Updated August 10, 2023

Transgender Women Involved in Strategies for Transformation (TWIST) is an intervention written by transgender women for transgender women. TWIST aims to reduce sexually transmitted diseases (STDs) and HIV transmission behaviors among transgender women by increasing sexual health knowledge, building self-efficacy to make decisions based on personal values and goals, and strengthening their social support network.


Transgender Women Involved in Strategies for Transformation (TWIST) is a behavioral intervention developed by transgender women for transgender women and aims to reduce HIV and STD transmission behaviors among participants. The TWIST intervention consists of four, 3-hour educational and skills-building sessions designed to be facilitated by transgender women to transgender women in small groups. The sessions of TWIST address specific needs and issues faced by transgender women regardless of HIV status, including gender affirmation, building their social support networks, increasing self-efficacy to set goals, identifying characteristics of healthy and unhealthy relationships, learning behaviors that can lower the chances of getting HIV, and coping with stress.

The TWIST intervention is an extensive adaptation of the WILLOW intervention guided by social cognitive theory, transgender theory, and gender affirmation theory. The TWIST intervention underwent extensive updating in 2022 and was piloted between November 2022 and March 2023. TWIST has not yet been formally evaluated for its impact on HIV and STD transmission behaviors.

The four sessions of TWIST and their objectives are:

  1. Gender Affirmation and Social Support
      • State the TWIST motto
      • List at least two ways you affirm your gender
      • Identify three personal values
      • Name one short-term goal and one long-term goal
      • Name at least one person in your social support network
  2. Managing my Relationships
      • Define stigma
      • List two qualities of healthy relationships
      • List two qualities of unhealthy relationships
      • Identify two types of abuse
      • Identify three examples of abusive behaviors from the power and control wheel
  3. Using my Voice
      • Describe what sexual health means to you
      • Describe three ways HIV can be transmitted
      • List at least three strategies you can use to protect your sexual health
      • Name the three communication styles
  4. Living my Best Life
      • Name at least two ways stress can impact you
      • List the six TWIST decision-making steps
      • Identify at least two RELAX techniques
      • Tell your TWIST story

TWIST Training

  1. Agencies implementing TWIST must be ready to provide HIV prevention services and services to address the needs of transgender women.
    • Implementing HIV Prevention Programs for Transgender Women
      • A virtual instructor-led training designed to equip program managers with best practices for planning and implementing HIV prevention programs and HIV care services for transgender women. This course provides tools and resources to support agencies during each of the program planning phases, from pre-implementation to implementation and maintenance.
      • Intended for executive directors, supervisors, and program managers who are planning to build, expand, and improve programs that meet the needs of transgender women in an inclusive, affirming, and respectful way.
    • Request technical assistance
      • Agencies implementing TWIST are expected to have the following capacities before conducting the TWIST intervention with clients:
        • Ability to hire and retain transgender women on staff
        • Complete a community assessment
        • Develop a Community Resource Directory
        • Engage with transgender persons in the community and recruit to agency services
        • Have a plan and process to assess and identify the needs of transgender women and to link these clients to services
        • Train staff who will serve as TWIST facilitators in the following topics:
          • Fundamentals of HIV and STIs
          • Basic facilitation skills
  1. It is highly recommended that TWIST is facilitated by transgender women. To prepare to facilitate the course, TWIST facilitators must take the following trainings:
    • TWIST Training of Facilitators
      • A live classroom training that prepares transgender women to serve as facilitators of the TWIST intervention.
      • Intended for transgender women who will be facilitating the TWIST intervention in their community.
    • Fundamentals of Motivational Interviewing (MI) for HIV
      • Provides a versatile skill set that can be used to assist clients as they work through challenges with behavioral change. This classroom training introduces learners to the foundational skills of MI.
      • Benefits many audiences, including TWIST facilitators by providing participants with skills that can be leveraged while facilitating TWIST.

To view and register for scheduled training:

  1. Access the National HIV Classroom Learning Center training calendar hosted on Cicatelli Associates, Inc.’s (CAI’s) website.
  2. Pre-register for your selected course via the link provided in the training calendar.
  3. Complete your registration on CDC TRAIN as directed when you receive an email from the National HIV Classroom Learning Center. You must join the HIV CBA Learning Group and locate the HIV CBA Training Plan in order to complete your CDC TRAIN registration for a specific classroom session (step-by-step instructions are available).

To request that a training session be scheduled:

  1. CDC’s directly funded health department and CBO partners may request delivery of a CDC-supported training by submitting a request in the CBA Tracking System.
  2. Organizations not directly funded by CDC may contact their local health department for assistance in submitting a training request.

To request technical assistance:

  1. CDC’s directly funded health department and CBO partners may request technical assistance by submitting a request in the CBA Tracking System.
  2. Organizations not directly funded by CDC may contact their local health department for assistance in submitting a request.

If you have questions or need additional assistance, please contact

Implementation and Marketing Materials

Materials and resources that support the implementation of TWIST are coming soon.