SF TG people and HIV risk JS edit 0614

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Transgender People in San Francisco and HIV Risk JoAnne Keatley, MSW Pacific AIDS Education and Training Center University of California, San Francisco Jae Sevelius, Ph.D. Department of Medicine Center for AIDS Prevention Studies HPPC Meeting - June 14, 2007

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Transgender Population Estimates No U.S. population-based studies yet conducted. However, it is likely they would be problematic, due to stigma-induced failure to disclose identity. Current estimates are transsexual-centric, i.e., focused on those who fit the DSM definition of Gender Identity Disorder or those who have had surgical sex reassignment, even though transsexuals are a minority within the overall transgender population. Jessica Xavier, MPH

U.S. Transgender Behavioral Risk and Needs Assessment Surveys, 1993 - present: 

U.S. Transgender Behavioral Risk and Needs Assessment Surveys, 1993 - present Universities, local health departments and community-based organizations Not all published in journals Copies of Technical Reports are difficult to obtain – only limited numbers printed Some limited to sex workers or substance users Only a few include FTMs Trans youth data is difficult to collect Few incidence studies Jessica Xavier, MPH

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U.S. Transgender HIV Prevalence Rates by City (All MTF Unless Noted) Minneapolis – St. Paul: 4% San Juan: 14% Philadelphia: 4% to 19% Chicago: 14% to 19% Los Angeles: 22% New York: 21% to 30% Houston: 27% Washington: 32% MTF, 3.3% FTM Atlanta (sex worker): 68% San Francisco: 25 - 47% MTF, 1.6% FTM

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Nemoto et. al (2004) MTFs of color: 26% HIV+ (self-report) DPH (2002) MTF: 25% HIV+ (self-report) Clements et. al (1999) MTF: 35% HIV+ (Orasure) FTM: 1.6% (n = 2 of 123) HIV+ (Orasure) Nemoto et. al (1996) MTF: 47% HIV+ (self-report) Prevalence Estimates in San Francisco

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  SF Transgender Community Health Project (Clements et. al, 2001) Predictors of HIV Positive Status in MTFs:   

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Examined correlates of HIV-related risk behaviors among samples of African American, Latina, and API transgenders in San Francisco. Sexual Behaviors: primary, casual, and commercial Health Outcomes: HIV/STD, Depression, Need and Access to Care Substance use: Substance use (lifetime, past 30 days), injection drug use, engaged in sex with primary, casual, or commercial partners while under the influence of any illicit drugs Psychosocial Factors (e.g., transphobia, depression, self-esteem, gender identity, social support) HIV Risk Behaviors among MTF Transgenders of Color (Nemoto et. al, 2004; J. Keatley, Project Director)

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Table 1. Demographics by Ethnicity

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Table 2. HIV/STD by Ethnicity

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Major Findings About three-quarters of the participants had recently engaged in receptive anal sex with primary, casual, and commercial sex partners. A significantly higher proportion (47%)had recently engaged in URAS with primary partners than with casual (26%) and commercial partners (12%). Current URAS with primary and casual partners, but not commercial partners, was significantly and independently correlated with having had sex under the influence of drugs HIV positive participants were 3.8 times more likely to engage in receptive anal sex as well as URAS with casual partners than HIV negative participants, controlling for other variables.

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Major findings continued: Although only 12% had reported URAS with commercial partners in the past 30 days, this risk behavior was significantly and independently correlated with African American race (4.5 times more compared with non-African Americans) and lowest income level (less than $500 of monthly income).

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Risk Factors Driving HIV Transmission in Transgender People Social Stigma → Discrimination, Harassment, Violence → Unemployment, Lack of Health Insurance, Poverty, Homelessness Survival Sex Work → Unprotected Sex, Substance Abuse Gender Identity Validation through Sex → Multiple sex partners, unprotected sex Lack of Regular Contact with Medical Providers → Lack of medical screening, including HIV/STDs, increased morbidity risks

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Risk Factors Driving HIV Transmission in Transgender People Culturally Incompetent Prevention Methods → Low Perception of Risk (especially among FTMs), Low HIV/STD testing rates Multiple Injection Risks (IDU, ISU, IHU) Barriers to Access to Transgender Care → self-medication through street hormones, ISU Traditional reluctance by MSM-serving AIDS Service Organizations to view transgender people as part of their service community

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Criticisms of Prevention Methods Used in Transgender Populations 'MTFs can’t identify with messages and images that do not fit their body or self-image' - Clements, Wilkinson, Kitano andamp; Marx, 1999 'MSM does not accurately describe male-to-female transgenders who, genetically male, experience a female gender identity' - Kammerer, Mason, Connors andamp; Durkee, in Bockting andamp; Kirk, 2001 'Existing prevention education is not inclusive of transgender people and oftentimes makes assumptions about sex and gender that are not applicable to their (anatomical) situation' - Bockting, Robinson andamp; Rosser, 1998  

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  Comments and Discussion JoAnne Keatley, MSW Joanne.keatley@ucsf.edu 415.597-4960 Jae Sevelius, Ph.D j.sevelius@ucsf.edu 415-597-9183