Differences between undiagnosed, HIV-positive and HIV-negative Black transgender women in the United States: Results from POWER Presented by Leigh A. Bukowski, M.P.H University of Pittsburgh, Graduate School of Public Health, Center for LGBT Health Research

Acknowledgements Co-authors: Steven M. Meanley, Derrick Matthews, and Ronald Stall POWER participants Community partner organizations Center for LGBT Health Research,

Significance Black transgender women (BTW) experience high rates of HIV infection—38% of Black transgender women in our sample are currently living with HIV Treatment as Prevention (TasP) could be an effective way to prevent new HIV infections within this population But for TasP to be effective, we need to address disparities along the HIV care continuum.

Significance Where along the HIV care continuum do Black transgender women get stuck?

Significance How do we move undiagnosed, HIV-positive Black transgender women along the care continuum? Understanding demographic and psychosocial differences between undiagnosed, HIV-positive Black transgender women and HIV-negative Black transgender women my help elucidate a means by which to advance HIV diagnosis in this population.

Significance What differentiates these groups? Possible correlates of undiagnosed, HIV-positive status: Education Homelessness Access to medical care Incarceration Engagement in sex work Experiences of physical assault Intimate partner violence Depression Poly-substance use Social support HIV testing history

Aims Examine demographic and psychosocial differences between undiagnosed, HIV-positive Black transgender women and HIV-negative Black transgender women

Methods Data comes from Promoting Our Worth, Equality, and Resilience (POWER), collaboration between the Center for Black Equity and the University of Pittsburgh, Graduate School of Public Health.

Methods In 2014 and 2015, POWER collected data during 48 Black Pride events in 6 U.S. cities using time location sampling

Behavioral Health Survey Self administered using QDS software on Dell Venue Pro tablets ~20 minutes to complete Participants compensated $10

Confidential HIV Testing Performed by local Community Based Organizations (CBOs) No changes were made to CBOs usual HIV testing procedures Participants received their test result and $10

Anonymous HIV testing Performed by POWER using OraQuick Participants did not receive their test result, but did receive $10

Study Population POWER eligibility criteria: 1.Assigned male sex at birth 2.Reported having a male sexual partner in their lifetime 3.18 years or older This study includes participants who: 1.Identified as “Black” or “African American” 2.Identified as female, transgender, or reported having transitioned from male to female gender 3.Had an HIV-negative or undiagnosed, HIV- positive status at the time of survey

Measures Demographics: age, education, city Dependent Variables: undiagnosed HIV-positive status Independent Variables: depression, poly-substance use, physical assault, intimate partner violence, incarceration, engagement in sex work, health insurance coverage, access to medical care, homelessness, social support, and past six-month HIV testing.

Measures Undiagnosed, HIV-positive Status: Self-report and biological data were used to assess previously undiagnosed HIV-positive status. Undiagnosed HIV-positive was determined if participants received a HIV-positive test result and responded “HIV-negative,” “Indeterminate,” or “I don’t know,” when asked about the result of their most recent HIV test. HIV-negative status: HIV-negative status was assessed with biological data only. HIV-negative status was confirmed via HIV test result.

Analysis 197 Black transgender women provided enough data to be included in our analysis Bivariate analysis compared undiagnosed, HIV-positive Black transgender women to HIV-negative Black transgender women Weighted, independent, multivariable logistic regression models controlling for age, education, and city were used to further examine differences between groups Utilized SAS version 9.4 Significance set to alpha = 0.05

Results Bivariate Analysis Compared to HIV-negative Black transgender women, undiagnosed HIV-positive Black transgender women reported: Higher prevalence of past-year physical assault o 58.3% vs. 40.4% (p=0.03) Higher prevalence of past-year intimate partner violence o 60.9% vs. 43.1% (p=0.03) Higher prevalence of past two-year incarceration o 52.1% vs. 31.9% (p=0.02)

Results Weighted, independent logistic regression models When controlling for age, education, and city, compared to HIV- negative Black transgender women, undiagnosed HIV-positive Black transgender women had: 2.22 times the odds of having experienced past-year physical assault (95% CI: 1.03, 4.76) 2.74 times the odds of having experienced past-year intimate partner violence (95% CI: 1.26, 5.94) 2.13 times the odds of past two-year incarceration (95% CI: 1.03, 4.41)

Discussion Developing and implementing interventions that address experiences of physical assault, intimate partner violence, and a history of incarceration may assist in informing the HIV disparity among Black transgender women in the United States More research is needed to identify and understand how these factors shape Black transgender women’s engagement with HIV-testing and HIV-care.

Discussion Though there was no difference in many factors we normally associate with undiagnosed, HIV-positive status, the prevalence of these outcomes are worth noting o Homelessness: 42% o Engagement in sex work: 19% o Poly-substance use: 24% o Depression: 50%

Discussion We need to address structural inequity in order to advance TasP among Black transgender women Frequencies of homelessness, engagement in sex work, incarceration and experiences of physical assault most likely result from social marginalization Structural interventions are necessary

Limitations and Strengths Limitations Undiagnosed, HIV-positive status was assessed with self-report data only Black transgender women were surveyed at Black Pride events These are preliminary findings Strengths Black transgender women were surveyed at Black Pride events

Conclusion Developing and implementing interventions that address HIV diagnosis in this population need to be a top priority Based on preliminary research, such interventions could target physical assault victimization, intimate partner violence, and recent incarceration More research is needed to identify and understand the structural, community, and individual-level barriers and facilitators that shape BTW’s engagement with HIV-testing and HIV-care.