JoAnne Keatley

HIV Risk Behaviors Among Male-to-Female Transgender Persons of Color in San Francisco

OBJECTIVES The authors examined HIV risk behaviors among African American, Asian/Pacific Islander (API), and Latina male-to-female (MTF) transgender persons in order to improve HIV prevention programs. METHODS Individual survey interviews with MTF transgender persons of color (n = 332; 112 African Americans, 110 Latinas, and 110 APIs) were conducted. RESULTS Prevalence and correlates of receptive anal sex and unprotected receptive anal sex (URAS) varied by type of partner (primary, casual, or commercial sex partners). URAS with primary partners was associated with drug use before sex; URAS with casual partners was associated with HIV-positive status and drug use before sex; and URAS with commercial sex partners was associated with African American ethnicity and low income. CONCLUSIONS Findings on current risk behaviors among MTF transgender persons provided meaningful implications for HIV prevention interventions.

Social context of HIV risk behaviours among male-to-female transgenders of colour

To explore the social context of drug use and sexual behaviours that put male-to-female (MTF) transgenders at risk for HIV, focus groups were conducted consisting of African American, Latina and Asian and Pacific Islander MTF transgenders (N=48) who reside or work in San Francisco, California. Participants were likely to report having unprotected sex with primary partners to signify love and emotional connection, as well as to receive gender validation from their partners. In contrast, viewing sex work with customers as a business encouraged intentious to use condoms. Safer sex intentions with customers were frequently undermined by urgent financial needs, which stemmed from transphobia, employment discrimination and costly procedures associated with gender transition. Participants reported using drugs as a way to cope with or escape life stresses associated with relationships, sex work, transphobia and financial hardship. Interventions with at-risk MTF transgenders should address the interpersonal and social context of unsafe sex and drug use, particularly the unique roles of relationship issues with male partners, stigma, discrimination and community norms regarding sex work and drug use.

Promoting health for transgender women: Transgender Resources and Neighborhood Space (TRANS) program in San Francisco.

Transgender women are at high risk for HIV, substance abuse, and mental health problems. We describe a health promotion intervention program tailored to transgender women in San Francisco. The program creates a safe space for providing transgender-sensitive education about HIV risk reduction, substance abuse prevention, and general health promotion. Transgender health educators conduct workshops and make referrals to appropriate substance abuse treatment programs and other services in the community. Evaluation findings indicate that this community-tailored intervention may be an effective way to reach transgender women and reduce sexual risk behaviors, depression, and perceived barriers to substance abuse treatment.

Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group

Transgender patients have particular needs with respect to demographic information and health records; specifically, transgender patients may have a chosen name and gender identity that differs from their current legally designated name and sex. Additionally, sex-specific health information, for example, a man with a cervix or a woman with a prostate, requires special attention in electronic health record (EHR) systems. The World Professional Association for Transgender Health (WPATH) is an international multidisciplinary professional association that publishes recognized standards for the care of transgender and gender variant persons. In September 2011, the WPATH Executive Committee convened an Electronic Medical Records Working Group comprised of both expert clinicians and medical information technology specialists, to make recommendations for developers, vendors, and users of EHR systems with respect to transgender patients. These recommendations and supporting rationale are presented here.

Barriers and Facilitators to Engagement and Retention in Care among Transgender Women Living with Human Immunodeficiency Virus

BackgroundTransgender 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.PurposeThis 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.MethodsThrough 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.ResultsOur 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.ConclusionsRecommendations are offered to inform intervention research and guide providers, emphasizing gender affirming HIV care that integrates transition-related healthcare needs.

HIV pre-exposure prophylaxis in transgender women: a subgroup analysis of the iPrEx trial.

Summary Background Oral emtricitabine-tenofovir disoproxil fumarate (FTC/TDF) pre-exposure prophylaxis (PrEP) is used to prevent the sexual acquisition of HIV. Transgender women (TGW) have unique characteristics that may relate to PrEP use, effectiveness, and safety. Methods The iPrEx trial was a randomized controlled trial (RCT) of oral FTC/TDF PrEP versus placebo among men who have sex with men (MSM) and TGW, followed by an open label extension (OLE). Drug concentrations were measured in blood by liquid chromatography and tandem mass spectroscopy. Findings Of the 2499 participants enrolled in the RCT, 29 (1%) identified as women, 296 (12%) identified as “trans”, 14 (1%) identified as men but reported use of feminizing hormones, such that 339 (14%) reported one or more of these characteristics (TGW). Compared with MSM, TGW more frequently reported transactional sex, receptive anal intercourse without a condom, or more than 5 partners in the past 3 months. Among TGW, there were 11 HIV infections in the active arm and 10 in the placebo arm, representing a hazard ratio of 1.1 (95% CI: 0.5 to 2.7). Among active arm participants, drug was detected in none of the TGW at the seroconversion visit, 18% (6/37) of seronegative TGW (P=0.31), and 52% (58/111) of seronegative MSM (P < 0.0001). PrEP use was not linked to behavioral indicators of HIV risk among TGW, while MSM at highest risk were more adherent. Interpretation There were no HIV infections among TGW having drug concentrations commensurate with use of 4 or more FTC/TDF tablets per week. TGW receiving PrEP had low drug concentrations, especially at times of potential HIV exposure, leading to no PrEP effectiveness among this subgroup. Funding U.S. National Institutes of Health and the Bill and Melinda Gates Foundation; study medication was donated by Gilead Sciences.

‘I am not a man’: Trans-specific barriers and facilitators to PrEP acceptability among transgender women

ABSTRACT The frequent conflation of transgender (‘trans’) women with ‘men who have sex with men (MSM)’ in HIV prevention obscures trans womens unique gender identities, social and behavioural vulnerabilities, and their disproportionately high rates of HIV infection. Pre-exposure prophylaxis (PrEP) is an efficacious biomedical HIV prevention approach. However, trans women are underrepresented in PrEP research, and are often aggregated with MSM without consideration for their unique positions within sociocultural contexts. This study examined PrEP acceptability among trans women via three focus groups and nine individual interviews (total N = 30) in San Francisco. While knowledge of PrEP was low, interest was relatively high once participants were informed. Due to past negative healthcare experiences, ability to obtain PrEP from a trans-competent provider was cited as essential to PrEP uptake and adherence. Participants noted that PrEP could address situations in which trans women experience reduced power to negotiate safer sex, including sex work. Trans-specific barriers included lack of trans-inclusive marketing of PrEP, prioritisation of hormone use, and medical mistrust due to transphobia. Findings underscore the importance of disaggregating trans women from MSM in HIV prevention strategies to mitigate disparate risk among this highly vulnerable population.

Transgender community voices: a participatory population perspective

Understanding the global health burden and needs of transgender communities necessitates meaningful engagement and involvement of transgender people. Against the backdrop of widespread social and economic exclusion facing people of diverse gender identities and experiences, community empowerment is essential for clinical services, public health programmes, and human rights eff orts that seek to design and implement eff ective services and population-level interventions to improve the health and wellbeing of transgender people. A part ic ipatory population perspective necessitates working with—and not through—local, national, and global transgenderled organisations in the conduct of research and evaluation, delivery of gender-affirmative clinical care, education and training, and policy and advocacy. From this perspective, we have invited transgender leaders to contribute narratives of their experiences in their local context. T h e s e t r a n s g e n d e r v o i c e s bring to life the social contexts, epidemiological data, and identifi ed health-care needs presented across the Lancet Series papers on transgender health; they are especially meant to accompany Sari Reisner and colleagues’ review of the global health burden and needs—a paper on which most of the authors are themselves transgender men and women. The voices narratives are not meant to be, nor could they be, representative of the entire global transgender community given the heterogeneity of transgender people worldwide. However, these voices are powerful examples of the lived knowledge and personal experiences of transgender people.

The Transgender Women of Color Initiative: Implementing and Evaluating Innovative Interventions to Enhance Engagement and Retention in HIV Care

To improve health outcomes among transgender women of color living with HIV, the Health Resources and Services Administrations Special Programs of National Significance program funded the Enhancing Engagement and Retention in Quality HIV Care for Transgender Women of Color Initiative in 2012. Nine demonstration projects in four US urban areas implemented innovative, theory-based interventions specifically targeting transgender women of color in their jurisdictions. An evaluation and technical assistance center was funded to evaluate the outcomes of the access to care interventions, and these findings will yield best practices and lessons learned to improve the care and treatment of transgender women of color living with HIV infection.

Collection of Gender Identity Data Using Electronic Medical Records: Survey of Current End-user Practices

Madeline B. Deutsch, MD, is The Clinical Lead at the Center of Excellence for Transgender Health, and an Assistant Clinical Professor in the Department of Family and Community Medicine at the University of California – San Francisco (UCSF), San Francisco, California, USA. JoAnne Keatley, MSW, is the Director of the Center of Excellence for Transgender Health at UCSF, San Francisco, California, USA. Jae Sevelius, PhD, is an Assistant Professor at the Center of Excellence for Transgender Health and the Center for AIDS Prevention Studies, Department of Medicine, UCSF, San Francisco, California, USA. Starley B. Shade, PhD, MPH, is an Assistant Professor at the Center for AIDS Prevention Studies, UCSF, San Francisco, California, USA.