Health and health care among male-to-female transgender persons who are HIV positive

Inclusion of trans women in pre-exposure prophylaxis trials: a review

Trans women are at high risk of HIV infection. We conducted a review to determine the extent to which trans women were eligible for inclusion in and enrolled into pre-exposure prophylaxis (PrEP) efficacy trials. Out of seven trials analyzing PrEP efficacy, we found that trans women comprised only 1.2% of one trial and 0.2% of total trial enrollments. Although an additional PrEP trial to determine efficacy among trans women may not be warranted, further research is needed to determine the effectiveness of PrEP in this marginalized population, through observational and feasibility studies. These studies should focus on unique barriers that trans women may experience while obtaining access to PrEP, such as gender discrimination, transphobia, and violence.

Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus

BACKGROUND

Transgender women have 49 times the odds of human immunodeficiency virus (HIV) infection compared to other groups, yet they are disproportionately underserved by current treatment efforts.

PURPOSE

This study aimed to examine culturally unique barriers and facilitators to engagement and retention in HIV care and strengthen efforts to mitigate health disparities, guided by the Models of Gender Affirmation and Health Care Empowerment.

METHODS

Through 20 interviews and five focus groups (n = 38), transgender women living with HIV discussed their experiences and life contexts of engagement in and adherence to HIV care and treatment.

RESULTS

Our participants faced substantial challenges to adhering to HIV care and treatment, including avoidance of healthcare due to stigma and past negative experiences, prioritization of hormone therapy, and concerns about adverse interactions between antiretroviral treatment for HIV and hormone therapy. Receiving culturally competent, transgender-sensitive healthcare was a powerful facilitator of healthcare empowerment.

CONCLUSIONS

Recommendations are offered to inform intervention research and guide providers, emphasizing gender affirming HIV care that integrates transition-related healthcare needs.

Factors associated with healthcare avoidance among transgender women in Argentina

Introduction

Transgender (TG) women in many settings continue to contend with barriers to healthcare, including experiences of stigma and discrimination. Argentina has a universal health care system and laws designed to promote healthcare access among TG women. However, little is known about barriers to healthcare access among TG women in this setting. The aim of this study was to explore individual, social-structural and environmental factors associated with healthcare avoidance among TG women in Argentina.

Methods

Data were derived from a 2013 nation-wide, cross-sectional study involving TG women in Argentina. We assessed the prevalence and factors associated with avoiding healthcare using multivariable logistic regression.

Results

Among 452 TG women included in the study, 184 (40.7%) reported that they avoided seeking healthcare because of their transgender identity. In multivariable analysis, factors positively associated with avoiding seeking healthcare were: having been exposed to police violence (adjusted odd ratio [aOR] = 2.20; 95% CI: 1.26 – 3.83), internalized stigma (aOR = 1.60, 95% CI: 1.02–2.51), having experienced discrimination by healthcare workers (aOR = 3.36: 95% CI: 1.25 – 5.70) or patients (aOR = 2.57; 95% CI: 1.58 – 4.17), and currently living in the Buenos Aires metropolitan area (aOR = 2.32; 95% CI: 1.44 – 3.76). In contrast, TG women with extended health insurance were less likely to report avoiding healthcare (aOR = 0.49; 95% CI: 0.26 – 0.93).

Conclusions

A high proportion of TG women in our sample reported avoiding healthcare. Avoiding healthcare was associated with stigma and discrimination in healthcare settings, as well as police violence experiences. Although further research is warranted, these finding suggests that socio-structural interventions tailored TG women needs are needed to improve access to healthcare among this population.

Correlates of antiretroviral adherence and viral load among transgender women living with HIV

Transgender women are 49 times more likely to become HIV infected than other groups, yet they are drastically underserved by current treatment efforts and report lower rates of treatment adherence then other groups. The objective of this study was to explore correlates of antiretroviral (ART) adherence and viral load among HIV-positive transgender women on ART utilizing a cross-sectional survey of a convenience sample of 59 transgender women. In multivariate models of ART adherence, correlates were age, stress appraisal of transphobic experiences, importance of gender affirmation, and adherence to hormone therapy. In multivariate models of self-reported viral load, correlates were stress appraisal of transphobic experiences and being in a relationship. This study provides preliminary evidence of transgender-relevant correlates of ART adherence and viral load.

HIV epidemics among transgender women

PURPOSE OF REVIEW

Recent data on the high burden of HIV among transgender women have stimulated interest in addressing HIV in this vulnerable population. This review situates the epidemiologic data on HIV among transgender women in the context of the social determinants of health and describes opportunities for effective interventions.

RECENT FINDINGS

Transgender women experience unique vulnerability to HIV that can be attributed to multilevel, intersecting factors that also influence the HIV treatment and care continuum. Stigma and discrimination, lack of social and legal recognition of their affirmed gender, and exclusion from employment and educational opportunities represent fundamental drivers of HIV risk in transgender women worldwide.

SUMMARY

Interventions to improve engagement in HIV prevention, testing, care, and treatment among transgender women should build on community strengths and address structural factors as well as psychosocial and biologic factors that increase HIV vulnerability and prevent access to HIV services.

Access to HIV Care and Support Services for African American Transwomen Living with HIV

Low access to HIV care and support has led to survival rates for transwomen that are half that of other populations at risk for HIV. Within the population, HIV disproportionately impacts African American transwomen. Interventions to increase access to HIV care and support are needed to better serve those most affected and vulnerable within the population. We conducted a study of barriers and facilitators to care and support services for African American transwomen to fill a gap in the literature to improve access for this particularly impacted population. A total of 10 in-depth interviews were conducted with African American transwomen living with HIV who lived outside the metro area of San Francisco. Three overarching thematic topics emerged-gender stigma, peer, and institutional distrust - giving insight into African American transwomen's barriers to HIV care and support services. A number of factors within these themes impacted access, such as whether organizations offered gender-related care, the geography of organizations as it relates to safe transportation and location, confidentiality and trust of peers and organizations, and trauma. Specific instrumental, institutional and emotional supports are provided that that may increase access to care and support services for African American transwomen living with HIV.

A two-question method for assessing gender categories in the social and medical sciences

Three studies (N = 990) assessed the statistical reliability of two methods of determining gender identity that can capture transgender spectrum identities (i.e., current gender identities different from birth-assigned gender categories). Study 1 evaluated a single question with four response options (female, male, transgender, other) on university students. The missing data rate was higher than the valid response rates for transgender and other options using this method. Study 2 evaluated a method of asking two separate questions (i.e., one for current identity and another for birth-assigned category), with response options specific to each. Results showed no missing data and two times the transgender spectrum response rate compared to Study 1. Study 3 showed that the two-question method also worked in community samples, producing near-zero missing data. The two-question method also identified cisgender identities (same birth-assigned and current gender identity), making it a dynamic and desirable measurement tool for the social and medical sciences.

HIV/AIDS programming in the United States: considerations affecting transgender women and girls

To be truly gender responsive, HIV/AIDS programming for women and girls also needs to be fully gender inclusive. Gender identity is not necessarily determined by one's sex assigned at birth and not everyone is only or always simply "male" or "female." Transgender women (transwomen) and girls are those individuals whose gender identity and/or expression do not align with the "male" sex they were assigned at birth. This definition is inclusive of a diverse population whose identities, language, communities, and behaviors may vary widely. However, based on recent increases in public health literature that aims to elucidate the social context that puts transwomen and girls at risk for adverse health outcomes, we offer some formative considerations for the implementation of gender-responsive and gender-inclusive HIV/AIDS programming in the United States.

Religiosity as a protective factor against HIV risk among young transgender women

PURPOSE

Young transgender women (YTW) face many challenges to their well-being, including homelessness, joblessness, victimization, and alarming rates of HIV infection. Little has been written about factors that might help in preventing HIV in this population. Our objective was to examine the role of religion in the lives of YTW and its relationship to HIV risk.

METHODS

This study is derived from baseline data collected for an HIV prevention intervention. A convenience sample of YTW aged 16-25 years from Chicago were recruited consecutively and completed an audio computer-assisted self-interview. Logistic regression models were used to evaluate the relationship between sexual risk taking (sex work, multiple anal sex partners, unprotected receptive anal sex), alcohol use, formal religious practices (service attendance, reading/studying scripture), and God consciousness (prayer, thoughts about God).

RESULTS

A total of 92 YTW participated in the study, their mean age being 20.4 years; 58% were African American, 21% white, and 22% other. On multivariate logistic regression, alcohol use was significantly associated with sexual risk in both models, with adjusted odds ratio (OR) of 5.28 (95% confidence intervals [CI]: 1.96-14.26) in the Formal Practices model and 3.70 (95% CI: 1.53-8.95) in the God Consciousness model. Controlling for alcohol use, it was found that Formal Practices was significantly associated with sexual risk (OR = .29, 95% CI: .11-.77), but God Consciousness was not (OR = .60, 95% CI: .25-1.47).

CONCLUSION

Among YTW, formal religious practices may attenuate sexual risk-taking behaviors and therefore HIV risk. Further research is needed to explore the role of the religion in the lives of YTW as a protective asset.

Antiretroviral therapy adherence among transgender women living with HIV

Despite disproportionate rates of HIV among transgender women and evidence that medication adherence is necessary for treatment success and increased likelihood of survival, there has been little investigation into antiretroviral therapy (ART) adherence issues among transgender women. This study examined rates of self-reported ART adherence among transgender women on ART (n = 35) and well-established correlates of nonadherence, including depression, adherence self-efficacy, patient perceptions of interactions with their providers, and perceived adverse side effects of ART compared to other respondents (n = 2,770). Transgender women on ART were less likely to report 90% adherence rates or higher and reported less confidence in their abilities to integrate treatment regimens into their daily lives. When transgender women were compared to other respondents, regardless of the current medication regimen, they reported significantly fewer positive interactions with their health care providers. Training for providers and integration of hormone therapy into HIV care is recommended.

HIV prevention and primary care for transgender women in a community-based clinic

Male-to-female transgender individuals, or transgender women (TW), are at high risk for HIV infection and face multiple barriers to HIV care. Advocates agree that numerous factors need to be addressed concurrently to prevent HIV infection in TW, including primary health care. This article examines how a community-based clinic that offers free or low-cost care addresses the health care needs of TW. A total of 20 TW who attended a health care clinic dedicated to community-based health were interviewed regarding best practices for HIV prevention and primary care. In-depth interviews were conducted, transcribed, coded, and analyzed. Factors reported to be effective for HIV prevention and primary care included (a) access to health care in settings not dedicated to serving transgender and/or gay communities, (b) a friendly atmosphere and staff sensitivity, and (c) holistic care including hormone therapy. Community-based health care settings can be ideal locales for HIV prevention and primary care for TW.