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Engagement in the HIV care cascade among transgender women enrolled in a public HIV clinic in Buenos Aires, Argentina, 2000-2012
M.E. Socías1,2, O. Sued1,2, C. Frola2, A. Iacchetti2, T. Kerr3,4, I. Aristegui1, V. Zalazar1, H. Pérez2, P. Cahn1,2
1Fundación Huésped, Buenos Aires, Argentina2Hospital Fernández, Infectious Diseases Division, Buenos Aires, Argentina
3British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada4University of British Columbia, Department of Medicine, Vancouver, Canada
Background• In Argentina, transgender (TG) women are a highly
vulnerable population– Life expectancy 35 years (vs. 79 in biological women)– Estimated HIV prevalence 34% (vs. 0.4% in the general
population)• Argentina´s policies are promoting gender equity– 2007: Right to self-perceived gender identity in healthcare
(Buenos Aires)– 2010: Same-sex Marriage Law– 2012: Gender Identity Law
• Little is known about engagement in HIV care among TG women
Argentina MoH, 2013
Objectives
• To characterize engagement in the HIV continuum of care among TG women enrolled in a public HIV clinic in Buenos Aires, Argentina
• To explore factors associated with virological suppression within the first year of HIV diagnosis
Methods I• Design
– Retrospective clinical chart review
• Study population– TG women newly diagnosed with HIV and starting care in Hospital
Fernández (HF) (linked to HIV care) between 2000-2012
• Definitions: HIV care cascade indicators– Engaged in HIV care: ≥ 2 HIV-related visits at least 3 months apart within
the first year of HIV diagnosis– Retained in HIV care at 1 year: 1 HIV-related visit and/or diagnostic tests
at 12 ± 3 months of HIV diagnosis – On ART: ART initiation within the first year of HIV diagnosis– Virologically suppressed: VL <50 copies/mL at 12 ± 3 months of HIV
diagnosis
US DHHS, Health Resources and Services Administration Institute of Medicine, 2012
Methods II
• Data analysis– Percentages at each step of the HIV care cascade
within the first year of HIV diagnosis – Bi- and multivariable logistic regression analyses
to investigate factors associated with virological suppression at 12 months of HIV diagnosis
Baseline characteristics of TG women enrolled in HF between 2000-12
N= 69Age at HIV diagnosis, median (IQR) 30 (26-35)Completed high school, n (%) 38 (58)Extended health insurance, n (%) 3 (4)Use of drugs, n (%) 27 (54)Use of alcohol, n (%) 29 (56)Sex worker, n (%) 28 (48)Employed (not sex worker), n (%) 15 (25.9)Days from HIV diagnosis to first HIV-related visit, median (IQR) 157 (22-730)
Baseline CD4, median (IQR) 261 (98-477)Days from HIV diagnosis to ART initiation, median (IQR) 310 (118-1126)
* Denominators for each variable may differ due to non-response on some questions
HIV care cascade during the first year of HIV diagnosis
0%10%20%30%40%50%60%70%80%90%
100%100.0%
60.9%
46.4%37.7%
15.9%(42.3% of TG women on ART)
69
Factors associated with ART initiation:CD4 ≤250 cells/μL: aOR = 3.90, 95%CI: 1.05 – 14.50Age ≥30: aOR = 4.11, 95%CI: 1.13 – 14.91
4232
26
11
Correlates of virological suppression (N = 69)Unadjusted Adjusted
Characteristic OR (95% CI) p - value OR (95% CI) p - value
Age ≥30 2.01 (0.53 – 7.62) 0.342
Completed high school 9.64 (1.15 – 80.54)* 0.018 8.37 (0.89 – 78.37) 0.063
Extended health insurance 2.80 (0.23 – 33.87) 0.411
Use of drugs 0.45 (0.09 – 2.13) 0.444
Use of alcohol 1.74 (0.38 – 7.87) 0.714
Sex worker 0.25 (0.05 – 1.34) 0.147
Employed (not sex worker) 8.89 (1.86 – 42.44)* 0.006 7.78 (1.49 – 40.52) 0.015
Baseline CD4 0.997 (0.994 – 1.001) 0.136
HIV diagnosis ≥2007 2.19 (0.43 – 11.16) 0.483
* Significant at p < 0.10 and entered into the multivariable model
Correlates of virological suppression among transwomen on ART (n = 26)
Unadjusted
Characteristic OR (95% CI) p - value
Age ≥30 0.78 (0.13 – 4.54) 1.000
Completed high school 7.07 (0.60 – 60.44) 0.179
Extended health insurance 0.78 (0.06 – 9.89) 1.000
Use of drugs 0.43 (0.06 – 2.97) 0.630
Use of alcohol 1.39 (0.22 – 8.92) 1.000
Sex worker 0.39 (0.06 – 2.70) 0.400
Employed (not sex worker) 9.17 (1.15 – 73.24) 0.037
Baseline CD4 1.001 (0.997 – 1.006) 0.421
HIV diagnosis ≥2007 1.82 (0.28 – 11.87) 0.668
Sub-analysis: Cascade of HIV care 2002-2006 and 2007-2012Impact of the new legislation
Engaged in HIV care
Retained in HIV care at 1 year
ART initiated within 1 year
Undetectable VL at 1 year
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
61.9%
47.6%
33.3%
9.5%
60.4%
45.8%39.6%
18.8%
2000-06 (n=21)2007-12 (n=48)
all p NS
Limitations
• Retrospective study• Focus on transwomen enrolled in HIV care• Small sample size
Conclusions• Low rates of engagement across the HIV Care
Cascade • High proportion of substance use, sex work,
and unemployment → broader risk environment of TGW shaping HIV outcomes
• Novel and culturally appropriate interventions tailored for HIV-infected TG women are urgently needed
Challenges & future directions• Since August 2013 in Hospital Fernández:– Multidisciplinary team: infectious diseases,
endocrinology, mental health, substance use, social services
– Offer of comprehensive health services adapted to TG women needs
Acknowledgements
•Infectious Diseases Division, Hospital Fernández•Fundación Huésped
