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Rapid testing at the US/Mexico border
What is the role of rapid testing for US-Mexico border and migrant populations?
why test for HIV?
Until recently, HIV rates in Mexico and among Mexican migrants in California appeared to be stable and relatively low; however, recent studies show that HIV may be expanding more aggressively in some populations, especially in border communities.1 One study of 374 young Latino men who have sex with men (MSM) in the San Diego/Tijuana region found high rates of HIV: 19% in Tijuana and 35% in San Diego.2 Another study of 1,068 pregnant women in labor in Tijuana found a 1.12% HIV rate.3 Yet a study of 1,041 Mexican migrants at border crossing locations in Tijuana found a 0% HIV rate.4 Getting tested for HIV is key to preventing the spread of HIV. Persons who test HIV+ can access counseling, prevention education, support services and medical care to stay healthy and not progress to AIDS. HIV- persons can access counseling and education to remain HIV-. It is estimated that 31% of all HIV+ persons in the US do not know they’re infected.5 Border and migrant populations may be at great risk for HIV yet they are less likely to be tested for HIV or return for test results. Many do not have access to (or fear accessing) traditional healthcare systems, lack transportation and frequently change address.6
why rapid testing?
Even when people are able to test for HIV, many never return for their results. In public test sites, up to 33% of persons who test HIV- and 25% of persons who test HIV+ never return for their results.7 This may be especially true for border and migrant populations because they may not have stable housing or legal status in the US. The rapid HIV test is a new approach to HIV testing that helps address many of these issues. Conventional HIV testing has been done with needle blood draws or mouth swabs which are sent to a laboratory for analysis. Clients need to return to the test site 1-2 weeks later to find out their results. With rapid tests, clients can take the test, receive counseling, and find out their results all in one visit. This can help increase the number of persons who take an HIV test and reduce the number of persons who don’t return for their results.8 Rapid testing can be done in most clinics and in non-traditional healthcare and outreach settings such as mobile vans, bars, parks and health fairs. One study of seasonal farmworkers found that men and women were more likely to accept a free HIV test if it used a finger stick and they could get results in 30 minutes.9 Many government and non-governmental agencies are moving towards rapid testing instead of conventional testing. The Centers for Disease Control and Prevention’s (CDC) Strategic Plan for 2005 seeks to increase the number of people who know their HIV status to 95%—using rapid testing is an integral part of the plan.3 In California, the goal is to have 80% of all state-funded HIV test sites use rapid tests by the end of 2006.10
how is it done?
Rapid testing uses a finger stick, blood draw or mouth swab to collect samples. The test counselor places the sample in a tube with chemicals to process it, and can read the results in 20 minutes or less. Counseling and risk reduction planning with the client can take place during the waiting time, or can be done before or after sample collection. There are four FDA-approved rapid HIV tests in the US: Reveal, OraQuick, Multispot and Uni-Gold.11 All tests are extremely accurate, with 99.6-100% sensitivity rates.12 OraQuick Advance uses a mouth swab and can be used in a wider range of settings and temperatures. Rapid testing can change the way HIV testing is done. Most HIV test sites currently have counselors and separate phelobotomists who take the blood or oral sample. With rapid testing, the test counselor can also take the sample and analyze it, becoming counselor, technician and laboratory all in one. In some sites, test counselors do the consent and counseling and a separate staff person still collects the sample and reads the results.13 Within 20 minutes, the OraQuick Rapid test will either be non-reactive—a negative test result—or reactive—a preliminary positive result. Currently, if a result shows preliminary positive, a second conventional blood or oral sample is required to confirm it. Final confirmation still takes 1-2 weeks. National data indicate that with rapid testing, 95% of clients who received a preliminary positive result returned for their confirmatory results.
is rapid testing rapid counseling?
No. One study found no difference in STD rates after counseling with rapid tests and conventional tests.14 Rapid testing still allows for plenty of counseling time. A counselor has about 20 minutes between taking a sample and receiving the results to provide focused and specific counseling about the client’s risks and possible exposure to HIV. Counseling can be more intense due to the immediacy of hearing results.15 Clients who receive a preliminary positive result and must return for their confirmation result may be more prepared to deal with their diagnosis. Clients often have had a week to think about what testing positive means and may be more emotionally prepared to listen to and digest referrals and options the counselors can provide. Test counselors need in-depth knowledge of referral resources for client’s that may emerge in new, more focused HIV counseling sessions. Referrals should be specifically tailored to the needs of border and migrant populations, including basic needs such as healthcare, housing, legal assistance and jobs. Materials should be available in Spanish and counselors should have culturally-relevant knowledge and training in migrant and immigrant issues. Because many persons travel back and forth between the US and Mexico, referrals may need to focus on resources in both countries. Counselors typically may have concerns about the new testing procedures and counseling initially, but after they’ve been trained and have provided a number of counseling sessions, they become more comfortable and often say they wished they had become involved in HIV rapid testing sooner.16
what’s being done?
Rapid testing is relatively new in most border settings. A 2003 survey of 85 border health centers (community and migrant health centers, tribal organizations and programs for homeless people, among others) found that 64 (75%) offered HIV testing. Of these, 45 also provided HIV medication and counseling services. None of the sites in any state offered rapid HIV testing.17 Currently, San Diego County offers rapid testing, prevention education and linkage to medical care along the Mexico/California border in various settings such as churches, homeless shelters, parks and beaches. Staff members underwent additional training on rapid testing and single-session HIV counseling. Since offering rapid testing at all anonymous test sites, client return rates have increased from 72% to 93%.18 La Fe CARE Center in El Paso, TX, offers rapid testing at their clinic and through a mobile van that visits gay bars, nightclubs and adult bookstores downtown. The mobile van has two counselors and uses the OraQuick Advanced mouth swab HIV test. The clinic uses the OraQuick finger stick HIV test. Clients prefer getting results quickly and not having a blood draw. Since offering rapid testing, the number of clients testing at La Fe has increased from 500 in 2002 to over 2000 currently.19
what is the future of rapid testing?
The future is now. Outside of the US, rapid testing is widely used and confirmatory tests are also done with rapid test, eliminating any waiting period for persons who test HIV+. Manufacturers have been slow to seek approval for tests in the US because the FDA has strict policies about licensing new HIV tests. Rapid testing has been met with great enthusiasm in some areas and great trepidation in others. As federal and state governments increase requirements for rapid testing, resources for training, technical assistance and funding need to increase for the agencies that implement rapid testing. State and federal reimbursement protocols, as well as public and private insurance, need to be changed to encourage rapid testing. It is not enough simply to offer HIV testing to Mexican and other immigrants. Persons who test positive will need quality HIV care and treatment, and persons at risk for HIV will need culturally specific education and prevention programs. Because many persons travel back and forth between the US and Mexico, bi-national cooperation is key in addressing these issues to improve public health in both countries.
Says who?
1. Sanchez MA, Lemp GF, Magis-Rodriguez C, et al. The epidemiology of HIV among Mexican migrants and recent immigrants in California and Mexico. Journal of Acquired Immune Deficiency Syndromes. 2004;37:S204-S214. 2. Ruiz, JD. HIV prevalence, risk behaviors and access to care among young Latino MSM in San Diego, California and Tijuana, Mexico. Presented at the Binational Conference on HIV AIDS. Oakland, CA. 2002. 3. Viani RM, Araneta MR, Ruiz-Calderon J, et al. HIV-1 infection in a cohort of pregnant women in Baja California, Mexico: evidence of an emerging crisis? Presented at the International Conference on AIDS, Bangkok, Thailand. 2004. Abst #ThPeC7301. 4. Martinez-Donate AP, Rangell MG, Hovell MF, et al. HIV infection in mobile populations: the case of Mexican migrants to the US. Revista Panamaña de Salud Publica. 2005;17:26-29. 5. Centers for Disease Control and Prevention. HIV Prevention Strategic Plan https://www.cdc.gov/nchhstp/strategicpriorities/default.htm 6. Solorio MR, Currier J, Cunningham W. HIV health care services for Mexican migrants. Journal of Acquired Immune Deficiency Syndromes. 2004;37:S240-S251. 7. Kendrick SR, Kroc KA, Withum D, et al. Outcomes of offering rapid point-of-care HIV testing in a sexually transmitted disease clinic. Journal of AIDS. 2005;38:142-146. 8. Sullivan PS, Lansky A, Drake A. Failure to return for HIV test results among persons at high risk for HIV infection: results from a multistate interview project. Journal of AIDS. 2004;35:511-518. 9. Fernandez MI, Collazo JB, Bowen GS, et al. Predictors of HIV testing and intention to test among Hispanic farmworkers in South Florida. Journal of Rural Health. 2005;2:56-64. 10. Dowling T. Outreach and prevention rapid HIV testing in non-clinical settings. Presented at the Rapid Testing Conference, California 2004. 11. Reveal: www.reveal-hiv.com/ OraQuick 12. Branson BM. Point-of-care rapid tests for HIV antibodies. Journal of Laboratory Medicine. 2003;27:288-295. 13. Kassler WJ, Dillon BA, Haley C, et al. On-site, rapid HIV testing with same-day results and counseling. AIDS. 1997;11:1045-1051. 14. Metcalf CA, Douglas JM, Malotte CK, et al. Relative efficacy of prevention counseling with rapid and standard HIV testing: a randomized, controlled trial (RESPECT-2). Sexually Transmitted Diseases. 2005;32:130-138. 15. Rapid HIV antibody testing. HIV Counselor Perspectives. 2003;12:1-8. 16. Birkhead GS, San Antonio-Gaddy ML, Richardson-Moore AL, et al. Effect of training and field experience on staff confidence and skills for rapid HIV testing in New York state. Presented at the International Conference on AIDS, Bangkok, Thailand. 2004. Abst #MoPeE4103. 17. Donohoe TJ, Ribo A. Border “330″ clinics: a preliminary report on survey data and an inventory & summary of HIV border services. Needs Assessment Report of Pacific AIDS Education and Training Center and Texas/ Oklahoma AIDS Education and Training Center. July 2003. 18. HIV, STD and Hepatitis Branch, San Diego County, CA. (619) 296-2120 19. La Fe CARE Center, El Paso, TX. (915) 534-7979 20. Rapid testing for HIV: an issue brief. NASTAD HIV Prevention Update. September 2000.
PREPARED BY Tom Donohoe* and Jay Fournier *UCLA/Pacific AIDS Education and Training Center May 2005 . Fact Sheet #S58E Special thanks to the following reviewers of this Fact Sheet: Denise Escandon Borntrager, Hector Carrillo, Carol Galper, Maria Teresa Hernández, Steve Trujillo, Rebecca Ramos, Octavio Vallejo, Rolando Viani. Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © May 2005, University of California
Prueba rápida a la frontera
¿Cuál es el papel de las pruebas rápidas para la frontera EE.UU.- México y las poblaciones migrantes?
¿por qué hacer pruebas del VIH?
Hasta hace poco, las tasas de infección por VIH en México y entre los migrantes mexicanos en California parecían estables y relativamente bajas. Sin embargo, investigaciones recientes demuestran que el VIH podría estarse extendiendo más agresivamente en algunas poblaciones, especialmente en las comunidades fronterizas.1 Un estudio entre 374 hombres latinos jóvenes que tienen sexo con hombres (HSH) de San Diego-Tijuana encontró tasas elevadas de VIH: 19% en Tijuana y 35% en San Diego.2 Otro estudio en Tijuana con 1,068 mujeres embarazadas en trabajo de parto encontró una tasa de infección del 1.12%.3 Sin embargo, otro estudio efectuado entre 1,041 migrantes mexicanos en puntos de cruce fronterizo en Tijuana encontró tasas de infección por VIH de 0%.4 Las pruebas del VIH son clave para prevenir el VIH. Las personas VIH+ pueden recibir consejería, servicios de educación preventiva y apoyo, y atención médica para mantenerse saludables e impedir el desarrollo del SIDA. Las personas VIH- pueden tener acceso a consejería y educación para permanecer seronegativos. El 31% de las personas VIH+ en EE.UU. ignoran que están infectadas.5 Las poblaciones fronterizas y migrantes pueden enfrentar un mayor riesgo de infección por VIH, pero tienen menor probabilidad de hacerse una prueba o regresar por sus resultados. Muchos no tienen acceso o tienen miedo de acceder los sistemas tradicionales de salud, no cuentan con medios de transporte y cambian de domicilio frecuentemente.6
¿por qué se recomienda la prueba rápida?
Aun cuando las personas pueden hacerse la prueba del VIH, muchos nunca regresan por sus resultados. En los lugares de pruebas que operan con fondos públicos, hasta el 33% de las personas que resultan VIH+ y un 25% de las que resultan VIH- nunca recogen sus resultados.7 Esto podría ser especialmente cierto para las poblaciones fronterizas y migrantes pues no cuentan con vivienda estable ni permiso legal para permanecer en EE.UU. La prueba rápida del VIH es una forma novedosa que confronta esta problemática. Las pruebas convencionales del VIH se realizan con extracciones de sangre con jeringa o tomas de muestras bucales que se envían al laboratorio para su análisis. Las personas deben regresar de 1 a 2 semanas después por sus resultados. Con la prueba rápida se puede tomar la prueba, recibir consejería y obtener resultados en una sola visita. Esto puede ayudar a aumentar la cantidad de personas que se hacen la prueba y disminuir la cantidad de quienes no regresan por sus resultados.8 Las pruebas rápidas se pueden hacer en la mayoría de las clínicas y en lugares alternativos de atención y promoción para la salud como furgonetas [vans], bares, parques y ferias de la salud. Un estudio entre trabajadores agrícolas temporaleros encontró que era más probable que los hombres y las mujeres aceptaran hacerse gratuitamente la prueba del VIH si se utilizaba un piquete de alfiler en el dedo y podían obtener sus resultados en 30 minutos.9 Muchas organizaciones gubernamentales y no gubernamentales se están inclinando por el uso de la prueba rápida en lugar de la prueba convencional. El Plan Estratégico de los CDC para el 2005 pretende incrementar al 95% la cantidad de personas que conocen su condición respecto al VIH, y el uso de la prueba rápida es una parte integral del plan.5 En California, la meta es que el 80% de los sitios financiados por el estado utilicen la prueba rápida para fines del 2006.10
¿cómo se efectúa la prueba?
La prueba rápida puede hacer uso de un piquete de alfiler en el dedo, de la extracción de sangre con jeringa o de una almohadilla para obtener la muestra bucal. El técnico a cargo de la prueba coloca la muestra en un tubo de ensayo con sustancias químicas para procesarla. Los resultados se obtienen en 20 minutos o menos. La consejería y la planeación para la reducción del riesgo con el paciente puede hacerse antes o después de obtener la muestra o durante el tiempo de espera. En la actualidad, cuatro pruebas rápidas han sido autorizadas por la FDA en EE.UU.: Reveal, OraQuick, Multispot y Uni-Gold.11 Todas son extremadamente precisas, con tasas de sensibilidad de entre 99.6 y 100%.12 OraQuick Advance utiliza una muestra bucal y puede efectuarse en una gama más amplia de situaciones y temperaturas. En 20 minutos, la mayoría de las pruebas rápidas proporcionan ya sea resultados negativos (no hay reacción) o bien resultados positivos preliminares (sí hay reacción). Si el resultado preliminar es positivo, se toma una segunda muestra convencional para confirmarlo. La confirmación final sigue requiriendo de 1-2 semanas. Datos a nivel nacional indican que con la prueba rápida, el 95% de los pacientes con un resultado positivo preliminar regresaron por sus resultados confirmatorios.13
¿la prueba rápida significa consejería rápida?
No. Un estudio no encontró diferencia en las tasas de enfermedades transmitidas sexualmente (ETS) al comparar la consejería de las pruebas rápidas y con la de las pruebas convencionales.14 La prueba rápida permite suficiente tiempo para la consejería. Un consejero tiene alrededor de 20 minutos mientras se toma la muestra y se obtiene el resultado para ofrecer una consejería enfocada y específica a los riesgos del paciente y su posible exposición al VIH. La consejería de la prueba rápida puede ser más intensa pues los resultados se obtienen de inmediato.15 Las personas que reciben un resultado positivo preliminar deben regresar por sus resultados confirmatorios. Estas podrían estar más preparadas para lidiar con su diagnóstico pues han tenido tiempo para pensar sobre su resultado positivo y quizá sean más receptivas a las recomendaciones y alternativas que se les ofrezcan. Los consejeros necesitarán conocer a fondo las referencias a los recursos disponibles que estas sesiones más enfocadas puedan requerir. Dichas referencias deben ser específicas a las poblaciones fronterizas y migrantes, incluyendo las necesidades básicas como atención médica, vivienda, consejería jurídica y empleo. Se debe disponer de materiales impresos en español y los consejeros tener conocimiento y capacitación culturalmente relevante a la problemática de la migración e inmigración. Ya que muchas personas viajan entre EE.UU. y México, las referencias deben considerar recursos en ambos países. Al principio, los consejeros tienden a inquietarse un poco por los nuevos procedimientos de la prueba y la consejería, pero después de haber recibido capacitación y ofrecido una serie de sesiones de consejería, se sienten más cómodos y reportan haber querido realizar esta prueba con anterioridad.16
¿qué se está haciendo?
La prueba rápida es algo relativamente nuevo en las zonas fronterizas. Una encuesta realizada en el 2003 entre 85 centros fronterizos de salud (centros de salud comunitarios y para migrantes, organizaciones de tribus indígenas y programas para personas desamparadas, entre otros) encontró que 64 centros (o sea, el 75%) realizaban la prueba del VIH. De estos, 45 también ofrecían medicamentos para el VIH y servicios de consejería. Ningún sitio en ningún estado fronterizo ofrecía la prueba rápida del VIH.17 En la actualidad, el condado de San Diego ofrece la prueba rápida, educación para la prevención y servicios de enlace con atención médica en varios lugares, como iglesias, albergues, parques y playas, a lo largo de la frontera entre México y California. Desde que comenzó a ofrecerse la prueba rápida en todos los sitios donde se hacía la prueba en forma anónima, la tasa de retorno de los pacientes aumentó del 72% al 93%.18 La FE CARE Center en El Paso, Texas, ofrece la prueba rápida en su clínica y a través de una camioneta que visita bares y centro nocturnos para gente gay y librerías para adultos en la zona centro. El vehículo tiene dos consejeros y utiliza la prueba rápida oral “OraQuick Advanced” para detectar el VIH. En clínica utilizan la prueba OraQuick de piquete en el dedo. Las personas prefieren obtener sus resultados rápidamente sin que se les extraiga sangre con una jeringa. Desde que se comenzó a ofrecer la prueba rápida, la cantidad de personas que se hacen la prueba en La Fe ha aumentado de 500 en 2002 a más de 2,000 en la actualidad.19
¿cuál es el futuro de la prueba rápida?
El futuro es ahora. Fuera de los EE.UU., la prueba rápida se utiliza ampliamente y las pruebas confirmatorias también se hacen con una prueba rápida, eliminado el periodo de espera para quienes que resultan VIH+. Los fabricantes se han demorado en solicitar la autorización para dichas pruebas en EE.UU. ya que la FDA tiene políticas muy estrictas. La prueba rápida ha sido recibida con gran entusiasmo en algunas áreas y con bastante aprehensión en otras. Conforme los gobiernos federales y estatales aumentan sus requisitos para la aplicación de esta prueba, los recursos para la capacitación, la asistencia técnica y el financiamiento para las organizaciones necesitan incrementarse para poder incentivar su uso. No basta con simplemente ofrecer la prueba rápida para el VIH a los inmigrantes mexicanos y de otras procedencias. La prueba rápida puede facilitar un mejor monitoreo epidemiológico del VIH en las poblaciones migrantes y fronterizas, ofreciendo una perspectiva más clara de la magnitud de esta infección. Las personas con resultados VIH+ necesitarán atención médica y tratamientos de alta calidad; y las personas en riesgo de contraer el VIH necesitarán acudir a programas de educación y prevención que sean culturalmente específicos. Ya que muchas personas viajan entre EE.UU. y México, la cooperación binacional indispensable para abordar esta problemática y mejorar la salud pública en ambos países.
¿quién lo dice?
1. Sanchez MA, Lemp GF, Magis-Rodriguez C, et al. The epidemiology of HIV among Mexican migrants and recent immigrants in California and Mexico. Journal of Acquired Immune Deficiency Syndromes. 2004;37:S204-S214. 2. Ruiz, JD. HIV prevalence, risk behaviors and access to care among young Latino MSM in San Diego, California and Tijuana, Mexico. Presented at the Binational Conference on HIV AIDS. Oakland, CA. 2002. 3. Viani RM, Araneta MR, Ruiz-Calderon J, et al. HIV-1 infection in a cohort of pregnant women in Baja California, Mexico: evidence of an emerging crisis? Presented at the International Conference on AIDS, Bangkok, Thailand. 2004. Abst #ThPeC7301. 4. Martinez-Donate AP, Rangell MG, Hovell MF et al. HIV infection in mobile populations: the case of Mexican migrants to the US. Revista Panamaña de Salud Publica. 2005;17:26-29. 5. Centers for Disease Control and Prevention. HIV Prevention Strategic Plan Through 2005. https://www.cdc.gov/nchhstp/strategicpriorities/default.htm 6. Solorio MR, Currier J, Cunningham W. HIV health care services for Mexican migrants. Journal of Acquired Immune Deficiency Syndromes. 2004;37:S240-S251. 7. Kendrick SR, Kroc KA, Withum D et al. Outcomes of offering rapid point-of-care HIV testing in a sexually transmitted disease clinic. Journal of AIDS. 2005;38:142-146. 8. Sullivan PS, Lansky A, Drake A. Failure to return for HIV test results among persons at high risk for HIV infection: results from a multistate interview project. Journal of AIDS. 2004;35:511-518. 9. Fernandez MI, Collazo JB, Bowen GS et al. Predictors of HIV testing and intention to test among Hispanic farmworkers in South Florida. Journal of Rural Health. 2005;2:56-64. 10. Dowling T. Outreach and prevention rapid HIV testing in non-clinical settings. Presented at the Rapid Testing Conference, California 2004. 11. Reveal: www.reveal-hiv.com/ OraQuick, Uni-Gold:ww.trinitybiotech.com/EN/index.asp Multispot: www.bio-rad.com 12. Branson BM. Point-of-care rapid tests for HIV antibodies. Journal of Laboratory Medicine. 2003;27:288-295. 13. Kassler WJ, Dillon BA, Haley C, et al. On-site, rapid HIV testing with same-day results and counseling. AIDS. 1997;11:1045-1051. 14. Metcalf CA, Douglas JM, Malotte CK et al. Relative efficacy of prevention counseling with rapid and standard HIV testing: a randomized, controlled trial (RESPECT-2). Sexually Transmitted Diseases. 2005;32:130-138. 15. Rapid HIV antibody testing. HIV Counselor Perspectives. 2003;12:1-8. 16. Birkhead GS, San Antonio-Gaddy ML, Richardson-Moore AL, et al. Effect of training and field experience on staff confidence and skills for rapid HIV testing in New York state. Presented at the International Conference on AIDS, Bangkok, Thailand. 2004. Abst #MoPeE4103. 17. Donohoe TJ, Ribo A. Border “330″ clinics: a preliminary report on survey data and an inventory & summary of HIV border services. Needs Assessment Report of Pacific AIDS Education and Training Center and Texas/ Oklahoma AIDS Education and Training Center. July 2003. 18. HIV, STD and Hepatitis Branch, San Diego County, CA. (619) 296-2120 19. La Fe CARE Center, El Paso, TX. (915) 534-7979 20. Rapid testing for HIV: an issue brief. NASTAD HIV Prevention Update. September 2000.
Preparado por Tom Donohoe* y Jay Fournier *UCLA/Pacific AIDS Education and Training Center. Traducción David Sweet-Cordero Mayo 2005. Hoja Informativa #S58S
Mujeres negras
¿Qué necesitan las mujeres negras para evitar el VIH?
¿Afecta el VIH a las mujeres negras?
Sí. Desde el inicio de la epidemia, el VIH ha azotado a los hombres y mujeres negros radicados en EE.UU. A pesar de componer sólo el 12% de la población femenina del país, en el 2006 las mujeres negras representaban el 61% de los casos nuevos entre mujeres.1 Se diagnostica el VIH a mujeres negras con 15 veces más frecuencia que a mujeres caucásicas.1 Las mujeres negras también tienen altas tasas de infecciones transmitidas sexualmente (ITS), lo cual puede promover la transmisión del VIH. En el 2006, la tasa de clamidia entre mujeres negras era 7 veces mayor, la de gonorrea 14 veces mayor y la de sífilis 16 veces mayor que entre mujeres caucásicas.2 Estas cifras y estadísticas no terminan de revelar toda la riqueza y diversidad de las vidas de las mujeres negras, un grupo que abarca a oficinistas y obreras, cristianas y musulmanas, habitantes de áreas urbanas y de suburbios, descendientes de esclavos e inmigrantes caribeñas recién llegadas. Ellas trabajan, estudian, crían a sus familias, se enamoran. El VIH entre las mujeres negras no se debe exclusivamente a su conducta individual, sino a un sistema complejo de aspectos sociales, culturales, económicos, geográficos, religiosos y políticos los cuales se entrelazan para afectar a su salud.3¿Cuáles de ellas corren riesgo de contraer el VIH?
Los principales factores de riesgo de contraer el VIH son: tener otra ITS que no sea el VIH, no protegerse durante las relaciones sexuales vaginales o anales con una persona VIH positiva e inyectarse drogas con equipos previamente usados por una persona VIH+. Otro riesgo es ignorar los riesgos de su pareja, por ejemplo, si él usa drogas inyectables o tiene otras parejas sexuales concurrentes, y desconocer su condición de VIH. De las mujeres negras infectadas por VIH en el 2005, el 80% se contagiaron por contacto heterosexual y él 18% por inyección de drogas.4 Las mujeres jóvenes y las adolescentes resultan excesivamente afectadas. En el 2004, el VIH fue la primera causa de muertes en mujeres negras de 25-34 años de edad.5 Las adolescentes (13-19 años de edad) negras componían el 69% de los nuevos casos de SIDA en el 2006, mientras que su proporción de la población general de adolescentes en EE.UU. apenas alcanza el 16%.6¿Qué aspectos influyen en el riesgo de contraer el VIH?
Al protegerse durante el sexo, muchas mujeres se preocupan más por evitar el embarazo que el VIH/ITS, y son menos propensas a combinar dos métodos de protección (por ejemplo: la pastilla anticonceptiva junto con el condón). Más jóvenes negras que caucásicas usan anticonceptivos implantados o inyectables (el parche, Norplant), por lo que es menos probable que usen condones los cuales las protegerían contra el VIH.7 También es más común que las mujeres negras, especialmente las que viven en zonas de bajos ingresos, recurran a la esterilización para controlar la natalidad.8 La prevención del VIH muchas veces pasa a segundo plano para las mujeres que luchan para conseguir trabajo, alimentos, vivienda o cuidado infantil. La mayoría de los casos de VIH/SIDA en mujeres negras ocurren en los cascos urbanos y áreas rurales, donde abunda la pobreza y escasean empleos y vivienda.9 Estas mujeres son más propensas a quedarse sin vivienda, tener sexo a cambio de dinero o alojamiento, consumir drogas (heroína, cocaína crack) y alcohol, depender de un hombre para su sustento y sufrir violencia o trauma. Todas estas condiciones minan la capacidad de la mujer para rechazar el sexo, usar condón y limpiar jeringas al inyectarse para protegerse contra el VIH. Otro factor que aumenta el riesgo de contraer el VIH es la alta proporción de hombres afroamericanos encarcelados, lo cual merma su presencia en la comunidad desestabilizando así a las parejas y promoviendo la formación de relaciones de pareja concurrentes de mayor riesgo (tener más de una pareja sexual durante cierto tiempo y alternar entre una y otra pareja).10 La proporción de hombres en relación con mujeres es mucho menor entre afroamericanos que cualquier otro grupo étnico en EE.UU. El gran número de hombres negros muertos por enfermedades y actos de violencia así como encarcelados genera muchas secuelas en la comunidad, entre ellas el reducido número de candidatos a parejas. Esto lleva a que algunas mujeres con conductas de bajo riesgo se emparejen con hombres cuya conducta es de alto riesgo.3¿Estarán enteradas las mujeres negras del riesgo que corren?
Al hacerse la prueba del VIH muchas mujeres negras responden que su categoría de transmisión es ninguna o desconocida, por lo que se ha inferido que ellas desconocen su riesgo de contraer el VIH. En comunidades negras existe una historia de relaciones sociales entre personas de alto riesgo y otras de menor riesgo,11 lo cual aumenta sus posibilidades de conocer y salir con una pareja con antecedentes riesgosos. Al contrario, es posible que aun conociendo los riesgos, las mujeres negras los acepten más debido a este entretejimiento social. Las mujeres negras reconocen el riesgo que corren, según lo evidencia la proporción de pruebas de VIH entre ellas en comparación con cualquier otro grupo racial. Casi los dos tercios (el 65%) de las mujeres negras de 15-44 años de edad se han hecho la prueba del VIH alguna vez, y dos veces más se sometieron a la prueba durante los últimos 12 meses que mujeres caucásicas (el 25% en comparación con el 13%).12 Debido a las tasas descomunales de ITS y VIH en su comunidad, los hombres y mujeres negros corren un riesgo mucho mayor de tener contacto con una persona infectada en comparación con otros grupos. Esto significa que aunque las mujeres negras practiquen menos conductas riesgosas que las mujeres caucásicas,3 tienen que hacer mucho más que otras mujeres para lograr protegerse.3¿Qué se está haciendo al respecto?
Once intervenciones han sido aprobadas por el CDC para mujeres y adolescentes negras en categoría de mejor o prometedora evidencia o forman parte del proyecto DEBI (Diffusion of Effective Behavioral Interventions).13 Otras organizaciones a lo largo de EE.UU. también brindan servicios innovadores de prevención del VIH con y para mujeres negras y enfocados en la mujer íntegra como parte de una comunidad, sin limitarse únicamente a su conducta sexual o consumo de drogas. Es importante apoyar a mujeres con parejas encarceladas. HOME (Health Options Mean Empowerment) capacitó a mujeres cuyas parejas masculinas estaban a punto de salir de la prisión estatal, capacitándolas para orientar a otras mujeres que visitaban a reclusos y también en la comunidad. HOME ofreció almuerzos grupales para mujeres mientras esperaban en la prisión antes de entrar a visitar a sus parejas; pláticas sobre la salud general (temas: diabetes, presión arterial, obesidad, dejar de fumar); la salud sexual–pláticas sobre el VIH/ITS; ferias de salud; y remisión a servicios en la comunidad y de apoyo para mujeres que visitan a sus compañeros encarcelados. Las participantes reportaron menos contactos sexuales sin protección, más pruebas de VIH y mejor comunicación con sus parejas sobre temas relacionados con el VIH.14 Un reciente ensayo grande implementado en varios lugares describió un programa para parejas afroamericanas VIH serodiscordantes, el Eban HIV/STD Risk Reduction Intervention, que ofrece 8 sesiones semanales de 2 horas para comentar los factores individuales, interpersonales y comunitarios que contribuyen en varios niveles a las conductas de riesgo del VIH. Cuatro sesiones se dedican a la comunicación, resolución de problemas y toma de decisiones sobre mayor protección durante el sexo dentro de la pareja. Las cuatro reuniones restantes abarcan cómo cambiar actitudes y normas entre pares, cómo eliminar el estigma de ser una pareja serodiscordante y cómo ampliar los apoyos para parejas en la comunidad.15 Para llegar a las mujeres negras en sus propias comunidades, muchas intervenciones de prevención del VIH se han ubicado en salones de belleza y de estética, que brindan un ambiente de confianza en donde recibir condones e información sobre el VIH. En el condado de Durham, NC, Project StraightTalk ha capacitado desde 1988 a peluqueros y esteticistas a informar a sus clientes sobre las ITS/VIH. El proyecto ofrece capacitaciones anuales, regala condones y materiales educativos a cada salón dos veces por mes y produce carteles individualizados para los salones.16¿Qué queda por hacer?
El VIH seguirá azotando a la comunidad afroamericana a menos que los esfuerzos de prevención y atención se combinen con otros con el fin de eliminar las causas subyacentes de la enfermedad.3 Las niñas, adolescentes y mujeres negras necesitan apoyos en su entorno social que les permitan desarrollar relaciones, familias, vecindarios y comunidades más fuertes y reducir su riesgo de contraer el VIH y otras enfermedades. Los programas de prevención del VIH destinados a sus compañeros pueden beneficiar tanto a las mujeres como a los hombres. Las mujeres negras deben crear y dirigir programas eficaces de prevención del VIH que incluyan capacitación laboral, consejería para parejas, bancos de alimentos, asistencia de vivienda, servicios de salud mental, tratamiento de abuso de alcohol y drogas, y servicios familiares. El gobierno y otros organismos de subvención necesitan entender que todos estos aspectos forman parte íntegra de la prevención del VIH y por tanto deben ser subvencionados como tal.¿Quién lo dice?
1. CDC. Subpopulation Estimates from the HIV Incidence Surveillance System—United States, 2006. Morbidity and Mortality Weekly Report. 2008;57;985-989. 2. CDC. Sexually Transmitted Disease Surveillance, 2006. November 2007. 3. Aral SO, Adimora AA, Fenton KA. Understanding and responding to disparities in HIV and other sexually transmitted infections in African Americans. Lancet. 2008;372:337-340. 4. Rose MA, Telfair Sharpe T, Raleigh K, et al. An HIV/AIDS crisis among African American women: A summary for prevention and care in the 21st century. Journal of Women’s Health. 2008;17:321-324. 5. HIV/AIDS among women. Fact sheet prepared by the CDC. August 2008. 6. Black Americans and HIV/AIDS. Fact sheet by the Kaiser Family Foundation. October 2008. 7. Abma JC, Martinez GM, Mosher WD, et al. Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2002. Vital and Health Statistics. 2004;23. 8. Mosher WD, Deang LP, Bramlett MD. Community environment and women’s health outcomes: Contextual data. Vital and Health Statistics. 2003;23. 9. Fullilove RE. African Americans, health disparities and HIV/AIDS. Report prepared by the National Minority AIDS Council. November 2006. 10. Harawa N, Adimora A. Incarceration, African Americans and HIV: advancing a research agenda. Journal of the National Medical Association. 2008;100:57-62. 11. Adimora AA, Schoenbach VJ, Doherty IA. HIV and African Americans in the Southern United States: sexual networks and social context.Sexually Transmitted Diseases. 2006;33:S39-S45. 12. Anderson JE, Chandra A, Mosher WD. HIV Testing in the United States, 2002. Advance Data for Vital and Health Statistics. 2005;363:16. 13. Centers for Disease Control and Prevention. Updated Compendium of Evidence-Based Interventions, 2007. 14. Grinstead O, Comfort M, McCartney K, et al. Bringing it home: design and implementation of an HIV/STD intervention for women visiting incarcerated men. AIDS Education and Prevention. 2008;20:285-300. 15. NIMH Multisite HIV/STD Prevention Trial for African American Couples Group. Eban HIV/STD Risk Reduction Intervention: Conceptual basis and procedures. Journal of AIDS. 2008;49:S15–S27. 16. Lewis YR, Shain L, Crouse Quinn S, et al. Building community trust: lessons from an STD/HIV peer educator program with African American barbers and beauticians. Health Promotion Practice. 2002;3:133-143.Una publicación del Centro de Estudios para la Prevención del SIDA (CAPS) y el Instituto de Investigaciones sobre SIDA (ARI), Universidad de California en San Francisco (UCSF). Se autoriza la reproducción (citando a UCSF) más no la venta de copias este documento. También disponibles en inglés. Para recibir las Hojas de Datos por correo electrónico escriba a [email protected] con el mensaje “subscribe CAPSFS nombre apellido” ©UCSF 2010
Mother-to-child transmission (MTCT)
Is Mother-to-Child HIV Transmission Preventable?
Prepared by Sarah A. Gutin, MPH* *CAPS, Community Health Systems- School of Nursing, UCSF Fact Sheet #34ER – September 2015 Special thanks to the following reviewers of this Fact Sheet: Yvette Cuca, Carol Dawson Rose, Shannon Weber In 2012, there were 2.3 million new HIV infections globally1. A large proportion of people newly diagnosed with HIV worldwide are in their reproductive years and these men and women are likely to want children in the future2-4. Addressing the sexual and reproductive health and rights of this population is critical to addressing the spread of HIV because HIV infection in childbearing women is the main cause of HIV infection in children5. Treatment for those who are already infected is also central to stopping the spread of HIV to infants and to uninfected sexual partners. How does transmission occur? Perinatal transmission of HIV, also called vertical transmission, occurs when HIV is passed from an HIV-positive woman to her baby during pregnancy, labor and delivery or breastfeeding. For an HIV-positive woman not taking HIV medications, the chance of passing the virus to her child ranges from about 15 to 45% during pregnancy, labor and delivery. If she breastfeeds her infant, there is an additional 35 to 40% chance of transmission6. Is the risk of perinatal transmission always the same? No. Global societal and economic inequities create a wide gap between women in developing nations and women in developed nations with regard to HIV prevention, voluntary counseling and testing and access to drugs which treat HIV infection and can prevent perinatal transmission. Developed countries- In many developed countries, pediatric HIV has been virtually eliminated7. In the US in 1994, the Public Health Service recommended HIV counseling and voluntary testing and AZT therapy for all pregnant women after the clinical trial known as “076” showed that AZT reduced rates of MTCT by two-thirds. Since then, a combination of interventions that includes treatment with ART to control the virus and make it undetectable, cesarean delivery, and avoidance of breastfeeding has helped further reduce perinatal transmission in the US, from an estimated 1,500 cases in 1992 to an estimated 162 perinatal infections in 20108. Although the estimated number of perinatal HIV infections in the US continues to decline, women of color, especially black/African American women are disproportionately affected by HIV infection and as a result, perinatal HIV infection is highest among blacks/African Americans (63%), followed by Hispanics/Latinas (22%)8. Although effective interventions have led to a significant reduction in the number of perinatal infections in the US, perinatal transmission still occurs. To close the final gap, the CDC has proposed a new framework to eliminate mother-to-child HIV transmission (EMCT) in the US8. This framework focuses on key areas including: comprehensive reproductive health care (that includes both family planning (FP) and preconception care) and comprehensive case-finding of pregnancies in HIV-infected women that is conducted through comprehensive clinical care and case management services for women and infants; case review and community action; continuous quality research in prevention and long-term monitoring of HIV-exposed infants; and thorough data reporting for HIV surveillance at the state and local health department levels8,9. Developing countries- Unfortunately, perinatal transmission of HIV continues to plague many developing countries despite recent prevention acceleration. In 2008, an estimated 1.4 million pregnant women in low and middle-income countries were living with HIV, of whom about 90% were in sub-Saharan African countries7. In 2012, UNAIDS reported that approximately 210,000 children became HIV infected1. Can perinatal transmission of HIV be reduced? Yes. Perinatal transmission encompasses a variety of highly effective interventions that have huge potential to improve maternal and child health. Advances in treatment and new classes of drugs have provided the opportunity to greatly reduce rates of perinatal transmission worldwide. Also, perinatal transmission can be reduced by preventing unintended pregnancies. Preventing unintended pregnancies is one of the most effective ways to prevent HIV infection in infants and stop spread of the epidemic to children10. For that reason, preventing unintended pregnancies among women living with HIV and offering family planning to delay, space or end childbearing is one of the four WHO pillars in the comprehensive approach to preventing perinatal transmission7. However, we have still not addressed the root cause of perinatal transmission, mainly heterosexual HIV transmission. The best way to prevent perinatal HIV transmission is to prevent HIV transmission in the mother and father. In order to reduce perinatal transmission, all pregnant women should have access to free or low-cost prenatal care and voluntary HIV testing and counseling. If a pregnant woman is HIV-positive, she should have access to lifelong ART to treat HIV and improve her own health and to decrease the chances of HIV infection in her infant. In June 2013, the WHO published updated guidelines on the diagnosis of HIV, the care of people living with HIV(PLHIV) and the use of ART for treating and preventing HIV infection1. In the US, the Department of Health and Human Services recommends that all HIV-infected pregnant women should be given ART during pregnancy to prevent perinatal transmission of HIV, regardless of whether ART is indicated for the woman’s own health11. Perinatal transmission can be reduced to less than 2% if a woman is on ART, has a low or undetectable viral load, follows the recommended treatment regimen and does not breastfeed7,8. Careful management during labor and delivery can also help reduce perinatal transmission, for example by avoiding unnecessary instrumentation and not prematurely rupturing membranes12. Also, although universal prenatal HIV testing is the standard in the US, if prenatal care has not been provided, the patient has HIV, or her HIV status is undocumented, it is critical for hospitals to determine a laboring patient’s HIV status upon admission. Even without the use of ART during the pregnancy, the use of ART during labor and for the infant can reduce the risk of perinatal transmission to between 6 to 13%13. It is therefore recommended that rapid HIV testing be performed in Labor and Delivery units on pregnant women with no HIV test during their pregnancy or with risk factors for infection since their last test14. In developing countries, perinatal transmission has been a priority since 1998, following the success of short-course zidovudine and single-dose nevirapine clinical trials7. In recent years, single-dose nevirapine as the primary antiretroviral medicine option for HIV-positive pregnant women to prevent transmission to their infants has been phased out, in favor of more effective and simplified triple ART regimens1. The WHO now recommends that all pregnant and breastfeeding women with HIV, regardless of CD4 count or clinical stage, should initiate a triple ART regimen which should be maintained for the duration of perinatal transmission risk, which includes pregnancy, delivery and throughout the breastfeeding period (this is known as Option B). In countries were more than one percent of the population has HIV (these are known as generalized epidemics) and where there is often limited access to tests that indicate the severity of HIV illness (such as CD4 testing), limited partner testing, long duration of breastfeeding and high rates of fertility, the WHO recommends that women meeting treatment eligibility criteria should continue lifelong ART (this strategy is referred to as Option B+)12. There are many benefits to lifelong treatment for all pregnant and breastfeeding women and these include increased coverage of those needing ART for their own health, a reduction in the number of women stopping and starting ART during repeat pregnancies, early protection against perinatal transmission in future pregnancies, reduced risk of infecting a partner who is HIV-negative and decreased risk of medication failure or the development of resistance12. The ultimate goal is to find the most effective and sustainable regimens for HIV treatment and the prevention of perinatal transmission worldwide. Economics, politics, poor infrastructure, access to healthcare and medications, stigma and cultural norms all pose significant challenges to providing this standard of care everywhere and not all PLHIV have equal access to treatment. What are the barriers to the prevention of perinatal transmission? Pregnant women face many difficult decisions, including decisions around HIV testing, treatment options and infant feeding. Understanding the barriers that women face and addressing barriers at various levels can help in realizing the full potential of prevention of perinatal transmission programs. A recent review article found that barriers to the prevention of perinatal transmission often fell into three broad categories that included the individual, their partners and community, and health systems15. At the individual level, studies suggest that a lower maternal education level, younger maternal age, and poor knowledge of HIV transmission and ART are associated with not receiving and/or not taking ART in order to treat and prevent the spread of HIV15. Additionally, a woman’s male partner(s), extended family, greater community and health care setting all influence her decision and ability to take advantage of prevention of perinatal transmission programs. Many qualitative studies have found that stigma regarding HIV status and fear of disclosure to partners and family members is a major barrier to the uptake of perinatal prevention interventions15. Women living with HIV also continue to report that stigma and discrimination, especially in health care settings, continue to be a barrier to accessing adequate information and services1. In various studies, PLHIV have reported negative staff attitudes and this has been cited as a barrier to returning to facilities for care15. In developing countries, health systems issues are also a barrier to greater prevention uptake. Key barriers that have been identified include a shortage of trained clinic staff, high patient volumes, long wait times, and brief and poor counseling sessions15. In addition, a lack of access or shortages of medications, including ART, as well as stock-outs of HIV test kits and condoms have been reported. Poor access to healthcare overall (long distances to facilities) and poor integration of services also contributes to low ART uptake. What about breastfeeding? Breastfeeding is usually the healthiest choice for both infants and mothers. However, HIV transmission can occur during breastfeeding, with chances of transmission increasing the longer the infant is breastfed. In the countries with the highest perinatal HIV rates, it is estimated that more than half of the children newly infected with HIV acquire it during the breastfeeding period1. However, the risk of transmitting HIV to infants through breastfeeding is low in the presence of ART12. Therefore, providing ART to mothers throughout the breastfeeding period is a critical step needed to further reduce rates of perinatal transmission1. It is recommended that HIV-positive mothers do not breastfeed when formula feeding is safe, well accepted and readily available. In the US, both the Centers for Disease Control and Prevention and the American Academy of Pediatrics recommends that HIV-infected women refrain from breastfeeding regardless of their ART status to avoid postnatal transmission of HIV to their infants through breast milk16,17. However, formula feeding requires clean water for mixing formula. Many women in developing countries do not have access to clean water or sanitation and cannot afford formula, and therefore cannot avoid breastfeeding. In developing countries where breastfeeding is the norm, formula feeding may also alert a woman’s family or community that she is HIV-positive, which may result in stigma or other negative repercussions. Therefore, the WHO recommends that when breastfeeding is unavoidable, mothers should take ART while breastfeeding and that infants should receive 6 weeks of prophylaxis with once-daily nevirapine12. The WHO further recommends that mothers known to be infected with HIV (and whose infants are HIV uninfected or of unknown status) should exclusively breastfeed for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life. It is recommended that breastfeeding should only stop when a nutritionally adequate and safe diet without breast-milk can be provided12. Access to ARVs during this extended breastfeeding period is critical12. What’s being done? Primary prevention of HIV among men and women of childbearing age: Various tools are now available to prevent HIV infections in men and women of childbearing age. Pre-exposure prophylaxis (PrEP), which is a special course of HIV treatment that aims to prevent people from becoming infected with HIV, has been found to protect against HIV-1 infection in heterosexual men and women and reduce HIV transmission by 67 to 75%18,19. PrEP is intended for people at-risk of becoming infected with HIV, for example in the case of couples where one partner is HIV-positive and the other is HIV-negative. In countries with generalized HIV epidemics, voluntary medical male circumcision for HIV-negative male partners in relationships with a positive partner has been shown to reduce the risk of HIV-acquisition in men by between 38% to 66%20. Using ART to decrease the chance of HIV transmission, a concept known as treatment as prevention, has also recently been found to be very efficacious, with studies in heterosexual populations showing that adherence to ART is very effective at preventing transmission of HIV to HIV-negative partners21-23. Couples-testing with treatment for infected partners in discordant partnerships is also a promising approach. Integrating couples counseling and partner testing into routine clinic and community services can increase the number of couples in which the status of both partners is known and can help identifying sero-discordant couples24. Preventing unintended pregnancies and Safer Conception Options: Preventing unintended pregnancies among women living with HIV (WLHIV) is a powerful prevention strategy. One study found that even modest reductions in the numbers of pregnancies among WLHIV could avert HIV-positive births at the same rates as the use of ART for PMTCT25. One targeted approach to strengthening FP programs is to integrate FP within HIV services. In Kenya, a recent cluster-randomized trial tried to determine whether integrating FP services into HIV care was associated with increased use of more effective contraceptive methods such as sterilization, IUDs, implants, injectables and oral contraceptives. Women seen at integrated sites were significantly more likely to use more effective methods of FP at the end of the study26. This makes the case for integrating FP within HIV care. Reducing the unmet need for FP will reduce new HIV infections among children and improve overall maternal and infant health. For HIV-positive or serodiscordant couples who would like to have children, there are many options available to make conception safer. When offering preconception care, HIV-positive couples will have specific needs, many of which can be addressed during their routine HIV care. When offering preconception counseling for HIV-positive women, the CDC recommends that health care providers should discuss a variety of topics, including: reproductive options and actively assessing women’s pregnancy intentions on an ongoing basis; Counseling on safe sexual practices that prevent HIV transmission to sexual partners, protect women from acquiring sexually transmitted diseases, and reduce the potential to acquire more virulent or resistant strains of HIV; Using ART to attain a stable, maximally suppressed maternal viral load prior to conception to decrease the risk of perinatal transmission and of HIV transmission to an uninfected partner; and encouraging sexual partners to receive counseling and HIV testing and, if infected, to seek appropriate HIV care11. For couples who want to conceive, in which one or both are HIV-positive, the positive partner should be on ART and have achieved maximal suppression of HIV infection. ART for the positive partner may not be fully protective against sexual transmission of HIV and so the administration of PrEP for the HIV-negative partner may offer an additional tool to reduce the risk of transmission. For discordant couples, when the positive partner is a woman, the safest conception option is artificial insemination. In discordant couples where the positive partner is male,the safest conception option is the use of donor sperm from an HIV-uninfected male with artificial insemination. When the use of donor sperm is unacceptable, the use of sperm preparation techniques together with either intrauterine insemination or in vitro fertilization is an option11. Preventing HIV transmission from WLHIV to infants: Increasing access to ART for WLHIV is critical to saving the lives of women and their children. The number of pregnant WLHIV receiving ART for their own health has increased from 25% in 2009 to 60% in 20121. One of the greatest success stories has been in Malawi where a policy of providing lifelong ART to all pregnant and breastfeeding women (irrespective of CD4 count or clinical status– a strategy referred to as Option B+) was enacted in 2011. Since then, Malawi increased the estimated coverage of women in need of ART from 13% in 2009 to 86% in 2012. The implementation of Option B+ has resulted in a 748% increase in the number of pregnant and breastfeeding women starting ART, from 1,257 in the second quarter of 2011 to 10,663 in the third quarter of 201227. As a result of Option B+, the perinatal transmission rate for women on ART is expected to be reduced, from approximately 40% without intervention to less than 5%. By decentralizing treatment services and offering lifelong HIV treatment to all pregnant and breastfeeding women, Malawi has been able to increase ART coverage both during pregnancy and the breastfeeding period1. Providing treatment, care and support to WLHIV and their children and families: Increasing access to ART for pregnant women living with HIV for their own health is critical to saving the lives of women and their children. Even developing countries, which at first lagged behind in reducing the number of children newly infected with HIV, have made great gains in recent years. In 2013, UNAIDS reported that in 7 high burden countries where access to treatment has increased, the rates of HIV transmission to children has fallen by 50% or more1. What still needs to be done? HIV is a preventable disease. Perinatal transmission is best prevented by effective, accessible and sustainable HIV prevention, access to HIV testing, early diagnosis and linkage to treatment programs for women, men and their children, access to family planning and abortion services to prevent unintended pregnancies, and access to an ongoing supply of ARVs to improve the health of women and their children. Structural interventions are also needed that increase access to health centers, improve health care infrastructure, provide food supplementation, and HIV treatments. Women are the key to the HIV response and the number of women acquiring HIV has to be reduced. All women have a right to be treated for HIV infection, not simply because they are bearing a child. All women living with HIV who are eligible for ART need to have access to it. Unfortunately, too many women are still lost along the prevention cascade and never get the care or treatment they need and deserve. Providing women with access to high quality healthcare for themselves and their families, whether they are HIV-positive or not, is imperative.Says who?
1. UNAIDS. AIDS by the numbers. Geneva, Switzerland, 2013. 2. Kanniappan S, Jeyapaul MJ, Kalyanwala S. Desire for motherhood: exploring HIV-positive women’s desires, intentions and decision-making in attaining motherhood. AIDS care 2008;20(6):625-30 doi: 10.1080/09540120701660361[published Online First: Epub Date]|. 3. Beyeza-Kashesya J, Kaharuza F, Mirembe F, et al. The dilemma of safe sex and having children: challenges facing HIV sero-discordant couples in Uganda. African health sciences 2009;9(1):2-12 4. Cooper D, Moodley J, Zweigenthal V, et al. Fertility intentions and reproductive health care needs of people living with HIV in Cape Town, South Africa: implications for integrating reproductive health and HIV care services. AIDS and behavior 2009;13 Suppl 1:38-46 doi: 10.1007/s10461-009-9550-1[published Online First: Epub Date]|. 5. UNAIDS. We Can Prevent mothers fom dying and babies from becoming infected with HIV. Geneva, Switzerland, 2010. 6. De Cock KM, Fowler MG, Mercier E, et al. Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice. JAMA : the journal of the American Medical Association 2000;283(9):1175-82 7. WHO. PMTCT Strategic Vision 2010-2015: Preventing mother-to-child transmission of HIV to reach the UNGASS and Millenium Development Goals. Geneva, Switzerland, 2010. 8. CDC. HIV Among Pregnant Women, Infants, and Children in the United States. Atlanta, 2012. 9. Nesheim S, Taylor A, Lampe MA, et al. A framework for elimination of perinatal transmission of HIV in the United States. Pediatrics 2012;130(4):738-44 doi: 10.1542/peds.2012-0194[published Online First: Epub Date]|. 10. Nakayiwa S, Abang B, Packel L, et al. Desire for children and pregnancy risk behavior among HIV-infected men and women in Uganda. AIDS and behavior 2006;10(4 Suppl):S95-104 doi: 10.1007/s10461-006-9126-2[published Online First: Epub Date]|. 11. Department of Health and Human Services Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. In: Bureau HA, ed. Washington, DC, 2014. 12. WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach. Geneva, Switzerland, 2013. 13. Kourtis AP, Lee FK, Abrams EJ, et al. Mother-to-child transmission of HIV-1: timing and implications for prevention. The Lancet infectious diseases 2006;6(11):726-32 doi: 10.1016/S1473-3099(06)70629-6[published Online First: Epub Date]|. 14. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control 2006;55(RR-14):1-17; quiz CE1-4 15. Gourlay A, Birdthistle I, Mburu G, et al. Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review. Journal of the International AIDS Society 2013;16(1):18588 doi: 10.7448/IAS.16.1.18588[published Online First: Epub Date]|. 16. American Academy of Pediatrics Committee on Pediatric A. HIV testing and prophylaxis to prevent mother-to-child transmission in the United States. Pediatrics 2008;122(5):1127-34 doi: 10.1542/peds.2008-2175[published Online First: Epub Date]|. 17. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Secondary Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. 18. Celum C, Baeten JM. Tenofovir-based pre-exposure prophylaxis for HIV prevention: evolving evidence. Current opinion in infectious diseases 2012;25(1):51-7 doi: 10.1097/QCO.0b013e32834ef5ef[published Online First: Epub Date]|. 19. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. The New England journal of medicine 2012;367(5):399-410 doi: 10.1056/NEJMoa1108524[published Online First: Epub Date]|. 20. Siegfried N, Muller M, Deeks JJ, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men. The Cochrane database of systematic reviews 2009(2):CD003362 doi: 10.1002/14651858.CD003362.pub2[published Online First: Epub Date]|. 21. Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet 2010;375(9731):2092-8 doi: 10.1016/S0140-6736(10)60705-2[published Online First: Epub Date]|. 22. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. The New England journal of medicine 2010;363(27):2587-99 doi: 10.1056/NEJMoa1011205[published Online First: Epub Date]|. 23. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. The New England journal of medicine 2011;365(6):493-505 doi: 10.1056/NEJMoa1105243[published Online First: Epub Date]|. 24. Medley A, Baggaley R, Bachanas P, et al. Maximizing the impact of HIV prevention efforts: Interventions for couples. AIDS care 2013 doi: 10.1080/09540121.2013.793269[published Online First: Epub Date]|. 25. Sweat MD, O’Reilly KR, Schmid GP, et al. Cost-effectiveness of nevirapine to prevent mother-to-child HIV transmission in eight African countries. Aids 2004;18(12):1661-71 26. Grossman D, Onono M, Newmann SJ, et al. Integration of family planning services into HIV care and treatment in Kenya: a cluster-randomized trial. Aids 2013;27 Suppl 1:S77-85 doi: 10.1097/QAD.0000000000000035[published Online First: Epub Date]|. 27. Centers for Disease Control and Prevention. Impact of an innovative approach to prevent mother-to-child transmission of HIV–Malawi, July 2011-September 2012. MMWR. Morbidity and mortality weekly report 2013;62(8):148-51Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©2009, University of CA. Comments and questions about this Fact Sheet may be e-mailed to CAPS.web@ucsf. edu.
Transgender Women and HIV Prevention and Care
Transgender Women and HIV Prevention and Care
‘Transgender women’ is an umbrella term to refer to persons who identify as women or trans women, or who have a feminine gender identity that differs from the male sex they were assigned at birth. Transgender women may identify with certain terms and not others and may express gender in a variety of ways. Gender identity terms vary by geographic region, race, ethnicity, age, and other factors, so it is best to ask people what they prefer. Best practices for obtaining information on gender identity in the context of research and health services continue to evolve.1
Transgender Women and HIV Risk
Transgender women are at disproportionate risk for HIV; an estimated 19.1% of transgender (‘trans’) women are living with HIV, according to a meta-analysis of studies from around the world.2 Internationally, trans women have 49 times higher odds of living with HIV compared to the general adult population;3 in the US they have the highest rates of new diagnoses by gender.4 Black and Latina trans women experience an extremely high HIV burden; more than half of trans people diagnosed with HIV are Black (44%) or Hispanic/Latinx (26%).5 Intersectional stigma—oppression rooted in racism, transphobia, and misogyny6—fuels structural vulnerabilities among trans women of color7-9 and has been linked with trauma symptoms, inconsistent condom use, suboptimal PrEP and ART adherence, and detectable viral load.10-12 Like many populations, those at greatest risk are more likely to be poor, homeless, young, people of color, and engage in sex work.13,14
Not all trans women are at risk for HIV; however, stigma and discrimination faced by trans women often results in social marginalization, increasing risk of poor health outcomes.15 Social isolation and rejection by family members is common, which can lead to anxiety, depression, experiencing homelessness at a young age, and heightened risk of suicidal ideation and attempts.16,17 School-based stigma and bullying make young trans women vulnerable to dropping out and poor mental health, disrupting education and employment pathways.18-20 Sex work, recent homelessness, and school dropout are associated with incarceration, which trans women experience at higher rates than the general population.21
HIV Prevention and Care for Transgender Women
The provision of gender-affirming HIV prevention and care services is of utmost importance to serving trans women effectively.22 Trans people often report avoiding health care settings due to stigma and past negative experiences; when seeking care, they tend to prioritize gender-affirming medical care, such as hormone therapy, over HIV prevention services such as PrEP.23-25 Barriers to PrEP use among trans women include low PrEP awareness, concerns about drug interactions with hormone therapy, and low access to gender-affirming care.26-28 A 2020 national probability sample of trans people found only 3% of sexually active respondents were currently taking PrEP.29
Efficacious prevention programming prioritizing the needs of trans women has increased in the last decade, although much work remains. The first National Transgender HIV Testing Day was held on April 18, 2016. In 2018, the Health Resources and Services Administration Special Projects of National Significance Division published the Transgender Women of Color Initiative: Project Interventions Manual and then in 2019, the Centers for Disease Control and Prevention published their Toolkit for Providing HIV Prevention Services to Transgender Women of Color. Trans women experience unique barriers to prevention and care, and therefore, trans women should not be subsumed into MSM programming.30 Research consistently demonstrates that programs based in gender affirmation have the greatest impact in optimizing health outcomes for trans women.31-38
Training for healthcare providers in creating inclusive, gender-affirming clinical environments. Quality, affirming healthcare is important for trans women. Despite their sincere concern to serve patients effectively, providers may have very little knowledge, experience, skills and therefore comfort with trans patients though the availability of transgender-specific training for medical students is increasing39. UCSF Transgender Care provides free online resources for healthcare providers and other professionals for guidance on staff training, creating welcoming spaces, and data collection.
HIV Testing and Prevention. Three interventions designed for trans women have demonstrated efficacy with reducing risk and increasing HIV testing. Couples HIV Intervention Program (CHIP) is designed for trans women and their cisgender male partners as an intervention to support the couple and promote HIV testing and safe sex practices. Project Life Skills is a group-based intervention for young trans women focused on communication skills and condom negotiation. Sheroes is an intervention for adult trans women of color comprised of five weekly group sessions emphasizing healthcare empowerment and gender affirmation.40 Facilitating PrEP use among HIV prevention strategies is a developing area in services that prioritize trans women. Recent research provides emerging evidence for a trans-specific advertising campaign promoting PrEP use (PrEP4Love)41 and there is also emerging evidence for a program to increase PrEP adherence using peer navigators (A.S.K.-PrEP).42
Linkage and retention in HIV care. Transgender Women Entry and Engagement to Care Project (TWEET) is a group-based intervention to link transgender women living with HIV to care and support their engagement in care. Transgender Women Involved in Strategies for Transformation (TWIST) is a peer-led, small-group, skills-building, and educational high-impact prevention (HIP) intervention for adult trans women living with HIV. Healthy Divas combines individual sessions with a peer counselor and a group workshop with a medical provider to promote engagement in gender-affirming and HIV medical care.43-45
Unaddressed Needs of Transgender Women
To address the devastating effects of stigma and discrimination on trans people, large-scale anti-stigma campaigns, as well as anti-discrimination laws, should be implemented across the country. Structural interventions such as job training, housing, and educational programs should be widely implemented and evaluated. Ongoing capacity building and sensitivity training should be provided for healthcare workers, school officials, service providers, and researchers working with trans women. More research is needed with sexual partners of trans women, as well as programs that work with trans women and partners together as a couple.46 Finally, more research should be done with trans youth to identify and develop strategies for HIV prevention for young adults identifying as trans and gender diverse.47 Interventions and programs that leverage the inherent resilience and support networks within trans communities are also promising approaches to optimizing health outcomes among trans women.48
Resources
- Center of Excellence for Transgender Health
- Transgender Law Center
- National Center for Transgender Equality
- Transgender HIV/AIDS Services Best Practices Guidelines
- World Professional Association for Transgender Health
| Fact Sheet Date | Authors |
|---|---|
| September 2008 / Revised 2015 |
JoAnne Keatley MSW / CAPS and Pacific AETC Walter Bockting Ph.D. / University of Minnesota |
| Revised June 2021 |
Beth Bourdeau, Ph.D. / Division of Prevention Science Jae Sevelius, Ph.D. / Division of Prevention Science Greg Rebchook, Ph.D. / Division of Prevention Science Jenna Rapues, MPH / San Francisco Department of Public Health Nasheedah Bynes-Muhammad/ The Journey Partners LLC |
Says who?
Orientation and Gender Identity Questions: A Qualitative Study. Archives of sexual behavior. 2020;49(7):2301-2318.
2. Baral S, Poteat T, Stromdahl S, Wirtz A, Guadamuz T, Beyrer C. Worldwide burden of HIV in transgender women: A systematic review and meta-analysis. The Lancet Infectious Diseases. 2013;13(3):214-222.
3. Baral SD, Poteat T, Stromdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. The Lancet infectious diseases. 2013;13(3):214-222.
4. Herbst J, Jacobs E, Finlayson T, McKleroy V, Neumann M, Crepaz N. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS and Behavior. 2008;12(1):1-17.
5. Clark H, Babu AS, Wiewel EW, Opoku J, Crepaz N. Diagnosed HIV infection in transgender adults and adolescents: results from the National HIV Surveillance System, 2009–2014. AIDS and Behavior. 2017;21(9):2774-2783.
6. Bailey M, Trudy. On misogynoir: citation, erasure, and plagiarism. Feminist Media Studies. 2018:1-7.
7. Palazzolo SL, Yamanis TJ, et al. Documentation status a contexual determinent of HIV risk among young transgender Latinas. LGBT Health. 2016;3(2):132-138.
8. Fletcher JB, Kisler KA, Reback CJ. Housing status and HIVrisk behaviors among transgender women in Los Angeles. Arch Sex Behav 2014;43:1651-1661.
9. Operario D, Nemoto T. HIV in transgender communities: Syndemic dynamics and a need for multicomponent interventions. J Acquir Immune Defic Syndr. 2010;55:S91-S93.
10. Richmond KA, Burnes T, Carroll K. Lost in trans-lation: Interpreting systems of trauma for transgender clients. Traumatology. 2012;18(1):45-57.
11. Smith LR, Yore J, Triplett DP, Urada L, Nemoto T, Raj A. Impact of Sexual Violence Across the Lifespan on HIV Risk Behaviors Among Transgender Women and Cisgender People Living With HIV. J Acquir Immune Defic Syndr. 2017;75(4):408-416.
12. Wirtz AL, Poteat TC, Malik M, Glass N. Gender-Based Violence Against Transgender People in the United States: A Call for Research and Programming. Trauma Violence Abuse. 2018:1524838018757749.
13. Becasen JS, Denard CL, Mullins MM, Higa DH, Sipe TA. Estimating the Prevalence of HIV and Sexual Behaviors Among the US Transgender Population: A Systematic Review and Meta-Analysis, 2006–2017. American Journal of Public Health. 2019;109(1):e1-e8.
14. Reback CJ, Clark K, Holloway IW, Fletcher JB. Health Disparities, Risk Behaviors and Healthcare Utilization Among Transgender Women in Los Angeles County: A Comparison from 1998–1999 to 2015–2016. AIDS and behavior. 2018;22(8):2524-2533.
15. Wesp LM, Malcoe LH, Elliott A, Poteat T. Intersectionality Research for Transgender Health Justice: A Theory-Driven Conceptual Framework for Structural Analysis of Transgender Health Inequities. Transgend Health. 2019;4(1):287-296.
16. Kota KK, Salazar LF, Culbreth RE, Crosby RA, Jones J. Psychosocial mediators of perceived stigma and suicidal ideation among transgender women. BMC public health. 2020;20(1):125-125.
17. Testa RJ, Michaels MS, Bliss W, Rogers ML, Balsam KF, Joiner T. Suicidal Ideation in Transgender People: Gender Minority Stress and Interpersonal Theory Factors. Journal of abnormal psychology (1965). 2017;126(1):125-136.
18. Hereth J, Garthe RC, Garofalo R, Reisner SL, Mimiaga MJ, Kuhns LM. Examining Patterns of Interpersonal Violence, Structural and Social Exclusion, Resilience, and Arrest among Young Transgender Women. Criminal justice and behavior. 2021;48(1):54-75.
19. Leppel K. Transgender Men and Women in 2015: Employed, Unemployed, or Not in the Labor Force. Journal of homosexuality. 2021;68(2):203-229.
20. Vance SR, Jr., Boyer CB, Glidden DV, Sevelius J. Mental Health and Psychosocial Risk and Protective Factors Among Black and Latinx Transgender Youth Compared With Peers. JAMA Network Open. 2021;4(3):e213256-e213256.
21. Hughto JMW, Reisner SL, Kershaw TS, et al. A multisite, longitudinal study of risk factors for incarceration and impact on mental health and substance use among young transgender women in the USA. J Public Health (Oxf). 2019;41(1):100-109.
22. Sevelius JM, Deutsch MB, Grant R. The future of PrEP among transgender women: the critical role of gender affirmation in research and clinical practices. Journal of the International AIDS Society. 2016;19(7Suppl 6):21105.
23. Braun HM, Candelario J, Hanlon CL, et al. Transgender Women Living with HIV Frequently Take Antiretroviral Therapy and/or Feminizing Hormone Therapy Differently Than Prescribed Due to Drug–Drug Interaction Concerns. LGBT health. 2017;4(5):371-375.
24. Reisner SL, Perez-Brumer AG, McLean SA, et al. Perceived Barriers and Facilitators to Integrating HIV Prevention and Treatment with Cross-Sex Hormone Therapy for Transgender Women in Lima, Peru. AIDS and behavior. 2017;21(12):3299-3311.
25. Sevelius JM, Keatley J, Calma N, Arnold E. 'I am not a man': Trans-specific barriers and facilitators to PrEP acceptability among transgender women. Global public health. 2016;11(7-8):1060-1075.
26. Cahill SR, Keatley J, Wade Taylor S, et al. “Some of us, we don’t know where we’re going to be tomorrow.” Contextual factors affecting PrEP use and adherence among a diverse sample of transgender women in San Francisco. AIDS Care. 2020;32(5):585-593.
27. Sevelius JM, Keatley J, Calma N, Arnold E. “I am not a man”: Trans-specific barriers and facilitators to PrEP acceptability among transgender women. Global Public Health. 2016(Special issue, The Trouble with ‘Categories’: Rethinking MSM, Trans and their Equivalents in HIV Prevention and Health Promotion).
28. Poteat T, Wirtz A, Malik M, et al. A Gap Between Willingness and Uptake: Findings From Mixed Methods Research on HIV Prevention Among Black and Latina Transgender Women. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2019;82(2).
29. Sevelius JM, Poteat T, Luhur WE, Reisner SL, Meyer IH. HIV Testing and PrEP Use in a National Probability Sample of Sexually Active Transgender People in the United States. Journal of acquired immune deficiency syndromes. 2020.
30. Sevelius JM, Keatley J, Calma N, Arnold E. 'I am not a man': Trans-specific barriers and facilitators to PrEP acceptability among transgender women. 2016.
31. Lacombe-Duncan A, Newman P, Bauer G, et al. Gender-affirming healthcare experiences and medical transition among transgender women living with HIV: A mixed-methods study. Sexual health. 2019;16(4):367-376.
32. Lama J, Mayer K, Perez-Brumer A, et al. Integration of gender-affirming primary care and peer navigation with HIV prevention and treatment services to improve the health of transgender women: Protocol for a prospective longitudinal cohort study. JMIR Research Protocols. 2019;8(6):e14091.
33. Mayo-Wilson L, Benotsch E, Grigsby S, et al. Combined effects of gender affirmation and economic hardship on vulnerability to HIV: A qualitative analysis among US adult transgender women. BMC PUBLIC HEALTH. 2020;20(1):782-717.
34. Reisner S, Bradford J, Hopwood R, et al. Comprehensive transgender healthcare: The gender affirming clinical and public health model of Fenway Health. Journal of Urban Health. 2015;92(3):584-592.
35. Reisner SL, White Hughto JM, Pardee D, Sevelius J. Syndemics and gender affirmation: HIV sexual risk in female-to-male trans masculine adults reporting sexual contact with cisgender males. International journal of STD & AIDS. 2016;27(11):955-966.
36. Sevelius J. Gender affirmation: A framework for conceptualizing risk behavior among transgender women of color. Sex Roles. 2013;68(11-12):675-689.
37. Sevelius JM, Chakravarty D, Dilworth SE, Rebchook G, Neilands TB. Gender Affirmation through Correct Pronoun Usage: Development and Validation of the Transgender Women's Importance of Pronouns (TW-IP) Scale. International journal of environmental research and public health. 2020;17(24):9525.
38. Sevelius JM, Deutsch MB, Grant R. The future of PrEP among transgender women: the critical role of gender affirmation in research and clinical practices. 2016.
39. Dubin SN, Nolan IT, Streed CG Jr, Greene RE, Radix AE, SD M. Transgender health care: improving medical students' and residents' training and awareness. Adv Med Educ Pract. 2018;9:377-391.
40. Sevelius J, Neilands T, Dilworth S, Castro D, Johnson M. Sheroes: Feasibility and acceptability of a community-driven, group-level HIV intervention program for transgender women. AIDS and behavior. 2019;24(5):1551-1559.
41. Phillips II G, Raman A, Felt D, et al. PrEP4Love: The Role of Messaging and Prevention Advocacy in PrEP Attitudes, Perceptions, and Uptake Among YMSM and Transgender Women. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2020;83(5):450-456.
42. Reback CJ, Clark KA, Rünger D, AE F. A Promising PrEP Navigation Intervention for Transgender Women and Men Who Have Sex with Men Experiencing Multiple Syndemic Health Disparities. J Community Health. 2019;44(6):1193-1203.
43. Cahill SR, Keatley J, Wade Taylor S, et al. "Some of us, we don't know where we're going to be tomorrow." Contextual factors affecting PrEP use and adherence among a diverse sample of transgender women in San Francisco. AIDS care. 2020;32(5):585-593.
44. Maiorana A, Sevelius J, Keatley J, Rebchook G. “She is like a sister to me”: Gender-affirming services and relationships are key to the implementation of HIV care engagement interventions with transgender women of color. AIDS and behavior. 2020.
45. Poteat T, Malik M, Scheim A, Elliott A. HIV Prevention Among Transgender Populations: Knowledge Gaps and Evidence for Action. Current HIV/AIDS Reports. 2017;14(4):141-152.
46. Gamarel KE, Sevelius JM, Neilands TB, et al. Couples-based approach to HIV prevention for transgender women and their partners: study protocol for a randomised controlled trial testing the efficacy of the ‘It Takes Two’intervention. BMJ Open. 2020;10(10):e038723.
47. Reisner SL, Jadwin-Cakmak L, Sava L, Liu S, Harper GW. Situated Vulnerabilities, Sexual Risk, and Sexually Transmitted Infections' Diagnoses in a Sample of Transgender Youth in the United States. AIDS Patient Care STDS. 2019;33(3):120-130.
48. Lacombe-Duncan A, Logie CH, Newman PA, Bauer GR, Kazemi M. A qualitative study of resilience among transgender women living with HIV in response to stigma in healthcare. AIDS Care. 2020;32(8):1008-1013.