Understanding and Addressing Human Immunodeficiency Virus and Sexually Transmitted Disease Disparities among Transgender Persons
Year: 2016
Type: article
Abstract: Luzzati et al1 contribute to the evidence of the global human immunodeficiency virus (HIV) disparity among male-to-female transgender persons with their article, Prevalence of human immunodeficiency virus, hepatitis B virus and hepatitis C virus infections among transgender persons referred to an Italian center for total sex-reassignment surgery (SRS). Italy is one of only a few countries in the world that allows individuals to change their official gender without having SRS. Additionally, SRS is provided free of charge through 7 SRS clinics, following a psychological assessment and court ruling. Despite this seemingly favorable gender and health care policy context, the 12.1% HIV prevalence among male-to-female transgender women found in this study is still substantially higher than the estimated adult HIV prevalence in Italy of less than 1%, which could reflect the cumulative effects of stigma, discrimination, and social exclusion experienced by transgender populations. Also of concern, Luzzati and colleagues1 found that HIV prevalence was significantly higher in the more recent cohort (2010 to 2014) of SRS clients, suggesting that there are prevailing gaps in the social and structural protections needed to promote health and wellbeing, including HIV prevention, among transgender persons in Italy. In the United States, where SRS is not universally accessible, users of SRS services were found to have significantly lower estimated odds of suicidal ideation, binge drinking, and noninjection drug use, which could either reflect that receiving these services can promote mental health and reduce HIV risk or that those who can access such services are already experiencing better health.2 Of note, in the United States, Latina and African American transgender women are significantly less likely to use SRS services, which reflects patterned disparities in healthcare access and HIV prevalence across race and ethnicity.2,3 The focus on a transgender sample recruited from an SRS clinic represents an important shift away including male-to-female transgender persons as a subgroup of the umbrella category of men who have sex with men. For example, the authors cite a recent HIV and sexually transmitted disease (STD) prevalence study of key populations in the Dominican Republic4 as one of the few recent studies to provide a point of comparison for their STD prevalence findings, noting that the prevalence of hepatitis B virus and hepatitis C virus in the Dominican Republic was much lower than what the authors found in Italy. The study population in the Dominican Republic, however, included gay, bisexual, other men who have sex with men and what the authors refer to as transsexuals, recruited using respondent driven sampling. Therefore, the Dominican sample is much more diverse than the Italian sample and does not provide an ideal comparison to a sample of transgender participants seeking SRS. It is important to note that while given the accessibility of SRS in Italy, this sample may be representative across socio-economic position; a group excluded from this study are transgender persons who are not interested in SRS or who are precluded from surgery for other reasons. There is a need for improved and expanded HIV and STD surveillance among transgender populations to continue characterizing and monitoring these epidemics and to inform appropriate responses. Although the focused nature of the Luzzati et al study sample addresses this need for transgender focused research, it is also important to note the fluidity in identities and definitions among transgender populations. In our attempt to differentiate male-to-female transgender women from men who have sex with men, we still need to allow for this fluidity and meaningful self-identification that does not focus on stigmatizing behaviors, overly homogenize populations, or lose important nuance along the spectrum of gender identities.3,5,6 We need rich, in-depth understanding of the language and meaning of terms in specific settings in order to avoid imposing labels inappropriately. All of these, of course, need to be balanced with the need to have some way of categorizing populations to facilitate interpretation of data and communication of findings. An important recommendation highlighted by Luzzati and colleagues is the integration of HIV testing, prevention and care services into SRS clinics. The 7 SRS clinics across Italy offer a unique opportunity to flip the model for HIV prevention and care by using SRS as the starting point and integrating HIV and STD prevention and care into what should be a safe, trusted, and high-quality care environment that offers a service that is of central interest to transgender populations. The inclusion of hormone therapy within HIV care and treatment services has been recommended as a way to respond to the salient health needs of transgender populations7 though there is limited published evidence of the outcomes of this type integration. Luzzati et al specifically discuss pre-exposure prophylaxis (PrEP) as an important HIV prevention innovation that could help to respond to what seems to be increasing HIV prevalence among SRS clinic patients. To date, transgender women have been underrepresented in PrEP research and outreach; improving use of PrEP among transgender populations will require a population-specific approach that responds to the unique barriers and facilitators to HIV prevention within this population and directly addresses concerns about interactions between PrEP and hormone therapy.6,8 Finally, Luzatti et al found that male-to-female transgender women who were originally from South America had higher HIV and hepatitis B virus prevalence than those born in Italy or other European countries. Research in the United States has also documented HIV disparities among Latina transgender women compared to white, non-Latina transgender women born in the United States,9 though few studies have focused on this population. The experiences of layered stigma and discrimination related to race, gender, immigration status and sexual orientation, in the context of limited access to healthcare, can create extreme HIV vulnerability for Latina transgender women. However, HIV occurs amidst many other concerns and priorities among Latina transgender women, which is another reason to identify ways to integrate HIV prevention, care and treatment services into other health and community development services.10 Among Latina transgender women in Washington DC, researchers found that documentation status was protective against HIV vulnerability and suggest integrating legal support services into health services for transgender women to address this structural determinant of health.11 There is an urgent need to continue documenting and improving understanding of HIV and STD disparities among male-to-female transgender populations across the globe to inform appropriate and effective prevention and treatment strategies. Differentiation and meaningful classification is critical and will require using both qualitative and quantitative research in specific contexts. Beyond targeting HIV and STD disparities, there is a broader need to improve the overall health and wellbeing of transgender persons by addressing stigma, discrimination, and social exclusion throughout the life course.
Source: Sexually Transmitted Diseases
Author: Clare Barrington
Institution: University of North Carolina at Chapel Hill
Language: English
Subfield: Social Psychology
Field: Psychology
Domain: Social Sciences
Open Access status: green
OpenAlex ID: W2435415299