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Mujeres negras
¿Qué necesitan las mujeres negras para evitar el VIH?
¿Afecta el VIH a las mujeres negras?
Sí. Desde el inicio de la epidemia, el VIH ha azotado a los hombres y mujeres negros radicados en EE.UU. A pesar de componer sólo el 12% de la población femenina del país, en el 2006 las mujeres negras representaban el 61% de los casos nuevos entre mujeres.1 Se diagnostica el VIH a mujeres negras con 15 veces más frecuencia que a mujeres caucásicas.1 Las mujeres negras también tienen altas tasas de infecciones transmitidas sexualmente (ITS), lo cual puede promover la transmisión del VIH. En el 2006, la tasa de clamidia entre mujeres negras era 7 veces mayor, la de gonorrea 14 veces mayor y la de sífilis 16 veces mayor que entre mujeres caucásicas.2 Estas cifras y estadísticas no terminan de revelar toda la riqueza y diversidad de las vidas de las mujeres negras, un grupo que abarca a oficinistas y obreras, cristianas y musulmanas, habitantes de áreas urbanas y de suburbios, descendientes de esclavos e inmigrantes caribeñas recién llegadas. Ellas trabajan, estudian, crían a sus familias, se enamoran. El VIH entre las mujeres negras no se debe exclusivamente a su conducta individual, sino a un sistema complejo de aspectos sociales, culturales, económicos, geográficos, religiosos y políticos los cuales se entrelazan para afectar a su salud.3¿Cuáles de ellas corren riesgo de contraer el VIH?
Los principales factores de riesgo de contraer el VIH son: tener otra ITS que no sea el VIH, no protegerse durante las relaciones sexuales vaginales o anales con una persona VIH positiva e inyectarse drogas con equipos previamente usados por una persona VIH+. Otro riesgo es ignorar los riesgos de su pareja, por ejemplo, si él usa drogas inyectables o tiene otras parejas sexuales concurrentes, y desconocer su condición de VIH. De las mujeres negras infectadas por VIH en el 2005, el 80% se contagiaron por contacto heterosexual y él 18% por inyección de drogas.4 Las mujeres jóvenes y las adolescentes resultan excesivamente afectadas. En el 2004, el VIH fue la primera causa de muertes en mujeres negras de 25-34 años de edad.5 Las adolescentes (13-19 años de edad) negras componían el 69% de los nuevos casos de SIDA en el 2006, mientras que su proporción de la población general de adolescentes en EE.UU. apenas alcanza el 16%.6¿Qué aspectos influyen en el riesgo de contraer el VIH?
Al protegerse durante el sexo, muchas mujeres se preocupan más por evitar el embarazo que el VIH/ITS, y son menos propensas a combinar dos métodos de protección (por ejemplo: la pastilla anticonceptiva junto con el condón). Más jóvenes negras que caucásicas usan anticonceptivos implantados o inyectables (el parche, Norplant), por lo que es menos probable que usen condones los cuales las protegerían contra el VIH.7 También es más común que las mujeres negras, especialmente las que viven en zonas de bajos ingresos, recurran a la esterilización para controlar la natalidad.8 La prevención del VIH muchas veces pasa a segundo plano para las mujeres que luchan para conseguir trabajo, alimentos, vivienda o cuidado infantil. La mayoría de los casos de VIH/SIDA en mujeres negras ocurren en los cascos urbanos y áreas rurales, donde abunda la pobreza y escasean empleos y vivienda.9 Estas mujeres son más propensas a quedarse sin vivienda, tener sexo a cambio de dinero o alojamiento, consumir drogas (heroína, cocaína crack) y alcohol, depender de un hombre para su sustento y sufrir violencia o trauma. Todas estas condiciones minan la capacidad de la mujer para rechazar el sexo, usar condón y limpiar jeringas al inyectarse para protegerse contra el VIH. Otro factor que aumenta el riesgo de contraer el VIH es la alta proporción de hombres afroamericanos encarcelados, lo cual merma su presencia en la comunidad desestabilizando así a las parejas y promoviendo la formación de relaciones de pareja concurrentes de mayor riesgo (tener más de una pareja sexual durante cierto tiempo y alternar entre una y otra pareja).10 La proporción de hombres en relación con mujeres es mucho menor entre afroamericanos que cualquier otro grupo étnico en EE.UU. El gran número de hombres negros muertos por enfermedades y actos de violencia así como encarcelados genera muchas secuelas en la comunidad, entre ellas el reducido número de candidatos a parejas. Esto lleva a que algunas mujeres con conductas de bajo riesgo se emparejen con hombres cuya conducta es de alto riesgo.3¿Estarán enteradas las mujeres negras del riesgo que corren?
Al hacerse la prueba del VIH muchas mujeres negras responden que su categoría de transmisión es ninguna o desconocida, por lo que se ha inferido que ellas desconocen su riesgo de contraer el VIH. En comunidades negras existe una historia de relaciones sociales entre personas de alto riesgo y otras de menor riesgo,11 lo cual aumenta sus posibilidades de conocer y salir con una pareja con antecedentes riesgosos. Al contrario, es posible que aun conociendo los riesgos, las mujeres negras los acepten más debido a este entretejimiento social. Las mujeres negras reconocen el riesgo que corren, según lo evidencia la proporción de pruebas de VIH entre ellas en comparación con cualquier otro grupo racial. Casi los dos tercios (el 65%) de las mujeres negras de 15-44 años de edad se han hecho la prueba del VIH alguna vez, y dos veces más se sometieron a la prueba durante los últimos 12 meses que mujeres caucásicas (el 25% en comparación con el 13%).12 Debido a las tasas descomunales de ITS y VIH en su comunidad, los hombres y mujeres negros corren un riesgo mucho mayor de tener contacto con una persona infectada en comparación con otros grupos. Esto significa que aunque las mujeres negras practiquen menos conductas riesgosas que las mujeres caucásicas,3 tienen que hacer mucho más que otras mujeres para lograr protegerse.3¿Qué se está haciendo al respecto?
Once intervenciones han sido aprobadas por el CDC para mujeres y adolescentes negras en categoría de mejor o prometedora evidencia o forman parte del proyecto DEBI (Diffusion of Effective Behavioral Interventions).13 Otras organizaciones a lo largo de EE.UU. también brindan servicios innovadores de prevención del VIH con y para mujeres negras y enfocados en la mujer íntegra como parte de una comunidad, sin limitarse únicamente a su conducta sexual o consumo de drogas. Es importante apoyar a mujeres con parejas encarceladas. HOME (Health Options Mean Empowerment) capacitó a mujeres cuyas parejas masculinas estaban a punto de salir de la prisión estatal, capacitándolas para orientar a otras mujeres que visitaban a reclusos y también en la comunidad. HOME ofreció almuerzos grupales para mujeres mientras esperaban en la prisión antes de entrar a visitar a sus parejas; pláticas sobre la salud general (temas: diabetes, presión arterial, obesidad, dejar de fumar); la salud sexual–pláticas sobre el VIH/ITS; ferias de salud; y remisión a servicios en la comunidad y de apoyo para mujeres que visitan a sus compañeros encarcelados. Las participantes reportaron menos contactos sexuales sin protección, más pruebas de VIH y mejor comunicación con sus parejas sobre temas relacionados con el VIH.14 Un reciente ensayo grande implementado en varios lugares describió un programa para parejas afroamericanas VIH serodiscordantes, el Eban HIV/STD Risk Reduction Intervention, que ofrece 8 sesiones semanales de 2 horas para comentar los factores individuales, interpersonales y comunitarios que contribuyen en varios niveles a las conductas de riesgo del VIH. Cuatro sesiones se dedican a la comunicación, resolución de problemas y toma de decisiones sobre mayor protección durante el sexo dentro de la pareja. Las cuatro reuniones restantes abarcan cómo cambiar actitudes y normas entre pares, cómo eliminar el estigma de ser una pareja serodiscordante y cómo ampliar los apoyos para parejas en la comunidad.15 Para llegar a las mujeres negras en sus propias comunidades, muchas intervenciones de prevención del VIH se han ubicado en salones de belleza y de estética, que brindan un ambiente de confianza en donde recibir condones e información sobre el VIH. En el condado de Durham, NC, Project StraightTalk ha capacitado desde 1988 a peluqueros y esteticistas a informar a sus clientes sobre las ITS/VIH. El proyecto ofrece capacitaciones anuales, regala condones y materiales educativos a cada salón dos veces por mes y produce carteles individualizados para los salones.16¿Qué queda por hacer?
El VIH seguirá azotando a la comunidad afroamericana a menos que los esfuerzos de prevención y atención se combinen con otros con el fin de eliminar las causas subyacentes de la enfermedad.3 Las niñas, adolescentes y mujeres negras necesitan apoyos en su entorno social que les permitan desarrollar relaciones, familias, vecindarios y comunidades más fuertes y reducir su riesgo de contraer el VIH y otras enfermedades. Los programas de prevención del VIH destinados a sus compañeros pueden beneficiar tanto a las mujeres como a los hombres. Las mujeres negras deben crear y dirigir programas eficaces de prevención del VIH que incluyan capacitación laboral, consejería para parejas, bancos de alimentos, asistencia de vivienda, servicios de salud mental, tratamiento de abuso de alcohol y drogas, y servicios familiares. El gobierno y otros organismos de subvención necesitan entender que todos estos aspectos forman parte íntegra de la prevención del VIH y por tanto deben ser subvencionados como tal.¿Quién lo dice?
1. CDC. Subpopulation Estimates from the HIV Incidence Surveillance System—United States, 2006. Morbidity and Mortality Weekly Report. 2008;57;985-989. 2. CDC. Sexually Transmitted Disease Surveillance, 2006. November 2007. 3. Aral SO, Adimora AA, Fenton KA. Understanding and responding to disparities in HIV and other sexually transmitted infections in African Americans. Lancet. 2008;372:337-340. 4. Rose MA, Telfair Sharpe T, Raleigh K, et al. An HIV/AIDS crisis among African American women: A summary for prevention and care in the 21st century. Journal of Women’s Health. 2008;17:321-324. 5. HIV/AIDS among women. Fact sheet prepared by the CDC. August 2008. 6. Black Americans and HIV/AIDS. Fact sheet by the Kaiser Family Foundation. October 2008. 7. Abma JC, Martinez GM, Mosher WD, et al. Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2002. Vital and Health Statistics. 2004;23. 8. Mosher WD, Deang LP, Bramlett MD. Community environment and women’s health outcomes: Contextual data. Vital and Health Statistics. 2003;23. 9. Fullilove RE. African Americans, health disparities and HIV/AIDS. Report prepared by the National Minority AIDS Council. November 2006. 10. Harawa N, Adimora A. Incarceration, African Americans and HIV: advancing a research agenda. Journal of the National Medical Association. 2008;100:57-62. 11. Adimora AA, Schoenbach VJ, Doherty IA. HIV and African Americans in the Southern United States: sexual networks and social context.Sexually Transmitted Diseases. 2006;33:S39-S45. 12. Anderson JE, Chandra A, Mosher WD. HIV Testing in the United States, 2002. Advance Data for Vital and Health Statistics. 2005;363:16. 13. Centers for Disease Control and Prevention. Updated Compendium of Evidence-Based Interventions, 2007. 14. Grinstead O, Comfort M, McCartney K, et al. Bringing it home: design and implementation of an HIV/STD intervention for women visiting incarcerated men. AIDS Education and Prevention. 2008;20:285-300. 15. NIMH Multisite HIV/STD Prevention Trial for African American Couples Group. Eban HIV/STD Risk Reduction Intervention: Conceptual basis and procedures. Journal of AIDS. 2008;49:S15–S27. 16. Lewis YR, Shain L, Crouse Quinn S, et al. Building community trust: lessons from an STD/HIV peer educator program with African American barbers and beauticians. Health Promotion Practice. 2002;3:133-143.Una publicación del Centro de Estudios para la Prevención del SIDA (CAPS) y el Instituto de Investigaciones sobre SIDA (ARI), Universidad de California en San Francisco (UCSF). Se autoriza la reproducción (citando a UCSF) más no la venta de copias este documento. También disponibles en inglés. Para recibir las Hojas de Datos por correo electrónico escriba a [email protected] con el mensaje “subscribe CAPSFS nombre apellido” ©UCSF 2010
Mother-to-child transmission (MTCT)
Is Mother-to-Child HIV Transmission Preventable?
Prepared by Sarah A. Gutin, MPH* *CAPS, Community Health Systems- School of Nursing, UCSF Fact Sheet #34ER – September 2015 Special thanks to the following reviewers of this Fact Sheet: Yvette Cuca, Carol Dawson Rose, Shannon Weber In 2012, there were 2.3 million new HIV infections globally1. A large proportion of people newly diagnosed with HIV worldwide are in their reproductive years and these men and women are likely to want children in the future2-4. Addressing the sexual and reproductive health and rights of this population is critical to addressing the spread of HIV because HIV infection in childbearing women is the main cause of HIV infection in children5. Treatment for those who are already infected is also central to stopping the spread of HIV to infants and to uninfected sexual partners. How does transmission occur? Perinatal transmission of HIV, also called vertical transmission, occurs when HIV is passed from an HIV-positive woman to her baby during pregnancy, labor and delivery or breastfeeding. For an HIV-positive woman not taking HIV medications, the chance of passing the virus to her child ranges from about 15 to 45% during pregnancy, labor and delivery. If she breastfeeds her infant, there is an additional 35 to 40% chance of transmission6. Is the risk of perinatal transmission always the same? No. Global societal and economic inequities create a wide gap between women in developing nations and women in developed nations with regard to HIV prevention, voluntary counseling and testing and access to drugs which treat HIV infection and can prevent perinatal transmission. Developed countries- In many developed countries, pediatric HIV has been virtually eliminated7. In the US in 1994, the Public Health Service recommended HIV counseling and voluntary testing and AZT therapy for all pregnant women after the clinical trial known as “076” showed that AZT reduced rates of MTCT by two-thirds. Since then, a combination of interventions that includes treatment with ART to control the virus and make it undetectable, cesarean delivery, and avoidance of breastfeeding has helped further reduce perinatal transmission in the US, from an estimated 1,500 cases in 1992 to an estimated 162 perinatal infections in 20108. Although the estimated number of perinatal HIV infections in the US continues to decline, women of color, especially black/African American women are disproportionately affected by HIV infection and as a result, perinatal HIV infection is highest among blacks/African Americans (63%), followed by Hispanics/Latinas (22%)8. Although effective interventions have led to a significant reduction in the number of perinatal infections in the US, perinatal transmission still occurs. To close the final gap, the CDC has proposed a new framework to eliminate mother-to-child HIV transmission (EMCT) in the US8. This framework focuses on key areas including: comprehensive reproductive health care (that includes both family planning (FP) and preconception care) and comprehensive case-finding of pregnancies in HIV-infected women that is conducted through comprehensive clinical care and case management services for women and infants; case review and community action; continuous quality research in prevention and long-term monitoring of HIV-exposed infants; and thorough data reporting for HIV surveillance at the state and local health department levels8,9. Developing countries- Unfortunately, perinatal transmission of HIV continues to plague many developing countries despite recent prevention acceleration. In 2008, an estimated 1.4 million pregnant women in low and middle-income countries were living with HIV, of whom about 90% were in sub-Saharan African countries7. In 2012, UNAIDS reported that approximately 210,000 children became HIV infected1. Can perinatal transmission of HIV be reduced? Yes. Perinatal transmission encompasses a variety of highly effective interventions that have huge potential to improve maternal and child health. Advances in treatment and new classes of drugs have provided the opportunity to greatly reduce rates of perinatal transmission worldwide. Also, perinatal transmission can be reduced by preventing unintended pregnancies. Preventing unintended pregnancies is one of the most effective ways to prevent HIV infection in infants and stop spread of the epidemic to children10. For that reason, preventing unintended pregnancies among women living with HIV and offering family planning to delay, space or end childbearing is one of the four WHO pillars in the comprehensive approach to preventing perinatal transmission7. However, we have still not addressed the root cause of perinatal transmission, mainly heterosexual HIV transmission. The best way to prevent perinatal HIV transmission is to prevent HIV transmission in the mother and father. In order to reduce perinatal transmission, all pregnant women should have access to free or low-cost prenatal care and voluntary HIV testing and counseling. If a pregnant woman is HIV-positive, she should have access to lifelong ART to treat HIV and improve her own health and to decrease the chances of HIV infection in her infant. In June 2013, the WHO published updated guidelines on the diagnosis of HIV, the care of people living with HIV(PLHIV) and the use of ART for treating and preventing HIV infection1. In the US, the Department of Health and Human Services recommends that all HIV-infected pregnant women should be given ART during pregnancy to prevent perinatal transmission of HIV, regardless of whether ART is indicated for the woman’s own health11. Perinatal transmission can be reduced to less than 2% if a woman is on ART, has a low or undetectable viral load, follows the recommended treatment regimen and does not breastfeed7,8. Careful management during labor and delivery can also help reduce perinatal transmission, for example by avoiding unnecessary instrumentation and not prematurely rupturing membranes12. Also, although universal prenatal HIV testing is the standard in the US, if prenatal care has not been provided, the patient has HIV, or her HIV status is undocumented, it is critical for hospitals to determine a laboring patient’s HIV status upon admission. Even without the use of ART during the pregnancy, the use of ART during labor and for the infant can reduce the risk of perinatal transmission to between 6 to 13%13. It is therefore recommended that rapid HIV testing be performed in Labor and Delivery units on pregnant women with no HIV test during their pregnancy or with risk factors for infection since their last test14. In developing countries, perinatal transmission has been a priority since 1998, following the success of short-course zidovudine and single-dose nevirapine clinical trials7. In recent years, single-dose nevirapine as the primary antiretroviral medicine option for HIV-positive pregnant women to prevent transmission to their infants has been phased out, in favor of more effective and simplified triple ART regimens1. The WHO now recommends that all pregnant and breastfeeding women with HIV, regardless of CD4 count or clinical stage, should initiate a triple ART regimen which should be maintained for the duration of perinatal transmission risk, which includes pregnancy, delivery and throughout the breastfeeding period (this is known as Option B). In countries were more than one percent of the population has HIV (these are known as generalized epidemics) and where there is often limited access to tests that indicate the severity of HIV illness (such as CD4 testing), limited partner testing, long duration of breastfeeding and high rates of fertility, the WHO recommends that women meeting treatment eligibility criteria should continue lifelong ART (this strategy is referred to as Option B+)12. There are many benefits to lifelong treatment for all pregnant and breastfeeding women and these include increased coverage of those needing ART for their own health, a reduction in the number of women stopping and starting ART during repeat pregnancies, early protection against perinatal transmission in future pregnancies, reduced risk of infecting a partner who is HIV-negative and decreased risk of medication failure or the development of resistance12. The ultimate goal is to find the most effective and sustainable regimens for HIV treatment and the prevention of perinatal transmission worldwide. Economics, politics, poor infrastructure, access to healthcare and medications, stigma and cultural norms all pose significant challenges to providing this standard of care everywhere and not all PLHIV have equal access to treatment. What are the barriers to the prevention of perinatal transmission? Pregnant women face many difficult decisions, including decisions around HIV testing, treatment options and infant feeding. Understanding the barriers that women face and addressing barriers at various levels can help in realizing the full potential of prevention of perinatal transmission programs. A recent review article found that barriers to the prevention of perinatal transmission often fell into three broad categories that included the individual, their partners and community, and health systems15. At the individual level, studies suggest that a lower maternal education level, younger maternal age, and poor knowledge of HIV transmission and ART are associated with not receiving and/or not taking ART in order to treat and prevent the spread of HIV15. Additionally, a woman’s male partner(s), extended family, greater community and health care setting all influence her decision and ability to take advantage of prevention of perinatal transmission programs. Many qualitative studies have found that stigma regarding HIV status and fear of disclosure to partners and family members is a major barrier to the uptake of perinatal prevention interventions15. Women living with HIV also continue to report that stigma and discrimination, especially in health care settings, continue to be a barrier to accessing adequate information and services1. In various studies, PLHIV have reported negative staff attitudes and this has been cited as a barrier to returning to facilities for care15. In developing countries, health systems issues are also a barrier to greater prevention uptake. Key barriers that have been identified include a shortage of trained clinic staff, high patient volumes, long wait times, and brief and poor counseling sessions15. In addition, a lack of access or shortages of medications, including ART, as well as stock-outs of HIV test kits and condoms have been reported. Poor access to healthcare overall (long distances to facilities) and poor integration of services also contributes to low ART uptake. What about breastfeeding? Breastfeeding is usually the healthiest choice for both infants and mothers. However, HIV transmission can occur during breastfeeding, with chances of transmission increasing the longer the infant is breastfed. In the countries with the highest perinatal HIV rates, it is estimated that more than half of the children newly infected with HIV acquire it during the breastfeeding period1. However, the risk of transmitting HIV to infants through breastfeeding is low in the presence of ART12. Therefore, providing ART to mothers throughout the breastfeeding period is a critical step needed to further reduce rates of perinatal transmission1. It is recommended that HIV-positive mothers do not breastfeed when formula feeding is safe, well accepted and readily available. In the US, both the Centers for Disease Control and Prevention and the American Academy of Pediatrics recommends that HIV-infected women refrain from breastfeeding regardless of their ART status to avoid postnatal transmission of HIV to their infants through breast milk16,17. However, formula feeding requires clean water for mixing formula. Many women in developing countries do not have access to clean water or sanitation and cannot afford formula, and therefore cannot avoid breastfeeding. In developing countries where breastfeeding is the norm, formula feeding may also alert a woman’s family or community that she is HIV-positive, which may result in stigma or other negative repercussions. Therefore, the WHO recommends that when breastfeeding is unavoidable, mothers should take ART while breastfeeding and that infants should receive 6 weeks of prophylaxis with once-daily nevirapine12. The WHO further recommends that mothers known to be infected with HIV (and whose infants are HIV uninfected or of unknown status) should exclusively breastfeed for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life. It is recommended that breastfeeding should only stop when a nutritionally adequate and safe diet without breast-milk can be provided12. Access to ARVs during this extended breastfeeding period is critical12. What’s being done? Primary prevention of HIV among men and women of childbearing age: Various tools are now available to prevent HIV infections in men and women of childbearing age. Pre-exposure prophylaxis (PrEP), which is a special course of HIV treatment that aims to prevent people from becoming infected with HIV, has been found to protect against HIV-1 infection in heterosexual men and women and reduce HIV transmission by 67 to 75%18,19. PrEP is intended for people at-risk of becoming infected with HIV, for example in the case of couples where one partner is HIV-positive and the other is HIV-negative. In countries with generalized HIV epidemics, voluntary medical male circumcision for HIV-negative male partners in relationships with a positive partner has been shown to reduce the risk of HIV-acquisition in men by between 38% to 66%20. Using ART to decrease the chance of HIV transmission, a concept known as treatment as prevention, has also recently been found to be very efficacious, with studies in heterosexual populations showing that adherence to ART is very effective at preventing transmission of HIV to HIV-negative partners21-23. Couples-testing with treatment for infected partners in discordant partnerships is also a promising approach. Integrating couples counseling and partner testing into routine clinic and community services can increase the number of couples in which the status of both partners is known and can help identifying sero-discordant couples24. Preventing unintended pregnancies and Safer Conception Options: Preventing unintended pregnancies among women living with HIV (WLHIV) is a powerful prevention strategy. One study found that even modest reductions in the numbers of pregnancies among WLHIV could avert HIV-positive births at the same rates as the use of ART for PMTCT25. One targeted approach to strengthening FP programs is to integrate FP within HIV services. In Kenya, a recent cluster-randomized trial tried to determine whether integrating FP services into HIV care was associated with increased use of more effective contraceptive methods such as sterilization, IUDs, implants, injectables and oral contraceptives. Women seen at integrated sites were significantly more likely to use more effective methods of FP at the end of the study26. This makes the case for integrating FP within HIV care. Reducing the unmet need for FP will reduce new HIV infections among children and improve overall maternal and infant health. For HIV-positive or serodiscordant couples who would like to have children, there are many options available to make conception safer. When offering preconception care, HIV-positive couples will have specific needs, many of which can be addressed during their routine HIV care. When offering preconception counseling for HIV-positive women, the CDC recommends that health care providers should discuss a variety of topics, including: reproductive options and actively assessing women’s pregnancy intentions on an ongoing basis; Counseling on safe sexual practices that prevent HIV transmission to sexual partners, protect women from acquiring sexually transmitted diseases, and reduce the potential to acquire more virulent or resistant strains of HIV; Using ART to attain a stable, maximally suppressed maternal viral load prior to conception to decrease the risk of perinatal transmission and of HIV transmission to an uninfected partner; and encouraging sexual partners to receive counseling and HIV testing and, if infected, to seek appropriate HIV care11. For couples who want to conceive, in which one or both are HIV-positive, the positive partner should be on ART and have achieved maximal suppression of HIV infection. ART for the positive partner may not be fully protective against sexual transmission of HIV and so the administration of PrEP for the HIV-negative partner may offer an additional tool to reduce the risk of transmission. For discordant couples, when the positive partner is a woman, the safest conception option is artificial insemination. In discordant couples where the positive partner is male,the safest conception option is the use of donor sperm from an HIV-uninfected male with artificial insemination. When the use of donor sperm is unacceptable, the use of sperm preparation techniques together with either intrauterine insemination or in vitro fertilization is an option11. Preventing HIV transmission from WLHIV to infants: Increasing access to ART for WLHIV is critical to saving the lives of women and their children. The number of pregnant WLHIV receiving ART for their own health has increased from 25% in 2009 to 60% in 20121. One of the greatest success stories has been in Malawi where a policy of providing lifelong ART to all pregnant and breastfeeding women (irrespective of CD4 count or clinical status– a strategy referred to as Option B+) was enacted in 2011. Since then, Malawi increased the estimated coverage of women in need of ART from 13% in 2009 to 86% in 2012. The implementation of Option B+ has resulted in a 748% increase in the number of pregnant and breastfeeding women starting ART, from 1,257 in the second quarter of 2011 to 10,663 in the third quarter of 201227. As a result of Option B+, the perinatal transmission rate for women on ART is expected to be reduced, from approximately 40% without intervention to less than 5%. By decentralizing treatment services and offering lifelong HIV treatment to all pregnant and breastfeeding women, Malawi has been able to increase ART coverage both during pregnancy and the breastfeeding period1. Providing treatment, care and support to WLHIV and their children and families: Increasing access to ART for pregnant women living with HIV for their own health is critical to saving the lives of women and their children. Even developing countries, which at first lagged behind in reducing the number of children newly infected with HIV, have made great gains in recent years. In 2013, UNAIDS reported that in 7 high burden countries where access to treatment has increased, the rates of HIV transmission to children has fallen by 50% or more1. What still needs to be done? HIV is a preventable disease. Perinatal transmission is best prevented by effective, accessible and sustainable HIV prevention, access to HIV testing, early diagnosis and linkage to treatment programs for women, men and their children, access to family planning and abortion services to prevent unintended pregnancies, and access to an ongoing supply of ARVs to improve the health of women and their children. Structural interventions are also needed that increase access to health centers, improve health care infrastructure, provide food supplementation, and HIV treatments. Women are the key to the HIV response and the number of women acquiring HIV has to be reduced. All women have a right to be treated for HIV infection, not simply because they are bearing a child. All women living with HIV who are eligible for ART need to have access to it. Unfortunately, too many women are still lost along the prevention cascade and never get the care or treatment they need and deserve. Providing women with access to high quality healthcare for themselves and their families, whether they are HIV-positive or not, is imperative.Says who?
1. UNAIDS. AIDS by the numbers. Geneva, Switzerland, 2013. 2. Kanniappan S, Jeyapaul MJ, Kalyanwala S. Desire for motherhood: exploring HIV-positive women’s desires, intentions and decision-making in attaining motherhood. AIDS care 2008;20(6):625-30 doi: 10.1080/09540120701660361[published Online First: Epub Date]|. 3. Beyeza-Kashesya J, Kaharuza F, Mirembe F, et al. The dilemma of safe sex and having children: challenges facing HIV sero-discordant couples in Uganda. African health sciences 2009;9(1):2-12 4. Cooper D, Moodley J, Zweigenthal V, et al. Fertility intentions and reproductive health care needs of people living with HIV in Cape Town, South Africa: implications for integrating reproductive health and HIV care services. AIDS and behavior 2009;13 Suppl 1:38-46 doi: 10.1007/s10461-009-9550-1[published Online First: Epub Date]|. 5. UNAIDS. We Can Prevent mothers fom dying and babies from becoming infected with HIV. Geneva, Switzerland, 2010. 6. De Cock KM, Fowler MG, Mercier E, et al. Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice. JAMA : the journal of the American Medical Association 2000;283(9):1175-82 7. WHO. PMTCT Strategic Vision 2010-2015: Preventing mother-to-child transmission of HIV to reach the UNGASS and Millenium Development Goals. Geneva, Switzerland, 2010. 8. CDC. HIV Among Pregnant Women, Infants, and Children in the United States. Atlanta, 2012. 9. Nesheim S, Taylor A, Lampe MA, et al. A framework for elimination of perinatal transmission of HIV in the United States. Pediatrics 2012;130(4):738-44 doi: 10.1542/peds.2012-0194[published Online First: Epub Date]|. 10. Nakayiwa S, Abang B, Packel L, et al. Desire for children and pregnancy risk behavior among HIV-infected men and women in Uganda. AIDS and behavior 2006;10(4 Suppl):S95-104 doi: 10.1007/s10461-006-9126-2[published Online First: Epub Date]|. 11. Department of Health and Human Services Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. In: Bureau HA, ed. Washington, DC, 2014. 12. WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach. Geneva, Switzerland, 2013. 13. Kourtis AP, Lee FK, Abrams EJ, et al. Mother-to-child transmission of HIV-1: timing and implications for prevention. The Lancet infectious diseases 2006;6(11):726-32 doi: 10.1016/S1473-3099(06)70629-6[published Online First: Epub Date]|. 14. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control 2006;55(RR-14):1-17; quiz CE1-4 15. Gourlay A, Birdthistle I, Mburu G, et al. Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review. Journal of the International AIDS Society 2013;16(1):18588 doi: 10.7448/IAS.16.1.18588[published Online First: Epub Date]|. 16. American Academy of Pediatrics Committee on Pediatric A. HIV testing and prophylaxis to prevent mother-to-child transmission in the United States. Pediatrics 2008;122(5):1127-34 doi: 10.1542/peds.2008-2175[published Online First: Epub Date]|. 17. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Secondary Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. 18. Celum C, Baeten JM. Tenofovir-based pre-exposure prophylaxis for HIV prevention: evolving evidence. Current opinion in infectious diseases 2012;25(1):51-7 doi: 10.1097/QCO.0b013e32834ef5ef[published Online First: Epub Date]|. 19. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. The New England journal of medicine 2012;367(5):399-410 doi: 10.1056/NEJMoa1108524[published Online First: Epub Date]|. 20. Siegfried N, Muller M, Deeks JJ, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men. The Cochrane database of systematic reviews 2009(2):CD003362 doi: 10.1002/14651858.CD003362.pub2[published Online First: Epub Date]|. 21. Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet 2010;375(9731):2092-8 doi: 10.1016/S0140-6736(10)60705-2[published Online First: Epub Date]|. 22. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. The New England journal of medicine 2010;363(27):2587-99 doi: 10.1056/NEJMoa1011205[published Online First: Epub Date]|. 23. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. The New England journal of medicine 2011;365(6):493-505 doi: 10.1056/NEJMoa1105243[published Online First: Epub Date]|. 24. Medley A, Baggaley R, Bachanas P, et al. Maximizing the impact of HIV prevention efforts: Interventions for couples. AIDS care 2013 doi: 10.1080/09540121.2013.793269[published Online First: Epub Date]|. 25. Sweat MD, O’Reilly KR, Schmid GP, et al. Cost-effectiveness of nevirapine to prevent mother-to-child HIV transmission in eight African countries. Aids 2004;18(12):1661-71 26. Grossman D, Onono M, Newmann SJ, et al. Integration of family planning services into HIV care and treatment in Kenya: a cluster-randomized trial. Aids 2013;27 Suppl 1:S77-85 doi: 10.1097/QAD.0000000000000035[published Online First: Epub Date]|. 27. Centers for Disease Control and Prevention. Impact of an innovative approach to prevent mother-to-child transmission of HIV–Malawi, July 2011-September 2012. MMWR. Morbidity and mortality weekly report 2013;62(8):148-51Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©2009, University of CA. Comments and questions about this Fact Sheet may be e-mailed to CAPS.web@ucsf. edu.
Transgender Women and HIV Prevention and Care
Transgender Women and HIV Prevention and Care
‘Transgender women’ is an umbrella term to refer to persons who identify as women or trans women, or who have a feminine gender identity that differs from the male sex they were assigned at birth. Transgender women may identify with certain terms and not others and may express gender in a variety of ways. Gender identity terms vary by geographic region, race, ethnicity, age, and other factors, so it is best to ask people what they prefer. Best practices for obtaining information on gender identity in the context of research and health services continue to evolve.1
Transgender Women and HIV Risk
Transgender women are at disproportionate risk for HIV; an estimated 19.1% of transgender (‘trans’) women are living with HIV, according to a meta-analysis of studies from around the world.2 Internationally, trans women have 49 times higher odds of living with HIV compared to the general adult population;3 in the US they have the highest rates of new diagnoses by gender.4 Black and Latina trans women experience an extremely high HIV burden; more than half of trans people diagnosed with HIV are Black (44%) or Hispanic/Latinx (26%).5 Intersectional stigma—oppression rooted in racism, transphobia, and misogyny6—fuels structural vulnerabilities among trans women of color7-9 and has been linked with trauma symptoms, inconsistent condom use, suboptimal PrEP and ART adherence, and detectable viral load.10-12 Like many populations, those at greatest risk are more likely to be poor, homeless, young, people of color, and engage in sex work.13,14
Not all trans women are at risk for HIV; however, stigma and discrimination faced by trans women often results in social marginalization, increasing risk of poor health outcomes.15 Social isolation and rejection by family members is common, which can lead to anxiety, depression, experiencing homelessness at a young age, and heightened risk of suicidal ideation and attempts.16,17 School-based stigma and bullying make young trans women vulnerable to dropping out and poor mental health, disrupting education and employment pathways.18-20 Sex work, recent homelessness, and school dropout are associated with incarceration, which trans women experience at higher rates than the general population.21
HIV Prevention and Care for Transgender Women
The provision of gender-affirming HIV prevention and care services is of utmost importance to serving trans women effectively.22 Trans people often report avoiding health care settings due to stigma and past negative experiences; when seeking care, they tend to prioritize gender-affirming medical care, such as hormone therapy, over HIV prevention services such as PrEP.23-25 Barriers to PrEP use among trans women include low PrEP awareness, concerns about drug interactions with hormone therapy, and low access to gender-affirming care.26-28 A 2020 national probability sample of trans people found only 3% of sexually active respondents were currently taking PrEP.29
Efficacious prevention programming prioritizing the needs of trans women has increased in the last decade, although much work remains. The first National Transgender HIV Testing Day was held on April 18, 2016. In 2018, the Health Resources and Services Administration Special Projects of National Significance Division published the Transgender Women of Color Initiative: Project Interventions Manual and then in 2019, the Centers for Disease Control and Prevention published their Toolkit for Providing HIV Prevention Services to Transgender Women of Color. Trans women experience unique barriers to prevention and care, and therefore, trans women should not be subsumed into MSM programming.30 Research consistently demonstrates that programs based in gender affirmation have the greatest impact in optimizing health outcomes for trans women.31-38
Training for healthcare providers in creating inclusive, gender-affirming clinical environments. Quality, affirming healthcare is important for trans women. Despite their sincere concern to serve patients effectively, providers may have very little knowledge, experience, skills and therefore comfort with trans patients though the availability of transgender-specific training for medical students is increasing39. UCSF Transgender Care provides free online resources for healthcare providers and other professionals for guidance on staff training, creating welcoming spaces, and data collection.
HIV Testing and Prevention. Three interventions designed for trans women have demonstrated efficacy with reducing risk and increasing HIV testing. Couples HIV Intervention Program (CHIP) is designed for trans women and their cisgender male partners as an intervention to support the couple and promote HIV testing and safe sex practices. Project Life Skills is a group-based intervention for young trans women focused on communication skills and condom negotiation. Sheroes is an intervention for adult trans women of color comprised of five weekly group sessions emphasizing healthcare empowerment and gender affirmation.40 Facilitating PrEP use among HIV prevention strategies is a developing area in services that prioritize trans women. Recent research provides emerging evidence for a trans-specific advertising campaign promoting PrEP use (PrEP4Love)41 and there is also emerging evidence for a program to increase PrEP adherence using peer navigators (A.S.K.-PrEP).42
Linkage and retention in HIV care. Transgender Women Entry and Engagement to Care Project (TWEET) is a group-based intervention to link transgender women living with HIV to care and support their engagement in care. Transgender Women Involved in Strategies for Transformation (TWIST) is a peer-led, small-group, skills-building, and educational high-impact prevention (HIP) intervention for adult trans women living with HIV. Healthy Divas combines individual sessions with a peer counselor and a group workshop with a medical provider to promote engagement in gender-affirming and HIV medical care.43-45
Unaddressed Needs of Transgender Women
To address the devastating effects of stigma and discrimination on trans people, large-scale anti-stigma campaigns, as well as anti-discrimination laws, should be implemented across the country. Structural interventions such as job training, housing, and educational programs should be widely implemented and evaluated. Ongoing capacity building and sensitivity training should be provided for healthcare workers, school officials, service providers, and researchers working with trans women. More research is needed with sexual partners of trans women, as well as programs that work with trans women and partners together as a couple.46 Finally, more research should be done with trans youth to identify and develop strategies for HIV prevention for young adults identifying as trans and gender diverse.47 Interventions and programs that leverage the inherent resilience and support networks within trans communities are also promising approaches to optimizing health outcomes among trans women.48
Resources
- Center of Excellence for Transgender Health
- Transgender Law Center
- National Center for Transgender Equality
- Transgender HIV/AIDS Services Best Practices Guidelines
- World Professional Association for Transgender Health
| Fact Sheet Date | Authors |
|---|---|
| September 2008 / Revised 2015 |
JoAnne Keatley MSW / CAPS and Pacific AETC Walter Bockting Ph.D. / University of Minnesota |
| Revised June 2021 |
Beth Bourdeau, Ph.D. / Division of Prevention Science Jae Sevelius, Ph.D. / Division of Prevention Science Greg Rebchook, Ph.D. / Division of Prevention Science Jenna Rapues, MPH / San Francisco Department of Public Health Nasheedah Bynes-Muhammad/ The Journey Partners LLC |
Says who?
Orientation and Gender Identity Questions: A Qualitative Study. Archives of sexual behavior. 2020;49(7):2301-2318.
2. Baral S, Poteat T, Stromdahl S, Wirtz A, Guadamuz T, Beyrer C. Worldwide burden of HIV in transgender women: A systematic review and meta-analysis. The Lancet Infectious Diseases. 2013;13(3):214-222.
3. Baral SD, Poteat T, Stromdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. The Lancet infectious diseases. 2013;13(3):214-222.
4. Herbst J, Jacobs E, Finlayson T, McKleroy V, Neumann M, Crepaz N. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS and Behavior. 2008;12(1):1-17.
5. Clark H, Babu AS, Wiewel EW, Opoku J, Crepaz N. Diagnosed HIV infection in transgender adults and adolescents: results from the National HIV Surveillance System, 2009–2014. AIDS and Behavior. 2017;21(9):2774-2783.
6. Bailey M, Trudy. On misogynoir: citation, erasure, and plagiarism. Feminist Media Studies. 2018:1-7.
7. Palazzolo SL, Yamanis TJ, et al. Documentation status a contexual determinent of HIV risk among young transgender Latinas. LGBT Health. 2016;3(2):132-138.
8. Fletcher JB, Kisler KA, Reback CJ. Housing status and HIVrisk behaviors among transgender women in Los Angeles. Arch Sex Behav 2014;43:1651-1661.
9. Operario D, Nemoto T. HIV in transgender communities: Syndemic dynamics and a need for multicomponent interventions. J Acquir Immune Defic Syndr. 2010;55:S91-S93.
10. Richmond KA, Burnes T, Carroll K. Lost in trans-lation: Interpreting systems of trauma for transgender clients. Traumatology. 2012;18(1):45-57.
11. Smith LR, Yore J, Triplett DP, Urada L, Nemoto T, Raj A. Impact of Sexual Violence Across the Lifespan on HIV Risk Behaviors Among Transgender Women and Cisgender People Living With HIV. J Acquir Immune Defic Syndr. 2017;75(4):408-416.
12. Wirtz AL, Poteat TC, Malik M, Glass N. Gender-Based Violence Against Transgender People in the United States: A Call for Research and Programming. Trauma Violence Abuse. 2018:1524838018757749.
13. Becasen JS, Denard CL, Mullins MM, Higa DH, Sipe TA. Estimating the Prevalence of HIV and Sexual Behaviors Among the US Transgender Population: A Systematic Review and Meta-Analysis, 2006–2017. American Journal of Public Health. 2019;109(1):e1-e8.
14. Reback CJ, Clark K, Holloway IW, Fletcher JB. Health Disparities, Risk Behaviors and Healthcare Utilization Among Transgender Women in Los Angeles County: A Comparison from 1998–1999 to 2015–2016. AIDS and behavior. 2018;22(8):2524-2533.
15. Wesp LM, Malcoe LH, Elliott A, Poteat T. Intersectionality Research for Transgender Health Justice: A Theory-Driven Conceptual Framework for Structural Analysis of Transgender Health Inequities. Transgend Health. 2019;4(1):287-296.
16. Kota KK, Salazar LF, Culbreth RE, Crosby RA, Jones J. Psychosocial mediators of perceived stigma and suicidal ideation among transgender women. BMC public health. 2020;20(1):125-125.
17. Testa RJ, Michaels MS, Bliss W, Rogers ML, Balsam KF, Joiner T. Suicidal Ideation in Transgender People: Gender Minority Stress and Interpersonal Theory Factors. Journal of abnormal psychology (1965). 2017;126(1):125-136.
18. Hereth J, Garthe RC, Garofalo R, Reisner SL, Mimiaga MJ, Kuhns LM. Examining Patterns of Interpersonal Violence, Structural and Social Exclusion, Resilience, and Arrest among Young Transgender Women. Criminal justice and behavior. 2021;48(1):54-75.
19. Leppel K. Transgender Men and Women in 2015: Employed, Unemployed, or Not in the Labor Force. Journal of homosexuality. 2021;68(2):203-229.
20. Vance SR, Jr., Boyer CB, Glidden DV, Sevelius J. Mental Health and Psychosocial Risk and Protective Factors Among Black and Latinx Transgender Youth Compared With Peers. JAMA Network Open. 2021;4(3):e213256-e213256.
21. Hughto JMW, Reisner SL, Kershaw TS, et al. A multisite, longitudinal study of risk factors for incarceration and impact on mental health and substance use among young transgender women in the USA. J Public Health (Oxf). 2019;41(1):100-109.
22. Sevelius JM, Deutsch MB, Grant R. The future of PrEP among transgender women: the critical role of gender affirmation in research and clinical practices. Journal of the International AIDS Society. 2016;19(7Suppl 6):21105.
23. Braun HM, Candelario J, Hanlon CL, et al. Transgender Women Living with HIV Frequently Take Antiretroviral Therapy and/or Feminizing Hormone Therapy Differently Than Prescribed Due to Drug–Drug Interaction Concerns. LGBT health. 2017;4(5):371-375.
24. Reisner SL, Perez-Brumer AG, McLean SA, et al. Perceived Barriers and Facilitators to Integrating HIV Prevention and Treatment with Cross-Sex Hormone Therapy for Transgender Women in Lima, Peru. AIDS and behavior. 2017;21(12):3299-3311.
25. Sevelius JM, Keatley J, Calma N, Arnold E. 'I am not a man': Trans-specific barriers and facilitators to PrEP acceptability among transgender women. Global public health. 2016;11(7-8):1060-1075.
26. Cahill SR, Keatley J, Wade Taylor S, et al. “Some of us, we don’t know where we’re going to be tomorrow.” Contextual factors affecting PrEP use and adherence among a diverse sample of transgender women in San Francisco. AIDS Care. 2020;32(5):585-593.
27. Sevelius JM, Keatley J, Calma N, Arnold E. “I am not a man”: Trans-specific barriers and facilitators to PrEP acceptability among transgender women. Global Public Health. 2016(Special issue, The Trouble with ‘Categories’: Rethinking MSM, Trans and their Equivalents in HIV Prevention and Health Promotion).
28. Poteat T, Wirtz A, Malik M, et al. A Gap Between Willingness and Uptake: Findings From Mixed Methods Research on HIV Prevention Among Black and Latina Transgender Women. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2019;82(2).
29. Sevelius JM, Poteat T, Luhur WE, Reisner SL, Meyer IH. HIV Testing and PrEP Use in a National Probability Sample of Sexually Active Transgender People in the United States. Journal of acquired immune deficiency syndromes. 2020.
30. Sevelius JM, Keatley J, Calma N, Arnold E. 'I am not a man': Trans-specific barriers and facilitators to PrEP acceptability among transgender women. 2016.
31. Lacombe-Duncan A, Newman P, Bauer G, et al. Gender-affirming healthcare experiences and medical transition among transgender women living with HIV: A mixed-methods study. Sexual health. 2019;16(4):367-376.
32. Lama J, Mayer K, Perez-Brumer A, et al. Integration of gender-affirming primary care and peer navigation with HIV prevention and treatment services to improve the health of transgender women: Protocol for a prospective longitudinal cohort study. JMIR Research Protocols. 2019;8(6):e14091.
33. Mayo-Wilson L, Benotsch E, Grigsby S, et al. Combined effects of gender affirmation and economic hardship on vulnerability to HIV: A qualitative analysis among US adult transgender women. BMC PUBLIC HEALTH. 2020;20(1):782-717.
34. Reisner S, Bradford J, Hopwood R, et al. Comprehensive transgender healthcare: The gender affirming clinical and public health model of Fenway Health. Journal of Urban Health. 2015;92(3):584-592.
35. Reisner SL, White Hughto JM, Pardee D, Sevelius J. Syndemics and gender affirmation: HIV sexual risk in female-to-male trans masculine adults reporting sexual contact with cisgender males. International journal of STD & AIDS. 2016;27(11):955-966.
36. Sevelius J. Gender affirmation: A framework for conceptualizing risk behavior among transgender women of color. Sex Roles. 2013;68(11-12):675-689.
37. Sevelius JM, Chakravarty D, Dilworth SE, Rebchook G, Neilands TB. Gender Affirmation through Correct Pronoun Usage: Development and Validation of the Transgender Women's Importance of Pronouns (TW-IP) Scale. International journal of environmental research and public health. 2020;17(24):9525.
38. Sevelius JM, Deutsch MB, Grant R. The future of PrEP among transgender women: the critical role of gender affirmation in research and clinical practices. 2016.
39. Dubin SN, Nolan IT, Streed CG Jr, Greene RE, Radix AE, SD M. Transgender health care: improving medical students' and residents' training and awareness. Adv Med Educ Pract. 2018;9:377-391.
40. Sevelius J, Neilands T, Dilworth S, Castro D, Johnson M. Sheroes: Feasibility and acceptability of a community-driven, group-level HIV intervention program for transgender women. AIDS and behavior. 2019;24(5):1551-1559.
41. Phillips II G, Raman A, Felt D, et al. PrEP4Love: The Role of Messaging and Prevention Advocacy in PrEP Attitudes, Perceptions, and Uptake Among YMSM and Transgender Women. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2020;83(5):450-456.
42. Reback CJ, Clark KA, Rünger D, AE F. A Promising PrEP Navigation Intervention for Transgender Women and Men Who Have Sex with Men Experiencing Multiple Syndemic Health Disparities. J Community Health. 2019;44(6):1193-1203.
43. Cahill SR, Keatley J, Wade Taylor S, et al. "Some of us, we don't know where we're going to be tomorrow." Contextual factors affecting PrEP use and adherence among a diverse sample of transgender women in San Francisco. AIDS care. 2020;32(5):585-593.
44. Maiorana A, Sevelius J, Keatley J, Rebchook G. “She is like a sister to me”: Gender-affirming services and relationships are key to the implementation of HIV care engagement interventions with transgender women of color. AIDS and behavior. 2020.
45. Poteat T, Malik M, Scheim A, Elliott A. HIV Prevention Among Transgender Populations: Knowledge Gaps and Evidence for Action. Current HIV/AIDS Reports. 2017;14(4):141-152.
46. Gamarel KE, Sevelius JM, Neilands TB, et al. Couples-based approach to HIV prevention for transgender women and their partners: study protocol for a randomised controlled trial testing the efficacy of the ‘It Takes Two’intervention. BMJ Open. 2020;10(10):e038723.
47. Reisner SL, Jadwin-Cakmak L, Sava L, Liu S, Harper GW. Situated Vulnerabilities, Sexual Risk, and Sexually Transmitted Infections' Diagnoses in a Sample of Transgender Youth in the United States. AIDS Patient Care STDS. 2019;33(3):120-130.
48. Lacombe-Duncan A, Logie CH, Newman PA, Bauer GR, Kazemi M. A qualitative study of resilience among transgender women living with HIV in response to stigma in healthcare. AIDS Care. 2020;32(8):1008-1013.
Woman
What are US women’s HIV prevention needs?
are women at risk?
Yes. HIV is taking an increasing toll on women and girls in the US. In 1985, women comprised 8% of all AIDS cases in the US, while by 2005, women made up 27% of all AIDS cases. In 2005, women accounted for 30% of all new HIV infections. Of these, 60% occurred among African Americans, 19% among Whites, 19% among Hispanics, and 1% each among Asian/Pacific Islanders and American Indian/Alaska Natives.
who are women most affected by HIV?
African American and Hispanic women in particular are disproportionately affected by HIV/AIDS. Although African American and Hispanic women comprise only 23% of the total female population in the US, in 2005 they accounted for 79% of all new HIV infections (African American women: 60%, Hispanic women: 19%). Accordingly, in 2004 HIV infection was the leading cause of death for Black women (including African American women) aged 25-34 years. Younger women are also affected by HIV/AIDS. In recent years, the largest number of HIV/AIDS diagnoses among women occured in women 15-39 years old. In 2005, young women represented 28% of AIDS cases among young men and women aged 20-24.
what places women at risk?
Most women are infected with HIV through heterosexual contact, especially women with injection drug using partners. In 2005, 80% of all new infections in women were from heterosexual contact. Women are more likely than men to acquire HIV via sexual intercourse, due to greater exposed surface area in the female genital tract. Injection and non-injection drug use places women at an increased risk for HIV and is strongly linked to unsafe sexual practices. Approximately 20% of new HIV cases in women is related to injection drug use. Women who use crack cocaine may also be at high risk of sexual transmission of HIV, particularly if they sell or trade sex for drugs. Sexually transmitted infections (STIs) other than HIV can increase the likelihood of getting or transmitting HIV. In the US, chlamydia and gonorrhea (both asymptomatic) are the most commonly reported STIs, with highest rates in women of color and young women and adolescents. Sexual abuse (both childhood and adult) and domestic violence play a substantial role in placing women at risk for HIV infection. In the US, annually 2.1 million women are raped and 4 million become victims of domestic violence; of these women, more than 10,000 rape victims and 79,000 violence victims require hospitalization. Women who report early and chronic sexual abuse are seven times more likely to engage in HIV-related risk behaviors compared to women without trauma history. Women disproportionately suffer from poverty, in particular women of color who are affected by HIV. Because of this, women are less likely than men to have health insurance and access to quality healthcare or prevention services. Approximately two-thirds of women with HIV in the US have an annual income of less than $10,000. Poverty can increase HIV risks such as exchanging sex for money, shelter, or drugs. In a survey of young and low-income women in California, women who reported sex work were more likely to have syphilis, herpes, hepatitis C, and a history of sexual abuse. Abuse, violence and poverty can all lessen a woman’s power to negotiate condom use or choose safer partners. They also can lead to psychological distress, such as depression, anxiety and post-traumatic stress disorder (PTSD). Having relationships that overlap in time (concurrent partners) can increase women’s risk of HIV transmission. Concurrency is more likely to occur among women who are not married, are young adults and are poor.
what can help?
Involving male partners. For women to protect themselves from HIV, they must not only rely on their own skills, attitudes, and behaviors regarding condom use, but also on those of their male partner. Often, men and women in relationships may find intimacy to be more important than protection against HIV. Involving women’s partners in HIV prevention programs can help strengthen intimacy and trust and improve sexual communication and negotiation, including asking about past and current partners. Support from other women. Many prevention programs for women offer groups to reduce women’s isolation and allow women to support each other and normalize safer behaviors. Greater social support can increase self esteem and allow women to make healthier choices. A program in Washington DC helped build support and empowerment for HIV+ African American women by holding educational groups during shared meals and providing small gifts (along with condoms) as incentives or thank-yous. Help with non-HIV factors. Women at risk for HIV face many behavioral and structural challenges beyond HIV: poverty and economic strain, unemployment, violence and unhealthy gender relations, migration, STIs, drug use, and caring for children and family members. HIV prevention programs for women should provide transportation, child care, nutritious food and compensation such as money, phone or store cards or gift packs. Programs should provide up-to-date referrals for employment, housing, medical care and mental health services trauma, abuse and depression.
what is being done?
Currently 17 women-specific interventions exist that have been approved by the CDC as best evidence or promising evidence or are part of the Diffusion of Effective Behavioral Interventions (DEBI) project: CHOICES, Communal Effectance-AIDS Prevention, Female and Culturally Specific Negotiation, Project FIO, Project SAFE, RAPP, SiHLE, SISTA, Sisters Saving Sisters, Sister to Sister, WHP, WiLLOW, Women’s Co-op, Condom Promotion, Insights, Safer Sex, and SEPA. The Women’s Leadership and Community Planning project in San Francisco, offered a 2-day training for women with HIV in California who want to take greater leadership roles in state Planning Councils. At the training, women network with each other, as well as learn skills in public speaking, decision-making, and conflict management. Women stay in touch through monthly conference calls. After the first training, 6 of 13 women moved into leadership positions on their local or state Councils. Respeto/Proteger: Respecting and Protecting our Relationships is an HIV prevention program for Latino teen mothers and fathers in Los Angeles, CA. Developed and tested with a community agency and academic researchers, the program recognizes risks young women face, including poverty, drug and alcohol use, history of STIs and physical or sexual abuse. The six-session intervention focuses on healing the wounded spirit and builds on feelings of maternal and paternal protectiveness using cultural and traditional teachings.
what needs to be done?
Because women are more likely to get HIV from their male partners, programs that target men (especially IDUs) will have a beneficial impact on women. Needle exchange and drug treatment strategies are critical. Public health agencies need to raise awareness about sexual abuse and domestic violence to not only help men and women develop the skills to prevent it, but also to curb its effect on the HIV epidemic. HIV testing campaigns that target women and women-friendly testing sites are also needed. Behavioral and structural HIV prevention interventions for women continue to be necessary, given the lack of evidence from biomedical interventions (microbicides, vaccines). However, research needs to continue on how women can protect themselves with an accessible, affordable, comfortable and discrete tool for safer sex. Although research has highlighted the subpopulations of women most affected by HIV/AIDS, it is even more important to translate and materialize study findings into tangible public health programs and effective policies. Interventions that address sexuality, family, culture, empowerment, self-esteem, and negotiating skills, as well as interventions located in varying community settings are especially valuable.
Says who?
1. Kaiser Family Foundation. Women and HIV/AIDS in the United States. Policy Fact Sheet. July 2007. 2. Centers for Disease Control and Prevention. Cases of HIV infection and AIDS in the United States and Dependent Areas, 2005. HIV/AIDS Surveillance Report. 2007;17. 3. Centers for Disease Control and Prevention. HIV/AIDS fact sheet: HIV/AIDS among women. June 2007. 4. National Institute of Allergy and Infectious Diseases at National Institutes of Health. Research on HIV infection in women. 2006. 5. Theall KP, Sterk CE, Elifson KW, et al. Factors associated with positive HIV serostatus among women who use drugs: continued evidence for expanding factors of influence. Public Health Reports. 2003;118:415-424. 6. Sangani P, Rutherford G, Wilkinson D. Population-based interventions for reducing sexually transmitted infections, including HIV infection. Cochrane Database of Systematic Reviews. 2004; 2:CD001220. 7. Weinstock H, Berman S, Cates W. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives in Sexual and Reproductive Health. 2004;36:6-10. 8. Koenig LJ, Moore J. Women, violence, and HIV: A critical evaluation with implications for HIV services. Maternal and Child Health Journal. 2000;4:103-109. 9. Wyatt GE, Myers HF, Loeb TB. Women, trauma, and HIV: an overview. AIDS and Behavior. 2004;8:401-403. 10. Bozzette SA, Berry SH, Duan N, et al. The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium. New Engand Journal of Medicine. 1998;339:1897-1904. 11. Cohan DL, Kim A, Ruiz J, et al. Health indicators among low income women who report a history of sex work: the population based Northern California Young Women’s Survey. Sexually Transmitted Infections. 2005;81:428-433. 12. Adimora AA, Schoenbach VJ, Bonas DM, et al. Concurrent sexual partnerships among women in the United States. Epidemiology. 2002;13:320-327. 13. Prosper! The Women’s Collective, Washington DC. 14. Dworkin SL, Ehrhardt AA. Going beyond “ABC” to include “GEM”: critical reflections on progress in the HIV/AIDS epidemic. American Journal of Public Health. 2007;97:13-18. 15. Centers for Disease Control and Prevention. Updated Compendium of Evidence-Based Interventions, 2007. 16. Women’s Leadership and Community Planning project, CompassPoint, San Francisco, CA. 17. Lesser J, Koniak-Griffin D, Gonzalez-Figueroa E, et al. Childhood abuse history and risk behaviors among teen parents in a culturally rooted, couple-focused HIV prevention program. Journal of the Association of Nurses in AIDS Care. 2007;18:18-27. 18. Landovitz RJ. Recent efforts in biomedical prevention of HIV. Topics in HIV Medicine. 2007;15:99-103.
Prepared by Roshan Rahnama, CAPS April 2008. Fact Sheet #4ER Special thanks to the following reviewers of this fact sheet: Abby Charles, Beth Freedman, Bridget Hughes, Winifred King, Linda Koening, Maureen Miller, Adeline Nyamathi, Nancy Padian, Kate Perkins, Gina Wingood, Gail Wyatt, Toni Young. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©April 2008, University of CA.
Mujeres
¿Qué necesitan las mujeres en la prevención del VIH en EEUU?
¿corren riesgo de contraer el VIH?
Sí. El VIH afecta a cada vez más mujeres y muchachas en EEUU. En 1985, las mujeres componían el sólo el 8 % de los casos de SIDA en EEUU, en comparación con el 27 % en el año 2005. Para el 2005, las mujeres ya representaban el 30 % de las nuevas infecciones por VIH, de las cuales el 60 % eran afroamericanas, el 19 % caucásicas, el 19 % hispanas y el 1 % asiáticas/isleñas del Pacífico e indígenas americanas/nativas de Alaska, respectivamente.
¿qué mujeres son más afectadas por el VIH?
El VIH/SIDA afecta desproporcionadamente a las mujeres afroamericanas y las hispanas. Aunque estos dos grupos componen sólo el 23 % de la población femenina de EEUU, en el año 2005 representaban el 79 % de los casos nuevos de infección por VIH (afroamericanas: 60 %, hispanas: 19 %). En el 2004 la infección por VIH fue la primera causa de muerte entre mujeres negras (incluidas las afroamericanas) entre 25 y 34 años de edad. El VIH/SIDA también afecta a mujeres más jóvenes. En años recientes, el mayor número de diagnósticos de VIH/SIDA entre mujeres se dio en las que tenían entre 15 y 39 años de edad. En el 2005, las mujeres jóvenes representaban el 28 % de los casos de SIDA entre mujeres y hombres de 20 a 24 años de edad.
¿qué pone en riesgo a las mujeres?
La mayoría de las mujeres contraen el VIH por medio del contacto heterosexual, especialmente si su pareja se inyecta drogas. En el 2005, el 80 % de las nuevas infecciones entre mujeres se debían al contacto heterosexual. Las mujeres son más propensas que los hombres a adquirir el VIH durante el coito debido a que, dentro del tracto genital femenino, una mayor superficie queda expuesta. El consumo de drogas (inyectables o no inyectables) aumenta el riesgo que corren las mujeres de contraer el VIH y está fuertemente vinculado a las prácticas sexuales riesgosas. Aproximadamente el 20 % de los nuevos casos femeninos de VIH se relaciona con el uso de drogas inyectables. Las consumidoras de cocaína en roca (crack) también pueden correr un riesgo elevado de transmisión del VIH, en particular si venden o intercambian el sexo por drogas. Las infecciones de transmisión sexual (ITS) que no sean el VIH pueden aumentar las posibilidades de adquirir o de transmitir el VIH. En EEUU, la clamidia y la gonorrea (ambas infecciones asintomáticas) son las ITS que se reportan con mayor frecuencia, con las tasas más altas entre las mujeres no caucásicas, las mujeres jóvenes y las adolescentes. El abuso sexual (en la niñez y en la edad adulta) y la violencia doméstica juegan un papel fundamental en aumentar el riesgo de contraer el VIH. Cada año 2.1 millones de mujeres son violadas y cuatro millones son víctimas de la violencia doméstica en EE.UU.; de estas mujeres, más de 10,000 mujeres violadas y 79,000 de las víctimas de abuso requieren hospitalización. Las mujeres que han sufrido abuso sexual desde temprana edad y en forma crónica son siete veces más propensas a participar en conductas que las ponen en riesgo de contraer el VIH que otras mujeres sin antecedentes de trauma. Las mujeres sufren desproporcionadamente de la pobreza, en particular las mujeres no caucásicas con VIH, lo cual reduce sus posibilidades de tener seguro médico y acceso a servicios médicos o preventivos de alta calidad. En EEUU, unos dos tercios de las mujeres con VIH tienen ingresos anuales por debajo de $10,000. La pobreza puede aumentar los riesgos de VIH tales como el intercambio del sexo por dinero, alojamiento o drogas. Entre las mujeres jóvenes y de bajos ingresos encuestadas en California, las que afirmaron haber hecho trabajo sexual tenían tasas más altas de sífilis, herpes, hepatitis C y antecedentes de abuso sexual. El abuso, la violencia y la pobreza pueden minar el poder de la mujer a la hora de negociar el uso de condones o de escoger parejas sexualmente más seguras. También pueden llevar a problemas psicológicos como la depresión, la ansiedad y el trastorno de estrés postraumático (PTSD en inglés). Tener parejas concurrentes puede incrementar el riesgo de contraer el VIH y es más común entre las mujeres jóvenes solteras pobres.
¿qué se puede hacer para ayudar?
Involucrar a las parejas masculinas. Para poder protegerse contra el VIH, las mujeres no sólo dependen de sus propias habilidades, actitudes y conductas con respecto al uso de condones, sino también de las de sus compañeros sexuales. En muchas relaciones románticas la intimidad pesa más que la protección contra el VIH. La inclusión de los hombres en los programas de prevención del VIH puede profundizar la intimidad y confianza y mejorar la comunicación y negociación sexual incluyendo las preguntas sobre parejas sexuales anteriores y actuales. Recibir el apoyo de otras mujeres. Muchos programas de prevención para mujeres ofrecen grupos para reducir el aislamiento y permitir el apoyo mutuo entre mujeres y la normalización de prácticas más seguras. Un aumento del apoyo social puede incrementar la autoestima y promover la toma de decisiones más saludables. Un programa en Washington, DC generó apoyo y empoderamiento para mujeres afroamericanas VIH+ por medio de pláticas educativas durante comidas comunales y la provisión de pequeños obsequios (junto con condones) a manera de incentivo o agradecimiento. Ayudar con otros problemas no relacionados con el VIH. Las mujeres vulnerables al VIH encaran muchos desafíos conductuales y estructurales además del VIH: la pobreza y otras dificultades económicas, el desempleo, la violencia y las relaciones de pareja dañinas, la migración, las ITS, el uso de drogas y la necesidad de cuidar de niños y otros familiares. Los programas de prevención del VIH para mujeres deben brindarles transporte, cuidado infantil, alimentos nutritivos y remuneración en forma de comida, tarjetas telefónicas o de tiendas y paquetes de regalos. También deben ofrecer remisiones adecuadas y actualizadas para servicios de empleo, vivienda, atención médica y de salud mental en caso de trauma, abuso y depresión.
¿qué se está haciendo al respecto?
Actualmente existen 17 intervenciones para mujeres las cuales han sido reconocidas por los CDC como ejemplos de “las mejores evidencias” o “evidencias prometedoras” o bien que forman parte del proyecto Diffusion of Effective Behavioral Interventions (DEBI): CHOICES, Communal Effectance-AIDS Prevention, Female and Culturally Specific Negotiation, Project FIO, Project SAFE, RAPP, SiHLE, SISTA, Sisters Saving Sisters, Sister to Sister, WHP, WiLLOW, Women’s Co-op, Condom Promotion, Insights, Safer Sex y SEPA. En San Francisco, el proyecto Women’s Leadership and Community Planningorganiza una capacitación de dos días para mujeres con VIH en California que quieren asumir papeles de mayor liderazgo en los concilios de planificación estatal. En las jornadas de capacitación las mujeres forman redes de contacto, aprenden sobre la pronunciación de discursos, la toma de decisiones y el manejo de conflictos. Ellas se mantienen en contacto por medio de conferencias telefónicas mensuales. Después de la primera capacitación, 6 de las 13 asistentes pasaron a ocupar puestos de liderazgo en sus concilios locales o estatales. Respeto/Proteger: Respecting and Protecting our Relationships es un programa de prevención del VIH para madres y padres adolescentes latinos en Los Ángeles, CA. Creado y probado conjuntamente por una organización comunitaria e investigadores académicos, el programa reconoce los riesgos que las adolescentes afrontan, como la pobreza, el uso de drogas y alcohol, y antecedentes de ITS, abuso físico o abuso sexual. La intervención consiste en seis sesiones destinadas a sanar el espíritu herido y cultivar los sentimientos de protección materna y paterna por medio de enseñanzas culturales tradicionales.
¿qué queda por hacer?
Los programas para los hombres (especialmente los UDIs) también beneficiarán a las mujeres. El intercambio de jeringas y el tratamiento para dejar las drogas son esenciales. Las agencias de salud pública necesitan aumentar la conciencia sobre el abuso sexual y la violencia domestica, no sólo para ayudar a los hombres y a las mujeres a aprender cómo evitarlas, sino también para mitigar sus efectos sobre la epidemia del VIH. También se necesitan campañas de detección del VIH dirigidas sólo a mujeres y sitios de pruebas donde las mujeres se sientan cómodas. Dada la falta de evidencias de intervenciones biomédicas (microbicidas y vacunas) eficaces, persiste la necesidad de brindar intervenciones conductuales y estructurales de prevención del VIH para mujeres. Sin embargo, debe continuar la investigación sobre cómo las mujeres pueden protegerse utilizando una herramienta accesible, económica, cómoda y discreta. Es importante trasladar y concretar los hallazgos de los estudios en programas tangibles de salud pública y en políticas eficaces. Son especialmente valiosas aquellas intervenciones que tomen en cuenta la sexualidad, la familia, la cultura, el empoderamiento, la autoestima y las habilidades de negociación, así como las intervenciones ubicadas en una variedad de ambientes comunitarios.
¿Quién lo dice?
1. Kaiser Family Foundation. Women and HIV/AIDS in the United States. Policy Fact Sheet. July 2007. 2. Centers for Disease Control and Prevention. Cases of HIV infection and AIDS in the United States and Dependent Areas, 2005. HIV/AIDS Surveillance Report. 2007;17. 3. Centers for Disease Control and Prevention. HIV/AIDS fact sheet: HIV/AIDS among women. June 2007. 4. National Institute of Allergy and Infectious Diseases at National Institutes of Health. Research on HIV infection in women. 2006. 5. Theall KP, Sterk CE, Elifson KW, et al. Factors associated with positive HIV serostatus among women who use drugs: continued evidence for expanding factors of influence. Public Health Reports. 2003;118:415-424. 6. Sangani P, Rutherford G, Wilkinson D. Population-based interventions for reducing sexually transmitted infections, including HIV infection.Cochrane Database of Systematic Reviews. 2004; 2:CD001220. 7. Weinstock H, Berman S, Cates W. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives in Sexual and Reproductive Health. 2004;36:6-10. 8. Koenig LJ, Moore J. Women, violence, and HIV: A critical evaluation with implications for HIV services. Maternal and Child Health Journal. 2000;4:103-109. 9. Wyatt GE, Myers HF, Loeb TB. Women, trauma, and HIV: an overview. AIDS and Behavior. 2004;8:401-403. 10. Bozzette SA, Berry SH, Duan N, et al. The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium. New Engand Journal of Medicine. 1998;339:1897-1904. 11. Cohan DL, Kim A, Ruiz J, et al. Health indicators among low income women who report a history of sex work: the population based Northern California Young Women’s Survey. Sexually Transmitted Infections. 2005;81:428-433. 12. Adimora AA, Schoenbach VJ, Bonas DM, et al. Concurrent sexual partnerships among women in the United States. Epidemiology. 2002;13:320-327. 13. Prosper! The Women’s Collective, Washington DC. 14. Dworkin SL, Ehrhardt AA. Going beyond “ABC” to include “GEM”: critical reflections on progress in the HIV/AIDS epidemic. American Journal of Public Health. 2007;97:13-18. 15. Centers for Disease Control and Prevention. Updated Compendium of Evidence-Based Interventions, 2007. 16. Women’s Leadership and Community Planning project, CompassPoint, San Francisco, CA. 17. Lesser J, Koniak-Griffin D, Gonzalez-Figueroa E, et al. Childhood abuse history and risk behaviors among teen parents in a culturally rooted, couple-focused HIV prevention program. Journal of the Association of Nurses in AIDS Care. 2007;18:18-27. 18. Landovitz RJ. Recent efforts in biomedical prevention of HIV. Topics in HIV Medicine. 2007;15:99-103.
Preparado por Roshan Rahnama, MPH, CAPS Traducido por Rocky Schnaath Septiembre 2008. Hoja de Dato #4SR