Project Summary The goal of this study is to develop and pilot test an integrated microeconomic (ME) intervention to reduce the risk of HIV transmission among economically disadvantaged male-to-female (MTF) transgender women (TGW). While some psychosocial interventions have been implemented for TGW, most lack rigorous evaluation data and/or economic determinants are largely unaddressed. Despite the high estimated HIV prevalence (>25%) among U.S. TGW (and up to 50% in African-American TGW), they have nevertheless not been targeted in the few available ME initiatives for HIV prevention. Recent studies suggest that there are a variety of factors contributing to HIV vulnerability in TGW, including economic and structural barriers such as experiencing discrimination in employment and housing and the high cost of medical and clinical services required for male-to-female transition, all of which lead to financial instability and reliance on high-risk income generation; and being victims of sexual violence and having much higher incidence of psychiatric symptoms and substance use, all linked to higher HIV prevalence and transmission. It is estimated that TGW are three times as likely as the general population to be unemployed; four times as likely to be unstably housed; and twice as likely to be poor. TGW of color especially experience these disadvantages. To address high rates of HIV and the related economic disadvantage of TGW (including many TGW of color), this study will use a two group experimental design to develop and longitudinally assess an integrated ME intervention tailored for economically disadvantaged TGW who are also behaviorally at risk for HIV. Microeconomic interventions, defined as very small-scale initiatives to improve the financial status of individuals have been shown in low-income countries to improve protective sexual behaviors, and HIV communication and testing, by combining HIV education and financial training, mentoring, and economic resources. Consistent with these results, we will finalize and evaluate the intervention via three project aims: Aim 1: Conduct formative work with TGW and key informants to assess TGW’s current experiences and preferences for each of the possible ME components (including supportive economic services, employment readiness and financial training, gender transition supports, and economics-based HIV education). Aim 2: Develop an integrated ME intervention for HIV prevention tailored for economically disadvantaged TGW which addresses multiple economic vulnerabilities in two U.S., HIV-prevalent, and resource-poor metropolitan areas (Richmond, VA and the St. Louis MO/IL metro area.) Aim 3: Using a randomized experimental study design, assess the feasibility and efficacy of the integrated ME for economically disadvantaged U.S. TGW in reducing economic vulnerability and HIV sexual risk-taking. The ultimate goal of this R34 project is to establish a feasible, acceptable, and scalable microeconomic intervention for HIV reduction in U.S. TGW communities to test within a larger, subsequent RCT.

Project Narrative Transgender women (TGW) face persistent discrimination and structural disadvantages including high rates of unemployment, unstable housing, poverty, and dramatically elevated rates of HIV. The proposed research, using a randomized experimental design, seeks to develop and test an integrated microeconomic intervention, and to assess the feasibility and efficacy of the intervention to improve the financial status of TGW and to reduce participation in high-risk income-generation strategies.