Transcript Document

SPNS Transgender
Retention in Care
December 10, 2013
For Audio: Dial-in#: 866.394.2346
Participant Code: 397 154 6368#
Welcome & Introductions
 Welcome & Introductions, 5min
 National Center of Excellence, 20min
 Community Healthcare Network, 20min
 Updates, Reminders & Evaluation, 5min
Michael Hager, MPH MA
NQC Manager,
in+care Campaign Manager
New York, NY
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In the chat room,
Enter your:
1. name,
2. agency,
3. city/state, and
4. professional
role at agency
Welcome & Overview
 This Partners in+care webinar is offered as part of the
in+care Campaign.
 The in+care Campaign is a national effort to improve
retention in HIV care.
 Webinars are one of many Partners in+care activities
designed to engage people living with HIV/AIDS and their
allies in the in+care Campaign.
For more information: www.incarecampaign.org
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Participation Guidelines
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 All webinars are recorded - do not use identifying information
when asking questions
For Audio: Dial-in#: 866.394.2346
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Participant Code: 397 154 6368#
Participation Guidelines
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For Audio: Dial-in#: 866.394.2346
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Participant Code: 397 154 6368#
HIV and Barriers to Care
among
Transgender Women
JoAnne Keatley, MSW
Director and Co- Principal Investigator
The CoE mission is to increase access to comprehensive,
effective, and affirming healthcare services for trans and
gender-variant communities
(Stefan D Baral, Tonia Poteat, et al; Lancet Infect Dis 2013; 13:214-22
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15countries including USA, six Asia-Pacific
countries, five in Latin America, and three in
Europe. N= 11,066 transgender women
HIV prevalence was 19·1%
The odds ratio for being infected with HIV
compared with all adults of reproductive age across
the countries was 48·8 (95% CI 21·2–76·3) and
participants were;
Less likely to have access to and utilization of HIV
services.
(Stefan D Baral, Tonia Poteat, et al; Lancet Infect Dis 2013; 13:214-22
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Policy
Community
Institutional
Interpersonal
Intrapersonal
Intrapersonal
Interpersonal
• Internalized
transphobia
• Transphobia
• Low selfesteem
• Peer
harassment
• Mental health
• High risk sex
partners
• Gender identity
validation
through sex
• Injection risks
(IDU, ISU, IHU)
• Family rejection
• Lack of comfort
disclosing
gender identity
Institutional
• Institutional
transphobia
• Health care
• Educational
settings
• Employment
• Housing
• Incarceration
• Religion
Community
Policy
•Societal transphobia
•Systemic transphobia
•Sex work
•Violence
•Anti-Discrimination
Policies
•Norm of substance
use
•Name and gender
changes
•Social stigma
•Immigration laws
•Lack of role models
•Health Insurance

A study of four US cities found that transgender
women living with HIV were less likely to
receive highly active antiretroviral therapy
(HAART) than a non-transgender control group
(59% vs. 82%, p < .001).
(Melendez et al, 2005)
Copyright 2013. Center of Excellence for Transgender Health. All Rights
Reserved.
Consistently between 2004-08, transgender
people represented at least 2% of the newly
diagnosed AIDS cases (SFDPH, 2008)
Copyright 2013. Center of Excellence for Transgender Health. All Rights
Reserved.
Survival curves for
persons diagnosed
with AIDS between
1996-2008 show
extreme drop off for
Transgender people
(SFDPH, 2008).
Copyright 2013. Center of Excellence for Transgender Health. All Rights
Reserved.
Although between 2004-08, transgender people
represented 2% of the newly diagnosed AIDS
cases, in 2008 they represented 7% of the total
deaths (SFDPH, 2008).
Copyright 2013. Center of Excellence for Transgender Health. All Rights
Reserved.
Barriers to Quality Care for Trans People
Other Medical and Social Priorities
Lack of Regular Contact with Medical Providers
Lack of Medical Screening, including HIV/STDs,
Increased Morbidity, Low Life Expectancy
 Challenges in Accessing Quality Transgender Care
Leads to self-medication, body modifications, use of soft
tissue fillers
 Negative Experiences with Health Care Providers
 EMR utilization
Copyright 2013. Center of Excellence for Transgender Health. All
Rights Reserved.
[email protected]
www.transhealth.ucsf.edu
www.facebook.com/transhealth
Catherine Abate
President/CEO
Matthew A. Weissman, MD, MBA, FAAP
Medical Officer/ VP of Medical Affairs
Retaining Transgender Patients in Care:
Interventions for Healthcare Providers.
Luis Freddy Molano, MD
VP HIV Programs and Services
Renato Barucco, MS
Transgender Family Program Manager
Addressing Challenges
We believe programs for transgender people should be client-centered, multidimensional,
comprehensive.
Programs should provide transgender patients with tools to reduce risk-taking behaviors by
acknowledging patient’s goals and priorities.
Strategies:
1.
Client input and involvement (focus groups, CAB meetings, quality improvement, etc).
2.
Patient navigation.
3.
Extensive list of referrals.
4.
Community-based, non-traditional outreach strategy
5.
Home-grown intervention: Teach Back
Interventions
CHALLENGES
RETENTION
Transgender specific EBI’s
PROVIDERS
ACTION
Client-centered care
Integration of care
Enhanced recruitment
Best Practices
• Identify support systems for the patients.
• Discuss safety at place of residence.
• Provide mental health referrals if needed.
• Discuss the use of street hormones .
• Discuss survival sex, HIV and its transmission.
• Assess transition plan and provide assistance in the planning process.
• Assess level of comfort.
• Think about the patient as a person not as another number or rare case.
• Assess sexual behavior in a professional manner.
• Remember that behavior does not equals identity.
• Policies and Procedure
Providers’ Tasks
WHAT
HOW
Identify stressors and provide
tools to overcome barriers.
Provide extensive and
comprehensive offer of services
on site and referrals.
Integrate primary care with
supportive services.
Provide medical services, case
management, educational
initiatives, interventions.
Create a sense of community.
Community based recruitment
initiatives, hire members of the
community, peer-led activities.
Enhanced Engagement in Care
Comprehensive case finding initiatives and linkage to care:
• Agency representation in the community through traditional (CBO’s, community events) and
non-traditional (clubs, street, ballroom) outreach.
• Ongoing monthly recruitment activities to link patients to care and develop trust-based help
partnership.
• Diffused health education and promotion on internet-based social networks and for a
(Facebook, Twitter, Craigslist, etc.).
• Peer-led engagement activities.
• Special events.
Integration of Care
Offering two or more services at the same facility during the same operating hours, with
the provider of one service actively encouraging clients to consider using the other services
during the same visit, in order to make those services more convenient and efficient.
Medical Providers
Nurses
Social Workers
Patient
Transgender Family Program Staff
Health Educators
Client-centered care
Bi-directional model (Barucco, Molano, 2008)
Medical Attention
(including HIV/AIDS
and HRT)
Providers Perspective
Mental Health
Risk reduction- ABC
Surgery and HRT
Housing
Name Change
Legal Issues
Housing
Benefits
Client Perspective
Transgender-specific EBI’s
TITLE T-Teach Back (Transgender Program - Teach Back)
TYPE
Group Level Intervention
NUMBER OF SESSIONS Five
TARGET POPULATION
Transgender patients, both trans-males and trans-females, and their allies
including partners, friends, roommates, family members, etc.
SETTING
Community Health Center
THEORY
Behavioral Science: Social Cognitive Theory, Transtheoretical Theory
METHODS OF DELIVERY
Facilitator identifies the ideal methods of delivery according to personal
preference. They can include Power Point Presentations, activities,
movies, group discussion, lecture, etc.
NUMBER OF PARTICIPANTS 10 to 20
FACILITATOR
The intervention is led directly by a previously selected transgender program client
with minimal supervision from the program staff
Our Program
PRIMARY CARE
PREVENTION
• Adult medicine
• Transgender care
• HIV care and services
• Nutritional Services
• Treatment adherence
• Access to healthcare
• Counseling and
testing
• Group interventions
• Individual counseling
• Support groups
• Community
involvement
BEHAVIORAL
HEALTH
• Psychosocial
assessment
• Prevention counseling
• Psychiatric services
• Letters of support
• Referrals
Case study
Name:
Vivian
Age:
22
Ethnicity:
African American
Gender:
Female
Medical History:
HIV positive
History for Syphilis
Social Conditions:
Severe Substance Use
Survival Sex
Incarceration
Violence and Discrimination
Lack of Education
ACTION
• Patient met with program staff and created a service plan. Goals included: keep appointments with
personal physician, follow treatment recommendations, participate in educational activities to promote
self-efficacy.
• Patient met with mental health therapist. No specific mental health issues were identified. Patient
enrolled in therapy to discuss relationship patters, loneliness and unresolved childhood issues while
previous substance use and commercial sex are addressed by the treatment facility.
• Patient met with medical provider who completed an initial appointment and will provide general
healthcare, HIV-related care and transgender care. Provider meets with the team for case-conferencing
every time the patient comes to the clinic for a medical appointment.
• Staff works in conjunction with the treatment facility to support the client recovery and avoid relapses
in substance use and commercial sex.
• Patient met in-house with representative for Transgender Legal and Education Found to start the name
and gender marker change process.
• Patient started to participate regularly to the program’s activities.
RESULTS
• Patient keeps medical appointments, regularly takes ARV medication with the supervision of a
treatment adherence specialist and is considering starting HRT.
• Patient completed therapy sessions without missing any appointment. Patient meet with the
nutritionist to monitor diet.
• Patient attends regularly workshops and volunteers to help the staff during outreach activities.
• Obtained the GED certificate
Take-home Points
• Program for transgender people need to include substantial client input in order
to capture the specificity of the population.
• Program should include comprehensive assessments, comprehensive offer of onsite services, extensive list of referrals for off-site services, qualified and cultural
competent staff (possibly peers).
• When possible, activities should be peer-led. Consumers should be involved in
program design as much as possible.
Thank you.
Luis Freddy Molano, MD
VP HIV Programs and Services
Renato Barucco, MS
Transgender Family Program Manager
Catherine Abate
President/CEO
Matthew A. Weissman, MD, MBA, FAAP
Medical Officer/ VP of Medical Affairs
Partners in+care Resources
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90 Church Street, 13th floor
New York, NY 10007
Phone 212-417-4730