Dedicated efforts are needed to engage transgender men and
women with clinical services and to encourage them to use pre-exposure prophylaxis (PrEP), Asa Radix of
the Callen-Lorde Community Health Center in New York told the recent 21st International AIDS Conference (AIDS
2016) in Durban, South Africa.
need to prevent HIV infections and improve the health of transgender men and
women is urgent. Globally, it is estimated that trans women have an HIV
prevalence of 19%, which is 49 times higher than that of the general
population. In high-income countries the prevalence is estimated to be 22%, with the highest
rate among trans women of colour. There are very few data on trans men.
Callen-Lorde is the largest specialist provider of health
services for lesbian, gay, bisexual and trans people in New York. It has over
15,000 clients, including 3095 trans men and women. Over half of trans clients are black
or Latino, one third do not have health insurance and 15% are homeless or
Demand for PrEP has been high, with a lot of new clients
attending for this purpose. However, uptake by transgender clients was slow to develop.
In the last two years,
Callen-Lorde has gone from having only one or two transgender people starting
PrEP each month to around 15 trans people enrolling each month. Now, of the
2324 individuals who have ever received PrEP from the centre, 195 are transgender.
Asa Radix set out to explain how the clinic had managed to achieve this.
Barriers to PrEP uptake that are
specific to this community include a dearth of PrEP marketing materials that
are trans-inclusive, concerns about potential interactions between PrEP and
hormonal therapies, and a mistrust of medicine, due to individuals’ experiences
of providers who are hostile or uninformed about transgender people’s needs.
Over half of the trans people taking PrEP are under the age
of 30. Two-thirds of those taking PrEP are trans women (individuals assigned a
male gender at birth and now identifying as female), with only 16% being trans
men (individuals assigned a female gender at birth and now identifying as
male). A further 17% are gender non-conforming and this group were mostly
assigned a male gender at birth.
Asa Radix said that it was vital to create a safe and
supportive environment. The registration forms and electronic patient records
at the clinic have been redesigned to be trans-inclusive. They can accommodate
differences between the sex an individual was assigned at birth, the sex listed
on their health insurance documents and the gender the person currently
identifies with. Patients are asked to specify the name and pronoun they would
like to be used.
“Many people underestimate how very difficult it is when you
come into a health centre and you are being mis-gendered,” said Asa Radix.
“Calling people by a gender they don’t identify with, or using Ma’am or Sir incorrectly, can be incredibly uncomfortable for people.”
An emphasis is put on respecting privacy and
confidentiality. Staff at the in-house pharmacy are familiar with trans issues.
At commercial pharmacies, staff may be disconcerted by apparent discrepancies
between a person’s official documents and their current gender identity.
Trans-identified staff have been recruited, are visible to
clients, and have been involved in developing clinic policies. A community
advisory board allows trans advocates and service users to provide input.
Images of trans people are included in PrEP brochures, PrEP
videos, and the clinic’s website.
Many of these resources had to be developed specifically by Callen-Lorde. PrEP
materials are prominently displayed in the clinic.
PrEP has been promoted at a
wide range of outreach activities, community events and forums. Staff have been instructed to discuss PrEP at every clinical encounter. It was necessary to raise rates of
screening for HIV and sexually transmitted infections (STIs), as PrEP is more likely to be proposed following such
testing. As some clients find physical examinations uncomfortable, self-swabbing
kits for STIs have been offered and have had a dramatic impact on the uptake of
STI screening. Self-swabbing also reduces the burden on clinical staff.
Dedicated staff help clients with health insurance and
coverage issues. This kind of support has been important for a wide range of
clients seeking PrEP, including trans people.
Uninsured patients have to be linked to medication
assistance programs or low/no cost health insurance plans. Clients with health
insurance may still encounter challenges due to high co-payments, insurance
denials and requirements to have drugs delivered by mail (difficult for people who are homeless). Medical staff have needed to be trained on these
Following the presentation, an audience member asked if
focusing on PrEP for trans people was an “easy way out” of not dealing with
underlying factors that make people vulnerable to HIV, such as poverty,
homelessness and sex work. Tonia Poteat of the Johns Hopkins Bloomberg School
of Public Health responded that there won’t be good engagement with PrEP unless these issues are addressed first.