Interventions that change social determinants of health form the base tier of the pyramid. Such interventions reach people collectively and include promoting social justice, improving economic opportunities and educational attainment, and increasing access to services.¹⁸ Transgender persons may benefit from policies applied to the general public. Examples include living wage ordinances, public transportation, distribution of free condoms, laws permitting pharmacy sale of syringes, interpreter services, and health insurance coverage under the Patient Protection and Affordable Care Act.¹⁹ However, transgender persons must find sensitive and experienced providers, and insurance coverage for GRPs is uncommon.²⁰ We could not identify HIV prevention efforts at this level that target transgender people.

Future prevention efforts to address underlying social determinants of health for transgender persons could consider including

general equivalency diploma (GED) programs, job training programs, and English language education;

Organizations could consider providing supportive services, such as HIV and hepatitis C testing, sexuality education, clothing, and referrals, for example, to substance abuse treatment, GED programs, and employment and legal services. Legal services could provide assistance with nondiscrimination protections and changing names and gender markers on identity documents. Monitoring HIV/AIDS prevalence, incidence, and prevention needs of local transgender populations may likely be improved by collecting epidemiologic data, including the two-question method for assessing gender,²¹ and separating transgender identities in reports.

The pyramid’s second tier represents interventions that change the environmental context for a population so that healthy options are the collective default choice. Non–HIV-related interventions at this level include clean water, road improvements, and smoke-free laws.¹⁸ We could not find widespread second-tier HIV prevention efforts specifically for transgender people. However, transgender persons benefit from policies applied to the general population, such as opt-out HIV screening.

Future interventions to change the environmental context for transgender people might appropriately include

programs to decrease violence against transgender persons;

Social marketing campaigns to eliminate stigma and discrimination may change community norms and improve availability and acceptability of healthful options for transgender persons. Behavioral economic interventions targeting transgender persons, such as conditional economic incentives for remaining free of sexually transmitted infections, could be researched as temporary alternatives to exchanging sex for basic needs.²²

Third-tier interventions are those that are directed toward individuals one time or infrequently and do not require ongoing clinical care.¹⁸ An HIV prevention intervention at this level is male circumcision, which can decrease HIV acquisition for cisgender males.²³ Male circumcision’s applicability to transgender persons may be limited to persons who were assigned male and who have not undergone gender reassignment surgery. Transgender persons may benefit from interventions for the general population (e.g., immunizations for hepatitis A and B and human papillomavirus), depending on their sexual and injection practices. To increase their safety in public settings and in relationships, transgender persons may choose to have voice and communication therapy or training in their presenting gender’s social and relationship skills.

Future long-lasting, protective interventions for transgender persons could include peer support groups. Although not intended as HIV prevention interventions, medically administered hormones and gender reassignment surgery could avoid unsafe injection practices and improve mental health and associated risk behaviors.¹⁴ In a recent study, postoperative transgender women were less likely to have condomless anal sex, a practice with a high risk of HIV transmission, compared with preoperative transgender women.²⁴

The fourth tier of the pyramid represents ongoing, evidence-based clinical care for individuals.¹⁸ Current HIV prevention at this level includes biological (e.g., antiretroviral therapy [ART], pre-exposure prophylaxis [PrEP], vaginal and rectal microbicides) and behavioral (e.g., substance abuse treatment, mental health services) interventions.⁷ Although biological interventions can lower community viral load and prevent HIV disease progression, transmission, and acquisition, their effect is limited by lack of access to clinical care, insufficient medication adherence, and imperfect effectiveness of the interventions. Fourth-tier HIV prevention efforts specifically for transgender persons are presented in the Substance Abuse and Mental Health Services Administration’s guidance on providing culturally competent services.²⁵ Transgender persons may benefit from ART and PrEP, but can experience decreased response to hormone replacement therapy (HRT) if they are on ART.¹⁵

Suggested future clinical interventions for transgender persons could include

training for improved provider attitudes and behavior toward transgender patients;

Although not an HIV prevention intervention, medically managed HRT could enhance transgender persons’ mental health,¹⁴ and HIV testing or monitoring could be done during HRT appointments. Mutual patient–provider trust is essential for transgender persons to discuss their treatment challenges, HIV risk behaviors, and gender reassignment history. If transgender persons do not disclose their sex assigned at birth, providers may base examinations on presenting gender and not perform necessary health screenings (e.g., for prostate cancer).

The fifth tier represents health education provided to individuals in clinical visits or other settings.¹⁷ Counseling and education interventions seek to discourage unhealthy or risky behaviors and to encourage healthy or safer behaviors. Individual effort is high in this tier and increases with each intervention session. Although changing environmental context has more population influence, counseling and education interventions are more feasible.¹⁸ Systematic reviews have shown that evidence-based interventions (EBIs) are efficacious in reducing HIV-related risk behaviors and in increasing protective behaviors among at-risk populations.¹ However, the Centers for Disease Control and Prevention’s Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention²⁶ notes that currently there are no EBIs specifically designed for transgender participants. Although several interventions have been developed for transgender women,^17,27–31 to date, few have been rigorously evaluated and two are undergoing randomized controlled trials.^30,31 No interventions have been developed for transgender men.

Analyses by Herbst et al.¹ indicate that future counseling and education interventions for transgender persons should contain

referrals to housing, job training, legal, and medical services;

Skills in coping with stress, disclosure of gender identity, and social behaviors of the presenting gender may also be beneficial. If these components are not covered by an EBI, they could be incorporated as adaptations with input from transgender persons.³² However, extensive adaptation requires time and resources for formative research, incorporation of findings, and evaluation of the reinvented intervention.

To minimize adaptation effort, HIV/AIDS service organizations could select EBIs that target risk behaviors and determinants common to the organization’s transgender clients and that match the organization’s implementation capacity. To aid EBI selection, we searched the Centers for Disease Control and Prevention’s list of EBIs²⁶ to find those with implementation manuals. We read the manuals to identify EBIs that target any of the previously discussed HIV risk behaviors and determinants common to transgender persons. We identified 12 EBIs that address at least four of these factors (Table 2). It is likely that an organization’s transgender clients may need multiple EBIs to address all of their relevant HIV risk factors. Table A, available as a supplement to the online version of this article at http://www.ajph.org, presents implementation capacity considerations.

When one is adapting EBIs, sensitizing content is important— for example, terminology for sexual behaviors and pre- and post-GRP anatomy, non-anatomical models for condom skills practice, and suitable examples of risk-reduction goals and barriers. Service organizations may want to consider adding relevant content, such as HIV risk from shared injection of hormones, commercial sex work customers, appropriate risk scenarios, vulnerabilities from stage of physical transition and desire for gender affirmation, and referrals to transgender-sensitive medical and social services. Depending on the EBI’s participants, organizations may consider omitting references to perinatal transfer, pregnancy, babies, breastfeeding, and pelvic inflammatory disease.