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CDR Community Spotlights: Detroit, Michigan
In the spring of 2021, a young woman received a positive HIV test result at the Health and Wellness Center located within Detroit’s Ruth Ellis Center, a community hub for LGBTQ+ teens and young adults. On its own, the diagnosis was not surprising to the Center staff: the Health and Wellness Center, which is run by providers from Detroit’s Henry Ford Health, sees a new HIV case every few months. More routinely, though, clients come to the Health and Wellness Center seeking primary and gender-affirming care.
“For many of these young people, just walking through the door to see us is an act of courage,” says Dr. Maureen Connolly, medical director of the Health and Wellness Center. “They have so many other challenges in their lives, and they’ve often felt rejected by traditional healthcare systems, so it’s important that we lead with the services they know they want and need.”
Officials at the Michigan Department of Health and Human Services (MDHHS) later discovered a network of genetically similar HIV sequences, including the virus sequence from the person diagnosed at the Health and Wellness Center. Because HIV changes quickly in each person’s body, similar genetic sequences in the virus from different people indicate that transmission is happening rapidly within a network. Many of the people affected by this rapid transmission were transgender women of color. This HIV transmission network, which grew to include 14 people, was particularly notable because most HIV diagnoses in the Detroit area occur among Black gay and bisexual men. A cluster of diagnoses among transgender women was unusual – and concerning.
“Nationally and anecdotally, we’ve known that transgender women, as a group, are disproportionately impacted by social determinants of health and HIV,” says Jacob Watson, HIV epidemiologist at MDHHS. “But these data showed very clearly that rapid transmission was occurring among transgender women of color in Detroit. It really catalyzed efforts to prioritize and coordinate prevention in a new way.”
Tracing transmission through SHiNe with active community participation
The transmission network was uncovered by Michigan’s Shared HIV Networks (SHiNe) program, established in 2017 to identify and investigate HIV transmission networks. SHiNe, Michigan’s program to implement CDC-funded HIV cluster detection and response activities, uses molecular HIV analysis to identify viruses that are genetically similar, thus indicating recent and rapid transmission of HIV among a network. State officials then work with local community-based organizations (CBOs) to ensure that individuals in their communities who may be part of the network have access to HIV care and prevention services.
“A network is made up of people, so our response has to be community-based,” says Loren Powell, emerging HIV networks coordinator for MDHHS. “We work hard to make sure we’re inviting the right community partners to the table to coordinate each response.”
Some of the diagnoses in this new HIV transmission network were made at facilities that specifically serve transgender people, including the Ruth Ellis Center and Corktown Health. MDHHS reached out to these and other partners with close connections to Detroit’s LGBTQ+ community, coordinating what became a series of more than 10 meetings to develop a collective response. These community meetings, along with follow-up interviews with people in the HIV transmission network, revealed important gaps in efforts to address structural factors—particularly access to housing and to safe, welcoming healthcare services—that are essential to HIV prevention.
Community inspired changes and mobile health
The findings from the community meetings brought new momentum to efforts already underway. For example, with support from MDHHS and others, the Ruth Ellis Center will soon open a 43-unit supportive housing facility where young people can live and access resources, including medical care, counseling services, job training, and employment services.
The community meetings also exposed a significant gap in health services for transgender adults, because Ruth Ellis Center serves clients younger than 30 years old. To address this need, MDHHS is now working with the Detroit Health Department, Henry Ford Health, and other partners to establish a mobile unit initiative called the ‘Pull Up Project’, that will offer clients needed care in a safe, accessible space. The Pull Up Project will establish a schedule among participating community partners to offer a comprehensive array of health and wellness services through mobile units in the Palmer Park area of Detroit, a neighborhood that serves as a gathering place for the LGBTQ+ community.
As part of its community-centered approach to comprehensive health, the Ruth Ellis Center’s Health and Wellness Center also provides public health emergency response services for COVID-19 and mpox.
“Just because someone turns 30 doesn’t mean all of their obstacles to wellness go away,” says Tahrima Khanom, who coordinates HIV programs at the Health and Wellness Center for Henry Ford. “Some of the people who age out are those who most need care, and they keep coming to the Center even though we can’t serve them anymore. We’re excited for them to have the mobile unit as an alternative.”
By partnering with multiple agencies, the Pull Up Project can offer a wide range of services on a rotating basis including gender-affirming care, which can otherwise be difficult to access. Other services planned include sexual health and wellness services, HIV and STI testing, immunizations, linkage to care, a food pantry, and referrals for other critical support services like transportation and housing. The Pull Up Project will operate during hours accessible to those who need it.
The value of status neutral care
The SHiNe response also reinforced the importance of providing status neutral care that integrates HIV prevention and treatment within the full continuum of primary health care to address the needs of the whole person, regardless of HIV status, referred to as a status neutral approach. The Ruth Ellis Health and Wellness Center initially offered a support group specifically for young transgender women with HIV. However, until organizers shifted to a status neutral approach, few people participated. The new iteration of the support group welcomes transgender women, regardless of HIV status, and allows participants to drive the discussion.
“We provide a space for trans women to talk about everything related to being trans,” explains Jey’nce Poindexter, Ruth Ellis Center case manager. “If you feel safe and strong and trust the ladies in your group enough to share your HIV status, that’s a wonderful thing. But no one is obligated to talk about HIV.”
Applying this knowledge, MDHHS, the Ruth Ellis Center, and Henry Ford Health are planning for a free-standing status neutral clinic that would provide status neutral care to LGBTQ+ people of all ages. While this initiative was already in motion, the discovery of the recent HIV transmission network highlighted the importance of ensuring that all community members have access to comprehensive care.
Community leadership, state support
The discovery of this HIV transmission network through molecular analysis, and the related response efforts, focused attention on the care and prevention needs of transgender women of color in Detroit, highlighting how services weren’t reaching people who needed them. Equally important, the response was able to tap into community relationships that MDHHS had worked hard to establish, and prioritized listening and responding to the voices of people affected. Together, these approaches generated a thoughtful, community-led, and comprehensive effort to improve services.
“At the state level, we can analyze the data that show where interventions are needed, but we turn to the CBOs to identify what interventions are needed,” says MDHHS’s Watson. “We believe the best response is state supported and locally mobilized. Detecting and responding to this network has driven a real upswell of urgency at both the state and community levels.”
“If you’re funding someone to do the work, you should rely on them in times of need,” says Liliana Angel Reyes, senior director of the Ruth Ellis Drop-in Center. “The state health department recognized our expertise and credibility within the community and pushed to work with us. It’s really a milestone that we accomplished together.”