Recent estimates indicate that only about 25 percent of those living with HIV are virally suppressed, and that a majority of those not taking antiretroviral therapy (ART) are not engaged in any medical care. In fact, more than 50 percent of people diagnosed with HIV/AIDS are not in continuous care, while as many as 25 percent of individuals who are engaged in care and eligible for ART are not receiving the therapy.
Yet, while the public health issue of people living with HIV and not taking ART is one that has been aggressively addressed with empirical studies, a key population has been largely overlooked: transgender women. Transgender women experience a high burden of HIV worldwide. In the United States, the burden of HIV for transgender women may be even higher.
A new multi-site study from the University of Kentucky, the Kinsey Institute at Indiana University, Georgia State University, and the University of Chicago tested three psychosocial measures for their potential to serve as counseling goals for promoting ART to transgender women living with HIV (TWLH). Dr. Richard Crosby, Good Samaritan Endowed Professor of Health, Behavior & Society at the University of Kentucky College of Public Health, is the corresponding author of the resulting publication: “Correlates of Not Using Antiretroviral Therapy Among Transwomen Living with HIV: The Unique Role of Personal Competence,” appearing in the journal Transgender Health. Co-authors are Dr. Laura F. Salazar, Georgia State University School of Public Health, and Dr. Brandon J. Hill, University of Chicago Center for Interdisciplinary Inquiry and Innovation in Sexual and Reproductive Health. Drs. Crosby and Hill also have appointments at the Kinsey Institute.
The investigators recruited study participants through referrals from community-based organizations providing services and support to transgender women in Atlanta and Chicago. Requirements included the following: being 18 to 65 years of age; having been assigned male at birth and self-identifying as either a transgender woman, female, or gender-nonconforming identity; and reporting sex with a cisgender male or non-transgender male in the past six months.
After providing written informed consent, each participant engaged in a face-to-face, 60 to 90 minute, structured interview with a trained graduate research assistant. All interview survey responses were recorded on a portable electronic tablet. Self-report of HIV status as “positive” was used to classify the analytic subset for the study. A single survey item assessed whether participants were currently taking ART. The sample of 69 transgender women ranged from 19 to 65 years of age. Most (95.7 percent) identified as black or African American.
For possible control variables, in addition to standard sociodemographic characteristics, investigators assessed several factors: current use of estrogen; whether participants had a legal name change to reflect their gender identity; whether participants were currently involved in what they considered to be a committed relationship; whether participants had health insurance (including Medicaid) at the time of study enrollment; and an ordinal measure of placement in terms of transitioning to a woman. This latter measure was devised by the study team to reflect various degrees of the transition process (not started, recently started, somewhat transitioned, mostly transitioned, and completely transitioned).
Three scale measures were assessed to identify potential counseling-amenable targets for change that may best foster ART use among those not taking advantage of this innovation in HIV/AIDS care. They were: personal competence, acceptance of self and life, and body image.
The study’s findings support the strong association of a construct-labeled personal competence as a counseling goal for TWLH who are not currently using ART. Specifically, counseling goals related to helping TWLH gain an increased sense of managing life, instilling self-discipline, finding meaning in life and pride in their accomplishments, and having a general sense of self-liking may all be valuable goals in terms of promoting their long-term use of ART. Community-based counseling for transgender women recently testing positive for HIV may benefit this population by seeking to help them construct more favorable perceptions of their personal competence. This goal may be achieved by providing individualized counseling, tailored to meet the needs of transwomen relative to the acquisition of enhanced personal competence.
The authors note that “in an era of treatment as prevention being the dominant approach to the control of HIV, this was an important initial investigation pertaining to a highly-marginalized population.”