Addressing Social Determinants

in the Context of HIV Care

Tonia Poteat, PhD, MPH, PA-C

Department of Social Medicine

Center for Health Equity Research

Pronouns: She/Her/Hers

DISCLOSURES

• Research grant support to my institution

» Viiv Healthcare

» Gilead Sciences

25/07/2019 2

What are social determinants?

Stigma, Discrimination, and Social Exclusion

Stigma/Discrimination

Labeling an attribute as negative

Requires exercise of power that results in

lost life chances

Intersectional stigma/oppression◼ sex work history, immigration status, race/ethnicity,

HIV status

Social exclusion

Lack of ability to fully participate in political, social, and economic life -

includes homophobia, transphobia, human rights violations and absence

of legal protection. (Caceres 2008)

Goffman 1963, Link 2001, Caceres 2008

Social Exclusion: Examples

Legal Protections

Non-discrimination

Access to health

Identification documents

Employment

Travel

Social Services

Domestic violence shelters

Homeless shelters

Public facilities

Jails, prisons, detention

Hospital wards, clinical services

Restrooms

Consequences of Stigma

❑ Structural Violence

Lack of congruent ID documents

Maltreatment by law enforcement

Low educational attainment

Unemployment

Poverty

Food insecurity

Homelessness

❑ Physical and Psychological Violence

Harassment and bullying

Physical and sexual assault

Depression and suicidality

James, S. E., et al. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.

https://www.theroot.com/sayhername-ashanti-carmon-transgender-woman-shot-an-1833723319

SDH influence HIV care

HIV Care Continuum

https://www.nastad.org/domestic/hiv-prevention-health-equity

HIV Prevention and Care Continuum

STIGMA

Adapted from NASTAD www.nastad.org/domestic/hiv-prevention-health-equity

Example: HIV Vulnerability

14 sites in 8 countries: Burkina Faso, Cote d’Ivoire, The Gambia, Lesotho, Malawi, Senegal, Swaziland, and Togo

Among 4,586 male SAB participants, 20% identified as TW or female (remaining were cis MSM) ⇒ 937 TW

HIV prevalence among TW: 25% (vs. 14% cis-MSM)

High levels of stigma: gossip (35%), rejection (30%), physical (33%) or sexual assault (28%)

Poteat et al. 2017

Violence, law enforcement stigma, and

depression significantly associated with HIV

Deutsch 2015 NHPC

9 HRSA SPNS demonstration sites in U.S.Preliminary Baseline Data

N=400 trans women

Example: HIV Care Engagement

Viral Suppression among Transgender Adults and Adolescents Served by the Ryan White

HIV/AIDS Program, 2017—United States and 3 Territories

Example: Viral Suppression

What can we do about them?

HIV Prevention and Care

Observational studies suggest gender affirmation reduces HIV risk, increases PrEP

uptake, increases engagement in HIV care

Sevelius Sex Roles 2013, Sevelius JAIDS 2016, Crosby Transgender

Health 2016, Reisner IJSTD/AIDS 2016, Garofalo 2018,, Reisner 2018

Priorities Identified by Trans People Living with HIV

1. Gender-affirming and non-discriminatory care

2. Hormone therapy and side effects

3. Mental health care, including trauma

4. Personal care, eg. nutrition

5. Antiretroviral therapy and side effects

Chung, Cecilia et al. (2016). Some kind of strength: findings on health care and economic wellbeing from a national needs assessment of transgender and

gender non-conforming people living with HIV. Oakland, CA: Transgender Law Center.

Positively Trans Survey, n = 157

28%

42% 42%

47%

12%

16%

21% 22%

PROVIDER RESTRICTED ACCESS TO HORMONES BASED ON ART

COMPLIANCE

PROVIDER FOR HIV CARE IS NEUTRAL OR HOSTILE

PROVIDER FOR TRANSITION-RELATED CARE IS NEUTRAL OR HOSTILE

PROVIDER FOR PRIMARY CARE IS NEUTRAL OR HOSTILE

Not suppressed Suppressed

Chung, Cecilia et al. (2016). Some kind of strength: findings on health care and economic wellbeing from a national needs assessment of

transgender and gender non-conforming people living with HIV. Oakland, CA: Transgender Law Center.

Provider Interactions and Viral Suppression

National sample of 157 transgender people living with HIV in U.S.

28%

42% 42%

47%

12%

16%

21% 22%

PROVIDER RESTRICTED ACCESS TO HORMONES BASED ON ART

COMPLIANCE

PROVIDER FOR HIV CARE IS NEUTRAL OR HOSTILE

PROVIDER FOR TRANSITION-RELATED CARE IS NEUTRAL OR HOSTILE

PROVIDER FOR PRIMARY CARE IS NEUTRAL OR HOSTILE

Not suppressed Suppressed

Chung, Cecilia et al. (2016). Some kind of strength: findings on health care and economic wellbeing from a national needs assessment of

transgender and gender non-conforming people living with HIV. Oakland, CA: Transgender Law Center.

Provider Interactions and Viral Suppression

National sample of 157 transgender people living with HIV in U.S.

Trans-Affirming Clinic Environments

Use chosen pronouns and name

Don’t assume gender identity or sexual orientation

Politely ask, in private, if unsure

Include chosen name on chart and train staff

Defer unnecessary questions and exams

Build rapport before performing sensitive exams

Avoid satisfying your curiosity

Conduct trauma-informed genital exams, only when necessary

Always explain the purpose of the exam

Use gender neutral terms

Ask patients what words they prefer you use for their anatomy

Anticipate existence of transgender patients

Patient education material appropriate for transgender people

Transgender affirming referrals and community resources

Transgender staff, gender inclusive restrooms, images of trans people

Evidence for Gender Affirmation

Participants: 858 TW with HIV

49% Latina, 42% Black, 36% virally suppressed

Method: Serial mediation model

Results: Significant pathways found

Trans discrimination → Gender affirmation

Gender affirmation → Healthcare empowerment

Indirect pathways from trans discrimination to viral suppression via

gender affirmation and empowerment

Sevelius 2019

Gender affirmation and healthcare empowerment

fully mediated the total effect of

anti-trans discrimination on viral suppression

Evidence-Informed Interventions

Group-Based

Project LifeSkills, group-based intervention

(multiple sessions) – CDC EBI

◼ HIV risk reduction behaviors in young trans women

and trans men in the U.S.

Couples-Based

CHIP, counseling for TW and partners (3

sessions) in the U.S. – CDC EBI

◼ HIV risk reduction behavior in both partners

Structural

Integration of gender-affirming primary care

and peer navigation with HIV prevention and

treatment services in Peru

◼ Outcomes: PrEP uptake and viral suppression Poteat et al. Current Opinions 2019

Reisner 2019, Garofolo 2016

https://www.cdc.gov/hiv/research/interventionresearch/compendium/index.html

Structural Interventions

Engaging all trans people, including sex workers, criminal

justice-involved, people who use drugs in holistic, gender

affirming, HIV prevention and care

Examples

Legal services

Case management

Peer navigation

Social support

Educational opportunities

Leadership opportunities

Job training and income generation

Community-Informed Recommendations

Embed HIV/STI services within programs that are responsive to community needs (e.g., job readiness, mental health support, housing)

Offer gender affirming care alongside HIV/STI services

Offer HIV/STI services at places where transgender women people already frequent and feel comfortable

Ensure regular staff training (including healthcare providers, administrative staff, security staff, etc.) in transgender competent care

Hire transgender people to lead programs

Tailor HIV/STI services, outreach, and advertising to community needs

Consider partners, family, community (beyond the individual)STROBE Study 2016

BTC Study 2015

Acknowledgements

All the transgender, nonbinary, gender expansive people who participated

in research studies

Researchers who dedicated their time and effort to gathering evidence

Advocates and activist who fight to ensure evidence is used to improve lives

Organizers of this event

Thank You!

Tonia Poteat, PhD, MPH, PA-C

tonia_poteat@med.unc.edu