Project Moxie: Results of a Feasibility Study of a Telehealth Intervention to Increase HIV Testing Among Binary and Nonbinary Transgender Youth

  • Rob StephensonEmail author
  • Kieran Todd
  • Erin Kahle
  • Stephen P. Sullivan
  • Michael Miller-Perusse
  • Akshay Sharma
  • Keith J. Horvath
Original Paper


Transgender youth have low rates of engagement in HIV prevention, shaped in part by experiences of transphobia and lack of access to culturally competent care. Project Moxie tested the feasibility of an intervention that provides home-based HIV self-testing coupled with video-chat counseling. A diverse sample of 202 binary and nonbinary transgender youth (TY) were recruited online, and randomized 2:1 to receive the intervention or a control condition of only home-based HIV self-testing. TY were willing to order HIV self-testing kits and report their results. Half of those in the intervention arm opted to use the video-chat counseling and, among those who did, levels of satisfaction were high. Project Moxie demonstrates the ability to recruit TY online and provide them with access to home HIV testing. Further work is required to develop online interventions for youth who do not wish to receive counseling through video-chat formats.


Transgender Home testing Telehealth Stigma 



Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health (Grant No. R01HD078131).

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Prevention CfDCa. HIV among transgender people [updated 2017.
  2. 2.
    Horvath KJ, Iantaffi A, Swinburne-Romine R, Bockting W. A comparison of mental health, substance use, and sexual risk behaviors between rural and non-rural transgender persons. J Homosex. 2014;61(8):1117–30.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Io Medicine. The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. Washington, DC: The National Academic Press; 2011.Google Scholar
  4. 4.
    Nemoto T, Bödeker B, Iwamoto M, Sakata M. Practices of receptive and insertive anal sex among transgender women in relation to partner types, sociocultural factors, and background variables. AIDS Care. 2014;26(4):434–40.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Nemoto T, Cruz TM, Iwamoto M, Sakata M. A tale of two cities: access to care and services among african-american transgender women in Oakland and San Francisco. LGBT Health. 2015;2(3):235–42.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Reisner SL, Vetters R, White JM, Cohen EL, LeClerc M, Zaslow S, et al. Laboratory-confirmed HIV and sexually transmitted infection seropositivity and risk behavior among sexually active transgender patients at an adolescent and young adult urban community health center. AIDS Care. 2015;27(8):1031–6.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Green N, Hoenigl M, Morris S, Little SJ. Risk behavior and sexually transmitted infections among transgender women and men undergoing community-based screening for acute and early hiv infection in San Diego. Medicine (Baltimore). 2015;94(41):e1830.CrossRefGoogle Scholar
  8. 8.
    Shields JP, Cohen R, Glassman JR, Whitaker K, Franks H, Bertolini I. Estimating population size and demographic characteristics of lesbian, gay, bisexual, and transgender youth in middle school. J Adolesc Health. 2013;52(2):248–50.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Reisner SL, Jadwin-Cakmak L, WhiteHughto JM, Martinez M, Salomon L, Harper GW. Characterizing the HIV prevention and care continua in a sample of transgender youth in the U.S. AIDS and Behav. 2017;21(12):3312–27.CrossRefGoogle Scholar
  10. 10.
    Kuhns LM, Reisner SL, Mimiaga MJ, Gayles T, Shelendich M, Garofalo R. Correlates of PrEP indication in a multi-site cohort of young HIV-uninfected transgender women. AIDS Behav. 2016;20(7):1470–7.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Bockting WO, Miner MH, Swinburne Romine RE, Hamilton A, Coleman E. Stigma, mental health, and resilience in an online sample of the US transgender population. Am J Public Health. 2013;103(5):943–51.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Brennan J, Kuhns LM, Johnson AK, Belzer M, Wilson EC, Garofalo R, et al. Syndemic theory and HIV-related risk among young transgender women: the role of multiple, co-occurring health problems and social marginalization. Am J Public Health. 2012;102(9):1751–7.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Herek GM. Sexual stigma and sexual prejudice in the United States: a conceptual framework. Nebr Symp Motiv. 2009;54:65–111.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    James S, Herman J, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 US Transgender Survey, viewed 30 January 2018. 2016.Google Scholar
  15. 15.
    Fredriksen-Goldsen KI, Cook-Daniels L, Kim HJ, Erosheva EA, Emlet CA, Hoy-Ellis CP, et al. Physical and mental health of transgender older adults: an at-risk and underserved population. Gerontologist. 2014;54(3):488–500.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Ramirez-Valles J, Kuhns LM, Campbell RT, Diaz RM. Social integration and health: community involvement, stigmatized identities, and sexual risk in Latino sexual minorities. J Health Soc Behav. 2010;51(1):30–47.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Garofalo R, Deleon J, Osmer E, Doll M, Harper GW. Overlooked, misunderstood and at-risk: exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. J Adolesc Health. 2006;38(3):230–6.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Edmiston EK, Donald CA, Sattler AR, Peebles JK, Ehrenfeld JM, Eckstrand KL. Opportunities and gaps in primary care preventative health services for transgender patients: a Systemic review. Transgend Health. 2016;1(1):216–30.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Connolly MD, Zervos MJ, Barone CJ 2nd, Johnson CC, Joseph CL. The mental health of transgender youth: advances in understanding. J Adolesc Health. 2016;59(5):489–95.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Reisner SL, Vetters R, Leclerc M, Zaslow S, Wolfrum S, Shumer D, et al. Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study. J Adolesc Health. 2015;56(3):274–9.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    Bockting WO. Transgender identity and HIV: resilience in the face of stigma. Focus. 2008;23(2):1–4.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Sevelius JM. Gender affirmation: a framework for conceptualizing risk behavior among transgender women of color. Sex Roles. 2013;68(11–12):675–89.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    MacCarthy S, Reisner SL, Nunn A, Perez-Brumer A, Operario D. The time is now: attention increases to transgender health in the united states but scientific knowledge gaps remain. LGBT Health. 2015;2(4):287–91.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Doorduin T, van Berlo W. Trans people’s experience of sexuality in the Netherlands: a pilot study. J Homosex. 2014;61(5):654–72.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Scheer S, Kellogg T, Klausner J, Schwarcz S, Colfax G, Bernstein K, et al. HIV is hyperendemic among men who have sex with men in San Francisco: 10-year trends in HIV incidence, HIV prevalence, sexually transmitted infections and sexual risk behaviour. Sex Transm Infect. 2008;84(6):493–8.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Kenagy GP, Hsieh C-M. The risk less known: Female-to-male transgender persons’ vulnerability to HIV infection. AIDS Care. 2005;17(2):195–207.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N, et al. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav. 2008;12(1):1–17.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Poteat T, Scheim A, Xavier J, Reisner S, Baral S. Global epidemiology of HIV infection and related syndemics affecting transgender people. JAIDS. 2016;72(Suppl 3):S210.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Harrison J, Grant J, Herman JL. A gender not listed here: Genderqueers, gender rebels, and otherwise in the National Transgender Discrimination Survey. 2012.Google Scholar
  30. 30.
    Operario D, Gamarel KE, Iwamoto M, Suzuki S, Suico S, Darbes L, et al. Couples-focused prevention program to reduce HIV risk among transgender women and their primary male partners: feasibility and promise of the couples HIV intervention program. AIDS Behav. 2017;21(8):2452–63.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Alemagno SA, Stephens RC, Stephens P, Shaffer-King P, White P. Brief motivational intervention to reduce HIV risk and to increase HIV testing among offenders under community supervision. J Correct Health Care. 2009;15(3):210–21.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Outlaw AY, Naar-King S, Parsons JT, Green-Jones M, Janisse H, Secord E. Using motivational interviewing in HIV field outreach with young African American men who have sex with men: a randomized clinical trial. Am J Public Health. 2010;100(S1):S146–51.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Prevention CfDCa. Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention 2019
  34. 34.
    Brown CH, Mohr DC, Gallo CG, Mader C, Palinkas L, Wingood G, et al. A computational future for preventing HIV in minority communities: How advanced technology can improve implementation of effective programs. J Acquir Immune Defic Syndrom. 2013;63(0 1):S72.CrossRefGoogle Scholar
  35. 35.
    Simoni JM, Kutner BA, Horvath KJ. Opportunities and challenges of digital technology for HIV treatment and prevention. Curr HIV/AIDS Rep. 2015;12(4):437–40.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Mitchell KJ, Ybarra ML, Korchmaros JD, Kosciw JG. Accessing sexual health information online: use, motivations and consequences for youth with different sexual orientations. Health Educ Res. 2013;29(1):147–57.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Ybarra ML, Liu W, Prescott TL, Phillips G, Mustanski B. The effect of a text messaging based hiv prevention program on sexual minority male youths: A national evaluation of information, motivation and behavioral skills in a randomized controlled trial of guy2guy. AIDS and Behav. 2018;22(10):3335–44.CrossRefGoogle Scholar
  38. 38.
    Koblin B, Hirshfield S, Chiasson MA, Wilton L, Usher D, Nandi V, et al. Intervention to match young black men and transwomen who have sex with men or transwomen to HIV testing options (all about me): protocol for a randomized controlled trial. JMIR Res Protoc. 2017;6(12):e254.PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    Patel VV, Masyukova M, Sutton D, Horvath KJ. Social media use and HIV-related risk behaviors in young Black and Latino gay and bi men and transgender individuals in New York City: implications for online interventions. J Urban Health. 2016;93(2):388–99.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Stephenson R, Metheny N, Sharma A, Sullivan S, Riley E. Providing home-based HIV testing and counseling for transgender youth (project moxie): protocol for a pilot randomized controlled trial. JMIR Res Protoc. 2017;6(11):e237.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Tickle-Degnen L. Nuts and bolts of conducting feasibility studies. Am J Occup Ther. 2013;67(2):171–6.PubMedPubMedCentralCrossRefGoogle Scholar
  42. 42.
    Lenth RV. Some practical guidelines for effective sample size determination. Am Stat. 2001;55(3):187–93.CrossRefGoogle Scholar
  43. 43.
    AIDSVu. Understanding HIV where you live 2019.
  44. 44.
    Way U. 211—Get Connected. Get Help 2019.
  45. 45.
    VSee. VSee: Video Telemedicine that Works. 2017.Google Scholar
  46. 46.
    Association GaLM. Ten things transgender persons should discuss with their healthcare provider 2017.Google Scholar
  47. 47.
    Bazzi AR, Fergus KB, Stephenson R, Finneran CA, Coffey-Esquivel J, Hidalgo MA, et al. A dyadic behavioral intervention to optimize same sex male couples’ engagement across the HIV care continuum: development of and protocol for an innovative couples-based approach (partner steps). JMIR Res Protoc. 2016;5(3):e168.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Morb Mortal Wkly Rep. 2006;55(14):1.Google Scholar
  49. 49.
    Testa RJ, Habarth J, Peta J, Balsam K, Bockting W. Development of the gender minority stress and resilience measure. Psychol Sex Orient Gender Divers. 2015;2(1):65.CrossRefGoogle Scholar
  50. 50.
    Grant JM, Mottet L, Tanis JE, Harrison J, Herman J, Keisling M. Injustice at every turn: A report of the national transgender discrimination survey: National Center for Transgender Equality; 2011.Google Scholar
  51. 51.
    Lim JR, Sullivan PS, Salazar L, Spaulding AC, Dinenno EA. History of arrest and associated factors among men who have sex with men. J Urban Health. 2011;88(4):677–89.PubMedPubMedCentralCrossRefGoogle Scholar
  52. 52.
    Sullivan PS, Peterson J, Rosenberg ES, Kelley CF, Cooper H, Vaughan A, et al. Understanding racial HIV/STI disparities in black and white men who have sex with men: a multilevel approach. PLoS ONE. 2014;9(3):e90514.PubMedPubMedCentralCrossRefGoogle Scholar
  53. 53.
    Spicer CM, Ford MA. Monitoring HIV care in the United States: indicators and data systems. Washington, DC: National Academies Press; 2012.Google Scholar
  54. 54.
    Gardner LI, Marks G, Craw J, Metsch L, Strathdee S, Anderson-Mahoney P, et al. Demographic, psychological, and behavioral modifiers of the Antiretroviral Treatment Access Study (ARTAS) intervention. AIDS Patient Care STDS. 2009;23(9):735–42.PubMedCrossRefPubMedCentralGoogle Scholar
  55. 55.
    Rebchook G, Keatley J, Contreras R, Perloff J, Molano LF, Reback CJ, et al. The transgender women of color initiative: implementing and evaluating innovative interventions to enhance engagement and retention in HIV care. Am J Public Health. 2017;107(2):224–9.PubMedPubMedCentralCrossRefGoogle Scholar
  56. 56.
    Cunningham WE, Weiss RE, Nakazono T, Malek MA, Shoptaw SJ, Ettner SL, et al. Effectiveness of a peer navigation intervention to sustain viral suppression among HIV-positive men and transgender women released from jail: the LINK LA randomized clinical trial. JAMA Intern Med. 2018;178(4):542–53.PubMedPubMedCentralCrossRefGoogle Scholar
  57. 57.
    Grinsztejn B, Hoagland B, Moreira RI, Kallas EG, Madruga JV, Goulart S, et al. Retention, engagement, and adherence to pre-exposure prophylaxis for men who have sex with men and transgender women in PrEP Brasil: 48 week results of a demonstration study. Lancet HIV. 2018;5(3):e136–45.PubMedCrossRefPubMedCentralGoogle Scholar
  58. 58.
    Kuhns LM, Mimiaga MJ, Reisner SL, Biello K, Garofalo R. Project LifeSkills—a randomized controlled efficacy trial of a culturally tailored, empowerment-based, and group-delivered HIV prevention intervention for young transgender women: study protocol. BMC Public Health. 2017;17(1):713.PubMedPubMedCentralCrossRefGoogle Scholar
  59. 59.
    McGowan I, Cranston RD, Mayer KH, Febo I, Duffill K, Siegel A, et al. Project gel a randomized rectal microbicide safety and acceptability study in young men and transgender women. PLoS ONE. 2016;11(6):e0158310.PubMedPubMedCentralCrossRefGoogle Scholar
  60. 60.
    Bauermeister JA, Pingel E, Zimmerman M, Couper M, Carballo-Dieguez A, Strecher VJ. Data quality in HIV/AIDS web-based surveys: handling invalid and suspicious data. Field methods. 2012;24(3):272–91.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.The Center for Sexuality and Health Disparities, University of MichiganAnn ArborUSA
  2. 2.Department of Systems, Population and Leadership, School of NursingUniversity of MichiganAnn ArborUSA
  3. 3.Department of Health Behavior and Biological Sciences, School of NursingUniversity of MichiganAnn ArborUSA
  4. 4.Department of PsychologySan Diego State UniversitySan DiegoUSA

Personalised recommendations