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Poteat T, Bothma R, Maposa I, Hendrickson C, Meyer-Rath G, Hill N, Pettifor A, Imrie J. Transgender-Specific Differentiated HIV Service Delivery Models in the South African Public Primary Health Care System (Jabula Uzibone): Protocol for an Implementation Study. JMIR Res Protoc 2024; 13:e64373. [PMID: 39269745 DOI: 10.2196/64373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND Almost 60% of transgender people in South Africa are living with HIV. Ending the HIV epidemic will require that transgender people successfully access HIV prevention and treatment. However, transgender people often avoid health services due to facility-based stigma and lack of availability of gender-affirming care. Transgender-specific differentiated service delivery (TG-DSD) may improve engagement and facilitate progress toward HIV elimination. Wits RHI, a renowned South African research institute, established 4 TG-DSD demonstration sites in 2019, with funding from the US Agency for International Development. These sites offer unique opportunities to evaluate the implementation of TG-DSD and test their effectiveness. OBJECTIVE The Jabula Uzibone study seeks to assess the implementation, effectiveness, and cost of TG-DSD for viral suppression and prevention-effective adherence. METHODS The Jabula Uzibone study collects baseline and 12-month observation checklists at 8 sites and 6 (12.5%) key informant interviews per site at 4 TG-DSD and 4 standard sites (n=48). We seek to enroll ≥600 transgender clients, 50% at TG-DSD and 50% at standard sites: 67% clients with HIV and 33% clients without HIV per site type. Participants complete interviewer-administered surveys quarterly, and blood is drawn at baseline and 12 months for HIV RNA levels among participants with HIV and tenofovir levels among participants on pre-exposure prophylaxis. A subset of 30 participants per site type will complete in-depth interviews at baseline and 12 months: 15 participants will be living with HIV and 15 participants will be HIV negative. Qualitative analyses will explore aspects of implementation; regression models will compare viral suppression and prevention-effective adherence by site type. Structural equation modeling will test for mediation by stigma and gender affirmation. Microcosting approaches will estimate the cost per service user served and per service user successfully treated at TG-DSD sites relative to standard sites, as well as the budget needed for a broader implementation of TG-DSD. RESULTS Funded by the US National Institutes of Mental Health in April 2022, the study was approved by the Human Research Ethics Committee at University of Witwatersrand in June 2022 and the Duke University Health System Institutional Review Board in June 2023. Enrollment began in January 2024. As of July 31, 2024, a total of 593 transgender participants have been enrolled: 348 are living with HIV and 245 are HIV negative. We anticipate baseline enrollment will be complete by August 31, 2024, and the final study visit will take place no later than August 2025. CONCLUSIONS Jabula Uzibone will provide data to inform HIV policies and practices in South Africa and generate the first evidence for implementation of TG-DSD in sub-Saharan Africa. Study findings may inform the use of TG-DSD strategies to increase care engagement and advance global progress toward HIV elimination goals. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/64373.
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Affiliation(s)
- Tonia Poteat
- Duke University School of Nursing, Durham, NC, United States
| | - Rutendo Bothma
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Innocent Maposa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Cheryl Hendrickson
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University, Boston, MA, United States
- South African Centre for Epidemiological Modelling and Analysis, Stellenbosch University, Stellenbosch, South Africa
| | - Naomi Hill
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey Pettifor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - John Imrie
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
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Karakısla FS, Fidanci C, Aydın R, Kabukcuoğlu K. "I Had Attained the Identity I Had Long Desired": A Grounded Theory Study of Experiences of Transgender Men in Türkiye. Issues Ment Health Nurs 2024; 45:906-916. [PMID: 39110854 DOI: 10.1080/01612840.2024.2371940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
Transgender individuals form a distinct community that often experiences marginalization within society. This marginalization is particularly pronounced in patriarchal countries, where transgender men encounter various challenges across psychological, medical, legal, and social domains during their transition. The study design to conduct a thorough analysis of the life experiences and perspectives of transgender men in Türkiye. It involved 15 participants and the collected data were subsequently analyzed using the constant comparative method, a key technique within grounded theory methodology. The coding process resulted in three main themes: "Realizing gender identity", "Impact of social support sources", and "The nature of being visible", and six sub-themes were formed, the core category being "… Despite the numerous challenges encountered along the way, when I gazed into the mirror, I realized I had attained the identity I had long desired". Transgender individuals in the study expressed encountering emotional, physical, and psychological challenges throughout their personal journeys. However, despite these difficulties, they reported experiencing a sense of satisfaction and contentment upon reaching the end of their transition process. It is recommended to implement counseling services specifically tailored for transgender individuals and their families and incorporate transgender-related content into the training programs of professionals working with transgender individuals.
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Affiliation(s)
| | - Cagla Fidanci
- Women's Studies and Gender Issues Research and Application Centre, Akdeniz University, Antalya, Türkiye
| | - Ruveyde Aydın
- Department of Gynecology and Obstetrics Nursing, Health Sciences Faculty, Ondokuz Mayıs University, Samsun, Türkiye
| | - Kamile Kabukcuoğlu
- Department of Gynecology and Obstetrics Nursing, and Department of Gynecology and Obstetrics Nursing, Faculty of Nursing, Akdeniz University, Antalya, Türkiye
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Fein LA, Barnett R, Liu T, Potter JE, Klatt NR, Alcaide ML, Jones DL. Gender Identity Stigma in Transgender Women Is Higher After Gender-Affirming Vaginoplasty. AIDS Res Hum Retroviruses 2024; 40:376-383. [PMID: 38084990 PMCID: PMC11301712 DOI: 10.1089/aid.2023.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
Gender affirmation may reduce stigma and gender-based discrimination that drive increased behaviors that can lead to HIV in transgender women (TW). For many TW, vaginoplasty is gender affirming, yet has not been previously evaluated with regard to likelihood of HIV. This pilot study of TW aimed to evaluate the influence of gender-affirming vaginoplasty on stigma and the drivers of HIV acquisition. Adult TW without HIV were recruited. Interviewer-administered surveys were used to assess demographics, gender identity stigma, psychosocial factors, importance of and satisfaction with gender affirmation, and behaviors that increase the likelihood of HIV in TW who had either undergone gender-affirming vaginoplasty (TWWV) or who had not (TWWOV). Statistical analysis was conducted using descriptive statistics, Fisher's exact tests, and Wilcoxon rank-sum tests. Thirty TW without HIV (19-83 years old) participated (TWWV = 10; TWWOV = 20). The majority identified with ethnic minority groups (n = 21, 70%) and on gender-affirming hormone therapy (n = 25, 83%). Gender identity stigma (38.0; 32.15, p = .03) and social oppression (53.6; 39.4, p = .05) scores were significantly higher among TWWV compared with TWWOV. Satisfaction with body (3.10; 1.95, p = .01), appearance (3.10; 2.10, p = .02), and femininity (3.40; 2.25, p = .001) were higher among TWWV than TWWOV. Present (n = 8, 27%) and past (n = 16, 53%) survival sex work, multiple sex partners (n = 16, 53%), and receptive condomless anal intercourse (n = 10, 33%) were reported but did not vary significantly between groups. Behaviors that may lead to HIV acquisition and their underlying drivers, including gender identity stigma, are present after gender-affirming vaginoplasty. As this procedure continues to increase among TW, interventions to mitigate chances of HIV acquisition are critically needed in this population.
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Affiliation(s)
- Lydia A. Fein
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rebecca Barnett
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Tianhao Liu
- Division of Biostatistics, Department of Public Health, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - JoNell E. Potter
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Nichole R. Klatt
- Division of Surgical Outcomes and Precision Medicine Research, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Maria L. Alcaide
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Deborah L. Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
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Jain JP, Hill M, Gamarel KE, Santos GM, Johnson MO, Neilands TB, Dilworth SE, Reback CJ, Sevelius J. Socio-ecological Barriers to Viral Suppression Among Transgender Women Living with HIV in San Francisco and Los Angeles, California. AIDS Behav 2023; 27:2523-2534. [PMID: 36682008 PMCID: PMC10362091 DOI: 10.1007/s10461-023-03979-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 01/23/2023]
Abstract
Troubling disparities in viral suppression persist among transgender (trans) women living with HIV in the US. We utilized baseline data from a randomized controlled trial of a behavioral intervention among trans women living with HIV in San Francisco and Los Angeles, to identify the socio-ecological correlates of biologically confirmed viral suppression (< 200 HIV-1 RNA copies/mL). Among 253 participants, the mean age was 43 (SD = 11), 46% identified as Black or African American and 35% were virally non-suppressed. In adjusted Poisson regression models, the following barriers to viral suppression were identified: injection drug use [adjusted risk ratio (aRR) 0.78, 95% CI 0.65-0.93, Z = - 2.64, p = 0.008], methamphetamine use (aRR 0.65, 95% CI 0.51-0.83, Z = - 3.45, p = 0.001), amphetamine use (aRR 0.62, 95% CI 0.44-0.87, Z = - 2.75, p = 0.006), homelessness (aRR 0.79, 95% CI 0.63-0.98, Z = - 2.06, p = 0.039), and sex work (aRR 0.60, 95% CI 0.41-0.86, Z = - 2.77, p = 0.009). These findings underscore the importance of interventions that address the socio-ecological barriers to viral suppression among trans women in urban settings.
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Affiliation(s)
- Jennifer P Jain
- Department of Community Health Systems, University of California, San Francisco, 2 Koret Way, San Francisco, CA, 94143, USA.
| | - Miranda Hill
- Department of Medicine, University of California, San Francisco, San Francisco, USA
| | - Kristi E Gamarel
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, USA
| | - Glenn-Milo Santos
- Department of Community Health Systems, University of California, San Francisco, 2 Koret Way, San Francisco, CA, 94143, USA
| | - Mallory O Johnson
- Department of Medicine, University of California, San Francisco, San Francisco, USA
| | - Torsten B Neilands
- Department of Medicine, University of California, San Francisco, San Francisco, USA
| | - Samantha E Dilworth
- Department of Medicine, University of California, San Francisco, San Francisco, USA
| | - Cathy J Reback
- Friends Research Institute, Los Angeles, CA, USA
- Center for HIV Identification, Prevention and Treatment Services, University of California, Los Angeles, Los Angeles, USA
| | - Jae Sevelius
- Department of Medicine, University of California, San Francisco, San Francisco, USA
- Department of Psychiatry, Columbia University, New York, USA
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King WM, Jadwin-Cakmak L, Trammell R, Gamarel KE. Structural vulnerability as a conceptual framework for transgender health research: findings from a community needs assessment of transgender women of colour in Detroit. CULTURE, HEALTH & SEXUALITY 2023; 25:681-697. [PMID: 35736653 PMCID: PMC9780405 DOI: 10.1080/13691058.2022.2086709] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/02/2022] [Indexed: 06/02/2023]
Abstract
The concept of structural vulnerability explains how systems of oppression drive health inequities by reducing access to survival resources (e.g. food, housing) for marginalised populations. Indicators of structural vulnerability such as housing instability, violent victimisation and poverty are often interconnected and result from intersectional oppression. We sought to demonstrate the utility of the structural vulnerability framework for transgender health research by examining patterns of structural vulnerability indicators among transgender women of colour in Detroit. We conducted latent class analysis and tested associations between classes and mental health and substance use outcomes. Membership to the Lowest Vulnerability class was negatively associated with post-traumatic stress disorder (PTSD) (aOR = 0.10, 95% CI: 0.02-0.59). High Economic Vulnerability membership was associated with daily marijuana use (aOR = 4.61, 95% CI: 1.31-16.16). Complex Multi-Vulnerability membership was associated with PTSD (aOR = 9.75, 95% CI: 2.55-37.29), anxiety (aOR = 4.12, 95% CI: 1.22-13.97), suicidality (aOR = 6.20, 95% CI: 1.39-27.70), and club drug use (aOR = 4.75, 95% CI: 1.31-17.29). Substantively different findings emerged when testing relationships between each indicator and each outcome, highlighting the value of theoretically grounded quantitative approaches to understanding health inequities. Community-driven interventions and policy changes that reduce structural vulnerability may improve mental health and substance use outcomes among structurally vulnerable trans women of colour.
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Affiliation(s)
- Wesley M King
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Laura Jadwin-Cakmak
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Racquelle Trammell
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
- Trans Sistas of Colour Project, Detroit, MI, USA
| | - Kristi E Gamarel
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
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Sevelius JM, Dilworth SE, Reback CJ, Chakravarty D, Castro D, Johnson MO, McCree B, Jackson A, Mata RP, Neilands TB. Randomized Controlled Trial of Healthy Divas: A Gender-Affirming, Peer-Delivered Intervention to Improve HIV Care Engagement Among Transgender Women Living With HIV. J Acquir Immune Defic Syndr 2022; 90:508-516. [PMID: 35502891 PMCID: PMC9259040 DOI: 10.1097/qai.0000000000003014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/25/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transgender women are disproportionately affected by HIV and are less likely to be optimally engaged in care than other groups because of psychosocial challenges. With community collaboration, we developed Healthy Divas, an individual-level intervention to increase healthcare empowerment and gender affirmation to improve engagement in HIV care. Healthy Divas comprises 6 peer-led individual sessions and one group workshop facilitated by a healthcare provider with expertise in HIV care and transgender health. SETTING/METHODS To test the intervention's efficacy, we conducted a randomized controlled clinical trial in San Francisco and Los Angeles among transgender women living with HIV; control was no intervention. Transgender field staff conducted recruitment. Assessments occurred at baseline and 3, 6, 9, and 12 months postrandomization. The primary outcome was engagement in HIV care, defined as the sum of (1) self-reported HIV care provider visit, past 6 months, (2) knowledge of most recent CD4 count, (3) self-reported antiretroviral therapy adherence ≥90%, and (4) self-reported antiretroviral therapy adherence ≥80%. RESULTS We enrolled 278 participants; almost half (46%) were African American/Black and one-third (33%) were Hispanic/Latina. At 6 months, participants in the intervention arm had over twice the odds of being in a higher HIV care engagement category than those in the control arm (aOR = 2.17; 95% CI: 1.06 to 4.45; P = 0.04); there were no significant study arm differences in the outcome at the other time points. CONCLUSIONS This trial demonstrates the short-term efficacy of an urgently needed behavioral intervention to improve engagement in HIV care among transgender women living with HIV; ongoing intervention may be needed to maintain positive impact over time. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT03081559.
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Affiliation(s)
- Jae M. Sevelius
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
- Center of Excellence for Transgender Health, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Samantha E. Dilworth
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Cathy J. Reback
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
- Center for HIV Identification, Prevention and Treatment Services, University of California, Los Angeles, CA
| | - Deepalika Chakravarty
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Danielle Castro
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
- Center of Excellence for Transgender Health, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Mallory O. Johnson
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Breonna McCree
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
- Center of Excellence for Transgender Health, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Akira Jackson
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
- Center of Excellence for Transgender Health, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Raymond P. Mata
- Friends Community Center, Friends Research Institute, Los Angeles, CA; and
| | - Torsten B. Neilands
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
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