Pilot Award Recipient: Deborah Goldstein, MD

Dr. Goldstein
HIV Treatment Cascade among Transgender Women in Washington, DC
July 26, 2017

The transfemale community, and especially transwomen of color, in Washington, DC bear a disproportionate burden of  HIV infection: 20% of transgendered people self-report being HIV-positive, which is nearly seven times the general population estimate of 3% for the District.  The study will assess health disparities in HIV treatment outcomes by proposing a retrospective chart review of the HIV continuum of care among Whitman Walker Health's (WWH) transfemale, HIV-positive population. To further focus efforts on this high risk population, the study will have a specific focus on transwomen of color and their participation in the HIV care continuum.

The HIV care continuum is an internationally recognized framework for evaluating the success of HIV care. The steps include diagnosis, linkage to care (LTC), retention in care (RiC), adherence to antiretroviral therapy (ART), and viral suppression (VS). Little is known about the HIV care continuum among transgender women, particularly among transwomen of color with HIV.

Most available data suggests significant health disparities between trans- and cis- populations, with significantly fewer transwomen receiving HIV care, receiving antiretrovirals, or reporting undetectable HIV viral loads than nontrans patients.  Social and political stigma and discrimination, legal and economic marginalization, violence, and gender abuse increase transfemales' vulnerability to HIV infection, and likely increase their risk of failure at each point along the HIV continum.

The researchers hypothesize that HIV-positive transwomen fall off the HIV care continuum at a higher rate than nontransgender patients resulting in a reduced proportion of these persons achieving HIV suppression. While the factors causing this suboptimal outcome are multiple, this is likely due to a combination of structural, health system and health literacy factors, as well as factors unique to transgender identity. A more detailed and informed understanding of these factors will assist HIV healthcare providers and healthcare systems improve health outcomes for these persons.

This pilot study will combine multiple analytic approaches.  It will describe key demographic characteristics of Whitman­ Walker Health's HIV-positive, transfemale population  and identify within this group a subgroup of HIV-positive transfemales of color. The study will then characterize the progressive steps of HIV care continuum among our HIV-positive transfemales along with a subgroup of HIV-positive transfemales of color.  Reserachers will perform a matched, case-control study to evaluate discrepancies occurring along the HIV care continuum between HIV-positive, transfemales and HIV+, nontransgender patients. They will explore the impact of provision of gender-affirming hormonal treatment as well as surgical referrals for gender transition on keeping HIV-positive transfemales engaged in the HIV care continuum.