HIV thrives in marginalized communities: When people face oppression and marginalization, many types of illness can follow. In America, transgender women, especially transgender women of color, face multiple forms of oppression and are therefore put at risk for HIV. The factors behind this disparity include stigma, discrimination, poverty, lack of housing, lack of proper employment, and lack of access to health care.
As many challenges as transgender women face outside of health care settings, those challenges don’t stop once they set foot inside the clinic—especially for trans women of color, who can face racism, misogyny, and transphobia in health care settings. Not to mention the reality that many of the challenges they face, both economically and socially, can impede them from getting into care or being able to make their appointments.
To find out how to better serve transgender women, researchers from Atlanta’s Emory University worked with the Grady Health System (GHS) HIV pre-exposure prophylaxis (PrEP) program to find out what strategies clinics can employ to protect transgender women as much as possible. The findings were presented at the IDWeek 2020 medical conference and published on March 1 in the journal AIDS.
The study began when clinicians noticed a large number of transgender women accessing services at GHS, according to lead researcher Amalia Aldredge, M.D. “We thought it would be an interesting subset to look at,” she said. “Our central question was just, are we retaining transgender women with factors for acquiring HIV, and are they staying in our care?”
Altogether, the study followed 42 transgender women who were referred for PrEP between March 2018 and February 2020. The median age was 29; 62% of participants were Black. Of the participants, 21% had a mental health diagnosis, 45% used substances, and 35% engaged in some kind of sex work.
Aldredge said that these background characteristics make clear that it’s up to clinicians to establish a bond with clients—and to overcome any squeamishness or prejudices they may have in order to give the best care they can.
“There’s an opportunity for many clinicians to ask uncomfortable questions,” she said. “An average primary care provider sometimes doesn’t ask those questions. But I think this is an opportunity: For someone who doesn’t work in a gender center or have patients from a sexual minority population, it’s really important to ask these uncomfortable questions and normalize that by explaining. People are happy to talk about those parts of their lives and can help identify people who are appropriate for PrEP.”
Of the 42 transgender women referred to the program, 36 ended up taking PrEP, and 26 remained in PrEP care (defined as coming in for a follow-up visit within six months of the end of the study period). Some participants were lost to follow-up, and two were diagnosed with HIV at their time of referral.
The Benefits of Multiple Types of Care Under a Single Roof
The GHS PrEP program launched in 2018 to help people who would not normally have access to PrEP be able to obtain the prevention tool. It is located in the same building as the GHS Gender Center, which offers comprehensive health care to transgender people, including primary care, hormone therapy, and mental health services.
The researchers found, as with similar studies among transgender women, that there was a significant drop in follow-up and retention, though it was smaller than usual in this study. An analysis of the data showed that there was no one factor associated with why trans women might be lost to care—even mental health.
One reason Aldredge believes they did better than usual with retention is because their PrEP program was linked to a center that gave gender-specific care. “[The Gender Center] would just call the PrEP clinic, and someone would go down one floor and meet with the patient there,” she said. “The patient didn’t have to go to multiple clinics, so they didn’t have to go anywhere.”
She added, “Patients gave a lot of positive feedback about that. They were happy to have one center where they could get all their needs met, including their PrEP needs.”
Aldredge said one of the reasons data may not have led them to a stronger conclusion is the small sample size. Ultimately, she and her research team hoped to use the data to be able to craft strategies that clinics could implement to help keep transgender patients in care. But Aldredge said she does have recommendations, based on the study, for any clinics or providers looking to offer PrEP to transgender women.
“It’s very important to integrate PrEP care into some kind of gender-affirming care or clinic, because that seems to increase people staying in PrEP care,” she said. “But if it’s not feasible to have PrEP care integrated into a gender clinic, feel comfortable asking uncomfortable questions of all patients, even if you don’t think people are at risk.”
She added, “Asking those questions and getting people linked to care is very important at helping prevent new HIV diagnoses, especially in somewhere like Atlanta.”