Transgender Global Disease Burden Systematic Review - WordPress

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6/24/2015GLOBAL HEALTH NEEDS OFTRANSGENDER PEOPLEStefan Baral, MD MPHAcknowledgements The men and transgender women across the world whoparticipate in these studies given significant risks andlimited personal benefitsThe community groups that make great personal andprofessional sacrifices to serve the unmet health andadvocacy needs of those most marginalized in the HIVresponseContributions of Ideas and New Data Sari Reisner, Sam Winter, Tonia Poteat, Kevan Whylie,Claire Holland, Ashley Grosso, Paul Semugoma, ChrisBeyrer, and othersOutline Health Issues Affecting Transgender PeopleConceptual Framework of Health Vulnerabilitiesamong Transgender People Structural Determinants of HealthModels of Care Delivery for Transgender PeopleHealth Care InterventionsAvailable dataMathematical ModelMoving ForwardKey Themes1

6/24/2015Transgender Global Disease BurdenSystematic Review 2008-2014 116 studies30 countries95 Definitions of Transgender 981 health-related outcomes Mental healthSexual and reproductive health Substance use Violence/victimization Stigma and Discrimination General Health Transgender Research by Assigned Sexat Birth60Number of Data Points (n)50484030232020169100Male onlyFemale onlyMale & Female(disaggregated)Male & Female (notdisaggregated)Not specifiedAssigned Sex at BirthReisner et al, Poteat, Baral., Lancet Special Issue, in pressGlobal Distribution of TransgenderResearchReisner et al, Poteat, Baral., Lancet Special Issue, in press2

6/24/2015Population Studies Yielding PrevalenceData for Transgender PeopleAuthor, Date,countrySampleMeasurePrevalence DataBirth AssignedMales (%)Birth AssignedFemalesAllConron, 2012,USA28662 AdultsIdentification asTransgender0.50.40.5Glen andHurrell, 2012,UK10039 AdultsIdentification asother gender orin another way0.60.40.5Clark, 2014,New Zealand8166 HighSchool StudentsIdentification astransgender1.31.21.2Kuyper andWijsen, 2014,NEtherlands8064 AdultsIdentificationgender spectrum1.10.80.9Van Caenergen,2015, Belgium1832 AdultsIdentificationgender spectrum0.70.60.6Winter, et al, Lancet Special Issue, in pressGlobal Health Burden: Six Health Outcome Categoriesin Transgender Health (n 981 Data Points), 2008-20148350303Number of Data Points (n)3002502191932001501051009368500Mental HealthSexual andReproductive HealthSubstance UseViolence/VictimizationHealth Outcome CategoryStigma/DiscriminationGeneral HealthReisner et al, Poteat, Baral., Lancet Special Issue, in pressMental Health OutcomesReisner et al, Poteat, Baral., Lancet Special Issue, in press3

6/24/2015Burden of Mental Health among Transgender Youth10 Percent (%) Retrospective Cohort using EMRN 180, age 12-29, 2001-2010Matches on multiple characteristics to non-transgender youth60Transgender YouthNon-Transgender Youth50403020100DepressionAnxietySuicide IdeationSuicide AttemptSelf-HarmOutpatient MHServicesMental Health (MH)Inpatient MHServicesReisner et al., 2015 in J Adolescent HealthSexual and Reproductive HealthOutcomesPubertySex WorkOther (BV, PCOS, anal tear)Viral dViral Hepatitis8083184050Other (BV, PCOS,anal tear)5607080Sex WorkPuberty231090Reisner et al, Poteat, Baral., Lancet Special Issue, in pressHIV Prevalence among TransgenderWomen 20114

6/24/2015Results The pooled global HIV prevalence was19.1% (95% CI 17.4-20.7)In 7,197 transgender women from 10 LMIC,HIV prevalence was 17.7%(95%CI 15.6-19.8)In 3,869 transgender women from 5 HIC, HIVprevalence was 21.6%(95% CI 18.8-24.3)HIV Prevalence Data among transgenderwomen compared to all adultsBaral et al., Lancet Infectious Diseases, 2013Burden of HIV among Transgender Women Pooled OR for HIV infection among transgender women compared to otherreproductive people 48.8 (95% CI 31.2-76.3)Source: Baral, et al. Worldwide Burden of HIV among Transgender Women The Lancet ID. 20135

6/24/2015Average HIV Prevalence Among TransgenderWomen by Region50%45%40%HIV Prevalence35%30%25%20%15%10%5%0%North America(n 25)Central and SouthAmerica (n 6)Africa (n 0)Europe (n 3)South and SouthEast Asia (n 6)Oceania (n 1) Multi-region (n 2)Region (number of studies included)Transgender Women across SubSaharan Africa Very rare for people to identify as transgender, butmore common to identify as women using two-stepgender assessment in studies focused on MSM16% In Burkina Faso19% In Malawi 25.5% in Swaziland (aOR for HIV 3.96 [1.66-9.43]) 8% In Lesotho (p 0.05 for HIV) Source, Baral SD, Ketende, Grosso, Adams et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18768, Poteat, et al. GenderedVulnerabilities: HIV prevalence and correlates of transgender and feminine gender identity among natal males who have sex with males in Burkina Faso,Gambia, Lesotho, and MalawiLevels of HIV Acquisition and Transmission RisksLevel of RisksStage of EpidemicPublic PolicyCommunityNetworkSource: Baral, Logie, et al. Modified Social Ecological Model of HIV Risk. BMC Public Health. 2013Individual6

6/24/2015The interaction of multilevel risks among Transgender PeoplePoteat et al., The Lancet, 2014Map of low-income and middle-income countries reportingcommunity level measurements for HIV risk among gay men, otherMSM, and Transgender Women, 2000-2014Violence/abuse and Fear of Seeking Healthcareamong Transgender Women and Intersex MSM aged 18 years recruited using RDS inBurkina Faso and TogoChi-square tests used to assess bivariateassociations with gender identityGeneralized structural equation model (GSEM)used to measure associations withviolence/abuse and fear of seeking healthcare Depression as mediatorStahlman et al, Baral, JIAS Supplement: Transgender Health and HIV, 20157

6/24/2015Violence/abuse and Fear of Seeking Healthcareamong Transgender Women and Intersex 355 (26.2%) identified as a woman or intersexAs compared with self-identified male participants,transgender women were more likely to report Depressed mood (38.9% vs. 30.3%, p 0.01) Verbal harassment (44.5% vs. 23.5%, p 0.01) Physical abuse (31.9% vs. 24.7%, p 0.01) Rape (20.6% vs. 8.0%, p 0.01) Afraid to seek healthcare (29.3% vs. 18.0%, p 0.01)Stahlman et al, Baral, JIAS Supplement: Transgender Health and HIV, 2015Violence/abuse and Fear of Seeking Healthcareamong Transgender Women2.18**RapedDepressed0.54*0.80Afraid to seekhealthcare2.17**Physically hurt2.08**VerballyharassedFigure 1. GSEM showing adjusted odds ratios for each pathway*p 0.05; **p 0.01; Model adjusts for age, education level, and study site locationStahlman et al, Baral, JIAS Supplement: Transgender Health and HIV, 2015Substance Use and Bullying in the US Teen Health and Technology Study Included 442 transgender 13-18 years oldTransgender YouthAny Use, Past 12 MonthsEver Drink AlcoholWithout Adjusting forBullyingWith BullyingProportion of Effect(%)aOR(95% CI)aOR(95% CI)Percent(95% CL)1.45 (1.17, 1.80)**1.22 (0.98, 1.53)43.2 (27.1, 59.3)***Ever Smoke Cigarettes1.42 (1.12, 1.81)**1.22 (0.95, 1.56)46.8 (24.3, 69.4)***Ever Marijuana Use1.66 (1.30, 2.13)***27.7 (15.4, 40.1)***Ever Non-Marijuana Illicit Drug Use1.80 (1.36, 2.37)***1.46 (1.14,1.89)**1.48 (1.12,1.97)**1.66 (1.21, 2.28)**1.48 (1.07, 2.04)*26.8 (10.6, 43.0)**1.75 (1.20, 2.56)**1.48 (1.01, 2.17)*32.9 (15.8, 50.1)**Regular Use, Past 12 MonthsRegular Marijuana UseRegular Non-Marijuana Illicit Drug Use33.9(22.1, 45.6)***Reference: Reisner et al. 2015 in J Sex Research8

6/24/2015Improving Delivery of Care Early introduction of modules on transgender health in medicaleducation Core leadership role of transgender communityTransdisciplinary care to ensure comprehensive servicesImportance of partnerships with different agenciesTools Even short training modules can help if introduced earlyThree themes of models of care in LiteratureHealth Care Equality Index (HRC) – 30 best practices for careAdvancing Effective Communication, Cultural Competence FieldGuide (TJC)Country specific examples: Trans Pulse in Canada, Gender Unitsin Spain, Borum Model for Transgender Youth in USADowshen, Nguyen, AJPH, 2014; Safer, Pearce, 2014 Endocrine Practice; Moll, 2014, Academic Emergency Medicine; Klotsbaugh, Spenser, 2014,JONA; Hardacker, Rubinstein, J. Nursing Mgmt. 2014; McCann, Sharek, 2013, Aging & Mental Health; Bauer, 2009, JANACHIV Prevention InterventionsPublished StudiesCountryIntervention(s)PeruMobile HIV testingIndia (2)**Community empowerment/combination prevention (include MSM)LaosCondom social marketingThailandCommunity-led peer educationOn-going trials (NIH RePORT)India**Anti-stigma program for health workersPeruTransPrep: Adherence Intervention Disconnect between measured burden of HIV andnumber of funded studies addressing the needs oftransgender peoplePoteat et al., The Lancet, 2014Modelling Scenarios2 distinct epidemiologic settings: Lima, Peru and San Francisco, U.S.ANumber of new HIV infections10 yearInterventionperiodwith stablepartnerswith clientsBaselinePrEPEarly ART50% reduction ?YearsTransactions forthe samePoteat et al., The Lancet, 20149

6/24/2015Modelling ResultsPoteat et al., The Lancet, 2014A condoms with clients; B condoms with partners; C numberof commercial transactions; D PrEP; E test and treatData Needs to Advance TransgenderHealth30 Large sample size Longitudinal prospective data Well-powered statistical analysisFollow-up over timeOpportunity for nested sub-studies Intervention studies Representation of hard-to-reach subgroups Information on treatment and health outcomes Diverse transgender participantsHIV alongside other health conditionsReisner et al, Poteat, Baral., Lancet Special Issue, in pressTransgender Studies by Year5045Number of Studies rReisner et al, Poteat, Baral., Lancet Special Issue, in press10

6/24/2015Key Themes Data Paradox There is the least amount of data characterizing the needs oftransgender women in the most stigmatizing settings Human Rights Imperative to be CountedEncouraging increase in level of focused research on transgenderhealthThe world is more similar than it is different Where studied across the world, transgender women havebeen found to have among the highest burden of HIVSignificant disconnect between the epidemiologic datahighlighting high burden of health issues and specificallyfunded intervention research and programs11

Services Inpatient MH Services Transgender Youth Non-Transgender Youth Mental Health (MH) 10 Burden of Mental Health among Transgender Youth ) Matches on multiple characteristics to non Reisner et al., 2015 in J Adolescent Health Retrospective Cohort using EMR N 180, age 12-29, 2001-2010 -transgender youth Sexual and Reproductive Health Outcomes

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