Integrating CBPR and Implementation Science to Develop a PrEP-Promotion Intervention for Black Transgender Women

Abstract

Black/African American transgender (trans) women experience disproportionately high rates of HIV, yet few evidence-based interventions are designed specifically for them. This study outlines the development of the Sisters United intervention through the adaptation of ChiCAS, an evidence-based intervention for trans Latinas. Sisters United promotes use of pre-exposure prophylaxis (PrEP), condoms, and medically supervised gender-affirming hormone therapy (GAHT) among Black/African American trans women. Integrating community-based participatory research and implementation science, our systematic process included multiple steps conducted in partnership with a steering committee of Black/African American trans women, other community representatives, scientists, practitioners, and consultants. We held focus groups and obtained iterative feedback about intervention objectives, messaging, and activities, including new activities focused on medical mistrust and the use of injectable PrEP, to guide the adaptation. Key intervention components developed through this process include an implementation manual, facilitator’s guides for in-person and virtual delivery, video segments, and an e-learning course to support effective implementation. Like the original ChiCAS intervention, Sisters United is designed to be delivered in two sessions, with a focus on raising awareness about HIV and GAHT, building condom use skills, and overcoming barriers to health care. This intervention fills a critical gap by offering a scalable solution to promote HIV health equity among Black/African American trans women. Moreover, our systematic process can serve as a guide for others developing, refining, or adapting interventions to meet the needs of a new community or population and/or infuse updated information and innovations into an existing intervention.

Keywords

health disparities health equity HIV interventions mixed methods population groups qualitative methods sexual and gender minorities sexual health sexually transmitted infections

It is well-established that transgender (trans) women are disproportionately affected by HIV, with current prevalence estimates in the United States ranging from 14% to 42%. Black/African American trans women have even higher prevalence than White trans women (e.g., Becasen et al., 2019; Centers for Disease Control and Prevention [CDC], 2021a). In the National HIV Behavioral Surveillance Among Transgender Women (NHBS-Trans) system (data collected in 2019–2020 in seven U.S. urban areas), 61.9% of Black/African American trans women tested positive for HIV (CDC, 2021a).

Despite the availability of pre-exposure prophylaxis (PrEP), its use remains low among Black/African American trans women. Estimates of PrEP use among trans women are imprecise but consistently much lower than needed to meet the Ending the HIV Epidemic (EHE) goal of reducing new HIV infections in the United States by 90% by 2030 (Fauci et al., 2019). In NHBS-Trans, 30% of Black/African American trans women reported using PrEP in the past 12 months (Morris et al., 2024). A study of Black/African American and Latina trans women in Baltimore found that 13.6% reported using PrEP in the past 12 months (data collected 2015–2017; Poteat et al., 2019). A U.S. probability sample found that 2.3% of racially/ethnically diverse trans women reported currently using PrEP (data collected 2017–2018; Sevelius et al., 2020). Complex and interrelated barriers to PrEP use exist among trans women, including lack of knowledge about PrEP and where and how to access and pay for it, misinformation, concerns about drug interactions with gender-affirming hormone therapy (GAHT), homelessness, limited insurance access, violence, stigma, medical mistrust, and profound discrimination in health care (Baldwin et al., 2021; Bass et al., 2022; Brookins et al., 2024; Cooney et al., 2022; Feldman et al., 2021; Kuhns et al., 2023; Olansky et al., 2020; Poteat et al., 2019; Sevelius et al., 2016; Smart et al., 2020; Tordoff et al., 2023).

Black/African American trans women also report high rates of condomless sex. In NHBS-Trans, 52.7% of Black/African American trans women reported condomless anal intercourse in the past 12 months (Hershow et al., 2024). Intersecting factors contributing to condomless sex include lack of knowledge about condoms, lack of available sexual health education and other services specifically designed for trans women, substance use, misconceptions and pressures from partners not to use condoms, and sexual health communication challenges. In addition, trans-negativity and discrimination based on race/ethnicity may create a heightened desire for trans women of color to feel safe and affirmed, causing them to take sexual risks if requested by partners. Among trans women who exchange sex for money or drugs, the risk may be further exacerbated by power imbalances or financial pressure to engage in sex without condoms (Hershow et al., 2024; McNulty et al., 2022; Morris et al., 2024; Nemoto et al., 2006; Rhodes et al., 2021; Sevelius, 2013; Smart et al., 2020).

Despite the documented mental health benefits of GAHT (e.g., lower rates of suicidal ideation and drug/alcohol use), which also shape HIV risk behaviors (Bockting et al., 2016; Institute of Medicine, 2011; Reisner et al., 2016; Sevelius et al., 2014; Wilson et al., 2015), Black/African American trans women have low rates of accessing and using medically supervised GAHT services (Goldenberg et al., 2019; Morris et al., 2024; Olansky et al., 2024; Smart et al., 2020). In NHBS-Trans, 66.0% of Black/African American trans women reported using GAHT, and 25.4% reported wanting to take GAHT (CDC, 2021a; Olansky et al., 2024). Black/African American trans women face a number of challenges to accessing and using medically supervised GAHT and health care more generally (CDC, 2021a; Grant et al., 2011; Olansky et al., 2024; Safer et al., 2016; White Hughto et al., 2017). Accordingly, high percentages of Black/African American and other trans women of color rely on non-medical sources of GAHT, which can be unsafe and lead to increased risk of adverse health effects. For example, trans women of color report purchasing hormones through the internet and from friends (Clark et al., 2018; Olansky et al., 2024; Rhodes et al., 2011, 2015; Sevelius, 2013; Song et al., 2012; Stroumsa et al., 2020). Trans women facing barriers to using GAHT often prioritize those services over HIV-related concerns and may engage in sex work or transactional sex to pay for services to affirm their gender identity, among other motivations (Sevelius et al., 2014; Smart et al., 2020).

Thus, there is a critical need for culturally responsive interventions that address the priorities of Black/African American trans women and reduce disparities through PrEP, condom, and medically supervised GAHT use. Designed for trans Latinas, the ChiCAS intervention is one of few existing HIV prevention behavioral interventions in the CDC Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention for PrEP promotion, and there is a critical need for tailored interventions for Black/African American trans women. Community-based participatory research (CBPR) and implementation science, which both aim to accelerate scientific advances and real-world practice, represent complementary approaches for adapting existing behavioral health interventions to new contexts, populations, and medical innovations (McKleroy et al., 2006; Wu et al., 2023).

The ChiCAS Intervention

Details on the ChiCAS intervention have been published previously; briefly, the intervention is comprised of two sessions delivered in small-group waves (Rhodes et al., 2021, 2022, 2024; Smart et al., 2024). ChiCAS is informed social cognitive theory (Bandura, 1986), empowerment education (Freire, 1973), and social support (Qiao et al., 2014). Although designed to promote the use of PrEP, condoms, and medically supervised GAHT, direct provision of PrEP and GAHT is not part of the intervention.

In a randomized controlled trial, ChiCAS increased PrEP use among trans Latinas. Participants included 144 HIV-negative Spanish-speaking trans Latinas, 18 to 59 years old. Participants were randomly assigned to participate in the ChiCAS intervention or to be part of the waitlist control group. Participants completed assessments about their health behaviors at baseline and 6-month follow-up. At follow-up, compared to control participants, ChiCAS participants reported significant increases in PrEP use; knowledge of HIV, sexually transmitted infections (STIs), and GAHT; PrEP awareness, knowledge, and readiness; condom use skills; and community attachment (Rhodes et al., 2024). Given these successes, we sought to adapt ChiCAS to develop Sisters United for Black/African American trans women. Our process also accommodated updated data (e.g., on the impact of HIV on Black/African American trans women and relevant factors such as racism and medical mistrust) and recent biomedical advances in HIV prevention (e.g., injectable PrEP).

Purpose

This article outlines the development of the Sisters United intervention through the systematic adaptation of ChiCAS to support health equity through HIV prevention for Black/African American trans women. We also describe Sisters United components and resources that resulted from this process designed to support the uptake of the intervention within communities.

Method

CBPR

Our team of community members and researchers has built a solid foundation through our work on CBPR HIV intervention studies. Blending the perspectives, experiences, and expertise of various partners (i.e., a steering committee of Black/African American trans women from across the United States, other representatives from the lay community and HIV and LGBTQ+ organizations, other scientists, practitioners, and consultants from Wake Forest University School of Medicine, Sentient Research, and CDC), we developed and applied a systematic and engaged process that promoted iterative feedback and built on the collective expertise of all members of the team while promoting and integrating community member participation throughout the process.

The Development of Sisters United

Our process incorporated proven systematic, evidence-based intervention adaptation strategies from CDC’s Division of HIV/AIDS Prevention (McKleroy et al., 2006) and implementation science frameworks (Wu et al., 2023) to fit Sisters United to the cultural context, social determinants, risk behaviors, and unique circumstances of Black/African American trans women without competing with or contradicting the internal logic, core elements, or key characteristics (Collins & Tomlinson, 2014; Galbraith et al., 2011; McKleroy et al., 2006) of ChiCAS (Rhodes et al., 2022).

Adaptation of ChiCAS to develop Sisters United included multiple steps (Figure 1) that accommodated iterative review and revision by partners, as data and feedback were obtained and integrated into intervention components. These steps are not necessarily linear, may overlap, and can be revisited as warranted. A critical initial step, however, was to convene the steering committee of Black/African American trans women from across the United States (N = 9). This committee provided insights, real-world perspectives, and guidance throughout each subsequent step of the intervention development, refinement, and adaptation process.

Figure 1.

A Systematic Intervention Development, Refinement, and Adaptation Process

We developed an intervention matrix (Wu et al., 2023). This matrix included a brief description of sessions and activities in the ChiCAS implementation curriculum; the underlying behavioral determinants associated with use of PrEP, condoms, and medically supervised GAHT that are addressed in each activity; and a “fit assessment” of the activity to the context and lives of Black/African American trans women. It also identified where input was needed and questions to answer during the process. This matrix helped us identify what we needed to explore within the focus groups, in the literature, and from other external experts. The matrix was a place to document revisions and changes made to the intervention as they were completed. Overall, creating this intervention matrix provided a comprehensive visual presentation of the intervention, allowing partners to identify the purpose of each activity and track activities that were preserved, strengthened, or revised between the original ChiCAS and adapted Sisters United interventions.

We also conducted four focus groups (each had 4–5 participants) with Black/African American trans women to review the ChiCAS intervention in its entirety and obtain input on questions identified in the intervention matrix. We harnessed existing professional network contacts from prior studies related to HIV prevention or care and trans health to recruit potential participants. To be included, each participant had to be ≥18 years old, speak English, and identify as a Black/African American trans woman.

The mean age of participants ranged from 18 to 62 years. These focus groups were conducted via the videoconferencing platform Zoom and included participants from across the United States, including California, Georgia, Illinois, New York, North Carolina, Tennessee, and Texas. Several participants also provided HIV prevention and care services to Black/African American trans women.

Participants provided insights about (a) facilitators of and barriers to engaging in PrEP, condom, and GAHT use and perspectives around receiving information about and referrals to locally available health care services; (b) admirable qualities and strengths of Black/African American trans women that promote pride and self-esteem; (c) impressions of the ChiCAS intervention curriculum and logo; (d) ideas for a name and logo for the adapted intervention; and (e) feedback on the original ChiCAS video segments and identification of needed revisions to the video storyboards and scripts for the adapted intervention.

Key findings from the focus groups included “Black” and “African American” as interchangeable terms with no preference for either among participants and Black/African American trans women being strong, resilient, hardworking, and “always breaking barriers.” Participants also noted within-group divisiveness that contributed to a lack of trans women supporting other trans women and the frequent use of apps, including Instagram, Facebook, Badoo, Twitter, Grindr, Hinge, and OkCupid, to find romantic and sexual partners as relevant to health promotion efforts among Black/African American trans women.

Identified barriers to PrEP use included lack of awareness about where and how to access PrEP services, lack of health insurance access, stigma related to gender identity and behaviors, mismatch of identification/documentation and identity, lack of transportation to services, and lack of competency around trans identities and bodies among clinic staff and providers. Barriers to condom use included partners not wanting to use condoms during sex and/or pretending to put on a condom but removing it, “getting caught up” in the “heat of the moment,” condom use conflicting with ideas about intimacy and partner trust, and substance use before and during sex.

When asked about GAHT, several participants noted that Black/African American trans women often must resort to obtaining GAHT from “underground” and online sources such as from international vendors, “on the streets,” and from friends. It was also noted that where a person lives can make a profound difference in how or whether they can access hormones. For instance, while a participant in California reported that she can get GAHT for free, a participant in Tennessee reported that laws there make it difficult to access GAHT.

When presented with ChiCAS, participants were excited about this type of intervention. As a participant concluded,

[Trans women] would enjoy participating [in the intervention] because it’ll build a sense of community among the girls. I think just being able to have these impactful, empowered conversations among ourselves will bring us together and help us understand our different point of views, where we come from, and how all of these things encompass our entire experience.

Concurrently, we continued to review the literature on emerging issues affecting Black/African American women, including PrEP, condoms, GAHT, and access to care. Through iterative discussions with the steering committee, we also finalized a name for the intervention (Sisters United), its logo (Figure 2), and video storyboards and scripts that were used to guide the new and updated versions of the video segments. We also adapted all other materials (including the facilitator’s guides) and then reviewed these adaptations with Black/African American trans women who had not participated in the process but reflected the women for whom the intervention was designed. This review was critical because community members who are engaged throughout the intervention development, refinement, and adaption process may become more like the other researchers involved in the process and less “in touch” with their community peers (Rhodes et al., 2017).

Figure 2.

The Sisters United Logo.

Throughout the entire process, we also worked with external scientific experts, including scientists and practitioners from the CDC National Center for HIV/AIDS, viral hepatitis, sexually transmitted disease (STD), and tuberculosis (TB) prevention. These experts reviewed and revised materials and suggested edits based on PrEP (CDC, 2021b) and GAHT (Coleman et al., 2022) guidelines and advances in HIV prevention science. They recommended HIV and STI prevention messaging and approved all Sisters United materials.

In addition, we were careful to strengthen the intervention while incorporating lessons learned from the ChiCAS trial (Smart et al., 2024), findings from the focus groups, ongoing literature review, and review and feedback from the steering committee and external experts. The original ChiCAS intervention did not significantly increase past 30-day condom use or current use of medically supervised GAHT (Rhodes et al., 2024), although in post hoc analyses there was a trend of increased use of medically supervised GAHT at follow-up among a subgroup of participants (i.e., those who reported not using but wanting to use medically supervised GAHT). Thus, we strengthened condom and GAHT use activities, messaging, and supporting materials in Sisters United. Strengthening included revising activities to be clearer and more comprehensive.

Finalized materials were then packaged for use with support from a professional graphic designer and video and media production companies. The adaptation process ensured that Sisters United reflected the needs and priorities of Black/African American trans women and was culturally responsive and meaningful. It ensured that the theoretical underpinnings, internal logic, and levers of change; core elements; and key characteristics of ChiCAS remained (Rhodes et al., 2021, 2022, 2024; Smart et al., 2024).

Results

Our process yielded the materials needed to implement the two-session Sisters United intervention with fidelity. These materials included an implementation manual, facilitator’s guides for in-person and virtual delivery, the associated video segments, and an e-learning course for implementing organizations.

Implementation Manual

The Sisters United implementation manual is intended to assist community organizations, such as HIV, trans, and LGBTQ+ organizations and health departments, plan for, implement, and evaluate Sisters United. The manual is divided into six chapters plus appendices. An overview of the content and format of the manual, its chapters, and appendices is presented in Table 1.

Table 1.

Components of the Sisters United Implementation Manual.

Chapter	Title	Overview
1	What is Sisters United?	Provides an overview of Sisters United, including its core elements, main components, in-person versus virtual implementation, and the trial demonstrating the original intervention’s effectiveness.
2	Understanding the health disparities that Sisters United addresses	Provides foundational knowledge about HIV and STI prevention and access to medically supervised GAHT among Black/African American transgender women and the factors that contribute to health disparities.
3	What does it take to implement Sisters United?	Outlines the necessary resources to successfully implement Sisters United in terms of staffing, budget items, and facilities, and offers a sample timeline of activities to prepare for and implement Sisters United.
4	Preparing for the Sisters United sessions	Explains how to build capacity to work cross-culturally in the community and to connect with local providers of services for Black/African American transgender women and describes successful strategies for recruiting and retaining Sisters United participants.
5	During the Sisters United sessions	Explains how to use the Sisters United facilitator’s guides and provides guidance on facilitation techniques and maintaining participant confidentiality.
6	Monitoring and evaluating Sisters United	Introduces key concepts related to monitoring and evaluating the Sisters United intervention, including the purpose of evaluation, process and outcome monitoring and evaluation approaches, selection of a lead evaluator, data storage and analysis, and reporting and applying findings.
Appendices		Includes relevant materials, such as related peer-reviewed publications, sample screening materials, Sisters United in-person and virtual facilitator’s guides, PowerPoint presentations and video segments used during sessions, sample observer’s guides to assess implementation fidelity, and sample evaluation materials.

The manual provides comprehensive guidance on the logistics of planning for and implementing Sisters United. Different chapters may be particularly relevant to different roles within an organization. For example, staff members (such as administrative staff) who are charged with development tasks and procuring funds to implement interventions, staff directly responsible for recruiting Sisters United participants or for facilitating the Sisters United sessions, or staff who supervise and support these roles. The manual includes important in-depth information about what is needed at the organization level to ensure that Sisters United is implemented in-person and/or virtually with fidelity. It describes how to create a safe space for participants and effective facilitation skills and behaviors.

The manual also provides guidance necessary for successful virtual implementation. This guidance includes step-by-step instruction on when to send materials to participants prior to sessions; helping participants identify a quiet, private, and safe space to participate in intervention delivery; practicing use of videoconferencing features and breakout rooms with participants; and reminding participants to have their phone, tablet, or laptop chargers handy and be near a power source. The Sisters United implementation manual also includes as appendices the facilitator’s guides for both in-person and virtual sessions, among other relevant appendices.

Facilitator’s Guides for In-Person and Virtual Delivery

We developed two facilitator’s guides: one for in-person delivery and a second for virtual delivery. The guides include detailed intervention curricula for those implementing the intervention, with learning objectives, important messages, and all activities and related materials (e.g., PowerPoint slides and handouts). The virtual guide is similar to the in-person guide and includes information about how activities are successfully delivered via videoconferencing.

Sisters United uses highly engaging interactive activities and group discussions to meet the objectives outlined in Table 2. These objectives align with critical factors found to be linked to the use of PrEP, condoms, and medically supervised GAHT among Black/African American trans women. Sisters United is designed to provide information about HIV prevention and medically supervised GAHT and to support trans women as they take action to improve their health by accessing resources. Like ChiCAS, direct PrEP and GAHT provision is not part of the intervention. However, if an implementing organization provides PrEP and/or GAHT services, Sisters United can be used to promote the use of these services.

Table 2.

Sisters United Objectives.

(1) Increase awareness of the impact of HIV and STIs and of the benefits of using medically supervised GAHT among Black/African American transgender women

(2) Increase knowledge of HIV and types of STIs, the ways HIV and STIs are transmitted, signs, symptoms, and prevention (including PrEP and condom use)

(3) Offer guidance on PrEP and medically supervised GAHT services and “what to expect” when accessing services and interacting with providers

(4) Build skills for using condoms and negotiating condom use with sexual partners

(5) Overcome barriers to accessing PrEP and medically supervised GAHT services

(6) Change norms and expectations that may harm health and promote norms and expectations that may improve or protect health

(7) Build supportive relationships and a sense of community

Sisters United also retains the seven core elements from the ChiCAS intervention. As defined, core elements of behavioral interventions are those components of the intervention that are essential to effectiveness and that should not be altered (Collins & Tomlinson, 2014; Galbraith et al., 2011; McKleroy et al., 2006). Altering them may reduce the intervention’s established efficacy. Sisters United core elements, based on the program model, are presented in Table 3.

Table 3.

Sisters United Core Elements.

(1) At least one transgender woman from the community of focus serves as a facilitator. This person must be trained in Sisters United implementation and should be knowledgeable about HIV, PrEP, condom use, GAHT, and existing local resources to access PrEP and medically supervised GAHT.

(2) Participants are HIV-negative Black/African American transgender women.

(3) Culturally congruent and trans-positive messages and materials are used.

(4) Implementation is in the preferred language of the participants.

(5) Implementation occurs in a setting where Black/African American transgender women feel safe and comfortable.

(6) Facilitator’s guides are used as designed. In particular, the following components are essential:

Uptake of PrEP, condom use, and medically supervised GAHT (via referrals to local providers) are main focuses.

The challenges transgender women of color face in the socio-cultural environment (focusing on concepts of sexism, religion, trans-negativity, homonegativity, and discrimination) are identified, acknowledged, and addressed.

Modeling, role-play, and feedback are strategies used to teach and practice skills and build participant self-efficacy.

Two video segments provide information and teach/role-model skills and behaviors.

(7) All activities are interactive and encourage group discussion.

Video Segments

The original ChiCAS intervention includes two video segments that were adapted for Black/African American trans women: “The Magnitude of HIV and STIs in Black, African American, and Trans Communities” and “Celeste Seeks Health Services: PrEP and Gender-Affirming Hormone Therapy.” The first video segment (approximately 10 minutes long), which is presented during session one, raises consciousness about the impact of HIV and STIs within different racial and ethnic groups, in Black/African American communities, and among trans women. The second video segment (approximately 15 minutes long), which is presented during session two, follows a Black/African American trans woman as she learns more about PrEP and medically supervised GAHT from a friend and role models the process of making a health care appointment, seeking PrEP and GAHT from a provider, articulating her concerns and asking questions, and working with a social worker to understand and select payment options. Ultimately, she decides to use PrEP and medically supervised GAHT, fills her prescriptions, and maintains follow-up appointments. The segment is designed to illustrate that, although the process may not be easy or ideal, the challenges encountered throughout the process are manageable and surmountable.

Online e-Learning Course

The e-learning course helps train staff at community organizations on planning for, implementing, and assessing the impact of Sisters United. The e-learning course, consisting of eight modules, provides an overview and introduction to Sisters United; background information on health disparities and contributing factors related to HIV and PrEP, condom, and GAHT use among Black/African American trans women; details around what is needed (e.g., staff, materials and associated budget items) to implement Sisters United; strategies for building connections with local organizations, recruiting participants, and retaining them; a detailed review of Sisters United sessions; tips and techniques for facilitating sessions and maintaining participant confidentiality; and information on monitoring and evaluating Sisters United. The e-learning course is designed to be used in conjunction with the implementation manual and the facilitator’s guides to ensure successful and effective implementation of the intervention by community organizations (e.g., HIV, trans, and LGBTQ+ organizations and health departments).

Discussion

Sisters United fills a critical gap in addressing the disproportionate HIV burden carried by vulnerable and underserved Black/African American trans women. The low uptake of PrEP among Black/African American trans women, compounded by social and structural barriers such as stigma and discrimination, medical bias, mistrust, and limited access to gender-affirming care, underscores the need for tailored intervention and programs to increase PrEP use among this population. Our systematic process led to the development of an implementation manual, facilitator’s guides for in-person and virtual delivery, video segments, and an e-learning course, all of which were designed to support effective implementation of the Sisters United intervention.

The inclusion of medically supervised GAHT within the intervention speaks directly to a critical need voiced by trans women themselves for safer gender-affirming care. By addressing both HIV prevention and medically supervised GAHT, Sisters United offers a comprehensive approach that aligns with the priorities of Black/African American trans women. This dual focus is essential, as previous research has shown that access to GAHT shapes HIV risk behaviors and may influence mental health outcomes. However, organizations adopting and implementing the intervention must ensure that GAHT is available in their community for the referral of participants. If GAHT is not available, then Sisters United may not be appropriate until such services can be accessed. Furthermore, GAHT is merely one component of gender-affirming care. Trans women need and deserve a range of medical, psychological, social, and behavioral interventions to support their health and well-being; Sisters United focuses only on a small part of what they need and deserve.

Moreover, Sisters United incorporates important aspects that effective HIV prevention interventions share, including incorporating locally collected data and tailoring to a defined audience; being gender specific; having a solid theoretical foundation; incorporating discussions of barriers to, and facilitators of, sexual health; exploring and reframing gender norms and expectations; boosting self-esteem and group pride; increasing risk reduction norms and social support for protection; building skills and efficacy to perform technical, personal, or interpersonal skills through role-plays and practice; and offering guidance on how to utilize available services (Kamitani et al., 2024; Lyles et al., 2006; Rhodes et al., 2013).

Finally, the delivery flexibility of the intervention—whether in-person or virtual—can expand its reach and ensures that more trans women can benefit from it, even in resource-limited and less densely populated areas as well as urban settings. The use of video segments and interactive modules further enhances engagement, providing role modeling and opportunities to practice learned skills and creating an empowering learning environment for participants.

Our process also contributes to the documentation of evidence-based models underlying intervention development, refinement, and adaptation designed to reduce health disparities. Our process was designed to build on the successes of the ChiCAS intervention while ensuring that Sisters United is not only based in evidence but also carefully tailored to the specific contexts of Black/African American trans women. The incorporation of input from community members; representatives from HIV, trans, and LGBTQ+ organizations; scientists; practitioners; and consultants throughout the process ensured that the intervention is culturally responsive, meaningful, and aligned with the needs and priorities of Black/African American trans women. Furthermore, the process described here can serve as a guide for others who are looking for ways to develop, refine, or adapt interventions and programs; infuse updated information and recent advances into an existing intervention; and/or strengthen the impact of an existing intervention. For example, we added current data on HIV and PrEP use among Black/African American trans women, activities to explore and address medical mistrust among this population, and information about injectable PrEP. To date, Sisters United is the first intervention we are aware of that includes injectable PrEP. We also strengthened activities in areas that were less impactful in the original ChiCAS intervention, such as condom use and medically supervised GAHT.

Overall, Sisters United is a promising intervention to reduce HIV disparities by addressing the intersection of race, gender identity, and health inequities, and our process also adds to the literature on intervention development, refinement, and adaptation methodology. The next step for Sisters United should be its testing to ensure its acceptability, feasibility, and impact on PrEP, condom, and GAHT use.

Footnotes

Acknowledgements

We thank members of our CBPR partnership and the trans women who shared their experiences and time and engaged in a yearlong process to develop the Sisters United intervention. We are particularly grateful for the trust and collaboration of the trans community in this important work. We hope this work contributes to improving health equity and access to care for trans women.

ORCID iD

Scott D. Rhodes

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was made possible in part by funding from the U.S. Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. government.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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