1 in+care Campaign Meet the Author November 12, 2013

2 Ground Rules for Webinar Participation  Actively participate and write your questions into the chat area during the presentation(s)  Do not put us on hold  Mute your line if you are not speaking (press *6, to unmute your line press #6)  Slides and other resources are available on our website at incareCampaign.org  All webinars are being recorded

3 Welcome & Introductions  Welcome & Introductions, 5min  Baligh Yehia, MD, MPP, MSHP, 30min  Q & A Session, 20min  Updates, Reminders & Evaluation, 5min In the chat room, Enter your: 1. name, 2. agency, 3. city/state, and 4. professional role at agency Michael Hager, MPH MA NQC Manager, in+care Campaign Manager New York, NY

Penn Medicine Retention in Care and Health Outcomes of Transgender Persons Living with HIV Baligh R. Yehia, MD, MPP, MSHP Assistant Professor of Medicine University of Pennsylvania Perelman School of Medicine Clin Infect Dis Sep; 57(5):744-6

Penn Medicine No Disclosures or Conflicts of Interests.

Penn Medicine Outline  Background  Transgender Individuals & HIV  Barriers to Care  Literature Review/Past Studies  Study Summary  Research Methods  Results & Conclusions  Limitations & Future Directions  Discussion/Q & A Baligh R. Yehia, MD, MPP, MSHP 6

Penn Medicine Transgender-Specific Research is Needed Baligh R. Yehia, MD, MPP, MSHP7  LGBT individuals have unique health experiences and needs, but as a nation, we do not know exactly what these experiences and needs are.  Focus Areas:  Demographic Research  Social Influences  Health Care Inequities  Intervention Research  Transgender-specific Health Needs

Penn Medicine HIV Prevalence Among Transgender Individuals Baligh R. Yehia, MD, MPP, MSHP8 Herbst, et al., AIDS Behav 2008 Meta-analysis of 29 studies conducted between in the U.S. and Puerto Rico to estimate HIV prevalence and risk behaviors among MTF transgender women.

Penn Medicine HIV Prevalence Among Transgender Individuals Baligh R. Yehia, MD, MPP, MSHP9 Herbst, et al., AIDS Behav 2008 Meta-analysis of 29 studies conducted between in the U.S. and Puerto Rico to estimate HIV prevalence and risk behaviors among MTF transgender women.

Penn Medicine HIV Prevalence Among Transgender Individuals Baligh R. Yehia, MD, MPP, MSHP10 Herbst, et al., AIDS Behav 2008 Meta-analysis of 29 studies conducted between in the U.S. and Puerto Rico to estimate HIV prevalence and risk behaviors among MTF transgender women. Limited data on FTM transgender men, but estimated to be ~3%.

Penn Medicine HIV Incidence Among Transgender Individuals Baligh R. Yehia, MD, MPP, MSHP11 CDC, 2009 Based on 2009 data from the CDC, the incidence of HIV was 2.6% among transgender persons compared to 0.9% among cisgender males and 0.3% among cisgender females. Highest among: Blacks (4.4%) and Hispanics (2.5%) transgender persons.

Penn Medicine Limited Access to and Delays in HIV Care Baligh R. Yehia, MD, MPP, MSHP12  Discrimination  Stigma  Social Isolation  Past negative experiences  Prioritization of gender-related health care  Concern about adverse interactions between ART and hormone therapy Sevelius et al., Women’s Health Issues 2011

Penn Medicine Discrimination by Medical Provider for Transgender People Baligh R. Yehia, MD, MPP, MSHP13

Penn Medicine Postponement of Care Due to Discrimination Baligh R. Yehia, MD, MPP, MSHP14

Penn Medicine Literature Review - Study 1: Decreased ART Use Baligh R. Yehia, MD, MPP, MSHP15 Objective: Examine whether MTF transgender persons with HIV face greater difficulties accessing health services than cisgender people with HIV. Methods: Adults in the Healthy Living Project, a trial designed to reduce sexual risk behaviors among HIV-infected persons MTF transgender persons matched cisgender person. Melendez et al., AJPH 2006

Penn Medicine Literature Review - Study 1: Decreased ART Use Baligh R. Yehia, MD, MPP, MSHP16 Melendez et al., AJPH 2006

Penn Medicine Literature Review - Study 1: Decreased ART Use Baligh R. Yehia, MD, MPP, MSHP17 Melendez et al., AJPH 2006

Penn Medicine Literature Review - Study 1: Decreased ART Use Baligh R. Yehia, MD, MPP, MSHP18 Limitations: Convenience Sample & Self-Reported Data Melendez et al., AJPH 2006

Penn Medicine Literature Review - Study 2: Decreased ART Adherence Baligh R. Yehia, MD, MPP, MSHP19 Objective: Examine rates of self-reported ART adherence among transgender women compared to cisgender people with HIV. Methods: Adults in the Healthy Living Project, a trial designed to reduce sexual risk behaviors among HIV-infected persons transgender women on ART - 2,770 cisgender persons on ART Sevelius et al., JANAC 2010

Penn Medicine Literature Review - Study 2: Decreased ART Adherence Baligh R. Yehia, MD, MPP, MSHP20 Sevelius et al., JANAC 2010

Penn Medicine Literature Review - Study 2: Decreased ART Adherence Baligh R. Yehia, MD, MPP, MSHP21 Sevelius et al., JANAC 2010

Penn Medicine Literature Review - Study 2: Decreased ART Adherence Baligh R. Yehia, MD, MPP, MSHP22 Sevelius et al., JANAC 2010

Penn Medicine Literature Review - Study 2: Decreased ART Adherence Baligh R. Yehia, MD, MPP, MSHP23 Sevelius et al., JANAC 2010 Limitations: Convenience Sample & Self-Reported Data

Penn Medicine Outline  Background  Transgender Individuals & HIV  Barriers to Care  Past Studies  Study Summary  Research Methods  Results & Conclusions  Limitations & Future Directions  Discussion/Q & A Baligh R. Yehia, MD, MPP, MSHP 24

Penn Medicine Study Objective and Design Baligh R. Yehia, MD, MPP, MSHP25 Objective: Examine whether retention in care, use of ART, and HIV viral suppression differed between cisgender and transgender people living with HIV. Design: A retrospective cohort of HIV-infected adults enrolled in care at 13 US HIV clinics between 2001 and 2011.

Penn Medicine Study Outcomes Retention in Care Jan 1Dec 31 ≥ 90 days Jan 1Dec 31 at any point Use of ART Jan 1Dec 31 median Viral Suppression

Penn Medicine Analyses Baligh R. Yehia, MD, MPP, MSHP27 We compared demographics for each cisgender group to the transgender group using the χ 2 test of independence. CD4 count and HIV viral load at enrollment were compared using the Kruskal-Wallis test due to their non-normal distribution. Multivariate logistic regression examined demographic (age, gender, race/ethnicity, HIV transmission risk, insurance coverage) and clinical factors (CD4 count) associated with each of the three outcomes, adjusting for calendar year and site of care.

Penn Medicine Results - Demographics Baligh R. Yehia, MD, MPP, MSHP28

Penn Medicine Results - Demographics Baligh R. Yehia, MD, MPP, MSHP29

Penn Medicine Results - Demographics Baligh R. Yehia, MD, MPP, MSHP30

Penn Medicine Results - Demographics Baligh R. Yehia, MD, MPP, MSHP31

Penn Medicine Results - Demographics Baligh R. Yehia, MD, MPP, MSHP32

Penn Medicine Results - Demographics Baligh R. Yehia, MD, MPP, MSHP33

Penn Medicine Results - Outcomes Baligh R. Yehia, MD, MPP, MSHP34 80% 76% 69% 82% 81% 77% 74% 69%

Penn Medicine Results – Multivariate Analyses Baligh R. Yehia, MD, MPP, MSHP35 RetentionUse of ARTSuppression Gender Transgender persons Cisgender men Cisgender women 1 [Reference] 1.15 ( ) 1.32 ( ) 1 [Reference] 0.98 ( ) 0.81 ( ) 1 [Reference] 1.11 ( ) 1.13 ( )

Penn Medicine Conclusions Baligh R. Yehia, MD, MPP, MSHP36 Reducing HIV-related disparities is a major goal of Healthy People 2020 and the National HIV/AIDS Strategy for the United States. Compared to prior studies, these results reflect improvements in health equity for transgender patients infected with HIV. Advances in HIV therapy and management have occurred since these studies were conducted, including expansion of available antiretroviral drugs, simplified dosing, greater tolerability, and improvements in evidence-based guidelines.

Penn Medicine Limitations Baligh R. Yehia, MD, MPP, MSHP37  Retrospective nature  Focus on patients engaged in care  Relative small number of transgender people with HIV  Generalizability  Unable to assess variations in health outcomes by subgroups (MTF, FTM, gender expression, sexual orientation)

Penn Medicine Future Directions Baligh R. Yehia, MD, MPP, MSHP38  Estimate the proportion of HIV-infected transgender persons out of care.  Develop interventions designed to improve access and linkage to care for transgender individuals.

Penn Medicine Outline  Background  Transgender Individuals & HIV  Barriers to Care  Past Studies  Study Summary  Research Methods  Results & Conclusions  Limitations & Future Directions  Discussion/Q & A Baligh R. Yehia, MD, MPP, MSHP 39

Penn Medicine Discussion/Q & A

41 Campaign Update

42 in+care Campaign in 2014 Campaign database running through 2018! Campaign website running through 2018! Partners in+care Facebook maintained indefinitely Campaign Newsletter moves to quarterly Campaign Webinars move to quarterly Partners in+care Webinars move to quarterly Campaign Coaching integrates into NQC Continuous TA Portfolios Local Retention Groups that wish to continue meeting should do so – NQC will support where possible

in+care Campaign Activities ActivitiesJULAUGSEPOCTNOVDECJANFEBMARAPRMAYJUNJULAUGSEPOCTNOVDEC 1-Campaign Webinar 2-Journal Club Webinar 3-Campaign Data Reporting Cycle by Participants 4-Availability of Database Benchmark Function 5-Improvement Strategy Cycle 6-in+care Website and Posting of Updates 7-Campaign Newsletter 8-Partners Webinar 9-Partners in+care Facebook 10-Campaign Coaching Availability 11-Local Retention Group Availability 12-Case Study Drafting 13-Final Report Drafting 14-Communications with participants around transition

44  Upcoming Webinars: ―Partners in+care Webinar | Retaining New Patients in+care Thursday, November 14, 2013 | 2pm ET ―in+care Campaign Webinar | The Transgender Experience and Retention in HIV Care Wednesday, November 20, 2013 | 1pm ET ―in+care Campaign Webinar | State-Level Efforts to Retain New Patients in HIV Care Wednesday, December 4, 2013 | 2pm ET  Data Collection Submission Deadline: December 2, 2013  Improvement Update Submission Deadline: November 15, 2013 Upcoming Events and Deadlines

45 Campaign Headquarters: National Quality Center (NQC) 90 Church Street, 13 th floor New York, NY Phone incareCampaign.org youtube.com/incareCampaign