Supporting Trans Affirmation, Relationships, and Sex, Phase 3

The purpose of this clinical trial is to evaluate and test a newly developed gender-affirming intervention that addresses the dual and interconnected risks of HIV and intimate partner victimization (IPV) among transgender women (TW). The main questions it aims to answer are: (1) will the study intervention reduce HIV risk within the context of IPV and related risk factors (e.g., substance use and PTSD); (2) will STARS improve primary prevention behaviors, such as condom use, pre-exposure prophylaxis (PrEP) use, and repeat HIV testing; and (3) what are the mechanisms of change relevant to the theoretical foundations of the intervention, including gender affirmation, empowerment, and self-efficacy. The findings from this study will provide the necessary groundwork to examine the efficacy of this combined HIV-IPV intervention in a future, large-scale clinical trial.

There are several components to this research study:

* First, participants will be asked to complete a series of screening interviews/questionnaires to determine eligibility, including completing a HIV test.
* If eligible, participants will then take part in a 2-3 hour baseline assessment consisting of both interviewer administered questionnaires as well as self-administered surveys.
* Participants will then be randomly assigned to one of two treatment conditions: (1) a newly developed gender affirming intervention, known as Program STARS (Supporting Trans Affirmation, relationships, and Sex) or (2) a time-matched, attention-controlled program that offers free training in relaxation and stress reduction techniques (a.k.a., the comparison group). Both interventions offer unique components and the researchers do not yet know the impact the programs may have on participants' overall well-being.
* Participants randomized to Project STARS, will be invited to complete a semi-structured exit interview (lasting 60-90 min.) after the completion of the program.
* This clinical trial has three follow-up assessments: (1) post-intervention (i.e., after the peer-counseling programs are complete); (2) at 4-months follow-up; and (3) at 6-months follow-up. The follow-up assessments are structured the same way as the baseline assessment and are estimated to take around 1-2 hours.

The total study involvement for this clinical trial is estimated to take approximately 10 to 12 hours over the course of six months.

Transgender women (TW) are among the populations most heavily affected by HIV in the United States (US), with nearly 1 in 5 TW living with HIV. The risk for HIV in TW often occurs in the context of intimate partner relationships. Moreover, in the context of these partnerships, TW are at elevated risk for intimate partner victimization (IPV). There is a strong link between IPV and HIV risk. IPV risk is amplified in TW who have a history of IPV or are in an abusive primary relationship. Thus, IPV and HIV as well as other sexually transmitted infections (STIs) are interconnected public health problems facing TW. Despite the dual and interconnected risks of HIV and IPV among TW, there are few empirically based HIV prevention interventions that target TW and none that target HIV risks related to IPV in this population.

This overall research study is a 3-phase project (NIH R34MH119968). In Phase 1, researchers conducted focus groups with TW and community-based service providers to identify specific strategies for a brief health educational counseling intervention to support safety and HIV risk reduction among TW who have experienced recent IPV and HIV risk. Phase 1 data collection activities and preliminary analyses have been completed, and a full draft intervention protocol was produced based on Phase 1 findings.

Phase 2 of this study involved conducting an open pilot trail (OP) of the full draft intervention protocol with 5 participants, using quantitative (i.e. surveys) and qualitative (i.e. individual interviews) methods to gain experience delivering the protocol and obtaining critical feedback on the intervention protocol, procedures and assessments. This knowledge has informed finalizing the intervention and assessment protocols, which will be used in the subsequent and final Phase 3 of the study.

Phase 3 (the clinical trial registered here), involves conducting a pilot, two-arm Randomized Control Trial (RCT) to evaluate the program's ability to increase knowledge of HIV and HIV risk factors and reduce risk of intimate partner victimization among participants. The two treatment conditions used in this clinical trial are: (1) a newly developed gender affirming intervention, known as Program STARS (Supporting Trans Affirmation, relationships, and Sex) - detailed below and (2) a time-matched, attention-controlled program that offers free training in relaxation and stress reduction techniques (a.k.a., the comparison group).

Participants will first complete a multi-step screening process to determine eligibility. If eligible, enrolled participants will then complete a 2-3 hour baseline assessment that can be conducted in-person or over Zoom. Assessments consist of interviewer administered safety measures as well as self-report online questionnaires. After completing the baseline assessment, participants will be randomly assigned to one of the two intervention arms. Assessments will also be conducted post-intervention as well as at 4-months and 6-months follow up. Participants who were randomized to the study intervention arm (i.e., the STARS Program) will also be invited to complete a 60-90 minute semi-structured exit interview via Zoom to provide qualitative feedback on the program.

The overall purpose of this study is to develop a brief intervention that concurrently targets HIV and IPV risk, as well as addresses inter-related risks of HIV and IPV (e.g., substance use and PTSD) for TW - referred to as Supporting Transwomen Affirmation, Relationships and Sex (STARS). Program STARS will:

* Be based on the Gender Affirmation Framework, which emphasizes interpersonal processes to positively affirm the identities and unique needs of TW.
* Integrate a trauma-informed empowerment approach.
* Include gender-affirming and empowering HIV prevention counseling that addresses HIV risk within the context of IPV and related risk factors (e.g., substance use and PTSD), and a range of HIV risk reduction options.
* Provide TW with behavioral skills and resources for addressing IPV and maximizing personal safety.

The aims of this treatment development research are to:

1. Develop a behavioral intervention manual that addresses the specific and unique HIV prevention needs of TW with IPV, and that uses a gender-affirmative, empowering, and trauma-informed approach; and
2. Evaluate the feasibility, acceptability, safety, and initial effects of STARS through three phases of intervention development.

Researchers are primarily interested in exploring the pattern of results for any evidence of support for the intervention's influence on the primary and secondary outcomes, which are listed below.

Primary Outcomes:

1. Composite Risk for HIV (CR-HIV) is a binary indicator of any HIV risk (e.g., yes=1 vs. no=0), which is an algorithm based on whether the participant:

   * report condomless anal sex with a HIV serodiscordant or status-unknown primary or other partner in the past 3 months;
   * is using PrEP;
   * is in a monogamous partnership with an HIV-uninfected partner or an ;
   * is in a monogamous partnership with an HIV-infected partner who is virally suppressed.
   * If participants are not certain about the latter two indicators, they are coded as having HIV risk according to this algorithm.
2. IPV frequency will be assessed with:

   * The Composite Abuse Scale revised short form (CASr-SF).and
   * A trans-specific IPV Scale (T-IPV Scale; Peitzmeier et al, in press) that assesses IPV unique to TW (e.g., being forced not pursuing aspects of gender transition that you wanted).
3. IPV safety will be assessed with the:

   * Measure Of Victim Empowerment Related to Safety (MOVERS; Goodman et al., 2015), which is a 13-item scale that measures IPV survivors' safety-related psychosocial skills and efficacy and expectations of support, as well as the extent to which survivors feel that their efforts to achieve safety might create new difficulties.

Secondary Outcomes:

* Biologically determined STI diagnoses, including HIV - The research staff will work with participants to find gender-affirming health care clinics in their area that provide free or low-cost STI and HIV testing. Participants will be encouraged to get tested for STIs as part of the research study; however, STI testing is not a requirement for participation. HIV self-test kits will be mailed to willing participants and the research staff will walk participants through testing procedures as well as post-test result counseling (as needed) over Zoom or in-person.
* Self-reported discrete behavioral risk indicators: CAS, multiple and concurrent partnerships, partners' HIV status, monogamy and sexual agreements, substance use including injection drug use, HIV testing behaviors (including self-testing) and knowledge, intentions to use PrEP, PrEP uptake, use of any HIV prevention services, and use of any additional IPV-related services/resources.

Long-term aim: The findings from this R34 intervention development study will provide the groundwork to examine the efficacy of STARS in a future, large-scale clinical trial, which can be readily implemented in real-world settings.

Dissemination

* Throughout the study, researchers will disseminate process reports and descriptive summaries of the findings to colleagues at social service and medical/health agencies with whom we established MOUs.
* As data are evaluated, researchers will prepare brief reports describing the major findings from the study which we will share with our community partners, HIV prevention and IPV scientists, and TW health and advocacy organizations through publications and presentations at professional conferences.

Eligibility Criteria:
Inclusion Criteria:

* 18+ years old;
* Assigned male at birth but identify as female, transgender, or transfeminine;
* Endorse at least one IPV incident during the previous 12 months based on the trans-specific IPV Scale (T-IPV Scale; Peitzmeier et al, in press);
* Report at least one instance of condomless anal sex in the last 6 months.

Exclusion Criteria:

* Have been diagnosed with HIV or test positive for HIV.