Addressing Social Determinants in the Context of HIV...
25
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
Transcript of Addressing Social Determinants in the Context of HIV...
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
