HIV prevalence, engagement in care, and risk behavior among trans women, San Francisco: Evidence of recent successes and remaining challenges

Abstract

Background Trans women have high HIV prevalence and lag behind 90–90-90 targets for HIV care. In San Francisco in 2017, 96% of trans women were aware of their status, 75% were on antiretroviral therapy, 88% had viral suppression. Initiatives to address gaps include peer navigators, free gender-affirming surgery, and housing. Our study updates HIV prevalence and engagement in care among trans women. Methods Cross-sectional community-based survey of trans women living in San Francisco sampled by respondent-driven sampling, 7/2019–2/2020 ( N = 201). Eligibility was: self-identified trans women or other gender and assigned male at birth; living in San Francisco; English/Spanish-speaking; and 18 years or older. Results HIV prevalence was 42.3% (95%CI 35.4.-49.4) and associated with having a partner who injected drugs (adjusted odds ratio [AOR] 3.30, 95%CI 1.58–6.90), ever injected drugs (AOR 2.28, 95%CI 1.06–4.89), cost not a barrier to healthcare (AOR 2.63, 95%CI 1.02–6.67), emotional support from family (AOR 2.85, 95%CI 1.43–5.65), and Black/African-American (AOR 2.59, 95%CI 1.16–5.79). Of trans women with HIV, 92.9% were previously diagnosed, 89.9% were on ART, 91.5% reported viral suppression. Conclusions Trans women met 90–90–90 targets in 2020, at 93–90–92. Interventions need to reach Black/African-American trans women, trans women who inject drugs, and partners of trans women.

Detectable viral load associated with unmet mental health and substance use needs among trans women living with HIV in San Francisco, California

“…Despite the importance of our results, we acknowledge data are from an intervention study, which creates inherent biases related to the eligibility criteria and limiting the generalizability of our results. Our eligibility criteria that trans women must be connected to the public health care system may have biased the sample, however, recent data shows that 92.5% of trans women in San Francisco reported having health insurance, with only 11.4% reporting private health insurance [ 3 ]. We also recognize that our small sample size may not be sufficient to detect significance in our results.…”

“…HIV viral load data were abstracted from the medical record at baseline for each participant. HIV viral load was categorized into [ 1 ] unknown if the most recent HIV viral load test was conducted over 180 days prior to their study initiation date, [ 2 ] detectable if viral load was ≥50 copies/mL, or [ 3 ] undetectable if there was no virus detected. Most people can lower their viral load to undetectable between 1 to 6 months of initiating ART, although this depends on the individual.…”

“…The HIV, mental health, and substance use care cascades were developed to identify gaps in care for trans women. The cascades start off with the total number of trans women who ever had a [ 1 ] HIV diagnosis, [ 2 ] screened positive for a mental health disorder, and [ 3 ] screened positive for a substance use disorder (including an alcohol or drug use disorder). Screening positive for a mental health disorder was defined as having moderate to high anxiety or depression (PHQ-4 score ≥ 6) or having high psychological distress (Kessler score ≥ 11) or having PTSD (PTSD score ≥ 4).…”

“…Only 67.2% of trans people in the U.S. were virally suppressed at their most recent viral load test [ 2 ]. Despite San Francisco offering a range of important health services like HIV specialty and gender-affirming care to trans women with and without health insurance, almost a quarter of trans women in our city remain virally detectable as of 2020 [ 3 ], and many suffer from threats to wellness due to stigma and discrimination. Almost half of trans women in 2020 were recently experiencing homelessness (47%), extremely low income (42.4%), and more than half (64.3%) recently injected drugs based on the latest National HIV Behavioral Surveillance data for trans women [ 3 ].…”

Structural disadvantage and HIV risk – comparing risk factors between trans women’s partnerships with cis men and trans women sexual partners

“…Living in an SRO has been associated with numerous health risks including substance use, mental illness, and HIV risk (21,22), which cis men partners and trans women may face. For trans women, unstable housing is associated with poor HIV care outcomes (23) (24), and elevated risk behavior (25), as are incarceration and low income (26). Half of trans women with cis men partners who had a history of incarceration also had partners with a history of incarceration.…”