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Toronto I-II 1:00 pm Trans is the new black: The intersection of visibility and vulnerability Jae Sevelius Assistant Professor of Medicine at University.

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Presentation on theme: "Toronto I-II 1:00 pm Trans is the new black: The intersection of visibility and vulnerability Jae Sevelius Assistant Professor of Medicine at University."— Presentation transcript:

1 Toronto I-II 1:00 pm Trans is the new black: The intersection of visibility and vulnerability Jae Sevelius Assistant Professor of Medicine at University of California, San Francisco, Jae is affiliated with both the Center for AIDS Prevention Studies and the Center of Excellence for Transgender Health Moderator: Winston Husbands Director of Research and Program Development at the AIDS Committee of Toronto and a co-chair of the African and Caribbean Council on HIV/AIDS in Ontario

2 Trans is the New Black: The intersection of visibility and vulnerability Jae Sevelius, PhD Assistant Professor, Department of Medicine Center for AIDS Prevention Studies OHTN Conference November 19, 2013

3 Terminology Transgender women: people with a female/feminine gender identity who were assigned male at birth (sometimes referred to as ‘male-to-female’ or ‘MTF’) Transgender men: people with a male/masculine gender identity who were assigned female at birth (sometimes referred to as ‘female-to-male’ or ‘FTM’) …and trans people report a myriad of gender identities within, between, and outside of these two categories.

4 Trans men Very little data on vulnerability to HIV and HIV prevention needs Some evidence that transgender men who have sex with men (trans MSM) may be at risk for HIV, but current reported prevalence rates are low (1-3%)

5 Laverne Cox, actress, “Orange is the New Black” Isis King, model, “America’s Next Top Model” Janet Mock, Writer/activist Trans women

6 History of invisibility If considered, often subsumed under the categories “LGBT” and “MSM” / “MSM-TG” – Recent example: iPrEx study and the rollout of PReP guidelines


8 “The systematic reviews… found limited but high-quality evidence of the effectiveness of oral PrEP, with evidence of acceptability for the intended populations.”


10 “Importantly, there were insufficient numbers of trans women in iPrEx to know whether PrEP can work for them, so we're not sure yet whether PrEP efficacy is similar in trans women compared with gay men.” – Robert Grant, MD, Principal Investigator of iPrEx (The Body Pro interview, Winter 2012,

11 “Results from VOICE provide an urgent reminder that products must meet the needs of the people using them. While disappointing, the results lend new urgency and direction to the search for additional safe and effective HIV prevention options for women.” -

12 How has/will recent increases in visibility impact the trajectory of HIV prevention and treatment among trans women ?

13 Positive impacts of increased visibility New research documenting disparities and resiliencies, increased funding Data collection recommendations to more accurately capture trans populations in census data and EMRs Trans-specific intervention development for transgender women

14 HIV-related disparities among trans women 49 times higher odds of infection (Baral et al, 2013) In 2008 in SF: 2% of HIV cases, 7% of AIDS- related deaths (CDHS, 2008) Almost 3x higher community viral load than non-trans adults in SF (Das et al, 2010) African-American transgender women are disproportionately affected (CDHS, 2008, 2012) Many psychosocial disparities, including major depression and suicidality, trauma, anxiety, substance abuse

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

16 Barriers and facilitators to HIV treatment engagement and adherence Qualitative interviews (n=20), 5 focus groups (n=38) Barriers: – avoidance of healthcare due to stigma and past negative experiences – Competing prioritization of hormone therapy – concerns about adverse interactions between antiretroviral treatment for HIV and hormone therapy Facilitators: – receiving culturally competent, trans-sensitive healthcare – social support – integration of hormone therapy and HIV treatment (Sevelius, et al. (in press) Annals of Behavioral Medicine)

17 Trans-inclusive data collection recommendations 2-step method: 1)What is your current gender identity? 2)What was your assigned sex at birth? Any difference between the two flags a person with an identity on the trans spectrum. (More info at:

18 Access to gender affirmation Access to support and affirmation from family, peers, society, and/or lovers and sex partners Ability to “pass” Access to gender-affirming health care Hormone use/access to hormones Need for gender affirmation Desire to pass or live “stealth” Importance of passing Desire to be affirmed as female Intensified through objectified body consciousness and internalized transphobia Model of Gender Affirmation

19 Unmet need for gender affirmation leads to health risks LOW need for gender affirmation HIGH need for gender affirmation LOW access to gender affirmation Lower riskHIGHEST risk HIGH access to gender affirmation Lowest riskLower risk NEED - ACCESS = UNMET need for affirmation, which is most likely to predict risk behavior (i.e. getting one’s needs met in risky ways and not engaging in appropriate self-care behavior).

20 Stigma Social Oppression Psychological Distress Decreased access to gender affirmation Increased need for gender affirmation Unmet need Limited options and competing priorities Risk Behavior: risky sex, substance use, diminished self-care Objectification Theory (Fredrickson and Roberts 1997; Moradi and Huang 2008) Identity Threat Model of Stigma (Major and O’Brien 2005) Oppression and Sex in High Risk Contexts (Diaz et al. 2001, 2004) Model of Gender Affirmation

21 Preliminary quantitative support for Model of Gender Affirmation Among HIV- participants (n=63), unmet need for gender affirmation was significantly correlated with unprotected receptive anal sex with HIV+ partners (r=.47, p<.03). Among HIV+ participants (n=63), unmet need for gender affirmation was significantly associated with self-report of having a detectable viral load (t=1.97, p<.05, df=52).

22 Small group, 5 session intervention that aims to reduce sexual risk behavior and increase self-care Developed in collaboration with community Informed by the Model of Gender Affirmation Peer facilitated Mixed HIV status, focused on transwomen of color Piloted for feasibility and acceptability with 3 cohorts Preliminary support for efficacy Pilot RCT to begin January 2014 (R34, NIMH)


24 Intervention to optimize engagement in HIV care and medication adherence among transgender women Informed by the Models of Gender Affirmation and Health Care Empowerment 3 sessions with peer educator, 1 group workshop with trans health care provider and HIV care provider

25 Enhancing Engagement and Retention in Quality HIV Care for Transgender Women of Color (HRSA SPNS) – Nine demonstration sites funded in 3 metropolitan areas of the US to design, implement and evaluate innovative interventions to improve timely entry, engagement and retention in quality HIV care for transgender women of color living with HIV. – UCSF/CAPS is the Evaluation and Technical Assistance Center.

26 Recommendations Consider implementing the two-step data collection method to accurately capture trans people. Use targeted peer outreach to more effectively reach transgender people. Include gender affirming content to attract and retain transgender clients and patients. Integrate hormone therapy provision into HIV care to increase appointment attendance and medication adherence.

27 Acknowledgements Funders: – NIH/NIMH K08MH085566, R34MH102109 – California HIV/AIDS Research Program: Community Collaborative Award, IDEA Award – UCSF Academic Senate Individual Investigator Grant 555242-34935 – CAPS Innovative Award Colleagues at the Center of Excellence for Transgender Health: – JoAnne Keatley, MSW, Madeline Deutsch, MD, Luis Gutierrez-Mock, MA, Danielle Castro, Greg Rebchook, PhD – Research team: Angel Ventura, Enzo Patouhas, MA Mentors (K08 Career Development Award): – Mallory O. Johnson, PhD (Primary) – Susan Kegeles, PhD, Tor Neilands, PhD, Diane Binson, PhD Community Advisory Boards (CAPS, CoE) Participants

28 Thank you!

29 References Baral SD, Poteat T, Stromdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis 2013;13:214-22. Budge SL, Adelson JL, Howard KAS. Anxiety and Depression in Transgender Individuals: The Roles of Transition Status, Loss, Social Support, and Coping. Journal of Consulting and Clinical Psychology 2013 Bockting WO, Miner MH, Swinburne Romine RE, Hamilton A, Coleman E. Stigma, Mental Health, and Resilience in an Online Sample of the US Transgender Population. American Journal of Public Health 2013:e1-e9. doi: 10.2105/ajph.2013.301241. Brennan J, Kuhns LM, Johnson AK, Belzer M, Wilson EC, Garofalo R. Syndemic Theory and HIV Related Risk Among Young Transgender Women: The Role of Multiple, Co- Occurring Health Problems and Social Marginalization. Am J Public Health 2012;102:1751-7. Burke, P (1991) Identity processes and social stress. American Sociological Review, 56(6), 836-849. Clements-Nolle K, Marx R, Guzman R, Katz M. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health 2001;91:915-921 doi: 10.2105/AJPH.91.6.915. PMCID: 1446468

30 References Das M, Chu PL, Santos GM, et al. Decreases in Community Viral Load Are Accompanied by Reductions in New HIV Infections in San Francisco. PLoS One 2010;5:e11068 Herbst J, Jacobs E, Finlayson T, McKleroy V, Neumann M, Crepaz N. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS and Behavior 2008;12:1-17 Melendez R, Exner T, Ehrhardt A, et al. Health and health care among male-to- female transgender persons who are HIV positive. Am J Public Health 2005;95:5-7. Nuttbrock L, Bockting W, Rosenblum A, et al. Gender Abuse, Depressive Symptoms, and HIV and Other Sexually Transmitted Infections Among Male-to- Female Transgender Persons: A Three-Year Prospective Study. Am J Public Health 2012:e1-e8. Sevelius J. Gender Affirmation: A Framework for Conceptualizing Risk Behavior among Transgender Women of Color. Sex Roles 2012:1-15 Sevelius J, Carrico A, Johnson M. Antiretroviral therapy adherence among transgender women. J Assoc Nurses AIDS Care 2010;21:256-64.

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