Implementation Barriers and Facilitators in a Pilot Long-Acting HIV Treatment Intervention for Trans Women Living with HIV in San Francisco

Little is known about long-acting HIV treatment implementation with trans women. We piloted and evaluated the implementation of novel strategies to increase uptake and use of long-acting HIV treatment among trans women in San Francisco. In 2022, qualitative formative nominal groups (<i>n</i> = 8) and in-depth interviews with providers (<i>n</i> = 11) were conducted to elicit facilitators and barriers to long-acting HIV treatment delivery among trans women living with HIV and to inform a pilot delivery model. Between August 2023 and August 2024, participants were enrolled into the program. Sequential mixed methods were used to evaluate formative and implementation data to understand barriers to starting long-acting treatment. Barriers for trans women were concerns about side effects, fear of needles, and difficulty adhering to bi-monthly injections. They were also concerned about missed injections from lack of transportation and incarceration and medical mistrust. Providers were most concerned with participant adherence due to social determinants (e.g., housing) and behavioral health challenges (e.g., methamphetamine use, mental health disorders). Buttock fillers and implants, patient worries about interactions with hormones, clinical barriers (e.g., availability of genotyping data), insurance, and managing prescriptions were also potential barriers. A significant barrier to implementation was the burden on referring clinic providers for eligibility screening and many trans women who were referred declined participation or were not eligible due to contraindicated clinical histories. Our study identified barriers to implementing long-acting HIV treatment among trans women living with HIV and provides novel implementation insights for clinics and interventions serving this community.