This document provides information on HIV prevention for transgender and gender non-conforming individuals. It discusses definitions of key terms, data on HIV rates from the 2015 US Transgender Survey showing that transgender women have disproportionately high rates of HIV. It also outlines risk factors, barriers to care, and voices from the transgender community. The document recommends best practices for inclusive HIV prevention, including taking an intersectional approach, engaging the community, assessing needs, increasing access to inclusive healthcare, and advocating for structural changes.

1. Miss Jai Smith
UA Petersen
Clinics
HIV PREVENTION FOR
TRANSGENDER AND
GENDER NON-CONFORMING
INDIVIDUALS

2. Assume best intent
Individual experiences and community
realities
Take what is useful from this
presentation
Doing something is better than nothing
Services developed for one group are not
in antithesis to other groups.
SOME AGREEMENTS

3. LANGUAGE AND IDENTITY
•Masculine, Feminine, Neutral
Pronouns
•Straight, Gay, Bisexual, Lesbian, Queer, etc.
Sexual Orientation
•Could be identity, also includes behavior outside of identity (e.g. MSM)
Sexual Behavior
•How an individual self-identifies their gender (transgender, gender queer, cis-gender)
Gender Identity
•Could be identity, also includes how individual expresses gender (in dress, mannerism,
etc.)
Gender Expression

4. LANGUAGE AND IDENTITY (CONT.)
http://uwf.edu/offices/university-college/departments/equity-diversity/lgbt-initiatives/definitions-terminology/

5.  Transgender individuals are living with HIV at higher rates that
the overall population (1.4% compared to 0.3%)
 Trans women are twice as likely to be living with HIV (3.4%)
and this increases with trans women of color
DEFINING THE NEED
The 2015 US Transgender Survey
Black Trans
Women,
19%
AI Trans
Women,
4.60%
Latina Tran
Women,
4.40%
0%
5%
10%
15%
20%
Living with HIV

6.  Rates of folks living with HIV varied across gender identity,
with transgender women having the highest self-report rates
(3.4%) compared to trans men (0.3%) and non-binary
individuals (0.4%)
 Regardless of gender identity, rates of folks living with HIV
still differs by race and ethnicity.
 15% of Undocumented residents and 3.6% of documented
non-citizens are living with HIV.
DEFINING THE NEED (CONT’D)
The 2015 US Transgender Survey

7.  55% of transgender people were tested for HIV (60% of which
had been tested in the previous two years)
 People currently working in the underground economy,
including sex work and drug sales, were more likely to have
been tested (78%)
 89% of those living with HIV had seen a doctor or healthcare
provider for HIV care in the previous 12 months, and 87%
received HIV care in the previous 6 months.
 82% of those living with HIV reported a CD4 count and viral
load test in the past 6 months.
 87% had been prescribed ART, 81% were currently taking their
ART, and 64% took their ART as prescribed.
DEFINING THE NEED (CONT’D)
The 2015 US Transgender Survey

8. COMPARING TO NATIONAL NEED
CDC - Understanding the HIV Care Continuum

9. 2017 Arizona HIV/AIDS Epidemiology Annual Report

10. Education
Poverty
Income
Employment
Illicit Substance Use
Underground Economy
RISK FACTORS TO HIV ACQUISITION
The 2015 US Transgender Survey
Underground
Economy
Illicit
Substance
Use
Employment

11.  Increased rates of violence
 Verbal Harassment
 Physical Harassment
 Sexual Violence
 Intimate Partner Violence
 Happening in a variety of settings (work, K-12, college,
incarceration, shelter, etc.)
 Lack of resources specifically for transgender individuals
BARRIERS TO SUPPORT
The 2015 US Transgender Survey

12. “I have consulted with
surgeons [for gender
transition] only to be
told they would charge
me 50-100% more for
the surgery because I
am HIV positive. Every
day is a double coming
out process as
transgender and being
undetectably HIV
positive.”
“The nurse refused to
give me HIV testing
because she said
those funds were
reserved for men who
have sex with men
and I’m ‘not a real
man.’ She told me I
was born female and
just needed to accept
reality.”
TRANS VOICES
The 2015 US Transgender Survey

13. “Stories are just data with a soul” – Brene Brown
Teo Drake’s Story
http://imfromdriftwood.com/teo_drake/
TRANS VOICES

14.  HIV services for trans people should address the specific
biological, psychological and social needs of trans people.
 Intersectional approach to care
 Anatomy-specific sexual behavior
 HIV risk for vaginoplasty, phalloplasty or metaoidioplasty unknown
 Truvada as PrEP and hormone therapy (trans women specific)
 Experience in Clinic
 Physical exams
 As medically necessary, with respect to individual need (appropriate
instrument for the area)
 http://www.checkitoutguys.ca/
 Binding, Tucking, Packing
 Accessibility and transitioning
TRANSGENDER HEALTH AND HIV
Transgender Health and HIV, Transgender Patients and the Physical Exam

15. MidAtlantic AIDS Education and
Training Center

17.  Lack of data (tMSM, hormone/ARV drug-drug interactions)
 Hormone therapy as incentive to ARV care
 “based on available data, most ART can likely be used safely with
estrogen with two exceptions: Amprenavir (Agenerase) and
unboosted fosamprenavir (Lexiva) are not recommended for co-
administration with estrogens due to a decrease in amprenavir serum
concentrations.”
 Potential reduction in hormonal contraceptive agents – NNRTIs,
ritonavir-boosted PIs, and cobicistat with INSTIs
 No interactions with ethinyl estradiol – NRTIs, CCR5 antagonists,
FI/Entry-inh, and non-boosted INSTIs
 No documented interactions with androgens or anti-androgens and
ART.
 Immunosuppressed pt. treatment and anti-androgens
 Trimethoprim–Sulfamethoxazole (TMP-SMX) and Spironolactone
TRANSGENDER HEALTH AND HIV (CONT’D)
Transgender Health and HIV

18.  8 Best Practices from Center of Excellence for Transgender
Health
ENGAGING HIV PREVENTION MESSAGING
Ground Your Work in the Community
Race & Ethnicity – One Size Does Not Fit All
Utilize Multidisciplinary Approaches to HIV Prevention
Get the Facts! Assess, Evaluate, & Enhance
Looking in All the Right Places
Increase Access to Health Care for Trans People
Invest in Developing and Supporting Your Staff
Advocate for Structural and Systemic Change on Behalf of Trans People

19.  Especially important when developing messages targeting a
specific community.
GROUND YOUR WORK IN THE COMMUNITY
Partnership Building
Centering trans people’s voices
Community involvement and feedback

21.  Lenses when working around Racial Justice and Health Concerns
 Key Elements for Racial Justice
 Call People In
 Nurture Relationships
 Stay Focused on Big Picture
 Allies: Discomfort is Part of the Work
 Key Elements for Trauma-Informed Response
 Safety
 Trustworthiness
 Choice Collaboration
 Key Elements for Building Assets
 Invest in Good Things
 Build Protective Factors
 Confront Scarcity Myths
 Help Practice Behaviors that Enhance Health
RACE AND ETHNICITY
Racial
Justice
Asset-
Building
Trauma-
Informed

22. Overall Health and
Wellness Focus
Focus on not only the
individual, but the
family, social
networks, schools,
communities,
organizations where
trans people are
present.
Moving beyond just
the individual level of
intervention.
MULTIDISCIPLINARY APPROACHES

23.  Create materials that collect data on trans experience, and
reflect gender identity of those we are seeing.
 Difference between what we are collecting and what we have
to report.
ASSESS, EVALUATE, AND ENHANCE
Needs Assessment
and Evaluations
Include Trans
Participants
Data is used in
program planning,
prevention efforts
and improvement
Results shared
amongst
stakeholders and
community

24.  Recruitment and
retention should
consider the needs and
circumstances of trans
folks.
 Not just what is
convenient, but what is
necessary to engage
the community.
 Beyond a “build it and
they will come” model,
provide services where
trans people
congregate.
LOOKING IN THE RIGHT PLACES
NOPE

25.  Central or multiple
locations should be easily
accessible by public
transportation
 Services in multiple
languages
 Develop connections with
primary care
 Providers trained to
understand both current
HIV needs and health care
issues of trans people.
 Collaborate to provide
referrals and support
services locally.
ACCESS TO HEALTH CARE

26. DEVELOPING AND SUPPORTING STAFF
Effective
Staff
Development
Prioritized
Top-down
development
On-going
education
provided by
trans people
& experts

27.  Community Partner
Collaborations
 Connections with grassroots
and smaller trans specific
orgs.
 Advocate for policy
development and social
change to identify
connections between HIV
and housing, employment,
transphobia, racism,
violence, lack of health
insurance, provider
education, and legalized
discrimination.
STRUCTURAL AND SYSTEMIC CHANGE
• DOC and restricting Gender
Reassignment (Confirmation)
Surgery
AZ HB 2293 – Kern
• AHCCCS and restricting Gender
Reassignment (Confirmation)
Surgery
AZ HB 2294 – Kern
• Strip funding from Universities
for social justice education.
AZ HB 2120 – Thorpe

28. ADDITIONAL TRANS INCLUSIVE PRACTICES
Pronoun Usage
Documentation
(Internal vs.
External)
Sex-Positive
Messaging
Underground
Economy
Support Services
Utilizing Multiple
Prevention
Strategies
Trans Advocacy
Outside of HIV
Prevention
Recognizing
Capacity
Cultural Humility
Trans Specific
Resources &
Programming

29. SEX POSITIVE PREVENTION MESSAGING
CENTERING TRANS VOICES

31.  National Transgender HIV Testing Day – April 18th, 2018
 Tucson’s Initiative
 Increased HIV Testing Hours
 Increased HIV Testing Locations
 Media and messages about HIV and the trans community created by and
for transgender people.
 Engagement with local trans advocacy
group (SAGA)
 PrEP education for transgender/GNC folks
 PrEP education for transgender friendly
medical providers
UPCOMING INVOLVEMENT

33. QUESTIONS?

34. Jai Smith
520-626-4196
jais@deptofmed.
arizona.edu
THANK YOU

35. 1. The 2015 US Transgender Survey
 http://www.ustranssurvey.org/
2. 2017 Arizona HIV/AIDS Epidemiology Annual Report
 http://www.azdhs.gov/documents/preparedness/epidemiology -disease-control/disease-integrated-services/hiv-
epidemiology/reports/2017/annual-report.pdf
3. CDC – Understanding the HIV Care Continuum
 https://www.cdc.gov/hiv/pdf/library/factsheets/cdc -hiv-care-continuum.pdf
4. National HIV/AIDS Strategy for the United States: Updated to 2020 Indicator Supplement. December 2016
 https://files.hiv.gov/s3fs-public/nhas-indicators-supplement-dec-2016.pdf
5. Transgender Health and HIV
 http://transhealth.ucsf.edu/trans?page=guidelines-hiv
6. Transgender Patients and the Physical Examination
 http://transhealth.ucsf.edu/trans?page=guidelines-physical-examination
7. Creating a Safe and Welcoming Clinic Environment
 http://transhealth.ucsf.edu/trans?page=guidelines-clinic-environment
8. MidAtlantic AIDS Education and Training Center
 https://www.maaetc.org/p/clinical-tools
9. Center of Excellence for Transgender Health
 http://transhealth.ucsf.edu/trans?page=lib-best-practices-hiv
10. National Transgender Testing Day
 https://www.aids.gov/news-and-events/awareness-days/transgender/
 http://transhealth.ucsf.edu/tcoe?page=ev-nthtd-2016
RESOURCES