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Peer Support and Networking: Two Ways to Reduce HIV Prevention Barriers for the Trans Community

Released: December 13, 2024

Expiration: December 12, 2025

Dinah Bons
Dinah Bons,
Jürgen Rockstroh
Jürgen Rockstroh, MD
Activity Information

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Key Takeaways
  • Peer-led approaches to HIV prevention services reduce stigma, foster trust, and provide a safe environment that can overcome critical barriers for the trans community.
  • Integrating gender-affirming care into HIV prevention services and establishing networks for referrals to nonhealthcare services (eg, for social and legal support) acknowledges and assists in addressing the wide-ranging inequities experienced by transgender people.

The negative impacts of stigma on the transgender community are wide ranging and include inequitable access to healthcare. There can be a compounded effect when stigma related to HIV and HIV risk is also involved, for example, when it comes to providing HIV pre-exposure prophylaxis (PrEP) services for transgender individuals. Inequitable access to HIV prevention services is evident in the disproportionately high HIV rates among trans communities across the globe. 

Although addressing the harm of discriminatory perceptions and practices requires the contributions of a broad range of societal sectors working together to increase awareness and understanding, there are several important approaches that healthcare professionals (HCPs) can take within their own clinical practices to markedly improve the experience of transgender people who want to engage with PrEP services.

In this commentary, Dinah Bons, Founder and Director of the Trans Clinic Amsterdam and Co-Chair of Trans United Europe Black and People of Color (BPOC) Trans Network Amsterdam, and Jürgen Rockstroh, MD, Professor of Medicine and Head of Infectious Diseases at University Hospital Bonn in Germany, discuss how implementation of 2 key strategies—peer-led care and networking to facilitate broader service referrals—can reduce inequities in access to HIV preventive care for the transgender community. They also discuss the importance of planning ahead for program continuity to safeguard services during times of political upheaval or disruptive changes in government priorities.

Peer Support 

Jürgen Rockstroh, MD: Hello, Dinah, it’s great to talk with you today about how HCPs can work to overcome barriers to engagement with HIV prevention services for the trans community. Let’s start with the role of peer support to promote an inclusive environment in healthcare settings. Can you share your insights on this from your work as founder of the Trans Clinic Amsterdam?

Dinah Bons: A critical feature of the Trans Clinic Amsterdam is that it is a collaboration between the trans community and the healthcare system. This community-led care model involves collaboration between HCPs and community members as well as with local governments and municipalities. With community-led care, members of the community educate the clinical staff on how to work differently with specific groups—in this case transgender people—and ensure they understand the challenges of systemic and institutionalized biases that present barriers for marginalized populations in traditional healthcare settings.

We found that the trans community prefers peer-led care over traditional healthcare models because it reduces stigma. We have also found that peer support needs to come first, before interactions with HCPs, such that these trusted peer interactions help to better connect individuals with their healthcare team. Peer-led care fosters trust and provides a safe environment for trans individuals. It also assists HCPs because it builds additional capacity within the clinic.

The way peer-led care works in practice is that when a transgender person is coming in to receive care, the first person they meet within the clinic is a member of the trans community who can begin to speak to the needs they have at that time and their preferences regarding care. They can also start to gather some of the information the healthcare team will need to know to best address the individual’s needs.

In addition, this interaction provides a safe space where the person can bring up issues that may be difficult to discuss directly with a non-trans HCP. Some examples could be a sex worker who has questions or health concerns related to their work, an undocumented migrant who fears being deported, or someone who is uncomfortable asking questions related to gender-affirming hormone therapy or sexuality. The peer support person can then deliver the key health-related information to the HCP so that they are already on the same page when they meet with the individual.

Jürgen Rockstroh, MD: The peer-led model seems to really be about facilitating communication between members of different communities, in this case the transgender community and the healthcare community. The HCP may be focused on one set of concerns—for instance, HIV testing and initiating PrEP or other technical interventions—whereas the person seeking care may be more concerned about their safety or survival at that given moment.

The model you are describing provides a more culturally sensitive approach that considers the lived experience of the individual, and for transgender individuals more pressing issues could be safety, hormone therapy, or other issues that may not be front-of-mind for the HCP focused on HIV prevention.

Dinah Bons: Yes, in a way, the peer support person serves as a type of cultural translator, allowing both the individual seeking care and the HCP to avoid miscommunication related to discomfort in sharing information or not having the most appropriate language to ask the right questions.

The peer-led model is not difficult to implement because a small number of people can make a big difference. Bringing in a few individuals from an organization that is well known and respected within the trans community can allow the clinic to much more effectively reach people in communities that exist under the radar, which is frequently the case for transgender people. These individuals are often more vulnerable to adverse situations, including HIV acquisition, because they are marginalized by society, particularly transgender migrants or those who are uninsured or not stably housed. Safe, stigma-free, and trauma-informed healthcare environments are particularly crucial for trans migrants who in many cases are fleeing persecution in their home countries.

Networking

Jürgen Rockstroh, MD: Those are excellent points. Digging deeper into the question of competing priorities and meeting the individual where they are, even when working toward improving HIV prevention and PrEP service access, is the issue of siloed vs integrated or at least well-networked service provision. How has the Trans Clinic Amsterdam approached this challenge? I think it concerns both non-HIV healthcare services, particularly gender-affirming hormone therapy, as well as nonhealthcare services.

Dinah Bons: That is an important question because inequitable access to HIV prevention services is only one of many inequities experienced by the trans community, the most critical of which is being able to simply live safely within society. In that context, it is easy to understand that healthcare may not be a top priority when compared with the need to live out of sight as much as possible for survival reasons.

To acknowledge and address this reality, the Trans Clinic Amsterdam partners with departments within the local municipality to provide services that go beyond healthcare, including social and legal services. Because our clinic also serves as a meeting place for the community and is inclusive of the most marginalized groups within it, including individuals without housing and migrants, we assist the work of these departments by connecting them with individuals in need of their services.

This connection enables them to reach people before they are in a severe crisis (eg, eviction, victim of violent crime), allowing interventions to potentially prevent these adverse outcomes.

We take an interdisciplinary approach in which the healthcare, legal, and social service providers meet to provide a comprehensive and holistic assessment of an individual’s situation and needs. There can be complex issues that are best considered as a group. For example, if a migrant without legal documentation is a victim of violent crime, they may not be willing to report that crime for fear of being evicted or deported. Another example could be a migrant who entered the country as a victim of human trafficking. The collective group allows enriched service provision and provides a strong asset to a community that is not able to easily access such services.

Jürgen Rockstroh, MD: That is a powerful model of care. Although no one expects every medical clinic to also have legal and social services readily available, these services are often provided within the municipality, and it is about networking so that you have referrals available to provide to patients who may need them.

Discussion between service providers engaged in the care of individuals in complex circumstances seems like an effective way to come up with and provide solutions. In large cities in Germany, this approach works well, at least for undocumented migrants, with a set of services that includes medical care.

I worry that this approach could be more challenging in less urban areas that may lack the critical mass of support organizations needed to create effective networks. Perhaps more rural regions can improve access by connecting with larger cities nearby to provide more geographic coverage.

Dinah Bons: However, I think the majority of transgender people reside in more urban areas, in part because it is easier to find community and to live under the radar than it is in small rural areas.

Gender-Affirming Hormone Therapy as a Gateway

Dinah Bons: Going back to your question regarding other healthcare services, provision of gender-affirming hormone therapy is indeed a top priority for the trans community, and integrating gender-affirming care into HIV prevention services is a great strategy for improving engagement. 

Jürgen Rockstroh, MD: Yes, as I have learned from our discussions, addressing healthcare needs related to hormone therapy is an important component of reducing stigma and authentically validating a person’s identity.

Dinah Bons: Yes, and some aspects of supporting gender-affirming therapy can easily weave into HIV PrEP services. For instance, if you are drawing a blood sample for HIV or other STI testing, it provides an opportunity to offer hormone level testing without additional appointments. It can be difficult for transgender individuals to find HCPs readily willing to provide affordable hormone level testing, so it is a meaningful hurdle that can be overcome while simultaneously demonstrating an understanding and acceptance of the needs and wishes of that person. Something as simple as offering hormone testing can go a long way toward establishing a relationship of trust, as well as providing them with a reason to want to return to the clinic because it is able to provide valuable information supporting their identity. It can be a strong tool for enabling continuity of care. 

Working Together

Jürgen Rockstroh, MD: The last topic I wanted to address is program stability, particularly as changing political tides result in reduced support for HIV services as well as ongoing and increased hostility toward the trans community in some regions.

Dinah Bons: Yes, this is a problem with dependence on government support, which is also shrinking for the communities that I work for and live in here in the Netherlands. I think it is important to bring like-minded groups together to work closely on safeguarding critical services such as HIV prevention. This needs to include those who would benefit from PrEP as well as HCPs and advocacy groups who can work together to find strategies for continuing the work that we are doing. Working together to garner political will and to identify other funding sources (eg, philanthropic organizations) can help to sustain programs.

A central aspect of this work is supporting research that demonstrates the level of impact effective solutions, such as expanded PrEP access, can have on reducing HIV rates. Unfortunately, PrEP services are not delivered at the level of the European Union (EU). Rather, each country develops its own PrEP action plan, or chooses not to in some cases. If PrEP were made available by the EU for certain groups at high risk for HIV, that would stabilize delivery and would have a substantially larger effect on reducing the burden of HIV. The feasibility of EU-level scaling and even global-level scaling of prevention efforts was certainly demonstrated during the COVID-19 pandemic.

Jürgen Rockstroh, MD: In the province where I practice, we are also anticipating substantial cuts to HIV services. We are currently in a challenging political environment for supporting marginalized communities, and I agree that it is critical that communities come together and are careful about not creating divisions within groups that are working towards similar human rights goals, with healthcare among those rights. It is important to recognize when we are fighting for a common cause because there is strength in numbers.

I also concur regarding the importance of tracking progress and goals achieved by the services we provide. At the community-based Checkpoint advice and testing sites in Germany, we track the number of diagnoses made to show how many would have been missed without the services, with the result being further transmission of HIV and other STIs.

From my perspective, HIV fits into the broader context of sexual health, understanding the shared transmission pathways between pathogens and the important role played by community-driven testing sites. The introduction of community-based testing has made a large contribution to increasing diagnoses and working toward the 95-95-95 UNAIDS HIV targets (95% of people living with HIV knowing their HIV status, 95% of people who know their HIV status initiating treatment, and 95% of people on HIV treatment having viral suppression). It is essential for community groups to reach out to governmental leaders and politicians to share these achievements, so they understand why it is important to continue supporting testing and prevention initiatives.

Dinah Bons: Yes, and I agree that this needs to be done more strategically through a collective approach. Different groups who experience inequities and discrimination while sharing the same overall human rights goals—the trans community, men who have sex with men, people who inject drugs, people who are unhoused—sometimes find themselves at odds with each other, competing for access to the same limited resources. I think they would be better served to work together to obtain a resourcing level that is sufficient to cover the broad healthcare and other basic needs of the whole group.

Your Thoughts?
Is peer support used in your clinic to reduce stigma and support HIV prevention service access for the trans community? What other strategies are you implementing to reduce barriers and overcome disparities in HIV prevention service access for transgender people? Get involved in the discussion by posting a comment below