Transgender Women Involved in Strategies for Transformation (TWIST) is an intervention for adult transgender women with HIV (TWH). TWIST seeks to reduce sexually transmitted diseases (STDs) and HIV transmission risk behaviors among TWH by fostering gender affirmation, self-pride, increased social support, increased HIV and STD knowledge, self-efficacy for relationship management, safer-sex practices, and stress reduction.
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Transgender Women Involved in Strategies for Transformation (TWIST) is a peer-led, small-group, social-skills-building, and educational high-impact prevention (HIP) intervention for adult transgender women with HIV (TWH) who have known their HIV status for at least three months. It consists of four 4-hour sessions, taught by two adult transgender women who are trained to deliver the intervention through attending a Training of Facilitators (TOF) course.
Currently, TWIST is the Centers for Disease Control and Prevention’s (CDC’s) only intervention for TWH. As an extensive adaptation of the Women Involved in Life Learning from Other Women (WILLOW) intervention, TWIST provides a framework for transgender women to share their lived experiences as a means of recognizing and valuing their social and cultural resilience. Intervention activities are guided by social cognitive theory, transgender theory, and gender affirmation theory. Intervention activities also include strategies that support gender identity and HIV-status disclosure.
Intervention Core Elements
- Conduct small-group interactive sessions that are supportive and meet the goals of the intervention.
- Implement TWIST with transgender women 18 years and older who have HIV, and who have known their HIV serostatus for at least 90 days, in community settings.
- Use two skilled, adult, transgender women facilitators to implement TWIST sessions. It is strongly recommended that, because TWIST is a peer-led intervention, at least one of the facilitators has HIV and is open and comfortable about disclosing her status.
- Use materials that are transgender women focused and culturally appropriate to foster gender affirmation, self-acceptance, and self-efficacy.
- Train transgender women in coping, decision making, goal setting, condom negotiation, and condom use skills, all of which are supportive of safer sexual behaviors.
- Discuss topics such as stigma and disclosure related to being a transgender woman with HIV, self-acceptance, self-care, consistent condom use, social support networks, and STD and HIV information, to support their decision-making about enhancing quality of life, sexual health, and HIV care issues.
- Inform transgender women about aspects of healthy and unhealthy relationships and types of abuse as related to the negotiation of safer sexual practices and HIV self-care and treatment.
- Educate transgender women to be actively involved in their own HIV care, treatment and adherence, and to establish a long-term goal of living well with HIV.
- Use an educational and informational focus in the sessions as opposed to a counseling and service provision focus.
Technical assistance for the implementation of TWIST is available.
To request technical assistance:
- CDC’s directly funded health department and CBO partners may request technical assistance by submitting a request in the CBA Tracking System.
- 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 DHAPCBB@cdc.gov.
Implementation and Marketing Materials
Materials and resources that support the implementation of TWIST are coming soon.
Key references related to TWIST are listed below. An expanded list is available at the end of the TWIST Implementation Manual.
- Bandura A. “Social Cognitive Theory and Exercise of Control over HIV Infection.” In: DiClemente RJ, Peterson JL (eds.). Preventing AIDS: Theories and Methods of Behavioral Interventions. New York City: Plenum Press; 1994. 25-29. Print.
- Bockting WO. “Transgender Identity Development.” In: Tolman DL, Diamond LM, Bauermeister JA, George WH, Pfaus JG, and Ward LM (Eds.). APA Handbook of Sexuality and Psychology: Vol. 1: Person-Based Approaches (pp. 739-758). Washington, DC: American Psychological Association; 2014.
- Centers for Disease Control and Prevention (CDC), HIV/AIDS Prevention Research Synthesis Project. Compendium of HIV Prevention Interventions with Evidence of Effectiveness (revised ed.); 1999. Retrieved from CDC: HIV/AIDS Prevention Research Synthesis Project website: https://www.cdc.gov/hiv/research/interventionresearch/compendium/index.html
- Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. HIV and Transgender People; 2018. Retrieved from CDC HIV/AIDS website: https://www.cdc.gov/hiv/pdf/group/gender/transgender/cdc-hiv-transgender-factsheet.pdf pdf icon[PDF – 365 KB]
- Sevelius JM, Patouhas E, Keatley JG, Johnson MO. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med 2014;47(1):5-16.
- Sevelius JM. Gender Affirmation: A framework for conceptualizing risk behavior among transgender women of color. Sex Roles 2013;68(11-12):675-689.
- The Well Project (2016). Trans Women Living with HIV. Retrieved from: https://www.thewellproject.org/hiv-information/trans-women-living-hivexternal icon.