Characterizing the HIV Prevention and Care Continua in a Sample of Transgender Youth in the U.S.
In the U.S., transgender and other gender minority (TG) youth are an at-risk group understudied in HIV prevention and treatment. This study sought to characterize the HIV prevention and care continua in a diverse sample of 181 sexually-active TG ages 16–24 years (mean age = 20.7 years; 76.8% trans feminine; 69.1% youth of color) recruited July–December 2015 in 14 U.S. cities. Overall, 30.9% reported living with HIV, of which 71.4% were on antiretroviral therapy (ART) and 55.0% were medication adherent; 65.6% were known to be virally suppressed. In multivariable models, medical gender affirmation was associated with lower odds of viral suppression. Medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. Among at-risk TG youth not living with HIV, only 8.2% had accessed pre-exposure prophylaxis (PrEP). Early biobehavioral prevention and treatment interventions are needed for TG youth.
KeywordsTransgender HIV Prevention Adolescents
We would also like to thank the following individuals, groups, and entities for their contributions to this study: Elliot Popoff and Bré Anne Campbell, University of Michigan research staff who made this study possible. The investigators and staff at the following sites that participated in this study: University of South Florida, Tampa (Emmanuel, Straub, Bruce, Kerr), Children’s Hospital of Los Angeles (Belzer, Tucker, Franco), Children’s National Medical Center (D’Angelo, Trexler, Carr, Sinkfield), Children’s Hospital of Philadelphia (Douglas, Tanney, DiBenedetto, Franklin, Smith), John H. Stroger Jr. Hospital of Cook County and the Ruth M. Rothstein CORE Center (Henry-Reid, Bojan, Balthazar), Montefiore Medical Center (Futterman, Campos, Wesp, Nazario, Reopell), Tulane University Health Sciences Center (Abdalian, Kozina, Baker, Wilkes), University of Miami School of Medicine (Friedman, Maturo), St. Jude’s Children’s Research Hospital (Gaur, Flynn, Dillard, Hurd-Sawyer), Baylor College of Medicine (Paul, Head, Sierra), Wayne State University (Secord, Cromer, Walters, Houston), Johns Hopkins University (George-Agwu, Anderson, Worrel-Thorne), Fenway Institute (Mayer, Dormitzer, Massaquoi, Gelman), University of Colorado Denver (Reirden, Hahn, Bernath). Network, scientific and logistical support was provided by the ATN Coordinating Center (C. Wilson, C. Partlow) at The University of Alabama at Birmingham and the ATN 130 protocol team. Network operations and data management support was provided by the ATN Data and Operations Center at Westat, Inc. (G. Price). The authors are grateful to the members of the Affirming Voices for Action (AVA) Youth Advisory Board for their insight and guidance. We would like to thank the trans* youth who raised their voices and shared their experiences with us. We hear you.
This work was supported by The Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) from the National Institutes of Health [U01 HD 040533 and U01 HD 040474] through the National Institute of Child Health and Human Development (B. Kapogiannis, S. Lee), with supplemental funding from the National Institutes on Drug Abuse and Mental Health. Dr. Gary Harper was the Protocol Chair (PI) of ATN 130: Assessing the Engagement of Gender Minority Youth Across the HIV Continuum of Care. Protocol Vice-Chairs (Co-Is) were Dr. Sari Reisner, Miguel Martinez, and Liza Salomon. The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of any of the sponsoring organizations, agencies, or the U.S. Government.
Compliance with Ethical Standards
All study activities were approved at the Institutional Review Boards at the 14 Adolescent Medicine Trials Unit (AMTU) sites, as well as investigators’ institutions.
Conflicts of interest
The authors have no relevant conflicts of interest to disclose.
All procedures performed in this study involving human participants were in accordance with the ethical standards of the Institutional Review Boards at the 14 participating sites, as well as with the investigators’ institutions, including with the 1964 Helsinki Declaration and its later amendments and ethical standards.
Informed consent was obtained from all individuals participants included in the study.
- 1.Centers for Disease Control and Prevention. HIV Among Youth. 2016. https://www.cdc.gov/hiv/group/age/youth/. Accessed 25 Jan 2017.
- 5.Health Resources and Services Administration. National HIV/AIDS Strategy for the United States: Updated to 2020. Washington; 2015.Google Scholar
- 7.The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC; 2011. https://iom.nationalacademies.org/Reports/2011/The-Health-of-Lesbian-Gay-Bisexual-and-Transgender-People.aspx.
- 8.Shields JP, Cohen R, Glassman JR, Whitaker K, Franks H, Bertolini I. Estimating population size and demographic characteristics of lesbian, gay, bisexual, and transgender youth in middle school. J Adolesc Health. 2013;52(2):248–50. https://doi.org/10.1016/j.jadohealth.2012.06.016.CrossRefPubMedGoogle Scholar
- 10.Flores A, Brown TM, Herman J. How Many adults identify as transgender in the United States. Los Angeles: Williams Institute UCLA School of Law; 2016.Google Scholar
- 18.Sevelius J. There’s no pamphlet for the kind of sex I have: HIV-related risk factors and protective behaviors among transgender men who have sex with nontransgender men. J Assoc Nurses AIDS Care. 2009;20(5):398–410. https://doi.org/10.1016/j.jana.2009.06.001.CrossRefPubMedPubMedCentralGoogle Scholar
- 21.Wilson EC, Chen Y-H, Arayasirikul S, et al. Differential HIV risk for racial/ethnic minority transfemale youths and socioeconomic disparities in housing, residential stability, and education. Am J Public Health. 2015;105:e41–7. https://doi.org/10.2105/AJPH.2014.302443.CrossRefPubMedPubMedCentralGoogle Scholar
- 22.Reisner SL, Vetters R, White JM, et al. Laboratory-confirmed HIV and sexually transmitted infection seropositivity and risk behavior among sexually active transgender patients at an adolescent and young adult urban community health center. AIDS Care. 2015;27(8):1031–36. https://doi.org/10.1080/09540121.2015.1020750.CrossRefPubMedPubMedCentralGoogle Scholar
- 24.Brennan J, Kuhns LM, Johnson AK, et al. Syndemic theory and HIV-related risk among young transgender women: the role of multiple, co-occurring health problems and social marginalization. Am J Public Health. 2012;102(9):1751–7. https://doi.org/10.2105/AJPH.2011.300433.CrossRefPubMedPubMedCentralGoogle Scholar
- 36.Olson-Kennedy J, Cohen-Kettenis PT, Kreukels BPC, et al. Research priorities for gender nonconforming/transgender youth: gender identity development and biopsychosocial outcomes. Curr Opin Endocrinol Diabetes Obes. 2016;23(2):172–9. https://doi.org/10.1097/MED.0000000000000236.CrossRefPubMedPubMedCentralGoogle Scholar
- 52.Centers for Disease Control and Prevention. HIV Among Transgender People 2016. https://www.cdc.gov/hiv/group/gender/transgender/. Accessed 25 Jan 2017.
- 55.Israel BA, Krieger J, Vlahov D, et al. Challenges and facilitating factors in sustaining community-based participatory research partnerships: lessons learned from the Detroit, New York City and Seattle Urban Research Centers. J Urban Health. 2016;83(6):1022–40. https://doi.org/10.1007/s11524-006-9110-1.CrossRefGoogle Scholar
- 58.Harper GW, Willard N, Ellen JM. Adolescent Medicine Trials Network for HIV/AIDS Interventions. Connect to Protect®: utilizing community mobilization and structural change to prevent HIV infection among youth. J Prev Interv Commun. 2012;40(2):81–6. https://doi.org/10.1080/10852352.2012.660119.CrossRefGoogle Scholar
- 60.Reisner SL, Conron KJ, Tardiff LA, Jarvi S, Gordon AR, Austin SB. Monitoring the health of transgender and other gender minority populations: validity of natal sex and gender identity survey items in a US national cohort of young adults. BMC Public Health. 2017;14:1224. https://doi.org/10.1186/1471-2458-14-1224.CrossRefGoogle Scholar
- 65.Harper GW, Jadwin-Cakmak L, Reisner S et al. Exploring utilization of HIV-related services and care among transgender and other gender minority youth in the U.S. National Transgender Health Summit, Oakland; 2015.Google Scholar
- 68.Agwu AL, Fleishman JA, Korthuis PT, et al. Disparities in antiretroviral treatment: a comparison of behaviorally HIV-infected youth and adults in the HIV Research Network. J Acquir Immune Defic Syndr. 2011;58(1):100–7. https://doi.org/10.1097/QAI.0b013e31822327df.CrossRefPubMedPubMedCentralGoogle Scholar
- 72.Kann L, McManus T, Harris W, et al. Youth Risk Behavior Surveillance-United States, 2013. Morbidity and Mortality Weekly Report. 2014;63:SS-4.Google Scholar
- 75.UNAIDS. 90-90-90: an ambitious treatment target to help end the AIDS epidemic. Geneva; 2014.Google Scholar
- 77.Greifinger R, Batchelor M, Fair C. Improving engagement and retention in adult care settings for lesbian, gay, bisexual, transgender and questioning (LGBTQ) youth living with HIV: recommendations for health care providers. J Gay Lesbian Ment Health. 2013;17(1):80–95. http://dx.doi.org/10.1080/19359705.2013.739533.CrossRefGoogle Scholar