Access to HIV and Sexual Health Care (and Who's Doing it Right): Recaps from the International Workshop on HIV and Transgender People

Headshot of Isabella Ventura, RN, MSN, AGPCNP-BC and logos for The Well Project and the International Workshop on HIV and Transgender People.

By Isabella Ventura, RN, MSN, AGPCNP-BC

The International Workshop on HIV and Transgender People strives to reduce gaps in knowledge related to people of transgender experience by encouraging information exchange among professionals across disciplines, from medicine to community work and beyond, to improve quality of life for transgender people living with or vulnerable to acquiring HIV. The Well Project medical editor Isabella Ventura, RN, MSN, AGPCNP-BC, and community advisory board member Katie Willingham, attended the virtual gathering in December 2021 and reported on compelling takeaways.

Table of Contents

HIV and STI Prevention

Presenters Lim Sin How, PhD, of the University of Malaya in Malaysia; Deyn Natthakhet Yaemim, MD, of Thailand's Pulse Clinic; and Dinah de Riquet-Bons of Trans United Europe in the Netherlands were the first to speak at the workshop, providing an overview of updates and challenges to preventing HIV and other sexually transmitted infections (STIs) for transgender and gender-diverse (TGD) populations. Overarching take-home messages from their session included:

  • TGD individuals, particularly trans women, are at highest risk of acquiring HIV and STIs
    • The data referenced at the workshop on the worldwide burden of HIV in TGD populations were actually outdated. In a more recent meta-analysis, trans women were found to be 66 times more likely to have HIV than the general population; and trans men were 7 times more likely living with HIV.
  • Available biomedical HIV prevention tools for TGD people include pre-exposure prophylaxis (PrEP) to prevent HIV prior to exposure – such as Truvada (tenofovir disoproxil fumarate + emtricitabine) and Descovy (tenofovir alafenamide + emtricitabine). Treatment as prevention (TasP) by keeping a client engaged with their treatment and care, leading to maintaining an undetectable HIV viral load and therefore being incapable of transmitting HIV through sex, is another tool. Long-acting injectable PrEP has also recently become available in the US.
  • In some parts of the world, TGD individuals are still considered "hard-to-reach populations." Some of the discussions around increasing uptake and engagement with HIV/STI prevention, screening and care included:
    • Utilizing peer-led models of care and services. This means hiring from within TGD communities to coordinate and facilitate outreach and recruitment
    • Providing wrap-around services that include, but are not limited to: gender-affirming hormone treatments and monitoring; referrals to surgical procedures; mental health support to family; HIV/STI testing and treatments; PrEP and PEP (post-exposure prophylaxis following a possible HIV exposure).
    • Tangerine Clinic in Thailand (also discussed below) was presented as an example of combined HIV, STI and health services. The clinic provides counseling on HIV, STIs, and hormone use; HIV and syphilis testing; hormone treatment and hormone-level monitoring; condoms and lubricant; high-resolution colposcopy, anoscopy and neovaginoscopy; PrEP and PEP; HIV treatments and biomarkers monitoring; STI treatment; immunizations, including for human papillomavirus, hepatitis A and hepatitis B; and referrals to gender-affirming surgeries, hormone blockers for children, and adolescent and family counseling.
  • There is also a lack of clinician knowledge, skills, and training to provide effective gender-affirming care to TGD populations. This session did not address the unwillingness of some clinicians to provide care to TGD individuals due to transphobia (stigma, discrimination and biases towards TGD people). Training existing and future clinicians on TGD health care needs is important to providing adequate care.
  • There is a great need for more research on TGD populations, particularly with new biomedical HIV prevention tools such as long-acting PrEP injectables.

Improving Access to Reproductive and Sexual Health Care

The session "Reproductive and Sexual Health for Transgender People Living With HIV – Researcher, Health Care Provider, and Community Perspectives" was presented by Ashley Lacombe-Duncan, MSW, PhD, of the University of Michigan School of Social Work in the US and Yasmeen Persad of The 519 in Canada on behalf of their team at Trans Women HIV Research Initiative (TWIRI), which also includes Sue Hranilovic, a nurse practitioner at St. Michael's Hospital in Canada, who contributed to the presentation. (View a video of this presentation on YouTube)

Lacombe-Duncan presented key findings from their study in four areas:

Barriers to HIV prevention, testing and care

  • Anticipated and enacted stigma and discrimination in health care settings. The team also identified a lack of provider knowledge about HIV and trans care and absence of trans-specific services as barriers to seeking care.
  • Internalized HIV-related stigma, unstable housing, transportation, and transphobia. Mental health was also a key factor in participants' engagement to HIV care.

Barriers to gender-affirming care

  • Researchers also observed how HIV stigma disrupts access to medical gender affirmation through prohibitions against people living with HIV undergoing certain gender-affirming procedures (e.g., electrolysis) at some sites

Intersecting stigmas in health care

  • Participants experienced stigma in many health care settings from numerous types of professionals due to multiple aspects of their identities, including HIV status, gender, race, class, substance use, and sex work experience

Recommendations to improve sexual health of TGD populations include:

  • Providing trauma-informed and trans-positive care
  • Autonomy and choice for trans women in selecting sexual and reproductive health services
  • Provider education
  • Trans inclusion in program development and implementation

This study has potential implications for providers' practices, including implementing the principles of intersectional trans-affirming and trauma-informed care; utilizing evidence-informed practices of trans-affirming sexual history taking and physical exams; advocating for comprehensive trans-affirming reproductive and sexual health care for TGD individuals; and holistic programs to support TGD people living with HIV.

Models and Investments for HIV Prevention and Care

Kent Klindera, MPH, of the US Agency for International Development (USAID) presented on updates in PEPFAR-USAID's HIV funding investments in TGD populations. Klindera shared the good news that there has been an increased investment in funding efforts for HIV prevention and treatment for TGD populations in many parts of the world. Most of the funding sources are from goodwill partnerships with local governments. There has also been an increase in demand for TGD health care providers in the US in the past 10 years.

Klindera also presented on three model clinic programs that were able to provide gender-affirming care despite PEPFAR not directly supporting such services (or most services not seen as directly related to HIV treatment, even if they are essential to retaining people in care):

  • Healthy Markets at the One Clinic in Vietnam – TGD community organizations are involved in delivery of these comprehensive services, including gender-affirming care; the clinic does a great job meeting people where they are at to meet their immediate needs
  • Wits RHI in South Africa – involves trans folks in their own care and also provides hormone therapy – a first for a PEPFAR program on the African continent
  • Tangerine Clinic in Thailand – completely developed by and for trans people and offers hormone therapy on a sliding scale; programs in Laos and Burma are in development based on Tangerine's success

Simran Bharucha, MSW, of Project ACCELERATE at Johns Hopkins University School of Medicine in India and Mitzi Zaira Fong Ponce, MD, of Clinica Especializada Condesa, Mexico, also presented on their programs as successful models for providing HIV prevention and care to TGD populations. Bharucha's ACCELERATE is an example of a transgender-led service delivery model. A "one size does not fit all" model was also named as an effective approach.

The presentations described services including HIV/STI prevention, screening, and treatment; hormone and primary care; and mental health, among other things. Presenters acknowledged that understanding the local political climates, laws, regulations and provisions is important when providing HIV prevention and care to TGD individuals.

More from The Well Project on the International Workshop on HIV and Transgender People 2021

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