HIV testing and the care continuum among transgender women: population estimates from Rio de Janeiro, Brazil

Abstract

Introduction: Evidence suggests that, of all affected populations, transgender women (transwomen) may have the heaviest HIV burden worldwide. Little is known about HIV linkage and care outcomes for transwomen. We aimed to estimate population-level indicators of the HIV cascade of care continuum, and to evaluate factors associated with viral suppression among transwomen in Rio de Janeiro, Brazil. Methods: We conducted a respondent-driven sampling (RDS) study of transwomen from August 2015 to January 2016 in Rio de Janeiro, Brazil and collected data on linkage and access to care, antiretroviral treatment and performed HIV viral load testing. We derived population-based estimates of cascade indicators using sampling weights and conducted RDS-weighted logistic regression analyses to evaluate correlates of viral suppression (viral load ≤50 copies/mL). Results: Of the 345 transwomen included in the study, 89.2% (95% CI 55–100%) had been previously tested for HIV, 77.5% (95% CI 48.7–100%) had been previously diagnosed with HIV, 67.2% (95% CI 39.2–95.2) reported linkage to care, 62.2% (95% CI 35.4–88.9) were currently on ART and 35.4% (95% CI 9.5–61.4%) had an undetectable viral load. The final adjusted RDS-weighted logistic regression model for viral suppression indicated that those who self-identified as black (adjusted odds ratio [aOR] 0.06, 95% CI 0.01–0.53, p < 0.01), reported earning ≤U$160/month (aOR 0.11, 95% CI 0.16–0.87, p = 0.04) or reported unstable housing (aOR 0.08, 95% CI 0.01–0.43, p < 0.01) had significantly lower odds of viral suppression. Conclusions: Our cascade indicators for transwomen showed modest ART use and low viral suppression rates. Multi-level efforts including gender affirming care provision are urgently needed to decrease disparities in HIV clinical outcomes among transwomen and reduce secondary HIV transmission to their partners.

Successes and final challenges along the HIV care continuum with transwomen in San Francisco

“…Approximately 86% accessed HIV care, 87% were on ART and 64% self‐reported an undetectable viral load. Our findings on HIV care engagement and treatment use were inconsistent with other studies that previously found low HIV care continuum indicators for transwomen relative to all those in San Francisco living with HIV . Previous data from 2014 in San Francisco found that 65% were on ART and only 44% reported viral suppression .…”

“…The few studies we found indicated that transwomen have low HIV testing rates and low awareness of HIV status, low engagement and retention in HIV care, low medication adherence and low virologic suppression rates [4][5][6]. Suboptimal HIV engagement rates were found among transwomen from Brazil and US transgender youth [7,8]. African American transwomen were found to have even poorer reported viral suppression (24.5%) [9].…”

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“…The Brazilian Public Health System (SUS) provides free of charge antiretroviral therapy (ART) to HIV-infected individuals since 1996 and daily oral pre-exposure prophylaxis (PrEP) with emtricitabine and tenofovir disoproxil fumarate (FTC/TDF) to those at substantial HIV risk since December, 2017 [ 14 ]. In addition, sexual minorities, especially transgender women, often present housing instability that may impact in adherence to social distancing measures [ 15 ].…”

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“…En este estudio también se pudo apreciar la importante proporción de participantes que ha involucrado alcohol durante las prácticas sexuales. En este punto, existen similitudes con estudios llevado a cabo por Zoni et al, 2013 (15) , Jalil EM et al, (16) y Kakchapati S et al, 2017 (17) , que si bien no son estudios llevados a cabo en población indígena, demuestran el consumo de alcohol como práctica de riesgo para adquisición de ITS. Las limitaciones del estudio se centran en el sesgo de memoria, puesto que al ser consultados sobre las prácticas de riesgo, es posible que algunos de los participantes no hayan revelado la verdadera practica realizada.…”