Transforming the Carolinas: Preparing to End the Epidemic for Transgender People of Color


TRANSforming the Carolinas cross-sectional, mixed methods study that aims to identify and prioritize community-driven interventions to address gaps in HIV prevention and care for transgender people of color in North and South Carolina. More specifically, the study aims to: (1) Identify regional structural, social and individual drivers of disparities in HIV prevention and care engagement among transgender people of color, (2) Map community assets available to address these barriers and increase facilitators of HIV prevention and care, and (3) Engage key community stakeholders in the prioritization of feasible and acceptable HIV prevention and care strategies.


HIV incidence among transgender women is estimated to be as high 2.8 per 100 person years. Nationwide, 44% of Black transgender women and 26% of transgender Latinas are living with HIV. [1]  HIV prevalence among transgender men is estimated at 3%, ten times the national prevalence, [1] with a disproportionate impact on among Black and Hispanic/Latino transgender men. [2] Despite elevated vulnerability to HIV, PrEP acceptability and uptake are low among transgender people of color. [3-5] Stigma, invisibility in PrEP advertising, and concerns about drug interactions have been identified as significant barriers to uptake.[4, 6] Among transgender people living with HIV, engagement along the HIV care continuum from testing to ART adherence is also lower than other populations. [7, 8] Limited access to gender affirming healthcare is a key barrier to engagement. [8, 9]

The majority of Black and Hispanic/Latino transgender people with HIV reside in the South,[10, 11] yet they are woefully underserved in the HIV response in the region. For these populations, intersectional stigma based on race, gender identity, HIV status, and HIV risk factors exacerbate barriers to engagement in HIV prevention and care. Stigma and discrimination are particularly problematic for transgender individuals in the southern U.S. [12] Transgender people in southern states and rural areas are less likely to receive affirming care than those in other environments.[13] Religiosity and social conservatism, which are known to be associated with lower acceptance of transgender individuals,[14] are more prevalent in the South. [15]









[1] Becasen, J.S., et al., Estimating the Prevalence of HIV and Sexual Behaviors Among the US Transgender Population: A Systematic Review and Meta-Analysis, 2006-2017. Am J Public Health, 2018: p. e1-e8.
[2] Lemons, A., et al., Characteristics of HIV-Positive Transgender Men Receiving Medical Care: United States, 2009-2014. Am J Public Health, 2018. 108(1): p. 128-130.
[3] Restar, A.J., et al., Acceptability of Antiretroviral Pre-exposure Prophylaxis from a Cohort of Sexually Experienced Young Transgender Women in Two U.S. Cities. AIDS Behav, 2018.
[4] Rael, C.T., et al., Barriers and Facilitators to Oral PrEP Use Among Transgender Women in New York City. AIDS Behav, 2018. 22(11): p. 3627-3636.
[5] Kuhns, L.M., et al., Correlates of PrEP Indication in a Multi-Site Cohort of Young HIV-Uninfected Transgender Women. AIDS Behav, 2016. 20(7): p. 1470-7.
[6] Sevelius, J.M., et al., ‘I am not a man’: Trans-specific barriers and facilitators to PrEP acceptability among transgender women. Glob Public Health, 2016. 11(7-8): p. 1060-75.
[7] Bukowski, L.A., et al., Characterizing the HIV Care Continuum and Identifying Barriers and Facilitators to HIV Diagnosis and Viral Suppression among Black Transgender Women in the United States. J Acquir Immune Defic Syndr, 2018. 79(4): p. 413-20.
[8] Kalichman, S.C., et al., Transgender women and HIV-related health disparities: falling off the HIV treatment cascade. Sex Health, 2017. 14(5): p. 469-476
[9] Sevelius, J.M., A. Carrico, and M.O. Johnson, Antiretroviral therapy adherence among transgender women living with HIV. J Assoc Nurses AIDS Care, 2010. 21(3): p. 256-64.
[10] Centers for Disease Control and Prevention. HIV Surveillance Report, 2017; vol. 29. November 2018 June 7, 2019]; Available from:
[11] Clark, H., et al., Diagnosed HIV Infection in Transgender Adults and Adolescents: Results from the National HIV Surveillance System, 2009-2014. AIDS Behav, 2017. 21(9): p. 2774-2783.
[12] Whitehead, J., J. Shaver, and R. Stephenson, Outness, Stigma, and Primary Health Care Utilization among Rural LGBT Populations. PLOS ONE, 2016. 11(1): p. e0146139. 
[13] Petersen, D., N. Sharon, and D. Karasic, Transgender in the Bible Belt, in Annual Meeting. American Psychiatric Association. 2015: Toronto, Ontario, Canada.
[14] GA, S. Views of transgender issues divide along religious lines. 2017 November 27 June 7, 2019]; Available from:
[15] M, L. and W. B. How religious is your state? 2016 February 29 June 7, 2019]; Available from: