The Center of Excellence for Transgender HIV Prevention: Bringing the Science to You!

1. The Center of Excellence for Transgender HIV Prevention: Bringing the Science to You! Jae Sevelius, PhD JoAnne Keatley, MSW Co-Principal Investigator Director

2. Topics • Emerging issues and service gaps in transgender HIV prevention and care • Best practices for transgender HIV prevention and care • How to locate resources and free training and consultation through the Center of Excellence for HIV Prevention (CoE)

3. How many transgender patients/clients have you provided services to? • < 5 • 5 - 15 • 15 - 25 • > 25

4. I feel comfortable providing services to transgender clients/patients. • Strongly Agree • Agree • Disagree • Strongly Disagree

5. Which of the following is the best definition of “transgender”? • People who have changed their sex on their birth certificate. • People who were born male but identify as female. • People who have used hormones and/or surgery to align their body with their gender identity. • People whose gender identity and/or expression does not match the gender they were assigned at birth.

6. Data Collection Challenges • Reliance on the binary system of classification (i.e. M, F, MTF, FTM)  misclassification and exclusion of gender variance • Social stigma  fear of disclosure and avoidance of medical settings • Living ‘stealth’ or ‘post-transsexual’ identity • Many agencies simply do not ask the question.

7. What is wrong with the format of the following question?Gender (please check one):  Male  Female  Transgender • It will miss some folks who we want to capture, but do not identify as ‘transgender’. • When people check ‘transgender’, it tells you little about their gender. • It assumes that people who are transgender do not identify as ‘male’ or ‘female’. • All of the above

8. How many trans people are there? • No population-based studies = no reliable estimate of the number of trans people in the US • All current population estimates are based on those receiving the GID diagnosis and/or those seeking services at gender clinics(i.e. self-identified as transsexual population estimates)  underestimation.

9. How many trans people are there? Range of current worldwide estimates: MTF 1 in 30,000 (.003%)1 to 6 in 1,000 (.6%)2 FTM 1 in 100,000 (.001%)1 to 1 in 33,800 (.003%)3 • American Psychiatric Association, 1994 • Winter, 2002 • DeCuypere et al, 2007

10. U.S. Transgender Population Estimates National(NCTE estimate, Newsweek, May 2007) 1% (“as many as 3 million”) San Francisco(SF Department of Public Health, 1994) 2.2% of total population (about 22,000) Washington, DC(WTNAS, Xavier et al, 2005) 0.7% of total population (about 4,000)

11. Why is a Center of Excellence for Transgender HIV Prevention necessary? High HIV prevalence rates High unmet needs for prevention, care, and treatment

12. HIV Prevalence Among Trans People • No national estimates • Regional studies have relied almost exclusively on convenience samples(i.e. participants recruited from social service agencies, bars, and streets) • Studies have focused on trans women; very little information is available on trans men

13. HIV Prevalence Among Trans People • A recent meta-analysis of 29 regional studies in the US1concludes that: • Average prevalence for trans women is 28%or1 in 4 (when results are lab-confirmed) 12% or 1 in 8(by self report) • African American transwomen have the highest prevalence (56%), compared to other racial/ethnic groups 2,3 • Herbst et al, 2008 • Clements, Marx, Guzman & Katz, 2001 • Nemoto et al, 2004

14. Transgender women and HIV • In California’s publicly-funded counseling and testing sites, transgender female clients have higher rates of HIV diagnosis (6%) than all other risk categories, including • MSM (4%) • partners of people living with HIV (5%) • African American transgender women have a substantially higher rate of HIV diagnosis (29%) than all other racial or ethnic groups. (California Department of Health Services, 2006)

15. Transgender women and HIV • A study of four US cities found that a sample of 59 transgender women living with HIV were less likely to receive highly active antiretroviral therapy (HAART) than a non-transgender control group (n=3755) (59% vs. 82%, p < .001). (Dayta, 2008; Melendez et al, 2005)

16. There are no known significant interactions between hormones and HIV medications. • True • False

17. Hormone therapy and HIV treatment • There are no known significant interactions between hormones and HIV medications, although several HIV medications can affect estrogen levels. • Hormone therapy for gender confirmation is not contraindicated for patients living with HIV, at any stage. (Kohler, 2005) • Hormone therapy has been shown to increase adherence to HIV medications and decrease other HIV-related behavioral risk factors. (Grimaldi & Jacobs, 1998)

18. Transgender men and HIV • Very few studies of trans people have included transmen. • Estimates of HIV prevalence range from 1 - 3% (Sevelius, 2007; Xavier, 2005; Clements-Nolle et al, 2001)

19. Please indicate which is the most significant barrier for you in providing services to trans patients/clients: • Lack of knowledge/training • Personal discomfort • Lack of access to clinical research • Lack of agency support • Religious/moral concerns • There are no trans people in my city • I have no barriers

20. Barriers to Care: Clients • Fear of disclosure/exposure • Social and geographic isolation • History of negative experiences with care providers • Intake forms, office environment, alienating process • Lack of insurance coverage - Trans-related care is often explicitly denied in insurance policies.

21. CoE Resource Inventory and Analysis • Inventory of resources for trans HIV prevention in California • Service gap analysis • Funding recommendations • Best Practices for Transgender HIV Prevention

22. Conclusions • Data collection issues must be addressed. • Access to hormones increases access to and utilization of other types of health care. • Evidence-based prevention programs specifically designed for transgender people are urgently needed. • HIV prevention and care programs prioritizing transgender people can benefit from sharing, documenting, and building upon their unique successes and challenges to improve services.

23. Recommendations • Adopt the 2-question format for collecting data on gender. (i.e. What is your current sex/gender? What was your gender assigned at birth?) • Increase education and training among providers. • Request free training from the CoE! • Testing must be increased among trans women. • Improve access to services through consultation with the CoE! • Increase resources and improve programs that address the severe health disparities experienced by transgender people of color.

24. The Center of Excellence for Transgender HIV Preventionwebsite www.transhealth.ucsf.edu