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AIDS 2014 Recap: Meeting the Needs of Transgender Women

, by San Francisco AIDS Foundation

AIDS2014_logo_600x191Transgender women are among the most marginalized and HIV-affected groups worldwide. HIV prevalence estimates range widely, largely because data on transgender populations around the globe are incomplete, but a recent meta-analysis suggests transwomen have a staggering 49 times greater chance of having HIV than are non-transgender adult women and men.

At AIDS 2014, two presentations in competing sessions on July 23 shed light on ways to address that statistic and others, and work with transgender women to improve health and well-being.

Addressing Unmet Needs

In a talk titled “Unmet needs for health and social services and HIV risk behaviors among transgender women living with HIV in the San Francisco Bay Area” (abstract WEAD0203), Tooru Nemoto of the Public Health Institute in Oakland, California, reported that transgender women are categorized as the most at-risk group for HIV in San Francisco, with an estimated HIV prevalence between 15.5% and 35%, and described results of a survey designed to assess links between access to care/unmet needs, HIV risk behaviors, and participant demographics.

The study sample consisted of 161 self-identified transgender women, HIV positive, age 18 or older, living in San Francisco or Oakland, and having had engaged in sex work. Participants completed a survey questionnaire about their needs for basic assistance (e.g., food, permanent housing, and employment), mental health, substance use treatment, and health care services (including general medical care and emergency services).

The survey also included measures of depression, self-esteem, identification with the transgender community, experience of transphobia (including physical and sexual violence, verbal harassment, and discrimination), perceived need for social support, and frequency of social support received.

Overall, 47% of transgender women in the study sample expressed unmet needs. African-Americans (52%), whites (57%), and Latinas (40%) expressed significantly greater unmet needs for health and social services than did Asian/Pacific Islanders (29%). Conversely, unmet needs for HIV primary care were higher among African-Americans and whites (16% and 19%, respectively) than among API and Latinas (0% and 4%, respectively).

Turning to mental health, unmet needs were significantly correlated with using drugs before sex, Nemoto reported. African-American and white transgender women were more likely to have had unprotected (condomless) receptive anal sex (URAS for short) within the past 30 days than were Latina and API transwomen. API transgender women were significantly less likely to have engaged in sex work in the past 6 months and were less depressed compared with other racial/ethnic groups.

“Those who reported higher levels of unmet needs for basic assistance also tended to report engaging in URAS with commercial sex customers,” Nemoto observed. “Also, those who reported higher unmet needs in mental health services tended to report engaging in URAS with commercial partners.” African-American ethnicity, younger age, transphobia experience, and social support needs strongly and significantly correlated with total number of unmet needs.

Participants who reported higher unmet needs also tended to be depressed, so the researchers compared depression rates among the four groups. More Latina transwomen reported depressive symptoms (76%), compared with whites (52%), African-Americans (52%), and API (46%). However, there were no group differences in reported self-esteem, transgender community identification, transphobia experience, or social support need. Group differences in social support received were only detected for support from non-transgender friends, with more white and African-American reporting this type of support.

Based in these findings, the research team offered these recommendations:

  • Future programs for HIV-positive transgender women must address basic needs such as employment, housing, and job training.
  • Programs must target specific groups: Latina, African-American, and white transgender women, younger transwomen, and those who have experienced transphobia.
  • Given that unmet needs for health care (including HIV primary) care were significantly correlated with depression, mental health issues among transgender women living with HIV should be addressed.

Finally, the researchers called for the elimination of individual and institutional transphobia through education for service providers, as well as media campaigns for the general public, “because transphobia prevents transgender women living with HIV from seeking help and utilizing health and social services.”

Housing as a Structural Intervention

In a similar vein, Virginia Shubert (abstract WEAD0301) with non-profit group Housing Works presented on the role of stable housing for transgender women living with HIV in New York City, where HIV prevalence among transwomen is estimated at nearly 28%.

Shubert acknowledged the complex interacting risks that contribute to marginalization and HIV prevalence in this community, and added, “We believe at Housing Works that addressing risk requires complex and multifaceted approaches.”

To this end, the organization created the Transitional Transgender Housing Project (TTHP) to serve transgender people living with HIV. Program participants live in individual housing units throughout the city. Abstinence from substances is not required, and residents have access to case management, support groups, HIV care, job training, and other services, Shubert explained.

To evaluate the program’s affect on participants’ HIV health, using viral suppression as a marker, the group compared 90 TTHP residents (assessed when they exited the program) with 90 age-and race-matched homeless HIV positive clients on antiretroviral therapy. Thirty in-depth interviews were conducted with TTHP participants to better understand these quantitative results.

“We’re very pleased to say that residence in the TTHP program was significantly associated with viral suppression,” Shubert said; 67% of participants achieved suppressed viral load, compared with 32% of homeless clients.

The main theme to emerge from the in-depth interviews was that “stable housing undermined chaotic and risky physical environments and facilitated service-utilization that ultimately reduced HIV risk and improved adherence.” Specifically, the program allowed participants to avoid substance-use environments, provided an environment that facilitated less risky sex, and reduced the need to engage in sex exchange in order to survive.

In addition, interviews revealed that the array of transgender-competent services available to TTHP participants supported medication adherence and regular medical appointments. Participants also had the privacy to negotiate their own gender expression, and the public space to advocate for themselves, Shubert explained.

“The bottom line,” concluded Shubert, “is that housing is an important structural factor that operates both as HIV prevention and treatment for transgender and gender-non-conforming persons living with HIV by undermining the complex risk environment and facilitating positive health behaviors, and it promotes personal and collective efficacy for the community.”


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