Abstract
Interventions that leverage telehealth technologies have the potential to improve health outcomes among people with HIV who experience multiple complex barriers to care. To assess the current state of knowledge on telehealth interventions for people with HIV in the United States, we searched the literature for recent (2019–2023) telehealth interventions designed to improve outcomes along the HIV care continuum, including linkage to care, retention in care, antiretroviral therapy adherence, and viral suppression. Our search identified 23 interventions. Text messaging was the most common telehealth delivery mode, followed by videoconferencing, commercially available applications, and novel applications. Nine interventions used more than one delivery mode. Common features across interventions to address barriers along the HIV care continuum included: HIV care self-management and monitoring tools; HIV treatment and adherence education; resources and referrals provision; live messaging for ongoing support or urgent issues; videoconference-based coaching, counseling, case management, or care; online peer-to-peer support; ecological momentary assessments to monitor and address barriers; and game-based elements to increase engagement. Interventions were reported as acceptable and feasible, with several showing an effect on antiretroviral therapy adherence. Further research is needed to fully leverage the potential of telehealth for ending the HIV epidemic in the United States.
Introduction
To end the HIV epidemic in the United States, it is necessary to develop and replicate interventions that improve outcomes along the HIV care continuum, including linkage to HIV care, adherence to antiretroviral therapy (ART), retention in care, and viral suppression. 1 During 2022, however, only 76% of the 1.02 million people with an HIV diagnosis in the United States received any HIV medical care, and only 65% had reached viral suppression (<200 copies/mL) on their most recent viral load test. 2 Multiple structural and individual psychosocial barriers prevent people with HIV from progressing along the HIV care continuum. 3,4 Interventions that use electronic or digital communication technologies to deliver synchronous or asynchronous health-related services or tools (referred to in this review as telehealth interventions), have the potential to overcome common barriers to HIV care engagement. 5 –7 For example, remote provision of health care through videoconferencing technologies may increase visit adherence by eliminating travel time and costs, and by minimizing stigma associated with attending an HIV clinic in person. 3,4,8 –12 Text messaging can streamline client–provider communication and send reminders to improve medication adherence and ultimately viral suppression. 13 Moreover, implementing telehealth HIV interventions in the United States is increasingly feasible given the near-universal usage of mobile phones and computers, and the dramatic increase in telehealth delivery of medical care since the onset of the coronavirus disease 2019 (COVID-19) pandemic. 14
At the same time, key groups of people with HIV in the United States experience disparities in telehealth access as well as HIV. These groups include people experiencing poverty, incarceration, substance use disorders, and/or homelessness, as well as those who live in rural areas, are Black/African American, speak a primary language other than English, and/or are aging. 12,15 –20 Barriers to telehealth interventions for these priority populations include: lower technological literacy; hesitance to engage due to language barriers, privacy concerns, or a general mistrust of health care systems; and unreliable access to internet services or devices. 12,15 –20 Tailored telehealth interventions that address these barriers are needed.
The rapid pace of technological developments requires frequent assessment of telehealth interventions and their capacity to meet the needs of both clients and HIV care organizations. The purpose of this review, therefore, was to examine the current state of knowledge regarding recent telehealth interventions designed to improve HIV care continuum outcomes among people with HIV in the United States. We conducted this work as part of Using Innovative Intervention Strategies to Improve Health Outcomes Among People with HIV (2iS), a four-year cooperative agreement (2021–2025) with the
Methods
To identify the most recent telehealth interventions with HIV care continuum outcome data, we searched PubMed for peer-reviewed articles published between January 1, 2019, and December 31, 2023, using combinations of the following search terms in the title and abstract fields: telehealth, teleconsultation, telemedicine, mHealth, mobile health, eHealth, HIV, intervention, and program. We also scanned previous telehealth intervention review articles for interventions missed by our search terms. Inclusion criteria were as follows: (1) the intervention included delivery through one or more of the following methods: text messaging; application (app) for smartphone, tablet, or computer; videoconferencing; web-based platform; or social media; (2) 100% of the study sample had a confirmed HIV diagnosis; (3) at least one primary quantitative outcome of the study was related to HIV linkage to care, retention in care, ART adherence, or viral suppression, and 4) the study was conducted in the United States.
Results
Our search yielded 23 interventions that met our inclusion criteria. Table 1 provides summary descriptions, priority populations, study designs, and key outcomes of each intervention.
Descriptions and Key Outcomes of Telehealth Interventions for People With HIV, 2019–2023
ART, antiretroviral therapy; EAM, electronic adherence monitoring; EMA, ecological momentary assessment; MI, motivational interviewing; ss, statistically significant; SOC, standard of care; VL, viral load; VS, viral suppression; y, year.
Latine is a gender-inclusive term that describes people living in the U.S. of Latin American origin or descent.
Delivery modes
We categorized the interventions by telehealth delivery modes (Table 2). Text messaging, including automated as well as manual “live” texting, was the most common delivery mode. 22 –29,32,36 –38,40,43,44,46 –52,57,59 The next most common delivery modes were videoconferencing, 24,25,27,28,36,45 –48,59 commercially available health care apps, 22,23,30,33,34,42,50 –52,58 and novel apps (i.e., apps developed specifically for the intervention. 31,32,35,41,46,47,53 –56 Delivery modes, used by two or fewer interventions were: electronic adherence monitoring (EAM) devices that provided medication reminders, 22,23,55,56 social media apps, 25,48 a novel program for computers or tablets, 43,44 and an internet-based platform with a social networking interface. 59
Delivery Modes of Telehealth Interventions for People With HIV, 2019–2023 (n = 23 Interventions)
The total number of delivery modes is greater than the total number of interventions because several interventions used more than one delivery mode.
Nine of the interventions integrated more than one delivery mode. 22 –28,32,36,37,43,44,46 –52,59 For example, one intervention provided EAM dosing reminders, videoconference-based coaching sessions, and follow-up text messages from coaches. 22,23 In another intervention, clients participated in weekly videoconference sessions, between which they received automated and manual texts with appointment reminders, goal check-ins, and resource referrals. 50 –52
Five interventions also had an in-person component. 29,31,40,46,47,58,60 For example, one intervention held in-person group and individual coaching sessions on digital and health literacy prior to receiving a health app to manage appointments and medications. 31 Another intervention held an in-person adherence coaching session followed by text message medication reminders and messages. 40
Priority populations
Fifteen interventions were designed to meet the sociocultural needs of specific demographic groups, or intersecting population groups. The most frequently prioritized population was adolescents and younger adults under the age of 34 years, although age ranges varied among these interventions (e.g., 13–24, 16–29, 18–34 years). 22 –28,33 –35,38,41,48 –54 Five interventions were designed specifically for gay, bisexual, and other men who have sex with men, of which two included transgender women. 24 –28,35,41,48,49 With regard to race and ethnicity, four interventions were developed for Black/African American people, 29,33 –35 including one focused on Black/African American adult cisgender women experiencing depression, 42 and one that also focused on Hispanic/Latine i people. 33,34 Additionally, three interventions were designed to support populations with substance use disorders, 32,40,58 and two interventions were developed for adults with current or recent incarceration experience. 30,43,44 None of the studies focused intentionally on populations that experience the greatest barriers to accessing and using telehealth, such as older adults, people experiencing homelessness, or people living in rural areas.
Studies did not consistently indicate meaningful involvement of community members in the design and planning of interventions, despite focusing on specific populations. Notably, two of the interventions for people with substance use disorders were shaped by qualitative interviews and focus groups with the priority populations, 40,58 and seven 33,35,38,41,48,50,53 of the interventions for adolescents and younger adults were informed by community advisors or formative qualitative research.
Key features of telehealth interventions
Each of the interventions consisted of one or more features designed to address barriers and promote engagement along the HIV care continuum. We grouped these features by theme (Table 3), as described below. Features were included only if they were delivered through a telehealth technology (i.e., not delivered in person). Many features overlapped and were used in combination within interventions, except where noted below.
Key Features of Telehealth Interventions for People With HIV, 2019–2023 (n = 23 Interventions)
The total number of features is greater than the total number of interventions because several interventions used more than one feature.
Adherence and HIV care self-management and monitoring tools
Sixteen interventions included at least one tool to support self-management and monitoring of ART adherence and other aspects of HIV care and treatment. 22 –29,31,32,36 –38,40,41,46,47,50 –57,59 These interventions featured automated medication and/or appointment reminders, via text messages or push notifications, that were either aligned with ART dosing schedules or triggered by an EAM device after a dose was missed. Reminders were either one-way (unidirectional), meaning participants received a message that did not prompt a response, or two-way (bidirectional), wherein the message prompted the participant to reply, usually with a “yes” or “no” as to whether they took their dose.
Three interventions enabled care team members to monitor client adherence via a dashboard, and follow-up via text or phone call when needed. 22,23,38,39,47 Another intervention monitored adherence by having clients submit a video of themselves taking ART within the dosing window; clients received monetary rewards on a reloadable gift card each time they submitted a video. 32
Additional adherence and care self-management features included prescription refill reminders, 53,54 medication logging tools, 36,53 –56 a “to-do” list of daily tasks related to HIV care, 55,56 and a list of questions to ask providers at a care visit. 31
HIV treatment and adherence education
Thirteen of the interventions included an educational feature to improve HIV treatment and adherence knowledge among participants. 22 –28,31,32,35,40,41,46 –56,59 Information was delivered in written form as part of an app, 31,32,41 through an avatar, 35,43 or during interactions with coaches, counselors, or case managers via text or videoconference sessions. 22 –28,40,46 –52,54 –56,59 Education was not a stand-alone feature of any intervention but rather part of a larger, integrated collection of features.
Referrals and resources provision
Eleven interventions implemented a range of methods to provide referrals and/or lists of resources to encourage and support clients in accessing supportive services for housing, employment, substance use disorder, and other needs. 24 –30,32,38,43,44,46 –54,59 For example, one intervention used an app with a social service search and tracking function. 59 In another intervention, participants received a printout with referrals after completing a computer-based program. 43,44 In other interventions, the coach, counselor, or case manager would offer referrals and resources via text or during videoconferencing sessions. As with health education, referrals and resources were not a stand-alone feature of any intervention.
Live messaging for ongoing support or urgent issues
Nine interventions used live text messaging between clients and providers (e.g., case managers, coaches, counselors, and health navigators) to address immediate and/or ongoing barriers, needs, and concerns. 22 –29,38,40,46 –54,59 Live messaging occurred through novel apps, text messaging, or social media apps. Depending on the intervention, a staff member (e.g., health educator, coach, case manager) would manually text only in response to a client’s request, missed appointment, or triggered alert (via ecological momentary assessment [EMA] or EAM), or would proactively text the client to follow up on the client’s stated goals and access to resources, or to promote adherence and social support. While most interventions integrated live messaging with other intervention components, one intervention used live messaging as its primary feature. 48,49
Videoconference-based coaching, counseling, case management, or care
Seven interventions connected clients to a provider via videoconferencing. 22,23,30,33,34,42,45,50 –52,58 Of these interventions, four consisted of multiple weekly sessions with a counselor or coach trained in motivational interviewing and problem-solving approaches to increase HIV treatment knowledge, improve adherence behaviors, and address a range of individual barriers along the HIV care continuum, 22,23,33,34,42,50 –52 including substance use and mental health concerns in two of these interventions. 42,50 –52 In contrast, one intervention held a single videoconference session with a case manager while clients were still incarcerated. 30 Finally, one intervention was unique in that it offered low-barrier, on-demand, videoconference access to an HIV care team when clients visited a trusted syringe services program. 58
Online peer-to-peer social support
Four interventions offered a feature to foster peer-to-peer social support, with the most common feature being an in-app social network or discussion forum. 53 –56,59 One of the novel apps offered social support to clients through in-app scripted social support messages that could be sent anonymously to other app users. 41 Users could create profile pages and avatars to build alliances and compare achievement medals with peer users.
Ecological momentary assessments to monitor and address client barriers
Three interventions conducted EMAs to support care team members in providing real-time responses to common barriers that arise in daily life. 24 –29,38 EMAs are brief two-way texts that survey mood, substance use, and/or basic subsistence needs, like housing and food security. Responses to EMAs go to a centralized dashboard that alerts care team members to intervene by text or phone, as needed.
Game-based elements to increase engagement
Three interventions added elements drawn from videogame design to motivate user interaction with the app, and to increase knowledge and advance behavioral change related to HIV care and treatment. For example, one novel app included a superhero game in which users could progress through a virtual world, earn digital badges for certain health-promoting behaviors (e.g., starting or continuing ART, reading educational articles), and acquire digital tokens to play additional mini-games. 41 Another novel app provided an interactive embodied conversational agent in the form of a customizable avatar to deliver HIV-related health information and motivational messages. 35 Similarly, one intervention used an interactive avatar to deliver adherence and linkage to care education through a single-session computer-based program for people who were incarcerated and preparing for community re-entry, and people recently released into the community. 43,44
Additional features
There were additional features that appeared in only one or two interventions. One was an app that included testimonials of lived experiences by people with HIV. 55,56 Two interventions featured scripted text messages to motivate clients to engage in behavioral change, such as relapse prevention and reduction of risk behaviors. 40,43
HIV care continuum outcomes
Among the 23 interventions identified for this review, study designs included five randomized controlled trials (RCTs), 22,23,31,41,48,49,55,56 one cluster randomized evaluation, 45 seven pilot RCTs, 32,40,42 –44,46,47,50 –52,57 three quasi-experimental trials, 29,30,36,37 five pre-post studies, 24 –28,33 –35,38,53,54 one pre-post study with a comparison group, 59 and one post-intervention pilot with participants who were not engaged in care or taking ART at baseline, 58 see Table 1. Measurement tools, follow-up periods, statistical methods, and sample demographics varied greatly across interventions. Twenty studies performed at least one test of statistical significance.
Linkage to care
Three intervention studies measured linkage to care. Of the two studies that had a control or comparison group, neither found a statistically significant difference in linkage outcomes between the intervention and control/comparison groups. 30,43 The third linkage study, called Tele-Harm Reduction, enrolled and linked 35 syringe service program clients who were not engaged in care into low-barrier telehealth HIV care within six months. 58 The study did not measure statistical significance.
Retention in care
Retention in care was measured in seven intervention studies. 25,29,38,45,48,55,57 The RCT of the intervention for which clients received a daily one-way message (“Here’s to your health!”) to their phones 57 found that the odds of retention in care were 20% greater in the intervention group than in the control group. The intervention called +LOVE, which combined two-way text adherence reminders and EMAs with in-person behavioral health therapy, found that clients who engaged in behavioral health therapy had 2.4 times higher odds of retention in care than those who only engaged in case management. 29 A pre-post study of the E-VOLUTION intervention, which featured two-way text adherence reminders and EMAs, including live texting, found that greater frequency of two-way texting with a case manager had a statistically significant association with retention in care (Spearman’s correlation coefficient: 0.46). 38 None of the other studies that measured retention found a statistically significant effect. 19,20,38,44
ART adherence
ART adherence was measured in 14 studies. 22,29,31,32,34 –36,40,41,47,50,53,55,57 The RCT of WiseApp (a novel app with stories of lived experiences linked to an EAM device that triggers medication reminders) 55 reported a statistically significant increase in adherence among participants in the intervention group (51%) compared to controls (37%) at 59 days, based on EAM data. 55 In the Triggered Escalating Real-Time Adherence (TERA) intervention, which combined EAM with video-based coaching sessions, the RCT found statistically significant greater median adherence days among participants in the intervention group compared to controls (72% vs. 41%), as measured by EAM at 12 weeks. 23 For both the WiseApp and TERA interventions, however, adherence declined over follow-up, and the differences between control and intervention groups were no longer statistically significant.
In the pilot RCT of TXT-CBT, which combined one in-person adherence session with automated text messages (adherence reminders, HIV treatment information, and motivational behavioral change messages) for people with substance use disorders, mean adherence scores in the TXT-CBT group were significantly higher (M = 1.00) than those in the control group (M = 0.87). 40 While the RCT of the game-based Epic Allies app did not find statistically significant between-group differences in ART adherence, a stratified analysis found that regular users (i.e., those who used the app more than 4 times per week) were 2.5 times more likely to be adherent compared to controls; however, only about 20% of participants were deemed regular users. 41 Among participants of SteadyRX, an intervention for people with substance use disorder that combined text medication reminders with videos of adherence in exchange for monetary awards, mean adherence was 16% higher than in the control group. Although this difference was not statistically significant after adjusting for covariates, there was a statistically significant group-by-time interaction. 32 An intervention called Y2TEC, which provided brief weekly videoconference counseling sessions enhanced by text appointment reminders and resources, found in the pilot RCT that adherence increased in the intervention group from baseline to 8 months (76% to 94%) and decreased in the waitlist control group (from 89% to 82%); the authors did not measure statistical significance. 50
Two pre-post studies found statistically significant increases in adherence. 34,35 Participants using the My Personal Health Guide app, which featured an avatar that promoted adherence, demonstrated improved adherence, from 62% at baseline to 88% at 3 months. 35 Participants who received ACCESS, a peer-led remote counseling intervention, had a 32% increase in doses of ART taken at post-intervention compared to baseline. 34 None of the other studies that measured adherence found statistically significant improvements. 29,31,36,46,47,57
Viral suppression
Eighteen studies measured viral suppression or viral load reduction. 23,25,27,31,34,36,38 –43,45,47,48,50,53,55,57 –59 The pilot RCT of the TXT-CBT intervention, described under adherence outcomes, found that the TXT-CBT group had a significantly lower viral load (log M = 3.38 copies/mL) than the control group (log M = 4.88 copies/mL) at post-intervention. 40 In a randomized cluster evaluation of a telehealth HIV care option for patients of Veterans Affairs Administration clinics, viral suppression among telehealth users was 11.5% higher after one year than among non-users in control clinics. This finding was statistically significant. 45 Similar to the adherence findings for the Epic Allies app, a stratified analysis found that regular users of the app had a 56% higher likelihood of viral suppression compared to similar participants in the control group. 41
Among the pre-post studies, Health eNav, which featured EMA and live texting between peer navigators and clients, reported a statistically significant increase in viral suppression from baseline (54.2%) to follow-up (76.1%). 25,27 E-VOLUTION, described in the retention section, found that a significantly greater proportion of participants were virally suppressed at 12-month follow-up compared to baseline (χ2 (1, 74) = 4.32), and that greater frequency of client texting with a case manager had a statistically significant association with increased viral suppression (Spearman’s correlation coefficient: 0.29). 38,39 None of the other studies that measured viral suppression and statistical significance found any change over time or between-group differences. 22,23,29,31,33,36,42,43,46 –48,55,57,59
There were three studies that measured viral suppression but not statistical significance. The pre–post pilot of the WYZ app (a multi-feature novel app) and the pilot RCT of the Y2TEC intervention (described under adherence outcomes) both found that viral suppression remained high in the intervention groups from baseline to eight months. 50 The evaluation of the Tele-Harm Reduction intervention (described under linkage to care), which enrolled people who reported they were not on ART (viral load was not measured at baseline), found that 78.1% of participants had reached viral suppression at least once in the six months after enrolling in the program. 53,58
Feasibility and acceptability
All of the pilot interventions were deemed by the study authors to be acceptable and feasible. 28,30,32,34 –36,40,42,47,50,52,58,59 Some minor but manageable feasibility challenges, however, did arise. For example, authors noted problems with app installation and crashes. 35 Videoconferencing issues revolved around unreliable internet access: 50,52 for instance, staff within carceral facilities encountered challenges with scheduling videoconference sessions for participants. 30 With regard to interventions that used medication reminders, some participants believed the reminders were too frequent, 36 or expressed a desire for a snooze button. 47
A few interventions reported low uptake of the intervention technology. For example, only 13.5% of participants in the Veterans Health Study chose to use telehealth over in-person care. 45 One of the medication apps was refused or never used by almost two-thirds of potential participants, 36 and for one of the game-based apps, only 20% used the app on a regular basis. 41 In addition, some of the texting, EAM, and app interventions reported that usage by clients declined over time. 36,38,39,41
Discussion
To end the HIV epidemic in the United States, there is a need to rapidly scale up interventions with demonstrated effectiveness for people with HIV who experience barriers to care and treatment. Telehealth interventions have the potential for overcoming common barriers to in-person care and interventions, such as travel time and cost, childcare needs, and HIV stigma. 61,62 As the US population becomes more accustomed to adopting new technologies, the feasibility and acceptability of telehealth interventions should continue to increase.
This narrative review identified 23 US-based telehealth interventions that sought to improve outcomes along the HIV care continuum of linkage to care, retention in care, adherence to medication, and viral suppression. Text messaging was the most common intervention delivery mode, followed by videoconferencing, existing apps, and novel apps. While interventions ranged considerably in their designs, common features among interventions included HIV care self-management and monitoring tools, such as automated reminder notifications timed to dosing. Other common intervention features were: the provision of HIV treatment education and/or resources and referrals; live text messaging with providers to expedite support; case management, care, and/or counseling via videoconference; online peer-to-peer social support; EMAs with triggered responses; and game-based elements to enhance engagement.
Similar to previously published reviews on telehealth interventions for people with HIV, 13,63,64 the pilot interventions we identified reported overall acceptability and feasibility. Typical issues revolved around connectivity to the internet, as well as loss of phones, which are common challenges when engaging with people experiencing poverty and homelessness, substance use disorders, and people living in rural areas. 15 –18 While these issues present concerns, they can be partly addressed by organizations applying for funding to purchase and replace devices, secure hot spots, or buy data plans. 17,65 Another strategy is to offer access to a device and internet service in shelters, mobile vans, 65 or in a convenient, community-based organization where these groups may feel more welcomed, such as a syringe service program, as demonstrated in the Tele-Harm Reduction intervention. 58 More consistent and meaningful involvement of key populations in the design, planning, and implementation of interventions may also help to overcome some of these barriers.
Another feasibility challenge was low enrollment in some interventions, especially in the Veterans Health Study; however, this study took place prior to 2020, i.e., before the COVID-19 pandemic. It is likely that enrollment would be higher today, given that the pandemic compelled people to become more adept at and comfortable with telehealth. Older age may also have been a factor, as 68% of telehealth participants in the study were over the age of 50 years. Older adults may hesitate to engage in technology-based interventions due to lower digital literacy, physical or cognitive limitations, or a preference to not change the way they access care. 17,18,45
In addition, some of the apps and texting interventions showed a decline in engagement over time. Research on attrition in usage of telehealth interventions is very limited and needs further study. 66 It is possible that certain types of apps or texting interventions are time-limited in their efficacy, or only appropriate for clients new to HIV care or who struggle with remembering to take medications.
Previous meta-analyses of telehealth interventions for people with HIV conducted both inside and outside the US have found overall small positive effects on medication adherence; 7,67 –70 however, the number of included studies in these reviews was small. In addition, the most recent meta-analysis found that only four of the 11 RCTs (36%) reviewed had a statistically significant positive effect on adherence. 70 Several RCTs in our review also found evidence for adherence improvement over controls; however, these findings did not always extend to viral suppression. Given that undetectable viral load is the most important indicator of health and longevity for people with HIV, as well as the key to stopping the transmission of HIV, 71 the null results of most studies are disappointing. The lack of efficacy on viral suppression, however, may have been due, in part, to pilot studies being underpowered to detect statistical differences, 28,30,32,34 –36,42,47,50,52,58,59 and some studies having samples with high viral suppression at baseline. 42,47
Conclusions and Future Directions
There is a clear need for more innovation and research in the field of telehealth interventions for people with HIV. Future research could focus on adapting telehealth interventions developed in other countries that have demonstrated effectiveness. 72,73 Cultural tailoring for priority populations is also needed to better engage and retain participants. An example is a recently developed intervention, tailored for and by young Black/African American and Hispanic/Latine LGBTQ+ people with HIV, that combines face-to-face coaching, phone calls and texts, and an adherence app. 74,75 Findings from the RCT of this intervention were not available at the time of this article’s publication.
Given that many interventions are combinations of delivery modes and features, studies should also consider using mixed methods and hybrid study designs to gain a deeper understanding of the efficacy, feasibility, and acceptability of each component of an intervention, and then look to combine elements based on those findings. Cost-effectiveness studies are also needed to understand the actual costs versus benefits of using telehealth interventions, which often require ongoing maintenance, troubleshooting, updating, and customization. Finally, researchers can adopt an implementation science approach to evaluate promising interventions in real-world settings, in order to characterize contextual effects on implementation processes. To this end, the authors are evaluating the implementation of E-VOLUTION and an adapted version of Y2TEC for adults in HIV service organizations, using an implementation science framework. Findings from these implementation efforts will help to inform multimedia intervention toolkits for widespread dissemination in 2025.
Footnotes
Authors’ Contributions
D.K. conducted the literature search, conceptualized the article, curated the data, completed the analysis, and wrote the article. H.G. and A.S.K. conceptualized and supervised the development of the article. H.G. reviewed the methodology, validated the findings, and wrote the article. M.D., D.K., M.P.M., N.S.C., D.P., A.D., B.B., P.S., C.G., K.H.M., and A.S.K. reviewed, provided comments, and helped to edit the article. M.P.M., N.S.C., and D.P. provided regulatory guidance. M.D., D.K., H.G., and A.S.K. finalized the article based on comments from all authors and other reviewer feedback.
Disclaimer
The views expressed in this publication are solely the opinions of the authors and do not necessarily reflect the official policies of the U.S. Department of Health and Human Services or the Health Resources and Services Administration, nor does mention of the department or agency names imply endorsement by the US government.
Author Disclosure Statement
A.S.K. declares royalties as editor of a McGraw Hill textbook on transgender and gender diverse health care and an American Psychiatric Association Publishing textbook on gender-affirming psychiatric care. The authors have no competing interests.
Funding Information
This article and initiative were funded by the U.S. Department of Health and Human Services, Health Resources and Services Administration under grant number U90HA42153.
i
Latine is a gender-inclusive term that describes people living in the United States of Latin American origin or descent.