- Email: [email protected]
HIV in transgender women in Brazil
Comment
HIV in transgender women in Brazil In The Lancet HIV, Beatriz Grinsztejn and colleagues1 advance the knowledge base for HIV and sexually transmitted diseases (STIs) among transgender women in Brazil by reporting results from a study remarkable for both its scientific rigour and meaningful community engagement. The authors use respondent-driven sampling methods and validation with national registry databases to estimate HIV prevalence and identify new diagnoses of HIV infection among transgender women. Their findings are consistent with previous non-probability studies2 in other settings and indicate high prevalence of HIV and STIs compared with other key populations in Brazil. The heavy burden of HIV and STIs in their young sample (median age 28 years) and the disparities noted in race, gender identity, sex work, and substance use histories highlight the importance of reaching marginalised transgender youth with HIV/STI prevention and care services. Almost a third of transgender women in this study were living with HIV and almost a quarter of these women with HIV had previously undiagnosed infections. At first glance, these data suggest low access to or uptake of HIV testing. However, 43·7% of the women with newly diagnosed infections had received a negative HIV test result within the previous 12 months. The young age of participants combined with a high proportion of newly acquired HIV point to an elevated incidence and prevalence in this population. In response to these alarming data, the authors assert an urgent need to make pre-exposure prophylaxis (PrEP) available to transgender women. However, although PrEP has proven efficacy in other key populations,3 crucial research gaps remain for PrEP acceptability, potential interactions with feminising hormones,4 and effective adherence strategies for transgender women.5 These issues must be addressed for transgender women to benefit fully from this intervention. Consistent with other populations and previous research on transgender women,6,7 new HIV diagnoses were associated with black race, sex work, and substance use. Importantly, the authors also note transgender-specific HIV risk and protective factors. Travesti and transsexual gender identities were associated with greater odds of HIV than was identification as a woman. Similar disparities by gender identity have
been found among transgender women in the USA.8 These identity-based disparities are poorly understood and under-researched. They illustrate the importance of collection of gender identity data within transgender populations and the essential need for qualitative research to better understand than at present how gender identities shape HIV risk. The low prevalence of gender-affirming surgeries and high proportion of participants who reported obtaining silicone and hormone therapy outside of formal medical settings highlight the challenges that many transgender women face in accessing medical gender affirmation.9 The authors noted that in univariate analyses, ever having had gender-affirming surgery was associated with a lower odds of a new HIV diagnosis than was never having had these surgeries. These findings present a reasonable and testable hypothesis that unfettered access to surgical gender affirmation is an effective HIV prevention intervention for transgender women. The study also tells a compelling story of HIV syndemics and structural drivers of risk. Poverty, violence, and substance use were common. The age of sexual debut was shockingly young and would be consistent with statutory rape in many countries. Even in the Brazilian context where the age of consent is as young as 12 years for people with sexual partners less than 6 years older than them, almost a third of the sample had sex before they reached the age of 12 years. Data for physical and sexual violence are alarming, with more than 70% of participants living with HIV reporting lifetime physical violence victimisation and almost 60% reporting lifetime sexual violence. These results exceed any documented estimates for cisgender women and are likely to be both drivers of HIV acquisition and barriers to HIV prevention and care.10–12 HIV among transgender women clearly cannot be addressed in isolation from the syndemic conditions within which HIV risk occurs. Research to identify appropriate and effective structural interventions that address the real needs of transgender women at risk of HIV are desperately needed. Additionally, qualitative and mixed methods research can help improve understanding of the unique psychosocial factors related to gender identity and HIV risk. Although much remains to be learned, the data provided here clearly
www.thelancet.com/hiv Published online February 7, 2017 http://dx.doi.org/10.1016/S2352-3018(17)30014-0
Lancet HIV 2017 Published Online February 7, 2017 http://dx.doi.org/10.1016/ S2352-3018(17)30014-0 See Online/Articles http://dx.doi.org/10.1016/ S2352-3018(17)30015-2
1
Comment
show that we cannot wait. A pressing need exists and we have actionable data that can be used now to prevent HIV and promote engagement in treatment and care for transgender women.
5
6 7
*Tonia Poteat, Andrea L Wirtz
8
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA [email protected]
9
We declare no competing interests. 1
2
3
4
2
Grinsztejn B, Jalil EM, Monteiro L, et al, for the Transcender Study Team. Unveiling of HIV dynamics among transgender women: a respondent-driven sampling study in Rio de Janeiro, Brazil. Lancet HIV 2017; published online Feb 7. http://dx.doi.org/10.1016/S2352-3018(17)30015-2. Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis 2013; 13: 214–22. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med 2010; 363: 2587–99. Sevelius JM, Keatley J, Calma N, Arnold E. ‘I am not a man’: trans-specific barriers and facilitators to PrEP acceptability among transgender women. Glob Public Health 2016; 11: 1060–75.
10
11
12
Deutsch MB, Glidden DV, Sevelius J, et al. HIV pre-exposure prophylaxis in transgender women: a subgroup analysis of the iPrEx trial. Lancet HIV 2015; 2: e512–19. Hoffman BR. The interaction of drug use, sex work, and HIV among transgender women. Subst Use Misuse 2014; 49: 1049–53. Poteat T, German D, Flynn C. The conflation of gender and sex: gaps and opportunities in HIV data among transgender women and MSM. Glob Public Health 2016; 11: 835–48. Mulatu M, Wang G, Zhang H, Song W, Wan C, Gilford J. HIV testing, seropositivity, and linkage to care among transgender persons in CDC-funded testing sites in the United States, 2012–2013. 2015 National HIV Prevention Conference; Atlanta, GA, USA; Dec 6–9, 2015. Abstract 1559. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality, 2011. Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet; 376: 41–48. Hatcher AM, Smout EM, Turan JM, Christofides N, Stöckl H. Intimate partner violence and engagement in HIV care and treatment among women: a systematic review and meta-analysis. AIDS 2015; 29: 2183–94. Roberts ST, Haberer J, Celum C, et al. Intimate partner violence and adherence to HIV pre-exposure prophylaxis (PrEP) in African women in HIV serodiscordant relationships: a prospective cohort study. J Acquir Immune Defic Syndr 2016; 73: 313–22.
www.thelancet.com/hiv Published online February 7, 2017 http://dx.doi.org/10.1016/S2352-3018(17)30014-0
HIV in transgender women in Brazil In The Lancet HIV, Beatriz Grinsztejn and colleagues1 advance the knowledge base for HIV and sexually transmitted diseases (STIs) among transgender women in Brazil by reporting results from a study remarkable for both its scientific rigour and meaningful community engagement. The authors use respondent-driven sampling methods and validation with national registry databases to estimate HIV prevalence and identify new diagnoses of HIV infection among transgender women. Their findings are consistent with previous non-probability studies2 in other settings and indicate high prevalence of HIV and STIs compared with other key populations in Brazil. The heavy burden of HIV and STIs in their young sample (median age 28 years) and the disparities noted in race, gender identity, sex work, and substance use histories highlight the importance of reaching marginalised transgender youth with HIV/STI prevention and care services. Almost a third of transgender women in this study were living with HIV and almost a quarter of these women with HIV had previously undiagnosed infections. At first glance, these data suggest low access to or uptake of HIV testing. However, 43·7% of the women with newly diagnosed infections had received a negative HIV test result within the previous 12 months. The young age of participants combined with a high proportion of newly acquired HIV point to an elevated incidence and prevalence in this population. In response to these alarming data, the authors assert an urgent need to make pre-exposure prophylaxis (PrEP) available to transgender women. However, although PrEP has proven efficacy in other key populations,3 crucial research gaps remain for PrEP acceptability, potential interactions with feminising hormones,4 and effective adherence strategies for transgender women.5 These issues must be addressed for transgender women to benefit fully from this intervention. Consistent with other populations and previous research on transgender women,6,7 new HIV diagnoses were associated with black race, sex work, and substance use. Importantly, the authors also note transgender-specific HIV risk and protective factors. Travesti and transsexual gender identities were associated with greater odds of HIV than was identification as a woman. Similar disparities by gender identity have
been found among transgender women in the USA.8 These identity-based disparities are poorly understood and under-researched. They illustrate the importance of collection of gender identity data within transgender populations and the essential need for qualitative research to better understand than at present how gender identities shape HIV risk. The low prevalence of gender-affirming surgeries and high proportion of participants who reported obtaining silicone and hormone therapy outside of formal medical settings highlight the challenges that many transgender women face in accessing medical gender affirmation.9 The authors noted that in univariate analyses, ever having had gender-affirming surgery was associated with a lower odds of a new HIV diagnosis than was never having had these surgeries. These findings present a reasonable and testable hypothesis that unfettered access to surgical gender affirmation is an effective HIV prevention intervention for transgender women. The study also tells a compelling story of HIV syndemics and structural drivers of risk. Poverty, violence, and substance use were common. The age of sexual debut was shockingly young and would be consistent with statutory rape in many countries. Even in the Brazilian context where the age of consent is as young as 12 years for people with sexual partners less than 6 years older than them, almost a third of the sample had sex before they reached the age of 12 years. Data for physical and sexual violence are alarming, with more than 70% of participants living with HIV reporting lifetime physical violence victimisation and almost 60% reporting lifetime sexual violence. These results exceed any documented estimates for cisgender women and are likely to be both drivers of HIV acquisition and barriers to HIV prevention and care.10–12 HIV among transgender women clearly cannot be addressed in isolation from the syndemic conditions within which HIV risk occurs. Research to identify appropriate and effective structural interventions that address the real needs of transgender women at risk of HIV are desperately needed. Additionally, qualitative and mixed methods research can help improve understanding of the unique psychosocial factors related to gender identity and HIV risk. Although much remains to be learned, the data provided here clearly
www.thelancet.com/hiv Published online February 7, 2017 http://dx.doi.org/10.1016/S2352-3018(17)30014-0
Lancet HIV 2017 Published Online February 7, 2017 http://dx.doi.org/10.1016/ S2352-3018(17)30014-0 See Online/Articles http://dx.doi.org/10.1016/ S2352-3018(17)30015-2
1
Comment
show that we cannot wait. A pressing need exists and we have actionable data that can be used now to prevent HIV and promote engagement in treatment and care for transgender women.
5
6 7
*Tonia Poteat, Andrea L Wirtz
8
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA [email protected]
9
We declare no competing interests. 1
2
3
4
2
Grinsztejn B, Jalil EM, Monteiro L, et al, for the Transcender Study Team. Unveiling of HIV dynamics among transgender women: a respondent-driven sampling study in Rio de Janeiro, Brazil. Lancet HIV 2017; published online Feb 7. http://dx.doi.org/10.1016/S2352-3018(17)30015-2. Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis 2013; 13: 214–22. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med 2010; 363: 2587–99. Sevelius JM, Keatley J, Calma N, Arnold E. ‘I am not a man’: trans-specific barriers and facilitators to PrEP acceptability among transgender women. Glob Public Health 2016; 11: 1060–75.
10
11
12
Deutsch MB, Glidden DV, Sevelius J, et al. HIV pre-exposure prophylaxis in transgender women: a subgroup analysis of the iPrEx trial. Lancet HIV 2015; 2: e512–19. Hoffman BR. The interaction of drug use, sex work, and HIV among transgender women. Subst Use Misuse 2014; 49: 1049–53. Poteat T, German D, Flynn C. The conflation of gender and sex: gaps and opportunities in HIV data among transgender women and MSM. Glob Public Health 2016; 11: 835–48. Mulatu M, Wang G, Zhang H, Song W, Wan C, Gilford J. HIV testing, seropositivity, and linkage to care among transgender persons in CDC-funded testing sites in the United States, 2012–2013. 2015 National HIV Prevention Conference; Atlanta, GA, USA; Dec 6–9, 2015. Abstract 1559. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality, 2011. Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet; 376: 41–48. Hatcher AM, Smout EM, Turan JM, Christofides N, Stöckl H. Intimate partner violence and engagement in HIV care and treatment among women: a systematic review and meta-analysis. AIDS 2015; 29: 2183–94. Roberts ST, Haberer J, Celum C, et al. Intimate partner violence and adherence to HIV pre-exposure prophylaxis (PrEP) in African women in HIV serodiscordant relationships: a prospective cohort study. J Acquir Immune Defic Syndr 2016; 73: 313–22.
www.thelancet.com/hiv Published online February 7, 2017 http://dx.doi.org/10.1016/S2352-3018(17)30014-0