ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

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Increasingly, trans and gender diverse people are being identified by global organisitions as a population in need of HIV resources, however as often as they are identified they are still not included in meaningful ways.

"There has probably never been a population both more heavily impacted and less discussed at scientific meetings the the transgender population around the world" (Poteat, 2016).

Decades of joint advocacy has ensured the inclusion of trans and gender diverse people at ASHM. The task ahead is to ensure sustainable and equitable strategies for these communities and that they are led by tans and gender diverse people. 

Globally, the prevalence data shows that 19.15 of trans women worldwide are estimated to be living with HIV (Baral et al, 2013). There is limited empirical evidence about prevalence among trans men, and no data about HIV among non-binary people. The "absence of evidence due to lack of resource allocation and or proper research is usually considered as 'evidence of absence', naturalizing the gaps in data collection and analysis" (IRGT, 2016). Less than 40% of countries report that their national HIV/AIDS strategies address trans and gender diverse people (Poteat et al, 2016).

There is a lack of data across countries, with the majority of data sitting in the global north. Often, sampling often includes only very particular populations.

In terms of the Australian experience, the Kirby Institute's analysis of ACCESS data (Callender et al, 2017), of 696 patients recorded as transgender, 29% were women, 32% were men and 40% did not have their gender identity captured. Of these patients, 5.2% were HIV positive. Prevalence among trans women was 8.9% and trans men 4.5%. Taylor Square Private Clinic reported prevalence as 4.5% among trans women and 0% among trans men (Pell, Prone and Viahakis, 2011). The Private Lives 2 Study found 1.4% of trans women live with HIV (Leonard et al, 2011).

The most comprehensive data of HIV prevalence among trans women (8.9%) is probably not accurate because of inadequate data collection methods.

HIV risk factors for these populations:

  • Receptive vaginal sex can pose a different level of risk for trans women (Cornelisse et al, 2017)
  • Stigma, discrimination, social exclusion from employment and education (Poteat et al, 2014)
  • Trans women more likely to report sex work (13%) than other cisgender patient groups (9%) and are more likely to report injecting drug use than gay and bisexual men (7% vs 4%) (Callander et al, 2017)
  • By contrast, trans men were no more likely than other groups to report sex work or injecting drug use (3%) (Callander et al, 2017)
  • HIV risk among tans men is similar to HIV risk for cisgender men (CSRH, 2016)
  • Research into trans women's experiences in Australian's men's prisons found that incarceration increases risk factors of HIV including physical and sexual violence (Wilson et al, 2016)

For transgender and gender diverse sex-workers, there are other intersecting social and cultural factors that impact upon their risk of contracting HIV.

Barriers to prevention include invisibilising methodological approaches, a lack of cultural competence, social and systemic barriers, geographical barriers, under representation in targeted health promotion strategies and legal barriers that perpetuate pathologisation. There is a low workforce literacy and systemic barriers (particularly legal) that exacerbate narrow clinical models and ultimately leads to entrenched mistrust among trans and gender diverse people.

"Other barriers to health and health care are the numerous socioeconomic determinants of health that legally, economically, and socially marginalize trans people. These include discrimination in employment, education, housing, and relationship recognition; police harassment, often as a result of actual or assumed association with sex work; and identity document policies that deny many trans people legal recognition in their true gender. They also include aspects of structural violence such as racism, violence against women, and poverty" (Open Society Foundation, 2013).

Both policy and legal environments need to be opened up and there needs to be a continuance of critique of systems that perpetuate structural violence.

Day 2 of the conference was informative, fun and interactive. Opportunities to use smartphone technology to interact using live polls added to the experience. Here are my key GP take home messages from day 2.

1. Hepatitis C is curable and can be eradicated! At present only 1% of people with Hepatitis C are offered treatment. There is an urgent need for more community prescribers. The new DAA should be PBS listed by the end of this year. These drugs offer 8 week treatment times, are well tolerated, and have minimal drug interactions. Regimens will be interferon free. These drugs are highly effective (over 90-95% cure rates, even in advanced cirrhotics and HIV/Hep C coinfected populations).

GPs will play a major role in the eradication of Hep C. Treatment needs to be accessible and affordable globally.

2. Integrase inhibitors should now be first line agents of choice for ARV naive patients. They have outperformed EFV, DRV, ATV and just about everything else. They are well tolerated, suppress viral load rapidly, have few drug interactions and have a good metabolic profile. They are also increasingly available in 'one pill daily' regimens.

3. We need to include the transgender community in our sexual health campaigns and research (see my blog "PASH" 17/9/15)

4. We should be open to HIV self testing, in the US HIV self testing kits were well received by patients, and available by voucher, post, sex on premises venues, and even from vending machines in car parks! Patients who tested positive did link in with care, and these tests offered a convenient, out of hours testing opportunity, potentially reducing barriers to HIV testing.

Looking forward to day 3!

Congratulations to Teddy Cook (ACON) and Jeremy Wiggins (VAC) for an important talk today about PASH, the Peer Advocacy network for the Sexual Health of trans masculinities. 

It took me a long time browsing through the ASHM program to find any content or posters addressing sexual health in the Trans community.

Trans MSM are often assumed to have low risk of STI's although this group are more likely to practice condomless receptive anal sex than other men. Trans MSM are often not included, and often deliberately excluded from research projects. During data collection the Trans community are often misgendered or expected to tick a 'transgender' box when they may identify as male, female, or non binary. Trans women are often misgendered as 'gay men'.
 
So it's not surprising that we have a lack of data about STI and HIV prevalence in Trans MSM. PASH aims to educate health practitioners, promote inclusive research, and provide health promotion and resources for transmen who have sex with other men. 

As health providers we need to lift our game and take action to prevent further discrimination and negative health outcomes for this often neglected group.

A great presentation, informative and concise. Thanks!

Teddy Cook and Jeremy Wiggins gave a talk on the inclusion of transgender men in the HIV response, which provided much food for thought for healthcare practitioners and a call to action for health policy makers.

The presenters raised concerns that trans men generally report significant HIV risk, yet are overlooked in the HIV response. They highlighted some issues in data collection that may have resulted in trans people not being accurately represented in HIV data.

Particularly, they made the enlightening statement that "Transgender is not a gender identity". Trans men have very different experiences from trans women, and have different health requirements, including different sexual health requirements. 

Also, health data collection does not accurately capture data on transgender people. For example, the Victorian Department of Health HIV notification form gives the gender options of "male", "female" and "transgender". By lumping trans men, trans women and genderqueer people into the same category, health data loses nuances that are important for informing health policy and health promotion.

Also, they highlighted some case studies illustrating how this simplistic gender categorisation has resulted in miscategorisation of trans people in HIV statistics. One case described a non-binary trans masculine person who was assigned female at birth who has sex with men, who was categorised as a heterosexual female on her HIV notification form. Obviously, in order to develop an appropriate public health response to address HIV risk in the transgender community, we need data that accurately reflects what is happening in the trans community.

The presenters suggested the following two-question gender classification in order to overcome some of these issues.

  • Question 1: What is your gender
  • Question 2: What gender were you assigned at birth

On a lighter note, Jeremy pointed out that a recent HIV testing campaign from Victoria did include a trans man. It's a fun campaign, so have a look at the video below: