Transgender women are 49 times more likely to become HIV positive than all adults worldwide. Data were unavailable for trans women's sexual and mental health in the Middle East and North Africa until 2015-2016, when HIV prevalence (10%) and suicide attempt (46%) rates were established in Lebanon. Because of the lack of evidence-based interventions for this marginalized group, the purpose of this study was to pilot test an adapted intervention, ''Baynetna,'' to assess preliminary impact on mental and sexual health. Using the gender affirmative model and community connectedness and social cohesion constructs, we pilot tested Baynetna among sixteen trans women, who attended 6 weekly 3-h trans-facilitated group-delivered sessions in Beirut with post-test assessments at 1, 3, and 6 months. Each participant acted as her own control; we used paired t-tests to assess changes at follow-up to evaluate potential differences in outcomes. Positive directionality in intervention impact on gender affirmation satisfaction, community connectedness, and social cohesion was demonstrated. An increase in HIV testing proportion between 6 months before and after enrollment was achieved. Higher social cohesion was associated with less suicidal thoughts (p = .05). There was a significant (p = .019) relationship between more community connectedness and lower depression scores. War event exposure was associated with higher anxiety (p = .02; p = .004). Those who reported never having had a sexually transmitted infection had higher gender affirmation satisfaction scores (7.5, 95% confidence interval: 1.4-13.6) (p = .019). Increases in community connectedness, social cohesion, and gender affirmation satisfaction scores confirm Baynetna's proposed mechanisms of impact. Proportional HIV testing increases demonstrate prevention objectives' progress. The significant results contribute to confidence in Baynetna's mechanisms of action and support the hypothesis that the Gender Affirmation model is applicable to the Lebanese context. We have shown for the first time that the adapted intervention, and its constructs, are applicable in this context outside the United States.

Transgender women are among the most at risk of populations for HIV infection and transmission globally. Feasible and acceptable intervention strategies that are culturally and contextually appropriate are urgently needed to address the burden of disease worldwide. The first study to address the unique health needs of transgender women in the Middle East and North Africa, this mixed-methods pilot (N = 16) demonstrated high levels of feasibility and acceptability among adult transgender women in Lebanon as measured quantitatively and qualitatively in the domains of: time allotment, venue, group dynamics, facilitation, content, and retention. The intervention, adapted from an existing trans-facilitated group support intervention, addresses the sexual and mental health of transgender women with mixed HIV status. Next steps should include scale-up, randomization, and testing to determine larger-scale feasibility, acceptability, and efficacy for mitigating sexual and mental health risk and promoting community connectedness and social cohesion.