HIV-Related Healthcare Needs and Access Barriers for Brazilian Transgender and Gender Diverse People

Mapping projects for expanding rapid HIV testing in key populations, Brazil, 2004-2021

The HIV/AIDS epidemic remains a persistent and real issue, especially in key populations such as men who have sex with men (MSM), travestis and transgender persons. Projects for expanding rapid HIV testing are strategic initiatives aimed at the earliest possible identification of individuals' serological status and thus early treatment, screening of sex partners, and upscaling of preventive actions to interrupt the transmission chain. This study thus maps, describes, and systematizes the projects for expanding rapid HIV testing implemented from 2004 to 2021 in Brazil, highlighting the on-going contribution of civil society organizations and discussing the interoperability and cooperation resulting from public governance processes. We selected 67 documents for analysis, including 30 scientific publications retrieved from electronic databases and 37 documents produced by government institutions and nongovernmental organizations (NGOs). Find Out (Fique Sabendo), I Want to Get Tested (Quero Fazer), The Time is Now (A Hora É Agora), Live Better Knowing (Viva Melhor Sabendo), and Live Better Knowing Young (Viva Melhor Sabendo Jovem) were the projects mapped. Results show that the projects have used strategies adapted to the key population, such as mobile testing units, peer education, and innovative community engagement approaches. Such actions were enabled by effective cooperation and interoperability between participating stakeholders, especially NGOs.

The Impact of COVID-19 on HIV Care in Rio de Janeiro, Brazil 2019-2021: Disparities by Age and Gender

We evaluated COVID-19's impact on HIV care indicators among INI/FIOCRUZ's HIV Clinical Cohort in Rio de Janeiro, Brazil: (1) Adequate care visits: two visits ≥ 90 days apart; (2) Adequate viral load monitoring: ≥ 2 viral load results ≥ 90 days apart; (3) Consistent viral suppression: all viral loads < 40 copies/mL; and (4) ART medication possession ratio (MPR) ≥ 95%. Chi-square tests compared the fraction of participants meeting each indicator per period: pre-pandemic (3/1/2019-2/29/2020) and post-pandemic (3/1/2020-2/28/2021). Logistic regression models were used to assess disparities in adequate care visits. Among 906 participants, care visits and viral load monitoring decreased pre-pandemic to post-pandemic: 77.0-55.1% and 36.6-11.6% (both p < 0.001), respectively. The optimal MPR rate improved from 25.5 to 40.0% (p < 0.001). Post-pandemic period (aOR 0.33, CI 0.28-0.40), transgender women (aOR 0.34, CI 0.22-0.53), and those aged 18-24 years (aOR 0.67, CI 0.45-0.97) had lower odds of adequate care visits. COVID-19 disrupted care access disproportionately for transgender women and younger participants.

Mortality rates by gender and sexual orientation reveal a disproportionally high mortality among cisgender men of unknown sexual orientation and men who have sex with women in a cohort of people living with HIV in Rio de Janeiro, Brazil

BACKGROUND

Antiretroviral therapy use has led to a decline in HIV-related mortality yet disparities by gender and/or sexual orientation may exist. In this study, we estimated hazards of death in people living with HIV (PLWH) according to gender and sexual orientation.

METHODS

We included PLWH ≥ 18 years enrolled between 2000 and 2018 at INI/Fiocruz, Rio de Janeiro, Brazil. Participants were grouped as cisgender or transgender women, cisgender men who have sex with men (MSM) or men who have sex with women, or cisgender men with unknown sexual orientation. We assessed disparities in the hazard of death using Cox proportional hazards models.

RESULTS

Among 5,576 PLWH, median age at enrollment was 35 years, 39% were MSM, 28% cisgender women, 23% men who have sex with women, 5% transgender women, and 5% men with unknown sexual orientation. A total of 795 deaths occurred in 39,141 person-years of follow-up. Mortality rates per 1,000 person-years were: 82.4 for men with unknown sexual orientation, 24.5 for men who have sex with women, 18.3 for cisgender, 16.6 for transgender women, and 15.1 for MSM. Compared to MSM, men with unknown sexual orientation had the highest death hazard ratio (adjusted hazard ratio [aHR] 2.93, 95% confidence interval [CI] 2.35-3.81), followed by men who have sex with women (aHR 1.17, 95%CI 0.96, 1.43); death hazard ratios for cisgender and transgender women were not statistically different.

CONCLUSION

We observed disparities in the hazard of death for men with unknown sexual orientation and men who have sex with women despite universal access to antiretroviral therapy in Brazil. Future work should characterize and assist men with unknown sexual orientation with tailored policies and interventions. Increased hazard of death was not observed for transgender women, which probably results from interventions implemented in our service to reach, engage, retain, and support this population.

Feasibility of communication platforms to empower transgender cultural competence among human immunodeficiency virus screeners: A qualitative analysis

Background

Human immunodeficiency virus (HIV) screeners have limited experience of interacting with trans people. The application of communication platforms between them to empower HIV screeners' trans-related cultural competence remains unknown.

Objective

This study aims to qualitatively explore the follow-up interviews of HIV screeners regarding their opinions on the feasibility of an online platform group discussion and web page to enhance communication between them and trans people and to explore their perspectives on how these components enhanced their promotion of cultural competence.

Methods

This study was conducted between October 2020 and June 2021. Purposive and snowball sampling were applied to recruit 6 trans persons and 11 HIV screeners. Six online platform group discussions were held on weekday evenings, each group meeting for 60 min, 360 min in total within 3 months, via a video chat room of Google Meet; this was supplemented by a closed web page. The major results were presented through content analysis of the HIV screeners' follow-up interviews.

Results

The HIV screeners identified the facilitators of participating in the communication platforms, which included a reminder message, easy-to-use interface, visible-audible and readable interaction, recalled and reviewable content and group belonging; the barriers included time and space limitation, device restrictions and operation problem. Two categories of trans-related cultural competence - trans awareness and action taken - were revealed, from which five major themes emerged: provoked to ask questions, improved cognition, reflection, trans-sensitive communication and self-enhancement.

Conclusion

The results revealed that the communication platforms could facilitate the mutual and vivid discussion between HIV screeners and trans people and empower the trans-related cultural competence of HIV screeners. The highly feasible intervention design of this research can be applied to digital training courses related to gender diversity issues.

“¿Por qué pasa esto? Porque vivimos en una sociedad que constantemente te dice que no eres mujer”: género y riesgo del VIH en mujeres trans del noreste mexicano

Las mujeres trans enfrentan un riesgo desproporcionado de adquirir el VIH. Este estudio analiza cualitativamente el riesgo del VIH en mujeres trans mexicanas desde el género como estructura social. Se trata de un estudio cualitativo realizado en el noreste de México. Se hicieron 15 entrevistas a mujeres trans de entre 22 y 69 años y se realizó un análisis temático. El análisis de las entrevistas reveló tres categorías temáticas: construcciones sociales del VIH y estigma, el género y el VIH en las relaciones interpersonales, y el género y el VIH en las instituciones y la política. Los resultados muestran que las construcciones sociales del VIH se tejen en el colectivo, a partir de la interacción con otras mujeres trans. El VIH es un fenómeno atravesado por la temporalidad sociohistórica y, en ese sentido, se generan las percepciones de riesgo frente a él. El género como estructura de opresión se vincula con las experiencias de estigma y discriminación, así como la búsqueda de la legitimación del género a través de las relaciones con parejas sexuales. Las instituciones y la política pública se relacionan con el acceso a los servicios de salud, además se identifican y analizan las barreras institucionales, personales y colectivas a partir de la identidad de género. La política sostiene y refuerza la marginalización de las mujeres trans impactando en el riesgo del VIH. Los resultados muestran que el riesgo del VIH es un fenómeno multicausal basado en el género como estructura de opresión con implicaciones sistémicas.

Sampling bias in Brazilian studies on transgender and gender diverse populations: the two-step measure for assessing gender identity in surveys

Abstract: Correctly recognizing gender identity in population-based surveys is essential to develop effective public health strategies to improve the living conditions of transgender and gender-diverse populations, as well as to adequately collect data on cisgender individuals. This study aims to present the two-step measure as the best strategy for assessing gender identity in Brazilian surveys, thus we performed two separate analyses. Firstly, we conducted a systematic review concerning HIV-related care among Brazilian transgender and gender-diverse populations to assess the strategy used to identify participants’ gender identity. Secondly, we re-analyzed data from a recent survey that included Brazilian transgender populations, comparing characteristics and health outcomes from the sample identified by single-item and by the two-step measure. Concerning the systematic review, from 6,585 references, Brazilian research teams published seven articles, and only one study used the two-step measure. Regarding this survey, the two-step measure recognized 567 cisgender and 773 transgender and gender diverse participants among the 1,340 participants who answered the questionnaire, whereas the single-item measure was able to recognize only 540 transgender and gender diverse people. Furthermore, 31 transgender women self-identified as “transgender men” on the single-item measure. Therefore, although scarcely used in Brazil, the two-step measure is a more accurate strategy to recognize gender identity.

'I'm not interested in research; i'm interested in services': How to better health and social services for transgender women living with and affected by HIV

This paper presents results of a research priority setting process focused on trans women living with and affected by HIV across Canada. It features data from semi-structured interviews and focus groups conducted with a diverse group of 76 trans women in five urban centers across the country on how they have navigated health and social service programming within their geographic context. The results focus on the structure and types of services. Respondents offered simple, yet creative ways to address barriers to vital services based on their individual and collective experiences. Notably, participants stressed the need for 1) trans-friendly and trans-specific services, 2) integrated health services, and aid in navigating complex, overlapping systems, and 3) comprehensive community-based services. They also suggest employing trans women as care coordinators or case managers in order to foster more trans-friendly environments and empower community members. We identify concrete ways to improve health and social services at the level of service delivery and program design, as well as recommendations for future participatory research. We close with an interrogation of trans people, and trans women living with and affected by HIV in particular, as 'hard to reach' populations.

Association between gender-based discrimination and medical visits and HIV testing in a large sample of transgender women in northeast Brazil

Background

Gender-based discrimination remains a substantial barrier to health care access and HIV prevention among transgender women in Brazil. The aim of this study was to investigate the association between gender-based discrimination and medical visits, as well as with HIV testing among transgender women in the last 12 months in northeast Brazil.

Methods

This is a cross-sectional study of 864 transgender women recruited using Respondent-Driven Sampling in three cities in northeastern Brazil in 2016. A socio-behavioral questionnaire was applied. Multivariate analyses were performed using logistic regression, with odds ratio and respective 95% confidence intervals estimation, to estimate the effect of gender-based discrimination on two outcomes: i) medical visits and ii) HIV testing in the last 12 months.

Results

547 transgender women (67·0%) had medical visits, and 385 (45·8%) underwent HIV testing in the last 12 months. In the multivariate analysis, gender-based discrimination was associated with a reduced likelihood of medical visits (OR: 0·29; 95%CI: 0·14–0·63) and HIV testing (OR: 0·41; 95%CI: 0·22–0·78) in the last 12 months.

Conclusion

Gender-based discrimination played an essential role in reducing the access of TGW to medical visits and HIV testing services. Furthermore, by confirming the association between gender-based discrimination and medical visits and HIV testing in the multivariate analysis, we have demonstrated how this predictive variable can affect by reducing access to health services. The findings point to the need for non-discriminatory policies based on the defense and promotion of human rights that may foster the access of transgender women to Brazilian health services.

Condom-Protected Sex and Minority Stress: Associations with Condom Negotiation Self-Efficacy, "Passing" Concerns, and Experiences with Misgendering among Transgender Men and Women in Brazil

This cross-sectional exploratory study aims to verify associations between condom-protected sex, condom negotiation self-efficacy, self-esteem, and four minority stressors (experiences with misgendering, "passing" concerns, anticipated prejudice, and perceived prejudice) among transgender men (TM) and transgender women (TW). 260 individuals (192 TW and 68 TM) residing in two Brazilian states participated in the study. Data was collected online and in two hospital programs for transgender people and included sociodemographic data, condom-protected sex, the Trans-Specific Condom/Barrier Negotiation Self-Efficacy (T-Barrier) Scale, the Rosenberg Self-Esteem Scale, and four minority stressors. Measures that were significantly associated with condom-protected sex were tested as independent variables in a linear regression model. The main results suggest that lower condom negotiation self-efficacy, higher "passing" concerns, and higher experiences with misgendering were predictors of lower frequency of condom-protected sex. These negative outcomes were found among both TM and TW, which justifies their inclusion in public health policies. Structural strategies and clinical interventions are suggested to address condom negotiation self-efficacy and "passing" concerns in transgender populations.

Key and general population HIV-related stigma and discrimination in HIV-specific health care settings: results from the Stigma Index Brazil

HIV-related stigma and discrimination lead to poorer mental health, lower levels of services usage, and less adherence to antiretroviral medications. Due to the overlap of different kinds of stigmas, HIV-positive key populations are the most susceptible to negative health outcomes. The Stigma Index is an instrument that measure worldwide trends in HIV-related stigma from the perspective of people living with HIV/AIDS (PLWHA). The present community-based study aims to estimate the prevalence of HIV-related discrimination in the past 12 months in HIV-related care, comparing general and key populations in Brazil. A total of 30 PLWHA were trained to recruit participants among their peer networks; 1768 PLWHA participated in the study and were asked if, in the past 12 months when seeking HIV-specific healthcare, they had experienced discrimination from health facility staff because of their HIV status. Overall, 269 (15.21%) participants experienced this kind of discrimination. The odds of experiencing discrimination in HIV-specific healthcare settings in the general versus key populations was OR 1.77 95% CI [1.30 -2.42]. It is noteworthy that in Brazil, after four decades of a human rights-based approach to the epidemic, we found high levels of discrimination in the HIV-specific healthcare context affecting the key populations more severely.

HIV continuum of care among trans women and travestis living in São Paulo, Brazil

OBJECTIVE

To examine the HIV care cascade among trans women and travestis in São Paulo - Brazil, the most populous city in South America.

METHODS

Using data from a cross-sectional study carried out between November 2016 and May 2017 in the city of São Paulo (Divas Research). Respondent driven sampling (RDS) was used to recruit 386 transgender women and travestis who participated in a HIV risk survey and were tested for HIV. The cascade was defined as HIV prevalence, HIV diagnosed, Antiretroviral (ART) Prescription, and currently on ART. A multiple analysis model was conducted to identify the association between sociodemographics and the cascade gaps.

RESULTS

Of the trans women living with HIV, 80.9% were already diagnosed, 76.6% of them had been prescribed, of which 90.3% were currently on treatment. Those who were registered in care had a higher rate of ART (aPR 2.06; 95%CI 1.09-3.88). Trans women between 31-40 years old (aPR 1.65; 95%CI 1.09-2.50) and those older than 40 (aPR 1.59; 95%CI 1.04-2.43) had higher prevalence of ART.

CONCLUSIONS

Our data suggest an increase in the testing and treatment policy implementation among trans women in the city of São Paulo, although gaps have been found in the linkage to care. However, young trans women and those not registered in health care service may benefit from efforts to engage this part of the population in care to improve HIV treatment and care outcomes.

High risk and low HIV prevention behaviours in a new generation of young trans women in Brazil

Adult trans women in Brazil are highly impacted by HIV, but little is known about risk for young trans women. Our study was conducted to compare the HIV prevalence and correlates of risk for young trans women ages 18-24 years old to adult trans women in Brazil. Trans women were recruited from Rio de Janeiro and Baixada (the metropolitan area of Rio de Janeiro), Brazil (N = 345). Youth ages 18-24 years of age had significantly greater odds of being HIV negative than adults (OR 0.4, 95% CI 0.2-0.6, p = 0.0002), but significantly lower odds of having post-exposure prophylaxis (PEP) knowledge (OR 0.5, 95% CI:0.3-0.9, p = 0.02) and PrEP awareness (OR 0.5, 95% CI: 0.3-0.8, p = 0.01). Young trans women also had significantly higher odds of using substances (OR 1.8, 95% CI 1.1-2.9, p = 0.02) and condomless anal intercourse with their last three sexual partners (OR 1.8, 95% CI: 1.1-3.0, p = 0.03) compared to adults. Already by age 24, one in four trans women in Brazil were infected with HIV pointing to a new generation at high risk of acquiring HIV. HIV prevention interventions are needed to change the healthcare system to reach and engage young trans women.

Health of transgender men in low-income and middle-income countries: a scoping review

INTRODUCTION

Despite the rapid growth of research on transgender (trans) health globally, the extent of research on trans men and other transmasculine persons assigned the female sex at birth remains unclear. We, therefore, conducted a scoping review on trans men's health in low-income and middle-income countries (LMICs).

METHODS

The review included peer-reviewed articles and conference abstracts, and grey literature published from 1 January 1999 to 5 July 2019 in English, French, Hindi or Spanish and reporting original quantitative and/or qualitative data on the health of trans men or transmasculine persons living in LMIC. Studies were excluded if they did not disaggregate data for trans men or if they only described surgical techniques or laboratory values.

RESULTS

We included 53 studies (42 peer-reviewed and 11 grey literature) from 19 LMIC. Most were conducted in higher-middle-income countries (n=12) and in Latin America (n=16, 30.2%), the Middle East (n=14, 26.4%) or Sub-Saharan Africa (n=12, 22.6%) and published in 2014 or later (n=44, 83.0%). Approximately half of studies used quantitative methods (52.8%, n=28), of which 64.3% (n=18) had fewer than 50 participants and 14.2% (n=4) had over 150. Across study designs, social determinants of health and gender-affirming care were the most commonly represented domains (49.1% and 47.1% of studies respectively), with common themes including gender-based violence, coercion and discrimination as well as unprescribed hormone use. Other domains represented included mental health (32.1%), sexual and reproductive health (24.5%), general healthcare access (18.9%), physical health (9.4%) and substance use (9.4%).

CONCLUSION

Greater inclusion and disaggregation of trans men and transmasculine persons in global health research is needed to support sex- and gender-based analyses of trans health. Community-based research approaches and theoretically driven research may help to increase the relevance and rigour of such research. Funders should invest in research on trans men's health in LMIC.

Gender Affirmation Is Associated with Transgender and Gender Nonbinary Youth Mental Health Improvement

Purpose: The present study aimed to evaluate the impact of each domain of gender affirmation (social, legal, and medical/surgical) on the mental health of transgender and gender nonbinary youth. Methods: Three hundred fifty transgender boys, transgender girls, and gender nonbinary Brazilian youth, from 16 to 24 years old, answered an online survey. Results: The final sample consisted of 350 youth who participated in this study. A total of 149 (42.64%) youth identified as transgender boys, 85 (24.28%) identified as transgender girls, and 116 (33.14%) identified as gender nonbinary youth. The mean age was 18.61 (95% confidence interval 18.34-18.88) years. Having accessed multiple steps of gender affirmation (social, legal, and medical/surgical) was associated with fewer symptoms of depression and less anxiety. Furthermore, engaging in gender affirmation processes helped youth to develop a sense of pride and positivity about their gender identity and a feeling of being socially accepted. Conclusion: Enabling transgender and gender nonbinary youth to access gender affirmation processes more easily should be considered as a strategy to reduce depression and anxiety symptoms, as well as to improve gender positivity.

A Retrospective Review of Medical Records of Laboratory-Tested Sexually Transmitted Infections of Transsexual Men from Southern Brazil

The present study assessed the prevalence of sexually transmitted infections (STIs) in 90 transsexual men (female-to-male transsexual persons) from southern Brazil. A retrospective review of the medical records of all transsexual men who visited an outpatient clinic in Rio Grande do Sul from 1998 to 2017 was performed. Although the sample had a high prevalence of risk factors for contracting STIs, such as drug use, one-third of the participants had never been tested for STIs and, when screened, it was mostly for HIV, but not for syphilis or other STIs. Based only on laboratory-tested transsexual men, the prevalence of syphilis and hepatitis C was 3.4% and 1.6%, respectively, which is higher than the general population. It is clear that health professionals need to broaden their understanding of transsexual men, acknowledging STIs as a possible diagnosis.

Dealing with gender-related and general stress: Substance use among Brazilian transgender youth

INTRODUCTION

Adolescent substance use is a major public health concern since it enhances adolescent morbidity and mortality, affecting adulthood health and well-being. Although current evidence shows a high risk for substance use among transgender populations, to date, few studies evaluate substance use among transgender youth.

METHOD

Brazilian transgender youth (ages between 16 and 25 years old) answered an online questionnaire measuring demographics, substance use and modifiable factors associated with drug use to deal with general stress, gender-related stress, and recreational use.

RESULTS

Cannabis was the most frequent substance used among transgender youth (20.88%; CI 95% 23.71-36.19), whereas 11.45% (CI 95% 11.38-21.47) of volunteers disclosed use of pain medication, such as codeine, and 5.05% (CI 95% 3.71-10.78) revealed use of sedatives and tranquilizers in the last 30 days. ADH medication (not prescribed), as well as cocaine and other drugs (such as antihistamines and Hookah), was also reported by 2.36% (CI 95% 0.92-5.84), 2.69% (CI 95% 1.24-6.49) and 4.04% (CI 95% 2.61-8.98) of transgender youth.

CONCLUSION

A logistic regression model showed that discrimination and home instability were the primary determinants of vulnerable to substance use among youth. Therefore, the harm reduction strategies must affect the social and physical aspects of transgender youth lives.

HIV-related care for transgender people: A systematic review of studies from around the world

RATIONALE

Transgender people face unique challenges, such as structural, interpersonal, and individual vulnerabilities to chronic diseases. Stigma and prejudice may hamper their access to health care and prevent their inclusion in the labor market, as well as cause exposition to violence. Labor market exclusion contributes to engagement in survival sex work, which increases HIV infection vulnerability. HIV continuum of care combines HIV prevention (including antiretroviral pre-exposure prophylaxis (PrEP), antiretroviral post-exposure prophylaxis (PEP) and HIV testing) with linkage to care (that is, initiating, maintaining and monitoring antiretroviral therapy). Currently, many studies evaluate the access barriers and facilitators to HIV care for transgender people.

OBJECTIVE

The present systematic review aimed to provide a clear summary of the current literature on HIV-related care for transgender men, transgender women and gender diverse people.

METHOD

Inclusion criteria were peer-reviewed quantitative studies, published through April 04, 2018, concerning transgender women, transgender men and gender diverse people and HIV-related care, which was any intervention aiming to prevent, treat or alleviate the impact of HIV on these populations.

RESULTS

From 6,585 references, 62 articles were included: Three articles had results on PEP, 18 on PrEP, 29 on HIV-testing, 17 on access to health care, and 13 on adherence to treatment.

CONCLUSIONS

The present study is the first systematic review evaluating HIV-related care for transgender people. Data collection is still scarce regarding transgender men and gender diverse people. Worldwide, testing for HIV infection does not necessarily enable access to the HIV continuum of care for transgender populations or even guarantee awareness of HIV seropositivity.

Optimizing HIV prevention and care for transgender adults

: Transgender women have recently been acknowledged as a unique and important risk group in HIV research and care. Although transgender men also face specific problems related to HIV infection, less is known about the risk behaviours and HIV prevalence of this important population. This article highlights key issues relating to the epidemiology, prevention, treatment and management of complications of HIV infection in transgender adults living with HIV, and explores future areas for HIV-related research, with the ultimate goal of improving healthcare provision and quality of life for transgender persons worldwide.

A Preliminary Assessment of Selected Social Determinants of Health in a Sample of Transgender and Gender Nonconforming Individuals in Puerto Rico

Purpose: Transgender and gender nonconforming (GNC) people continue to experience suboptimal health care, social exclusion, and lower quality of life. Globally, lack of access to services, institutional violence, and public harassment have been reported. However, there is limited data on transgender health in Puerto Rico and the Caribbean. The purpose of this study is to assess the social determinants of health and wellbeing of transgender and GNC people living in Puerto Rico. Methods: Utilizing a community-based participatory research approach, 52 self-identified transgender and GNC individuals living in Puerto Rico completed a survey, which included questions on access to health care services, social support, and violence, among others. Data were collected from March to Ma y of 2015 and descriptive statistical analysis was conducted. Results: Most of the participants reported experiences of discrimination across multiple social settings, most commonly at school (70.6%) and work (67.4%). Regarding experiences of violence, more than half (65.4%) had been verbally attacked in a public space. Many reported that access to gender-affirming health care services is difficult in Puerto Rico (88.5%) due to lack of knowledgeable providers (59.6%) and discomfort during the encounter (55.8%). The main perceived priority for their wellbeing was a transgender health care center. Conclusion: Although the LGBT equality movement has reached great milestones, access to gender-affirming health services and safe educational and work spaces are still needed. Findings from the study provide guidance for actions to reduce health disparities by addressing the needs for health and wellbeing among transgender and GNC individuals.