Current issues in HIV research with transgender populations

1. Current Issues in HIV Research
with Transgender Populations
Jae Sevelius, PhD
Assistant Professor
Center for AIDS Prevention Studies
Department of Medicine
Centers for Disease Control and Prevention
Translating Research into Practice
July 2015

2. In diversity there is beauty
and there is strength.
- Maya Angelou

4. Commonly used terminology
 Gender identity
 Gender expression
 Genderqueer/Gender non-conforming
 Transgender/Trans
 Transgender woman/Trans woman
 Transgender man/Trans man
 Intersex/Disorders of Sex Development
 Transition
 Cisgender/Non-transgender

5. Gender Identity Disorder (GID) vs. Gender Dysphoria

7. Population size estimates
 U.S. estimates range from 0.3% – 0.5%
 Approx 956,700 – 1,594,500 trans people in U.S.
 For comparison, in 2013 U.S. census data:
 0.2% of people reported their race/ethnicity as Native
Hawaiian or Other Pacific Islander
 0.9% reported their race as American Indian or Alaska
Native
Conron et al. 2012; Williams Institute, 2011

8. Johanna

9. Data collection challenges
 “If you don’t count us, we don’t count.”
 Why count trans people?
 Which trans people count?

10. Bestpracticesfortrans-inclusivedatacollection
 Two-step measure:
1) What is your current gender identity?
 Female
 Male
 Transgender female
 Transgender male
 Genderqueer/Gender non-conforming
 Different identity (please state):
2) What was your assigned sex at birth (on your original birth
certificate)?
 Female
 Male
Any difference between the two flags a person with an identity on the trans
spectrum.
Center of Excellence forTransgender Health, 2009;The GenIUSS Group, 2014

11. Bestpracticesfortrans-inclusivedatacollection
 Single item measure:
Some people describe themselves as transgender when
they experience a different gender identity from their sex at
birth. For example, a person born into a male body, but who
feels female or lives as a woman.
Do you consider yourself to be transgender?
 Yes, transgender, male to female
 Yes, transgender, female to male
 Yes, transgender, gender non-conforming
 No
Conron et al., 2011

13. History of invisibility

14. HIV-relateddisparitiesamongtranswomen
 34 times higher odds of infection than general
population in U.S. (Baral et al, 2013)
 Highest percentage of newly identified HIV-
positive test results (2.1%), compared to non-
trans males (1.2%) and non-trans females
(0.4%). (CDC, 2011)
 Almost 3x higher community viral load than non-
trans adults in SF (Das et al, 2010)
 African-American transgender women are
disproportionately affected (Herbst et al, 2008)

15. 0
10
20
30
40
50
60
70
Latina African-
American
A&PI White Mixed Race
HIV prevalence among transgender women
in U.S. regional studies, by ethnicity

16. Transgender women
have highest rates of
HIV of any group
These rates are
included in rates of
HIV among MSM
$$$ is allocated
to research and
services for MSM
based on these rates
Impact on Research:
# of EBIs for trans women: 0
iPrEx: No evidence that PrEP
works for trans women
Impact on Services:
MSM service organizations
do not effectively include
and serve trans women
Use of the BRP
“MSM” contributes
to HIV-related
disparities among
trans women

17. Access to
gender
affirmation
Need for
gender
affirmation
Desire for
transition-related
procedures
Desire to be
affirmed as
female
Desire to “pass” or
“live stealth”
Gender affirming
health care
Ability to “pass”
Affirming relationships:
Family, peers, and/or
lovers and sex partners
Sevelius, J. 2012. Sex Roles

18. NEED
for gender affirmation
LOW HIGH
ACCESS
to gender
affirmation
LOW Lower risk HIGHEST risk
HIGH Lowest risk Lower risk

19. Stigma
Social Oppression
Psychological
Distress
Decreased
access to gender
affirmation
Increased need for
gender
affirmation
UNMET
NEED
Psychological distress
Reduced self-care
Risk behavior
Model of GenderAffirmation
Sevelius, J. 2012. Sex Roles

20. Gender
affirmation
(hormones/s
urgery, social
affirmation)
Decreased
depression
Improved
health,
quality of life
Decreased
sexual risk
Budge et al. 2013. J Clin Couns Psych
Gorin-Lazard et al. 2012 J of Sex Med
Colton et al. 2011. J of Gay Lesb Ment Health
Sevelius, in press

21. Trans men and HIV
 Risk behaviors among
TMSM:
 ncRAI/ncRVI: 26 – 60%
 STDs/unintended pregnancies
 Sex for gender affirmation
 HIV prevalence studies:
 Small convenience samples
 Estimates range from 2 – 5%
Reisner et al. 2013; Sevelius 2009; Light et al. 2014; Herbst et al. 2008

22. HIV treatment-relateddisparities
 Transgender women living with HIV (TWH) are
 less likely to take antiretroviral therapy (ART)
Those who do initiate ART:
 have lower rates of ART adherence
 have lower self-efficacy for integrating ART into daily
routines
 report fewer positive interactions with health care
providers than non-transgender adults
Melendez et al, 2005; Sevelius, Carrico, & Johnson, 2011

23. Talia

24. BarriersandfacilitatorstoHIVtreatment
engagementandadherence
 Facilitators:
 receiving culturally competent, trans-informed healthcare
 integration of hormone therapy and HIV treatment
 Barriers:
 avoidance of healthcare due to stigma and past negative
experiences
 prioritization of transition-related healthcare
 concerns about adverse interactions between
antiretroviral treatment for HIV and hormone therapy
Sevelius et al, 2014. Ann Beh Med

25. Trans women and PrEP
 Low levels of awareness, even in SF
 No trans-specific guidance for
implementation (WHO, CDC)
 Low levels of enrollment and retention in
demonstration projects
 Rarely included in observational studies,
rarely disaggregated
 Of the 7 clinical trials, iPrEx is the only one
with confirmed enrollment of trans women
Escudero et al. 2014

26.  Of the 2499 participants:
 29 (1%) identified as women
 296 (12%) identified as “trans”
 14 (1%) reported use of feminizing hormones
 339 (14%) reported one or more of these
characteristics.
 Among trans women:
 11 HIV infections in the active arm
 10 in the placebo arm
 Hazard ratio of 1.1 (95%CI: 0.5 to 2.7)
 Zero effectiveness on an intention to treat basis
 Those on hormones were less likely to have
protective drug levels than those not on
hormones
Trans women in iPrEx
Grant et al. 2014; Deutsch et al. 2014

27. “Never”: no detection of TFV-DP at any visit
“Some”: detection at more than one but less than all visits
“Always”: detection at all visits
Consistency of drug detection, gender, and non-condom
receptive anal intercourse (ncRAI)

28. PrEP acceptability among trans women
 Qualitative data collection with transgender women
in San Francisco:
 3 focus groups
 9 individual interviews
 total N=30
 Focused on knowledge of, interest in, and concerns
about PrEP for HIV prevention
 Transcripts were analyzed in an iterative process
using a template analysis framework
 Results presented here focus on issues of particular
relevance to trans women
Sevelius, in press

29. Results: Facilitators/Barriers
to PrEP acceptability
 Facilitators
 obtaining PrEP from a trans-informed provider
 education about PrEP from trusted sources
 risk perception
 Barriers
 information not disseminated via trans networks
 concerns about interactions with hormones
 medical mistrust

30. “Some of us, you know, we do sex work on the
side, and some of us, we’re part of that
marginalized community and we don’t really
have that much opportunity for employment. So
we end up trying to make a quick buck with sex
work and that’s a lot of exposure, and that’s a
risk and I think that’s one of the reasons why I
would go for it.”
Risk perception and acceptability
- African American, age 33

31. Concerns about interactions with hormones
“If it stopped my hormone progress, I would be
irate, because I like to look pretty and pretty is
a soft face. And if hormones do not give me
that soft face while taking a pill that’s
supposed to stop something that condoms do
pretty just fine doing by themselves…that
would definitely make me stop
instantaneously.”
- African American, age 27

32. “I would love to see stats on trans involvement [with
PrEP] and I would like to see it talked about a little
more because trans women, just being trans women,
are at risk for HIV, AIDS and STDs. So anything that
can detour that risk, definitely needs to be had in
broader conversations…and brought to the same
plateau as it has been [discussed] in the gay
community. Because, I’m pretty sure it’s being talked
about like it’s the holy grail over in the gayborhood.
But it’s not being talked about over here in
Transtasia.”
Lack of information via trans networks
- African American, age 35

33. Medical mistrust
“Most [providers] see us as gay men and most
don’t understand that we’re women and most
don’t treat us as such…So, I have gone to [a
PrEP clinic in San Francisco] before for testing
and I felt completely uncomfortable because I
am the only trans woman sitting there, and
yet they see me as just another guy. It’s like,
it’s not fair...Everyone has the right to the
same healthcare.”
- Focus Group 2

34. Recommendations
 We can promote PrEP uptake among trans
women by:
 Identifying opportunities for disseminating
information about PrEP via trans networks
 Discussing PrEP in the context of broader
conversations about sexual health and wellness,
transition-related goals
 Addressing misinformation and assumptions,
including medical mistrust

35. Syndemic
theory
Poor
mental
health
Substance
use
Trauma
StigmaPoverty
HIV
Incarceration
Operario D, et al. 2010. AJPH

36. Transphobia
Poor health
outcomes
Social
support
Identity
pride
Coping
Gender
affirmation
Resilience / Protective Factors

37. Funded by NIH/NIMH R34MH102109, K08MH085566,
CHRP Community Collaborative Award
Session Topic
1 Gender Pride
2 Looking Good, Feeling Good
3 Let’s Talk About Sex
4 Taking Back the Power
5 Surviving and Thriving

38. 6 sessions with peer educator, 1 group workshop
Funded by NIH/NIMH R01MH106373, California HIV/AIDS Research Program IDEA award, UCSF
Academic Senate Individual Investigator Grant 555242-34935, CAPS Innovative Award
Intervention to optimize engagement in HIV care and
medication adherence among HIV+ transgender women

39. For incarcerated trans women preparing to return to the community
Systematic adaptation and pilot RCT of Project START intervention
Focus is on linkage to and engagement in health care in 4 domains:
1) HIV testing and prevention (for HIV- or unknown status
participants) or HIV treatment (for HIV+ participants),
2) substance use treatment,
3) mental health care, and
4) transgender-related medical care.
Funded by NIH/NIDA R34DA038541

40. Research gaps
 Trans men and HIV risk/sexual health needs
 Addressing trans people’s needs in sex-
segregated settings (e.g. shelters, corrections
facilities, substance abuse treatment)
 Trans-inclusive PrEP implementation guidance
 Barriers and facilitators to trans inclusion in
services for gender of identity (e.g.
#WeAreAllWomen)

41. the power of being seen

42. www.transhealth.ucsf.edu

43. Thank you!
jae.sevelius@ucsf.edu

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Estimating HIV prevalence and risk behaviors of transgender persons in the United
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9299-3
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of Consulting and Clinical Psychology 2013
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