for Trans and Gender Diverse Communities In Ontario, Canada

Background and Purpose: Trans and gender diverse (TGD) people experience persistent inequities in HIV and other sexually transmitted and blood-borne infections (STBBIs), driven by anti-trans and intersecting stigmas, including those embedded within health systems. While access to gender-affirming healthcare (GAHC), including gender-affirming hormone therapy and surgeries, has been identified as a key facilitator of HIV/STBBI prevention/testing and care among TGD communities, knowledge of the availability of and multilevel barriers and facilitators to such care remains limited. Thus, we sought to integrate system-level and stakeholder perspectives to quantify the availability of integrated GAHC and HIV/STBBI services and to identify multilevel (structural/system, organizational, and interpersonal) barriers and facilitators shaping access, with implications for sexual health equity-oriented social work practice and systems change alongside TGD communities.

Methods: We used a convergent mixed-methods design integrating (1) an environmental scan of 198 HIV/STBBI clinic websites and (2) qualitative interviews with service providers (n=20) and TGD community members (n=22) in Ontario, Canada (June-October 2024). The environmental scan assessed availability of HIV/STBBI prevention/testing and care services, visibility of TGD inclusion, and integration of GAHC. Qualitative interviews explored experiences with access, service delivery, provider knowledge, and priorities for training and system change. Quantitative data were analyzed descriptively; qualitative data were analyzed using directed content analysis informed by intersectionality, gender affirmation, and social ecological frameworks.

Results: Of 198 clinic websites, 72.2% endorsed providing HIV prevention/testing services, 22.2% HIV care, and 84.3% STBBI prevention/testing. Almost half of all clinic websites had no visual or textual representation of TGD people (44.9%); only 21 clinic websites (10.6%) indicated providing integrated GAHC. Qualitative findings identified structural and system-level barriers to HIV/STBBI prevention/testing and care, including long wait times, limited availability of GAHC, and fragmented care requiring navigation across multiple providers. Participants described how lack of integration between HIV/STBBI and GAHC services created substantial access burdens and discontinuities in care. Interpersonal and organizational barriers included cisnormative clinical practices, stigma (both HIV and anti-trans), and gaps in provider knowledge regarding GAHC, HIV/STBBI prevention, and holistic care needs. Facilitators to access included affirming and knowledgeable providers, peer support and community-based navigation, and integrated or co-located models of care. Participants emphasized the importance of gender-affirming communication, trauma-informed approaches, and TGD representation within healthcare settings. Across stakeholder groups, there was strong interest in low-barrier, “one-stop” models integrating HIV/STBBI prevention and GAHC to improve access, continuity, and quality of care.

Conclusions and Implications: Findings demonstrate that inequities in HIV/STBBI prevention/testing and care for TGD populations are shaped by multilevel gaps in service availability, integration, and provider preparedness. Advancing sexual health equity among TGD communities requires moving beyond individual-level approaches to address structural barriers, institutional practices, and health system fragmentation. Social work plays a central role in advancing TGD sexual health equity through interdisciplinary collaboration, community-engaged research, care navigation, advocacy, and implementation of trauma-informed, stigma-reducing, and intersectionality-informed interventions. This study provides actionable, practice- and policy-relevant evidence to inform the development and scaling of integrated, gender-affirming sexual health systems that enhance access, uptake, and equity for TGD communities.