Faculty Bibliography

Transgender (trans) communities worldwide, particularly those on the trans feminine spectrum, are disproportionately burdened by HIV infection and at risk for HIV acquisition/transmission. Trans individuals represent an underserved, highly stigmatized, and under-resourced population not only in HIV prevention efforts but also in delivery of general primary medical and clinical care that is gender affirming. We offer a model of gender-affirmative integrated clinical care and community research to address and intervene on disparities in HIV infection for transgender people. We define trans terminology, briefly review the social epidemiology of HIV infection among trans individuals, highlight gender affirmation as a key social determinant of health, describe exemplar models of gender-affirmative clinical care in Boston MA, New York, NY, and San Francisco, CA, and offer suggested "best practices" for how to integrate clinical care and research for the field of HIV prevention. Holistic and culturally responsive HIV prevention interventions must be grounded in the lived realities the trans community faces to reduce disparities in HIV infection. HIV prevention interventions will be most effective if they use a structural approach and integrate primary concerns of transgender people (eg, gender-affirmative care and management of gender transition) alongside delivery of HIV-related services (eg, biobehavioral prevention, HIV testing, linkage to care, and treatment).

BACKGROUND: Terminology related to sexuality and gender is constantly evolving, and multiple factors are at play when individuals answer questions on surveys. METHODS: We examined patterns of responding to the National Health Interview Survey (NHIS) sexual identity questions in a multisite health intervention study for lesbian and bisexual women aged 40 to 84 years. RESULTS: Of 376 participants, 80% (n = 301) chose "lesbian or gay," 13% (n = 49) selected "bisexual," 7% (n = 25) indicated "something else," and 1 participant chose "don't know the answer." In response to the follow-up question for women who said "something else" or "don't know," most (n = 17) indicated that they were "not straight, but identify with another label." One participant chose "transgender, transsexual, or gender variant," five chose "You do not use labels to identify yourself," and three chose "you mean something else." Lesbian, bisexual, and "something else" groups were compared across demographic and health-related measures. Women who reported their sexual identity as "something else" were younger, more likely to have a disability, more likely to be in a relationship with a male partner, and had lower mental health quality of life than women who reported their sexual identity as lesbian or bisexual. CONCLUSIONS: Respondents who answer "something else" pose challenges to analysis and interpretation of data, but should not be discarded from samples. Instead, they may represent a subset of the community that views sexuality and gender as fluid and dynamic concepts, not to be defined by a single label. Further study of the various subsets of "something else" is warranted, along with reconsideration of the NHIS question options.

PURPOSE: Provider curricula to reduce potential weight bias or stigma in treating lesbian and bisexual (LB) women who are overweight or obese were pilot-tested in two unique settings. Trainings used LB cultural competency and motivational interviewing techniques to improve provider-patient interactions. METHODS: Two training formats were used: Clinic Format and Academic Format. Clinic Format training was pilot tested at Lyon-Martin Health Services, a Program of HealthRight360, a community health center serving women, lesbians, and transgender people in San Francisco and in two community settings. Academic Format training was pilot tested by the Mautner Project of Whitman-Walker Health with physicians, medical residents, and students at Georgetown, George Washington, Howard, and Vanderbilt Universities. Both programs measured provider knowledge and attitude change. RESULTS: Both programs saw significant percentage point gains in knowledge about LB women's avoidance of health care based on body size. Participants in the Academic Format program saw the greatest gain in knowledge about understanding health care avoidance (30 percentage point increase), whereas Clinic Format program participants gained most in understanding how to appropriately discuss weight loss with patients (23 percentage point increase). CONCLUSIONS: Both programs increased provider knowledge about the barriers to health care facing LB women who are overweight and obese, reducing the potential for future negative interactions. However, the two programs differed in how they conceptualized the relationship between weight and health, likely contributing to differences in knowledge gain among participants at each site. Future studies should test differences between the two formats across site type or staff baseline knowledge differences.

PURPOSE OF REVIEW: Transgender persons suffer significant health disparities and may require medical intervention as part of their care. The purpose of this manuscript is to briefly review the literature characterizing barriers to healthcare for transgender individuals and to propose research priorities to understand mechanisms of those barriers and interventions to overcome them. RECENT FINDINGS: Current research emphasizes sexual minorities' self-report of barriers, rather than using direct methods. The biggest barrier to healthcare reported by transgender individuals is lack of access because of lack of providers who are sufficiently knowledgeable on the topic. Other barriers include: financial barriers, discrimination, lack of cultural competence by providers, health systems barriers, and socioeconomic barriers. SUMMARY: National research priorities should include rigorous determination of the capacity of the US healthcare system to provide adequate care for transgender individuals. Studies should determine knowledge and biases of the medical workforce across the spectrum of medical training with regard to transgender medical care; adequacy of sufficient providers for the care required, larger social structural barriers, and status of a framework to pay for appropriate care. As well, studies should propose and validate potential solutions to address identified gaps.

IMPORTANCE: Although acute HIV infection contributes disproportionately to onward HIV transmission, HIV testing has not routinely included screening for acute HIV infection. OBJECTIVE: To evaluate the performance of an HIV antigen/antibody (Ag/Ab) combination assay to detect acute HIV infection compared with pooled HIV RNA testing. DESIGN, SETTING, AND PARTICIPANTS: Multisite, prospective, within-individual comparison study conducted between September 2011 and October 2013 in 7 sexually transmitted infection clinics and 5 community-based programs in New York, California, and North Carolina. Participants were 12 years or older and seeking HIV testing, without known HIV infection. EXPOSURES: All participants with a negative rapid HIV test result were screened for acute HIV infection with an HIV Ag/Ab combination assay (index test) and pooled human immunodeficiency virus 1 (HIV-1) RNA testing. HIV RNA testing was the reference standard, with positive reference standard result defined as detectable HIV-1 RNA on an individual RNA test. MAIN OUTCOMES AND MEASURES: Number and proportion with acute HIV infections detected. RESULTS: Among 86,836 participants with complete test results (median age, 29 years; 75.0% men; 51.8% men who have sex with men), established HIV infection was diagnosed in 1158 participants (1.33%) and acute HIV infection was diagnosed in 168 participants (0.19%). Acute HIV infection was detected in 134 participants with HIV Ag/Ab combination testing (0.15% [95% CI, 0.13%-0.18%]; sensitivity, 79.8% [95% CI, 72.9%-85.6%]; specificity, 99.9% [95% CI, 99.9%-99.9%]; positive predictive value, 59.0% [95% CI, 52.3%-65.5%]) and in 164 participants with pooled HIV RNA testing (0.19% [95% CI, 0.16%-0.22%]; sensitivity, 97.6% [95% CI, 94.0%-99.4%]; specificity, 100% [95% CI, 100%-100%]; positive predictive value, 96.5% [95% CI, 92.5%-98.7%]; sensitivity comparison, P < .001). Overall HIV Ag/Ab combination testing detected 82% of acute HIV infections detectable by pooled HIV RNA testing. Compared with rapid HIV testing alone, HIV Ag/Ab combination testing increased the relative HIV diagnostic yield (both established and acute HIV infections) by 10.4% (95% CI, 8.8%-12.2%) and pooled HIV RNA testing increased the relative HIV diagnostic yield by 12.4% (95% CI, 10.7%-14.3%). CONCLUSIONS AND RELEVANCE: In a high-prevalence population, HIV screening using an HIV Ag/Ab combination assay following a negative rapid test detected 82% of acute HIV infections detectable by pooled HIV RNA testing, with a positive predictive value of 59%. Further research is needed to evaluate this strategy in lower-prevalence populations and in persons using preexposure prophylaxis for HIV prevention.

PURPOSE OF REVIEW: This article describes methodological challenges, gaps, and opportunities in US transgender health research. RECENT FINDINGS: Lack of large prospective observational studies and intervention trials, limited data on risks and benefits of sex affirmation (e.g., hormones and surgical interventions), and inconsistent use of definitions across studies hinder evidence-based care for transgender people. Systematic high-quality observational and intervention-testing studies may be carried out using several approaches, including general population-based, health systems-based, clinic-based, venue-based, and hybrid designs. Each of these approaches has its strength and limitations; however, harmonization of research efforts is needed. Ongoing development of evidence-based clinical recommendations will benefit from a series of observational and intervention studies aimed at identification, recruitment, and follow-up of transgender people of different ages, from different racial, ethnic, and socioeconomic backgrounds and with diverse gender identities. SUMMARY: Transgender health research faces challenges that include standardization of lexicon, agreed upon population definitions, study design, sampling, measurement, outcome ascertainment, and sample size. Application of existing and new methods is needed to fill existing gaps, increase the scientific rigor and reach of transgender health research, and inform evidence-based prevention and care for this underserved population.

PURPOSE: Adult lesbian and bisexual (LB) women are more likely to be obese than adult heterosexual women. Achieving a healthy weight reduces health risks and improves quality of life, but the evidence based on successful weight interventions is limited. To inform a national initiative, a metasynthesis (a form of qualitative meta-analysis) of focus group data was conducted to gather lesbian and bisexual womens' perspectives. METHODS: Analysis used de-identified transcripts and narrative reports from 11 focus groups guided by different semi-structured discussion guides with 65 participants from five locations. A literature search was conducted to identify existing themes in published literature and unpublished reports. RESULTS: Six key themes were identified: aging; physical and mental health status; community norms; subgroup differences; family and partner support; and awareness and tracking of diet and physical activity. Participants expressed feeling unprepared for age-related changes to their health and voiced interest in interventions addressing these issues. Their perspectives on community acceptance of body size shifted as they aged. Participants cited age, class, race, ethnicity, sexual identity, and gender expression as potential characteristics that may influence participation in interventions. Families were both a barrier to and a facilitator of health behaviors. Awareness and tracking of dietary habits, stressors, and physical activity levels emerged as a theme in more than half of the groups. CONCLUSION: An unsolicited, overarching theme was aging and its influence on the participants' perspectives on health and weight. Interventions should be tailored to the needs, goals, and community norms of LB women.

Worldwide, transgender women who engage in sex work have a disproportionate risk for HIV compared with natal male and female sex workers. We reviewed recent epidemiological research on HIV in transgender women and show that transgender women sex workers (TSW) face unique structural, interpersonal, and individual vulnerabilities that contribute to risk for HIV. Only six studies of evidence-based prevention interventions were identified, none of which focused exclusively on TSW. We developed a deterministic model based on findings related to HIV risks and interventions. The model examines HIV prevention approaches in TSW in two settings (Lima, Peru and San Francisco, CA, USA) to identify which interventions would probably achieve the UN goal of 50% reduction in HIV incidence in 10 years. A combination of interventions that achieves small changes in behaviour and low coverage of biomedical interventions was promising in both settings, suggesting that the expansion of prevention services in TSW would be highly effective. However, this expansion needs appropriate sustainable interventions to tackle the upstream drivers of HIV risk and successfully reach this population. Case studies of six countries show context-specific issues that should inform development and implementation of key interventions across heterogeneous settings. We summarise the evidence and knowledge gaps that affect the HIV epidemic in TSW, and propose a research agenda to improve HIV services and policies for this population.