1. Engagement in the HIV care cascade among transgender women enrolled in a public HIV clinic in Buenos Aires, Argentina, 2000-2012 M.E. Socías 1,2, O. Sued 1,2, C. Frola 2, A. Iacchetti 2, T. Kerr 3,4, I. Aristegui 1, V. Zalazar 1, H. Pérez 2, P. Cahn 1,2 1 Fundación Huésped, Buenos Aires, Argentina 2 Hospital Fernández, Infectious Diseases Division, Buenos Aires, Argentina 3 British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada 4 University of British Columbia, Department of Medicine, Vancouver, Canada

2. Background In Argentina, transgender (TG) women are a highly vulnerable population – Life expectancy  35 years (vs. 79 in biological women) – Estimated HIV prevalence 34% (vs. 0.4% in the general population) Argentina´s policies are promoting gender equity – 2007: Right to self-perceived gender identity in healthcare (Buenos Aires) – 2010: Same-sex Marriage Law – 2012: Gender Identity Law Little is known about engagement in HIV care among TG women Argentina MoH, 2013

3. Objectives To characterize engagement in the HIV continuum of care among TG women enrolled in a public HIV clinic in Buenos Aires, Argentina To explore factors associated with virological suppression within the first year of HIV diagnosis

4. Methods I Design – Retrospective clinical chart review Study population – TG women newly diagnosed with HIV and starting care in Hospital Fernández (HF) (linked to HIV care) between 2000-2012 Definitions: HIV care cascade indicators – Engaged in HIV care: ≥ 2 HIV-related visits at least 3 months apart within the first year of HIV diagnosis – Retained in HIV care at 1 year: 1 HIV-related visit and/or diagnostic tests at 12 ± 3 months of HIV diagnosis – On ART: ART initiation within the first year of HIV diagnosis – Virologically suppressed: VL <50 copies/mL at 12 ± 3 months of HIV diagnosis US DHHS, Health Resources and Services Administration Institute of Medicine, 2012

5. Methods II Data analysis – Percentages at each step of the HIV care cascade within the first year of HIV diagnosis – Bi- and multivariable logistic regression analyses to investigate factors associated with virological suppression at 12 months of HIV diagnosis

6. Baseline characteristics of TG women enrolled in HF between 2000-12 N= 69 Age at HIV diagnosis, median (IQR)30 (26-35) Completed high school, n (%)38 (58) Extended health insurance, n (%)3 (4) Use of drugs, n (%)27 (54) Use of alcohol, n (%)29 (56) Sex worker, n (%)28 (48) Employed (not sex worker), n (%)15 (25.9) Days from HIV diagnosis to first HIV-related visit, median (IQR) 157 (22-730) Baseline CD4, median (IQR)261 (98-477) Days from HIV diagnosis to ART initiation, median (IQR)310 (118-1126) * Denominators for each variable may differ due to non-response on some questions

7. HIV care cascade during the first year of HIV diagnosis (42.3% of TG women on ART) 69 Factors associated with ART initiation: CD4 ≤250 cells/μL: aOR = 3.90, 95%CI: 1.05 – 14.50 Age ≥30: aOR = 4.11, 95%CI: 1.13 – 14.91 42 32 26 11

8. Correlates of virological suppression (N = 69) UnadjustedAdjusted CharacteristicOR (95% CI)p - valueOR (95% CI)p - value Age ≥302.01 (0.53 – 7.62)0.342 Completed high school9.64 (1.15 – 80.54)*0.018 8.37 (0.89 – 78.37)0.063 Extended health insurance2.80 (0.23 – 33.87)0.411 Use of drugs0.45 (0.09 – 2.13)0.444 Use of alcohol1.74 (0.38 – 7.87)0.714 Sex worker0.25 (0.05 – 1.34)0.147 Employed (not sex worker)8.89 (1.86 – 42.44)*0.006 7.78 (1.49 – 40.52)0.015 Baseline CD4 0.997 (0.994 – 1.001)0.136 HIV diagnosis ≥20072.19 (0.43 – 11.16)0.483 * Significant at p < 0.10 and entered into the multivariable model

9. Correlates of virological suppression among transwomen on ART (n = 26) Unadjusted CharacteristicOR (95% CI)p - value Age ≥300.78 (0.13 – 4.54)1.000 Completed high school7.07 (0.60 – 60.44)0.179 Extended health insurance0.78 (0.06 – 9.89)1.000 Use of drugs0.43 (0.06 – 2.97)0.630 Use of alcohol1.39 (0.22 – 8.92)1.000 Sex worker0.39 (0.06 – 2.70)0.400 Employed (not sex worker)9.17 (1.15 – 73.24)0.037 Baseline CD4 1.001 (0.997 – 1.006)0.421 HIV diagnosis ≥20071.82 (0.28 – 11.87)0.668

10. Sub-analysis: Cascade of HIV care 2002-2006 and 2007-2012 Impact of the new legislation

11. Limitations Retrospective study Focus on transwomen enrolled in HIV care Small sample size

12. Conclusions Low rates of engagement across the HIV Care Cascade High proportion of substance use, sex work, and unemployment → broader risk environment of TGW shaping HIV outcomes Novel and culturally appropriate interventions tailored for HIV-infected TG women are urgently needed

13. Challenges & future directions Since August 2013 in Hospital Fernández: – Multidisciplinary team: infectious diseases, endocrinology, mental health, substance use, social services – Offer of comprehensive health services adapted to TG women needs

14. Acknowledgements eugenia.socias@huesped.org.ar Infectious Diseases Division, Hospital Fernández Fundación Huésped