International Workshop on HIV and Transgender People
July 20, 2019, Mexico City, Mexico
Reshmie Ramautarsing, M.D., Ph.D
Thai Red Cross AIDS Research Centre
The first International Workshop on HIV and Transgender People took place on July 20, 2019 in Mexico City, Mexico, prior to the International AIDS Society Conference 2019. This much-needed initiative gathered cross-disciplinary experts in a workshop setting to discuss the medical, clinical, and social challenges faced by transgender people at risk for and living with HIV. A scientific platform was created through didactic lectures and the sharing of best practices based on real-life experiences in order to discuss opportunities and challenges in the provision of healthcare for transgender people ultimately aiming to improve their quality of life. This report summarizes highlights presented during the workshop.
Context and Epidemiology
Amaranta Gomez-Regalado, a social anthropologist and activist at the Universidad Veracruzana, Xalapa, México, provided a life course perspective regarding sexual orientation, gender identity and gender expression (SOGIE). Transgender people face multiple denials of transgender identity throughout their life, resulting in a lonely childhood, early education abandonment, limited job opportunities in adulthood, and little recognition of emotional experiences. The average life expectancy of transgender women in Latin America and the Caribbean is only 32 to 34 years, and the quality of their life is compromised due to stigma, discrimination, and a systematic violation of their human rights. Transgender men need more visibility to address unplanned and forced pregnancies, clandestine abortions, HIV and other sexually transmitted infections (STIs). A new narrative of transgender people in Latin America and the Caribbean is necessary, with accelerated access to education, jobs, health and wellness, allowing transgender people to reach old age.
Ayden Scheim, University of California, San Diego, USA, presented a global overview on HIV epidemiology among transgender people, showing a very high burden of HIV among transgender women across countries. In line with this research, recent findings indicate that transgender women have a higher HIV burden compared to the general population and men who have sex with men in sub-Saharan Africa, a region with the highest HIV prevalence. Pre-exposure prophylaxis (PrEP) engagement and HIV treatment outcome data mostly address transgender women and generally show poor outcomes. Although new epidemiological data are emerging, global data on HIV among transgender men are very limited, and mostly originates from the USA and Canada. Structural factors, such as unstable housing, are important drivers of poor treatment outcomes reflected in unsuppressed viral load and should be addressed to prevent HIV acquisitions and improve cascade outcomes.
The session ended with a panel discussion on transgender health, social and epidemiological situations, moderated by JoAnne Keatley, the UCSF Center of Excellence for Transgender Health, USA. Kritima Samitpol (Jemma), Thai Red Cross AIDS Research Centre, Thailand, discussed the gender recognition laws and their impact across several countries in Asia. In a setting where gender recognition laws are in place, such as India, healthcare policies can move forward quicker, while in Thailand, which is often seen as an open and easy place for transgender people, no gender recognition laws are in place. This results in high levels of stigma and discrimination, especially in health services, causing people to seek assistance outside of their national healthcare system. Max Appenroth, Charité Universitätsmedizin Berlin, Germany, explained that while gender recognition laws are in place in a lot of European countries, the actual recognition depends on an assessment by another person. While transgender people should be considered the experts of their own experience, their knowledge is unfortunately not valued, resulting in the paucity of data regarding the transgender population in Europe. Leigh Ann van der Merwe,Social, Health and Empowerment Feminist Collective of Transgender Women of Africa, South Africa, echoed this point, stating that transgender people are no longer merely peer educators, activists or advocates, but are scientists as well. Like in Europe, gender recognition laws are in place, but the recognition is up to the discretion of the person handling the application. In sub-Saharan Africa, the criminalization of sex work and of same sex behavior are barriers for transgender women to utilize health services. Jessica Xavier, USA, pointed out the potential impact of transgender needs assessment studies indicating that those surveys provide immediate results and can be used as advocacy tools to improve access to transgender health services. Alexandra Rodriguez, IRGT, Mexico, mentioned that Mexico City, with over 20 million people, has only two clinics specializing in transgender healthcare. Even in these clinics, the focus is mostly on HIV.
An emerging theme throughout the discussion was the importance of primary care in general, and gender affirming primary care in particular. Globally, transgender people experience difficulties in receiving primary care. The health needs of transgender people are not being fulfilled, and insufficient measures are undertaken to provide appropriate, stigma-free healthcare services. In South Africa, transgender women with HIV present in a very advanced stage of the disease, and clinicians should realize that HIV among transgender people cannot be addressed without addressing gender affirmation. There is also a big gap in primary care services for young transgender people. Most healthcare providers do not have enough expertise in regard to the health of transgender people. Being respectful, asking questions and listening to patients’ needs are essential for providing quality primary care for transgender people, and training on transgender health needs should start in medical school.
Jae Sevelius, the UCSF Center of Excellence for Transgender Health, San Francisco, USA, showed how enacted, anticipated and internalized stigma among transgender people contributes to negative health outcomes. Mental health disorders like depression, anxiety and psychological distress disproportionately affect transgender people. People having multiple oppressed social identities or positions are subjected to intersectional stigma that can create increased vulnerability and negative health outcomes. Emerging data indicate that gender non-conforming people have a higher burden of psychological distress compared to gender-binary transgender people. Protective factors against stigma are family support, peer support and transgender community connectedness, internal resources like identity pride, structural resources such as employment and housing, and gender affirmation. These factors can predict improved health outcomes, and should be incorporated in interventions addressing stigma.
Madeline Deutch, UCSF Medical Center, San Francisco, USA, provided an overview of the practicalities of hormone use and hormone monitoring. The decision to use hormone therapy is not identity-based, but informed by the situation and goals of the individual, while taking into account coexisting medical or mental health conditions. Discussion on realistic expectations and outcomes of hormone therapy is essential. Due to genetic differences in enzyme activities, guidelines generally provide a very wide range of hormone dosing. Therefore, prescribing hormone therapy should be client-tailored and focused on their specific goals. Because sex characteristics are mainly determined by testosterone level, the main goal of feminizing hormone therapy should be to reduce testosterone to the female range, and aim for the lowest tolerable dose of estrogen to counter adverse effects like hot flashes, reduced libido, or osteoporosis. More estrogen is not necessarily better. For transgender men, the goal is to have testosterone in the male range.
Asa Radix, Callen-Lorde Community Health Center, New York, USA, presented the latest data on interactions between gender affirmative hormone therapy (GAHT) and antiretroviral therapy (ART). ART that has the lowest potential to impact GAHT includes unboosted integrase inhibitors, like dolutegravir and raltegravir, and non-nucleoside reverse transcriptase inhibitors (NNRTIs), like rilpivirine. NNRTIs efavirenz, etravirine and nevirapine could lead to a decreased concentration of dutasteride, finasteride, and testosterone, while boosted protease inhibitors, efavirenz, etravirine and nevirapine may decrease estradiol concentrations. Hormone level monitoring is recommended in these situations. While GAHT is not affected by PrEP, plasma and tissue tenofovir concentrations are reduced by feminizing hormone therapy, and a higher level of adherence might be needed.
Poonmissamai Suwajo, Chulalongkorn University, Bangkok, Thailand,presented the peritoneal vaginoplasty, which is one of the most recent techniques for sex reassignment surgery for transgender women who wish to undergo genital surgery, in which tissue from the peritoneum is used to create the neo-vagina. This procedure is shorter, and has a smaller amount of intraoperative blood loss compared to the more classical penile inversion procedure. The cosmetic and functional result resembles the biological female genitals very closely. Common procedures for transgender men are phalloplasty and metoidioplasty. The latter utilizes the clitoral enlargement that results from testosterone use, and is an alternative for those not wanting to undergo a complete phalloplasty. For all procedures, a multidisciplinary team is vital for providing both pre- and post-operative care for transgender patients.
Tonia Poteat, from the University of North Carolina at Chapel Hill, USA, stressed the importance of addressing social determinants, such as stigma, discrimination, and social exclusion, in the context of HIV care. Data from eight countries in sub-Saharan Africa indicated that violence, law enforcement stigma, and depression were significantly associated with HIV. In the USA, factors such as homelessness, temporary or unstable housing were negatively associated with outcomes along the HIV treatment cascade, while healthcare empowerment was shown to increase ART adherence and the likelihood of achieving viral suppression. Social, psychological, medical and legal gender affirmation reduces HIV risk, increases PrEP uptake, and increases the engagement in HIV care, highlighting the importance of trans-affirming clinical environments.
HIV Prevention and Treatment Service Delivery Models
During the third session, different service delivery models for HIV prevention and treatment from settings across the world were presented. In Manila, the Philippines, a community-led service delivery model is implemented by Victoria by Loveyourself. Yanyan Araña, explained that this community-led model addresses the stigma and discrimination transgender people experience accessing HIV services. Victoria by Loveyourself is located in the community, and members of the community provide HIV testing, linkage to HIV treatment, STI testing and treatment, and hormone monitoring services. Since its start in 2017, Victoria by Loveyourself has served 4,183 clients. PrEP and HIV self-testing services are expected to be launched soon.
An example of a primary care clinic-based delivery model, was provided by Maribel Acevedo Quiñones, Centro Ararat, San Juan, Puerto Rico. A full trans-centric primary care clinic was implemented in 2016 to fill a gap in well-trained, gender-sensitive healthcare providers. Meaningful community involvement and provision of personal and professional development opportunities are core elements of this model. Between 2016 and 2019, 173 transgender and non-binary participants were served in the clinic, utilizing HIV, STI, PrEP, or hormone therapy services. Services are provided by a multidisciplinary team, as a one-stop-shop as much as possible.
Rena Janamnuaysook, Thai Red Cross AIDS Research Centre, PREVENTION, Bangkok, Thailand, presented a sexual health clinic-based delivery model. Tangerine Clinic is Asia’s first clinic providing transgender health services. A community consultation was organized to assess health needs among transgender people in Thailand, which led to the establishment of Tangerine. The clinic integrates hormone services with sexual health and well-being services, and is led by transgender people. Gender sensitivity training is mandatory for all staff. A total of 2,623 transgender clients were served at Tangerine, with a 93% acceptance of HIV testing, and a 12% HIV prevalence. Those who received hormone related services were more likely to come back to the clinic, to have repeat HIV and syphilis testing, and accept PrEP. Among 141 transgender men, 5% reported to have sex with cisgender men, while 92% reported having sex with cisgender women. Tangerine has launched the Tangerine Academy that provides apprenticeships and onsite technical assistance to facilitate the replication of this successful model.
Finally, a hospital-based delivery model was shared by Iliassou Mfochive Mjindam, CHAMP, Cameroon. Transgender women in Cameroon have a high burden of HIV, but structural barriers, stigma and discrimination limit access to health services. Several non-governmental organizations and community-based organizations provide stigma-free services and are connected with trans-friendly hospitals to facilitate referrals for complex health issues. There are 15 hospitals which are considered trans-friendly. These hospitals have focal points to ease navigation within health services based on transgender women’s needs, and provide free services such as HIV, STI, tuberculosis, hepatitis B and C testing, hepatitis B vaccinations, and the management of gender-based violence.
Identifying Strategies for Providing Effective Transgender Health
Zil Goldstein, Callen-Lorde Community Health Center, New York, USA, provided a comprehensive overview of strategies to minimize barriers and maximize health through primary healthcare services for transgender people. Callen-Lorde Community Health Center provides sensitive, quality healthcare and related services to New York’s lesbian, gay, bisexual and transgender communities, regardless of their ability to pay. Services provided include primary care, sexual health services, behavioral health, health outreach to teens, and dental services. Creating a welcoming environment is essential, and includes having visible transgender staff in a wide range of roles, documenting correct names and pronouns, and allowing patients to keep as much clothing on as possible during physical examinations. Primary care includes, but is not limited to, the provision of hormone therapy. It encompasses preventive care screening and routine health maintenance as well as regular wellness visits and vaccinations, sexual health and risk reduction counseling, and screening for behavioral health issues. This should include cervical and chest cancer screening for transgender men, and breast cancer screening for transgender women.
In conclusion, transgender people globally face many challenges, including a disproportionate burden of HIV, unmet primary care needs, stigma and discrimination, and a myriad of other structural factors that negatively impact health.
Data on all aspects of transgender health – not just HIV – are needed from across settings and countries, and while data are emerging, not enough is done to include transgender men and non-binary people. More attention needs to be paid to accurately characterize risks, intersectionality, and structural barriers impacting transgender health in order to inform the design and implementation of multi-level interventions.
Access to appropriate primary healthcare is imperative for a long and healthy life, and transgender people across the world generally do not have this access. Healthcare providers do not have the necessary expertise to provide trans-specific services, or clinical environments are not transgender-friendly, resulting in additional barriers for transgender people to engage in care. Providing clinical care to transgender people, whether prescribing hormones, antiretroviral medications for HIV prevention or treatment, or gender-affirming surgery, should always have the patients at the center. Gender affirmation is an important aspect of all approaches to healthcare for transgender people, and no model of healthcare and service delivery can be designed or implemented without input and leadership from transgender people.