Johns Hopkins University Press
Abstract

Research on gender affirmative models (GAM) of training and service provision is emerging. This study aims 1) to summarize 2018–2019 survey data on GAM training and service provision at Southern HIV Service Organizations (HSOs) in the U.S. South and 2) identify barriers in the region. Methods. Data were collected from Southern HSOs (n=207). Relations between GAM training and service provision were examined through frequency distributions and logistic regressions. Results. Few (46.6%) received training. Most (73%) used clients' asserted names and pronouns. Only 62% engaged with transgender, nonbinary, and gender nonconforming (TGNC) communities and 55% provided a gender autonomous (i.e., based on self-determination) facility. Gender affirmative model-trained HSOs had at least twice the odds of implementing GAM elements compared with non-trained HSOs. Barriers included funding (61%), expertise/knowledge (59%), capacity/staff-ing (52%), and political climate (23%). Discussion. This study identifies gaps and highlights the urgent need for funding, training, and meaningful TGNC community partnerships.

Key words

TGNC, transgender, nonbinary, gender nonconforming, gender affirmation, gender affirmative model, HIV service organizations, U.S. South

The context of HIV-affected TGNC communities in the U.S. South

The history and recent acceleration of White male systems of dominance in the United States [End Page 119] (U.S.) shape social and structural contexts, uniquely affecting community health and wellness in regions such as the U.S. South.1,2 This region is also known to be a current epicenter of HIV, with a disproportionate burden experienced by the most systematically affected communities.3–5 Among the groups most systematically affected in the U.S. South are individuals whose gender differs from that assigned at birth, including people of transgender, non-binary, and gender nonconforming (TGNC) experience, particularly transgender women and femmes of color.6–8 One study in North and South Carolina explored a socio-cultural factor specific to the South. They interviewed care providers, advocates, religious leaders, and public health administrators about the role of religious institutions in HIV service provision for transgender Southerners.8 Their findings highlighted participants' acknowledgment of pervasive anti-transgender and HIV stigma perpetuated by faith communities' moral judgment toward people of trans-gender experience and individuals living with HIV. Furthermore, these compounding stigmas were identified as public health concerns affecting transgender people of color in the region.

Health care experiences of transgender Southerners

Several studies highlight the ways in which systemic racism, anti-transgender stigma, and transmisogynoir9,10 (all legacies of White male systems of dominance) extend to policies and practices across institutions, including health care agencies. One study in North Carolina explored the health care experiences of Black transgender women.11 This study revealed regular anti-transgender interactions from providers such as dehumanization, misgendering, and exoticization, driving the need for more gender-affirming treatment in health care settings. Similarly, a study in Mississippi identified anti-transgender stigma and discrimination in health care settings as barriers to primary and HIV health care among transgender women and men.12 This study identified the need for transgender-specific training on TGNC-affirming services, transition-related health care, and mental health services. Another study in Arkansas identified education and training across disciplines as one of the top three health care concerns of transgender and non-binary individuals.13 This study highlighted the need for focused training on gender-inclusive language, misgendering, transition-related care, and referrals to TGNC affirming specialized care. Transgender, nonbinary, and gender nonconforming community-led studies have also highlighted health care gaps in the U.S. South. One study on the experiences of TGNC Southerners found affirming primary and HIV health care as a priority issue among 44% of participants.14 In addition, a needs assessment in South Florida identified routine and quality health care, including HIV, among top five health concerns of TGNC people living with HIV.15 Another needs assessment of TGNC people living with HIV in New Orleans, Louisiana found trans-affirming health care and access to different HIV treatments among top health concerns.16 In Bradford et al.15 and Chung et al.,16 and Chung et al.17 stigma and discrimination were cited as barriers to general and HIV health care.

Gender affirmative model

As a set of tenets, the gender affirmative model (GAM) guides practice with people of transgender, non-binary, gender diverse, expansive, and nonconforming lived experience.17 It asserts: a) gender variations of identities and presentations are not disorders (i.e., depathologizing and destigmatizing); b) differences across cultures, requiring cultural sensitivity; c) involvement of biology, development [End Page 120] and socialization, and culture and context; d) fluid or non-binary possibilities; and e) recognition of pathology (e.g., trauma-related symptoms or mental health challenges) as stemming from experiences of anti-transgender societal reactions. Gender-affirmative model approaches encompass the recognition and respect of an individual's gender identity and expression, with consideration of social and cultural contexts. Applied across fields of practice, GAM service provision is multidimensional, culturally responsive, contextual, and interdisciplinary.

We conceptualize GAM service provision as three components: infrastructure, wellness/wellbeing, and community. Elements of infrastructure encompass affirming and destigmatizing policies, procedures, and systems or models of care. Examples include internal policies prioritizing TGNC inclusion or liberation, participatory budgeting priorities, inclusive intake forms or case notes, co-location of services, and availability of gender-autonomous18 facilities (e.g., use of all-gender and gender specific bathrooms based on self-determination in accordance with gender identity).19–25 In addition, elements of wellness/wellbeing components include general, HIV, and transition-related care. Some practices include affirming and destigmatizing interpersonal interactions across primary health, mental health, and HIV care services, as well as access to affirming hormones, medical procedures, vocal training, and identification documents. Finally, in the context of HIV, elements of community components draw from the principles of Meaningful Involvement of People Living with HIV/AIDS (MIPA),26 which: 1) recognize important contributions of people living with and affected by HIV/AIDS in the response to the epidemic as equal partners and 2) create space within society for involvement and active participation of people living with HIV in all aspects of that response. Through the lens of MIPA, elements of community components include meaningful engagement with TGNC communities and prioritizing individuals of TGNC experience living with and most systematically affected by HIV in decision-making roles throughout the organization. Modalities of expanding organizational GAM capacity at Southern HSOs may include in-person/online training or webinars,27 shared learning,28 coaching/mentorship/tailored consultation,29 or a combination.

A national survey of TGNC individuals found that a variety of GAM elements were associated with favorable mental and physical health care outcomes. More specifically, having affirmed identification documents, medical intervention, and family support were associated with decreased mental distress and increased engagement with general and HIV health care.30 Similarly, another study on the experiences of mostly Latina (49%) and Black (42%) transgender women living with HIV in urban cities across the U.S. found that gender affirmative care in the context of HIV primary health in combination with health care empowerment improved HIV health outcomes.31 This study revealed that despite anti-transgender discrimination, HIV health improvement was more likely when participants experienced informed, committed, collaborative, and affirming HIV care. These findings are consistent with research emphasizing the importance of the health care relationship. In their study on well-being predictors among predominantly TGNC individuals of color in the U.S., Stanton, Ali, and Chaudhury found that greater well-being was associated with TGNC individuals' comfort with their health care provider.32

GAM training efficacy

Empirical research on GAM training interventions is [End Page 121] emerging.33–37 An example specific to the field of medicine focuses on transgender health education. One scoping review examined the literature on transgender health training for undergraduate and graduate medical students.38 While their review yielded no consensus on "best practice" training models, they found that transition-related health care and gender-affirming medical procedures, particularly for trans-gender women and men, occupied most education intervention publications. This review also found that transgender health education interventions have often been implemented in aggregate with broader lesbian, gay, bisexual, queer (LGBQ) health training.38,39

Regarding providers' perceptions of GAM, multiple studies have identified a desire among medical providers for health training specific to transgender communities. One study explored nurses' and physicians' perspectives on training to work with transgender youth.40,41 In their study, inadequate training and resources, as well as various levels of comfort and confidence, were identified as influencers of meaningful engagement and evidence-based service provision. Similarly, another study identified training gaps among nurse practitioners.42 Despite their desire to provide quality health care, a lack of training, knowledge, and gender-affirming resources were linked to uncertainty and fear, thus contributing to harmful interactions and the perpetuation of health inequities in this community.

Gender affirmative model-training interventions have also been associated with improved provider comfort, attitudes, knowledge, and skills.40–44 For instance, one report described an evaluation of a community-academic partnership model of a gender-affirming education intervention in Arkansas.42 Their findings highlighted that even a brief (e.g., 2-hour) workshop changed knowledge and comfort, as well as sex and gender-related beliefs across interdisciplinary groups. Another study examined a gender affirming pilot training for administrative staff in a large academic medical center, inpatient and outpatient psychiatric units, and a community hospital.23 The authors reported that administrators in these settings benefited from formal education and training opportunities through advanced gender affirming knowledge and practice skills. Additionally, a published protocol detailed the development and implementation of a gender affirming education pilot intervention for health care and social service providers in Canada.43 This study also contributes to empirical literature on gender affirming training intervention research aimed at improving service provision through interviews with transgender women living with HIV and service providers.

The role of HIV service organizations

Given the positionality of HIV service organizations (HSOs) in the development and implementation of community-engaged programs,44,45 HSOs have an essential role in advancing TGNC and HIV health equity. Studies have established improved individual-level outcomes in relation to the service provision of GAM infrastructure, wellness/wellbeing, and community components.31,43,46,47 In addition, GAM training in the context of the HIV care continuum has shown promising improvement in areas of TGNC community partnership, mental health, and physical health. One study noted the socio-cultural context (e.g., HIV and anti-trans stigma) of access to HIV primary care in the California East Bay Area.46 In this study, a transgender-focused motivational interviewing-based training intervention implemented in HSOs, health, and social service agencies was found to improve HIV [End Page 122] primary care experiences of Black transgender women living with HIV. Improvement in services reported by participants also included access to gender-affirming care, increased social support, health care knowledge, and navigation skills. Another study examined a community-based peer-led intervention to address HIV disproportionality among transgender groups in Philadelphia.47 In a partnership with HSOs, their intervention was found to increase programmatic engagement of Black and Latinx individuals of transgender experience.

Without GAM training, HSO providers continue to perpetuate health inequities experienced by TGNC communities, particularly people living with and most systematically affected by HIV. For instance, one study in urban Canadian health settings used a mixed methods approach to better understand the HIV health care experiences of transgender women living with HIV.48 This study revealed that HIV health services and HIV care providers shape the process of gender-affirming interventions, such as transition-related medical procedures. More specifically, this study uncovered the systematic exclusion of transgender women living with HIV from accessing gender-affirming health care due to a lack of extending comprehensive transition-related health insurance coverage. Despite receiving HIV care, a large proportion of participants also reported transphobia, indicating the need for gender-affirming training across the HIV care continuum.48 Thus, HSOs are well-positioned to respond to TGNC communities' call to improve primary and HIV health services. In the contemporary U.S. South, GAM training is particularly important, given the region's socio-cultural realities (which strongly affect HSOs and HIV-affected TGNC groups).8–18,48 This study aims 1) to summarize survey data from September 2018–August 2019 on GAM training and service provision at HSOs in Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee and Texas; and 2) to examine barriers to implementing GAM training and service provision.

Methods

Study design

Authors conducted a secondary analysis of data from a large two-part survey which asked organizational representatives about organizational characteristics, services provided, and training received. A subset of survey questions addressed elements of GAM service provision and receipt of GAM training. Both studies were reviewed and approved by Duke University and University of Houston Institutional Review Boards.

Setting

Survey data were collected from Southern HIV service organizations (Southern HSOs) via Survey Monkey between September 2018 and August 2019.

Participants

Organizations were identified using the National Prevention Information Network (NPIN) and Substance Abuse and Mental Health Services Administration (SAMHSA) databases. The NPIN database only includes HIV-related organizations. Organizations listed in SAMHSA's database were eligible if they had "special programs" for people living with HIV.49,50 During 2018–2019, the COMPASS Initiative focused on Southern states. Therefore, the study included organizations in nine states of the U.S. South (AL, FL, GA, LA, MS, NC, SC, TN, TX).

Data source

Eligible organizations were emailed a two-part survey. Part one included questions about Southern HSOs' organizational characteristics (e.g., organizational [End Page 123] type, location, number of individuals served, staff size); the range of HIV/STI, mental health, substance use, and stigma-related services provided; details on organizational capacity development, and organizational training history and needs. Upon completing the first survey, organizations were invited to respond to a second, more in-depth survey inquiring about the perceived adequacy of regional HIV, mental health, substance use, and stigma-related services, specifics regarding stigma interventions provided by the organization, and organizational implementation of trauma-informed care, harm reduction approaches, as well as GAM training and elements of service provision. Participants who completed the second survey received a $10 gift card. Of the 1412 organizations identified as eligible for the survey 340 organizations completed the first survey (25%) and 207 (15%) went on to complete the second survey. This paper analyzes data related to GAM training and elements of service provision from the 207 Southern HSOs that completed both surveys. Survey results from trauma-informed care, harm reduction, and stigma studies are reported in Ali, Stanton, McCormick, et al.51; Stanton, Ali, McCormick52; and Belden, Reif, Cooper, et al.53

Variables

Three dichotomous outcome variables were constructed to measure elements of GAM service provision: 1) wellness/wellbeing: whether the organization uses clients' asserted names and pronouns, 2) community: whether the organization engages with TGNC communities, and 3) infrastructure: whether access to bathrooms or housing based on gender identity was available. Having received GAM training was conceptualized as a predictor variable. Given structural challenges experienced by emergent and grassroots organizations to access training resources, the number of years Southern HSOs provided HIV services and the number of staff (a proxy for organizational size) were selected as covariates.

Statistical methods

Data analysis consisted of frequency distributions of survey questions related to elements of GAM service provision. Valid percentages were used for frequencies and the specific sample for each survey item is noted in Table 1. The primary analysis focused on three logistic regression models to identify key predictors of GAM service provision, controlling for covariates. Elements of GAM service provision were used as outcome variables, which included the use of clients' asserted names and pronouns, TGNC community engagement, and access to bathrooms and housing in accordance with gender identity. Gender-affirmative model training was used as the predictor variable. Study analyses were conducted with SPSS version 28,53 and a significance level (p value) of .05 was used to assess statistical significance. Data were determined to be missing at random, and listwise deletion accounted for more than 10% of the dataset; therefore, we used multiple imputation (i.e., 10 imputations) to account for the missing data.

Results

Organizational characteristics

A total of n=207 Southern HSOs from nine states participated in the survey, including Florida (n=47, 22.7%), Georgia (n=36, 17.4%), Texas (n=32, 15.5%), North Carolina (n=21, 10.1%), South Carolina (n=20, 9.7%), Louisiana (n=16, 7.7%), Alabama (n=13, 6.3%), Tennessee (n=12, 5.8%), Mississippi (n=8, 3.9%), [End Page 124]

Table 1. DESCRIPTIVE STATISTICS OF HIV SERVICE ORGANIZATIONS IN THE U.S. SOUTH AND THEIR IMPLEMENTATION OF GAM, 2018–2019, N=207
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Table 1.

DESCRIPTIVE STATISTICS OF HIV SERVICE ORGANIZATIONS IN THE U.S. SOUTH AND THEIR IMPLEMENTATION OF GAM, 2018–2019, N=207

[End Page 125] and multiple states (n=2, 1%). Southern HSOs indicated providing HIV services for several months to 50 years* (inline graphic years, SD=11.7), and ranged in staff size from zero** to 1,607 (inline graphic, SD=183.7). Southern HSOs indicated serving a large range of clients annually, ranging from one to 1.2 million clients (inline graphic, SD=95,238), with an average of 3,637 people living with HIV each year (SD=36,907). Of note, two large multi-site hospital systems are included in this dataset. The median number of clients and people living with HIV served annually was 2,000 and 155, respectively.

Frequencies: GAM training and service provision at Southern HSOs

Less than half (n=69, 46.6%) of Southern HSOs received GAM training. Regarding specific elements of GAM organizational service provision, 72.7% (n=144) of Southern HSOs reported using clients' asserted names and pronouns, 62.1% (n=123) engaged with TGNC community groups, and 54.5% (n=108) provided access to bathrooms or housing in accordance with gender identity. Thirteen Southern HSOs (7.1%) reported implementing elements of GAM in "other" ways, including having TGNC staff members, cultural competency training, specific programming for TGNC communities, and participation in local Pride events. Few Southern HSOs (n=12, 7.3%) stated they did not implement elements of GAM. The majority of Southern HSOs reported interest in using GAM (n=138, 84.7%). Most Southern HSOs reported a lack of funding (61.4%), lack of expertise/knowledge (58.6%), capacity/staffing issues (52.4%), and the political climate (22.8%) as barriers to implementing GAM. Additional details are provided in Table 1.

Logistic regression: GAM training and service provision at Southern HSOs

All three models were significant. Controlling for the number of years served, PLWHA, and the number of full-time staff, Southern HSOs who received GAM training had 2.91 times the odds (95% CI=[2.36, 3.60]) of using clients' asserted names and pronouns, 2.49 times the odds (95% CI=[2.07, 2.99]) of TGNC community engagement, and 2.57 times the odds (95% CI=[2.14, 3.07]) of providing a gender autonomous facility compared with Southern HSOs who did not receive GAM training. Additional details are provided in Table 2.

Discussion

Our study reveals significant gaps in GAM training and elements of service provision among Southern HSOs. Few (46.6%) reported having ever received GAM training. This finding is consistent with empirical research illustrating gaps in GAM training and service provision across the U.S. South.11–16 Notably, many Southern HSOs reported implementing elements of GAM service provision, such as the use of clients' asserted names and pronouns on organizational documentation (72.7%). However, only 62.1% engaged with TGNC community groups and 54.5% had a gender-autonomous facility. In addition, our results indicate that GAM-trained Southern HSOs had at least 2.5 times the odds of implementing these elements. Furthermore, our study also highlights several barriers to GAM training and service provision at Southern HSOs. Respondents [End Page 126]

Table 2. LOGISTIC REGRESSION ANALYSIS ASSESSING ASSOCIATIONS BETWEEN GAM TRAINING AND IMPLEMENTATION OF GAM ORGANIZATIONAL STRATEGIES AMONG HIV SERVICE ORGANIZATIONS IN THE U.S. SOUTHa
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Table 2.

LOGISTIC REGRESSION ANALYSIS ASSESSING ASSOCIATIONS BETWEEN GAM TRAINING AND IMPLEMENTATION OF GAM ORGANIZATIONAL STRATEGIES AMONG HIV SERVICE ORGANIZATIONS IN THE U.S. SOUTHa

cited a lack of funding (61.4%), expertise/knowledge (58.6%), capacity/staffing (52.4%), and political climate (22.8%) as obstacles, reflecting the challenges brought by the socio-cultural context of the U.S. South.3–8,54

Despite the lack of GAM training among Southern HSOs, elements of the three conceptualized components of GAM service provision were implemented (i.e., infrastructure, wellness/wellbeing, and community). However, greater implementation of additional elements, evaluation, and research are needed. This includes intentional and equitable partnerships with TGNC groups most systematically affected by HIV. In addition, GAM training and service gaps remain. To decrease this service gap, community-engaged research38,44–46,54 and community-identified24–26,44–46,54 service needs must be prioritized. For example, training content and goals should be reflective of health priorities identified by TGNC communities living with and most systematically affected by HIV. Focus areas should comprehensively include TGNC affirming primary, HIV, and transition-related health care, dental care, mental health services, general wellness, and referrals to affirming specialized care.24–26,38,54 Furthermore, GAM training interventions should seek to improve GAM service provision and enhance TGNC individuals' comfort with their provider—an empirically established predictor of well-being among TGNC individuals of color in the U.S.32

Of respondents who did not receive GAM training (n=79, 53.4%), 84% reported interest in receiving GAM training. One reason that may have contributed to over half of the sample not receiving GAM training is the implementation of some elements of GAM service provision. While some reported some GAM elements at their organization, a need for a more comprehensive model remains. Additionally, respondents' level of interest may have been influenced by anti-transgender stigma and discrimination, which have been identified as public health concerns in the U.S. South.8,55–65 Of note [End Page 127] was the acceleration of anti-TGNC stigma reinforced by proposed legislation during the survey timeframe.66,67 Between 2018 and 2019, bills restricting TGNC individuals' access to health care, public facilities, and affirmed identification documents, were proposed nationally with particular concentration in the U.S. South. Given the social, cultural, and political context of the region at this time, anti-TGNC stigma likely proliferated (and remains) in health care, public accommodation, legal, and religious domains, thus heightening awareness and interest in improving the quality of service and care. Therefore, strategic investment is also needed to change the political climate of the U.S. South in favor of TGNC and HIV health equity through GAM training and service provision at Southern HSOs.

Implications

Our study underscores two primary domains of research investment needed in the U.S. South: communities and Southern HSOs.

Communities

Investment in growing the leadership and collective power of TGNC Southerners living with and most systematically affected by HIV is foundational to Meaningful Involvement of People Living with HIV26 and Health Equity Implementation research.68 Building collective power requires the prioritization of HIV-affected TGNC community members as co-researchers69 in the development, implementation, and evaluation of GAM training and service provision among HSOs across the South. Additionally, individuals most systematically affected by cis-hetero-White-male dominance (e.g., Black and Brown transgender women and femmes living with HIV in the South, TGNC Southerners of non-dominant languages) should hold decision-making, content expert, staff, and advocacy roles across all levels of organizational change. Investment opportunities may include intentional funding, training, coaching, or a combination to support an infrastructure that recognizes community members as co-researchers. Relatedly, documented successes of community-based participatory action research38,44,45 with TGNC communities substantiate the importance of meaningfully involving the most systematically affected TGNC Southerners in the development, implementation, and study of GAM training and service provision at Southern HSOs.

Southern HSOs

Secondly, research gaps remain on components of training and service provision of a gender affirmative model. Conceptually, studies exploring the interconnectedness of a gender affirmative model, model of gender affirmation, gender affirmative care, and trans health provision are needed to better understand their application to research on organizational change. In addition, opportunities to further develop research on GAM training and service provision at Southern HSOs remain. These opportunities include the development of modalities (e.g., training, coaching) tailored to the diverse conditions in which HSOs operate across the South. Gender affirmative model service provision, the components, and their elements may also be explored, to further more in-depth and descriptive understandings. Additionally, research on systems of GAM service provision may examine the multidimensions of GAM structural, wellness/well-being, and community components and their elements more comprehensively. Example methodologies include path analysis, factor analysis, and structural equation modeling. Additionally, research examining the effectiveness and replication of GAM organizational interventions is needed. Drawing from scholars in the field of gender-affirming care and HIV, individual-level effectiveness of these organizational interventions will be limited if they do not simultaneously address the [End Page 128] socio-cultural context.37,43,44,45 Therefore, local, state, and regional advocacy must be fundamental to the architect of forthcoming GAM research.

Strengths and limitations

Our study provides valuable information about GAM training and service provision among Southern HSOs. For example, our study contributes to research focused on HIV Service Organizations in the U.S. South, which is otherwise scarce. Relatedly, the raw sample of 207 is sizable given the socio-cultural context. In addition, our study highlights existing aspects of GAM training and service provision, which suggests opportunities for continued organizational development across the region. Our study also explores multidimensions of organizational GAM service provision. More specifically, our findings suggest a more holistic GAM approach at Southern HSOs given the association between training and elements of infrastructure, wellness/well-being, and community engagement components. Finally, findings from our study are consistent with research on gender-affirming training as a promising modality of expanding organizational GAM capacity at HSOs.29,30,42 There are also limitations to our study. By design, this study is based on data from a large two-part survey. Due to the nature of a large survey encompassing various aspects of training and services, more descriptive data were not collected. Regarding selection bias, the Southern HSOs were recruited through SAMHSA and NPIN databases, underrepresenting HSOs of disparate geographic, resource, or structural conditions. In addition, some respondents may be less familiar with survey language and the relation to TGNC and HIV health equity, given the emergent nature of concepts related to a gender affirmative model. Though the respondent group represented a range of organizational types, locations, and sizes, the response rate was low (15%). Finally, our recruitment was purposefully limited to HSOs in the U.S. South. Therefore, our findings cannot be generalized to HSOs across all regions or socio-cultural environments.

Conclusions

In conclusion, this study highlights several important findings about GAM training and service provision at Southern HSOs. Interestingly, while less than half of organizations reported ever receiving GAM training, many reported the use of clients' asserted names and pronouns, some reported TGNC community engagement and few provided a gender-autonomous facility. In addition, GAM-trained Southern HSOs had more than twice the odds of implementing GAM service provision. We also found that organizations faced barriers related to funding, knowledge, capacity, and political climate. Thus, given the HIV disproportionality among TGNC communities in the U.S. South, these findings reveal the urgent need for investment to grow the leadership and collective power of TGNC Southerners living with and most systematically affected by HIV. Additionally, our findings highlight the need to invest in expanding the capacity of HSOs to test and implement GAM training and service provision multidimensionally, as well as transform the social, structural, and political context of the region.

Bec Sokha Keo, Katie McCormick, Megan Stanton, Samira Ali, and The SUSTAIN Center

BEC SOKHA KEO is affiliated with the University of Houston Graduate College of Social Work and the SUSTAIN Center. KATIE MCCORMICK is affiliated with the University of Texas at Austin Steve Hicks School of Social Work and the SUSTAIN Center. DR. MEGAN STANTON is affiliated with the Department Social Work at Eastern Connecticut State University and the SUSTAIN Center. DR. SAMIRA ALI affiliated with the Department of Doctoral Education and the SUSTAIN Center. THE SUSTAIN CENTER is an equity-focused funding, training, and coaching center that partners with Community Based and HIV/AIDS Service Organizations in the US South to enhance trauma-informed, harm reduction, mental health, and community wellness services in the context of HIV. SUSTAIN includes scholars, activists, and community members committed to prioritizing individuals of lived experience and disproportionately impacted groups.

Please address all correspondence to Bec Sokha Keo, University of Houston, Graduate College of Social Work, 3511 Cullen Blvd Room 117, Houston, TX 77204-4013; Email: bskeo@uh.edu.

Acknowledgments

Community. The authors would like to thank: the ancestors of the HIV movement, people living with and most systematically affected by HIV, community-based and HIV service organizations, community partners, Collective for Community Action, team members Lladira Aguilar, Alejandra Aviles, Marcus Stanley, Masonia Traylor, and Maria Wilson, Coordinating Centers, Journal of the Health Care for the Poor and Underserved—Editorial Staff, manuscript reviewers, HIV and racial justice activists, advocates, and scholars who came before us, and people of trans, nonbinary, and gender nonconforming experience. Their wisdom, guidance, scholarship, and collective movement made this study possible.

Disclaimer

Supported by grant funding from Gilead Sciences, Inc. Gilead Sciences, Inc. has had no input into the development or content of these materials.

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Footnotes

* Southern HSOs responded with total years of service, including years before the emergence of HIV.

**. Southern HSOs with zero staff represent volunteer-run organizations who did not have paid staff members.

Copyright © 2020 Meharry Medical College

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