Beyond Gender Affirmation Addressing root causes of HIV

Beyond Gender Affirmation – Addressing root causes of HIV risk and disease among trans women, data from the Trans*National study Erin C. Wilson www. transnationalstudy. org erin. wilson@sfdph. org San Francisco Department of Public Health Share your thoughts on this presentation with #IAS 2019

I have no conflicts of interest.

Trans*National Study San Francisco, USA São Paulo, Brazil Nanjing, China Windhoek, Namibia • Survey/HIV testing • Cohort study • Survey/HIV testing • Qualitative interviews

Trans*National AIMS 1 2 3 Establish a population-based cohort of trans women in San Francisco and São Paulo to measure HIV incidence To test hypotheses on social and biomedical gender transition events as causal factors in HIV acquisition among trans women To initiate HIV prevention research for trans women in China and sub-Saharan Africa

Nanjing, China: Survey (250 participants) San Francisco: Survey (629 participants) and 18 -month cohort study (429 participants) São Paulo, Brazil: 18 month cohort study (583 participants) Windhoek, Namibia: Qualitative interviews (25 participants)

HIV prevalence in context of gender affirming care access HIV prevalence 38. 8% 35. 0% 31. 6% TEACH 2013 TEACH 2016 1993 - Trans Tues clinic opens Trans Community Health Study, 1997 TEACH 2010 1. Castro Mission Health Services – Esperanza clinic & Dimensions clinic for youth 2. Lyon Martin trans health clinic 3. SF Community Health Center 4. + Private Providers at Kaiser, UCSF Mt Zion, UCSF Gender clinic for adolescents and youth, and more!

Trans*National 6 mos assessment, N=270 IS SURGERY ASSOCIATED WITH LESS MENTAL HEALTH DISTRESS AND/OR SUBSTANCE USE?

Demographics, N=270 N 270 Total Gender identity Woman or female Trans woman or trans female Other Race/ethnicity Black/African American Hispanic/Latinx Other White Age, M & SD % 100. 0 135 100 35 50. 0 37. 0 13. 0 80 12 60 118 35 29. 6 43. 7 22. 2 4. 4 14. 0

Education Less than HS or HS Diploma/GED Some college/technical degree Bachelor's degree or higher Current housing situation Stable Unstable Average annual income Above poverty level At or below poverty level 95 35. 2 93 34. 4 82 30. 4 166 104 61. 5 38. 5 82 188 30. 4 69. 6

Gender-related surgeries and procedures Laser hair removal 112 41. 5 2 0. 7 Orchiectomy 23 8. 5 Vaginoplasty 36 13. 3 Breast implants 45 16. 7 FFS 16 5. 9 3 1. 1 66 24. 4 Voice surgery 3 1. 1 Tracheal shave 8 3. 0 Fat transfer 4 1. 5 Voice therapy 7 2. 6 Other 24 8. 9 None 109 40. 4 Penectomy Dermal fillers Electrolysis Of those who have not had any procedure (n=109) • 15% do not want any procedures • 33% cannot pay for procedures • 10% report unstable housing as a barrier to surgeries

Considerable mental distress Mental and behavioral health outcomes Depression PTSD Anxiety Psychological distress Well Mild/moderate Severe N 30 27 28 % 11. 1 10. 0 10. 4 57 119 91 21. 1 44. 1 33. 7

Significant substance use Substance use, last 12 months Binge drank Meth use Crack use Painkillers Ecstasy Club drugs Downers Heroin Any IDU N 113 45 18 20 29 17 22 9 17 % 41. 9 16. 7 7. 4 10. 7 6. 3 8. 1 3. 3 6. 3

Results: Utilization of gender affirming procedures and surgery was not associated with less… – Mental health distress – Substance use Table 2. Mental health outcomes for trans women by medical service access, Trans*National, 2016 - 2018 a. OR Depression 95%CI p a. OR PTSD 95%CI p a. OR Anxiety 95%CI p Distress: Mild/moderate vs. well a. OR 95%CI p Distress: Severe vs. well a. OR 95%CI p Medical services access groups Accessed and desired medical services Ref Ref Ref Did not access, but desired, medical services 0. 95 (0. 37 - 2. 45) 0. 92 1. 24 (0. 47 - 3. 24) 0. 67 1. 68 (0. 66 - 4. 30) 0. 28 1. 19 (0. 55 - 2. 58) 0. 66 1. 18 (0. 51 - 2. 73) 0. 70 Notes: a. OR, adjusted odds ratio comparing odds of mental health outcomes by medical services access after adjusting for housing instability; CI, confidence interval; Ref, reference group (accessed medical services); distress outcomes modeled using multinomial logistic regression for categorical outcomes Table 3. Substance use outcomes for trans women by medical service access, Trans*National, 2016 - 2018 a. OR Medical services access groups Accessed and desired medical services Did not access, but desired, medical services Any IDU 95%CI Ref 2. 63 (0. 66 - 10. 45) Any crack, meth, cocaine, club drugs, ecstasy a. OR 95%CI p p 0. 17 Ref (0. 80 - 2. 72) 1. 48 Any heroine, painkillers, downers a. OR 95%CI p 0. 21 Ref (0. 54 - 1. 71) 0. 97 0. 90 Notes: a. OR, adjusted odds ratio comparing odds of substance use outcomes by medical services access after adjusting for housing instability; CI, confidence interval; Ref, reference group (accessed medical services)

Persistently high HIV incidence among trans women, San Francisco Erin C. Wilson 1, Caitlin Turner 1, Jess Lin 1, Maria Amelia Veras 2, Hongjing Yan 3, and Willi Mc. Farland 1 1. 2. Center for Public Health Research, San Francisco Department of Public Health (San Francisco, CA) Santa Casa University, Sao Paulo, Brazil, 3. Jiangsu Center for Disease Control and Prevention, Nanjing, China RESULTS • A total of 429 HIV-uninfected trans women were enrolled in the cohort; 412 had at least one follow-up visit and were included in the present analysis (96% retention). • Eight seroconversions were observed for a preliminary HIV incidence of 1. 4 per 100 person-years (PY) (95% CI: 0. 60 -2. 76). • Preliminary incidence was very high among younger trans women ages 18 -24 years (3. 88 per 100 PY). • All seroconversions were among trans women of color, with the majority being Latinas (incidence 2. 76 per 100 PY). • One participant who seroconverted was previously on Pr. EP.

es ni ti tu fo rm lth ea l h re em l o pp or na io at Ed uc st sy ice en ta 43 M un ity m Co m y et Sa f s ice rv 113 Se s tie ni op po rtu s es cc l a ed ica r 126 Ju st M he Ot 119 ic on om ec t/ en m oy pl Em g us in Ho ce an pt ce Ac n io at in sc rim Di a/ igm d St En 141 If you could change one thing for trans women in the Bay Area, what would it be? 93 71 57 39 29 18 10

What next • Gender affirming services are a necessary human right for trans women • Gender affirming services alone are not sufficient for reducing HIV risk among trans women • The final frontier for addressing the HIV risk and care needs of trans women will require addressing big structural factors like stigma, discrimination, violence and housing in health care and society

Thank you! • Trans*National research team: Sofia Lynn, Theo Beltran, Victory Le, Karen Aguilar, Corey Drew, Willi Mc. Farland, Henry Fisher Raymond, Oriana Saportas, Marla Fisher, Andres Pomart, Rafael Gonzalez, Cat Kazbour, Caitlin Turner, Jess Lin • Trans*National participants