1. www.aids2014.org Unmet Needs for Health and Social Services and HIV Risk Behaviors among Transgender Women Living with HIV in the San Francisco Bay Area Tooru Nemoto, Ph.D., Mariko Iwamoto, M.A., Sachiko Suzuki, MPH, and Taylor Cruz Public Health Institute, Oakland, California, USA Session: Living Better, Living Longer, Living Stronger: Women Living with HIV Date: 23 July 2014 Time: 11:00-12:30p Room: Plenary 3

2. www.aids2014.org Background HIV Sero-Prevalence among Transgender Women –HIV infection rates among transgender women in the U.S. ranged from 0.5%-60% with an estimated prevalence rate of 28% (CI: 25%-31%). 1 –Transgender women are categorized as the highest risk group for HIV in San Francisco. 2 –Studies in San Francisco have estimated that HIV prevalence ranges from 15.5% to 35%. 2-4 San Francisco HIV Prevention Planning Council identified transgender women as being disproportionately affected by HIV. 5 –Studies in San Francisco have found particularly high HIV prevalence among African American (33%-41%) and Latina (23%-29%) transgender women. 6,3,7

3. www.aids2014.org Background (continued) Social and Psychological Factors related to Access to Care and HIV-related Risk Behaviors –Studies reported that transgender persons lack access to transgender sensitive health care, 8,10-11 and often experience transphobia in health care and treatment. 1,11 –Transgender persons are frequently exposed to violence, sexual assault, and harassment in everyday life, mainly due to transphobia. 1,8-9,10-12 –High prevalence of depression and suicidal ideation and attempts were reported among transgender women. 13 –A limited amount of literature has described the prevalence of health disparities, unmet needs, and transphobia among transgender women, 9-11 particularly among those living with HIV.

4. www.aids2014.org Methods Survey Questionnaire – developed based on focus groups Participants were recruited based on purposive sampling methods from the targeted community venues and the collaborating AIDS service organizations in San Francisco and Oakland. First Wave (Nov. 2000 to July 2001) –332 Transgender women of color (112 African Americans, 110 APIs, and 110 Latinas) were recruited in San Francisco. Second Wave (Aug. 2004 to July 2006) –118 Caucasian transgender women in San Francisco and 123 African American transgender women in Oakland were recruited. Inclusion Criteria –Self-identified transgender woman –18 years or over 18 years –History of sex work –Live or work in San Francisco or Oakland/Alameda County

5. www.aids2014.org Methods (continued) Unmet needs were assessed using 19 items. –9 items for basic assistance (e.g., permanent housing, food, employment, and job training) –4 items for mental health (e.g., counseling) –1 item for substance abuse treatment –5 items for healthcare services (e.g., emergency medical services and general medical care) First asked whether a service was needed; if yes, asked whether assistance was received; Score one for unmet need if expressed need but service was not received.

6. www.aids2014.org Psychosocial Measures Depression – CES-D scale 14 Self Esteem – Rosenberg Self-Esteem Scale 15 Transgender Community Identification – 9-item Likert scale modified from the collective self-esteem scale 16 Transphobia – Measured experience of physical and sexual violence, verbal harassment, and discrimination in two time periods (12 to 18 years and as an adult), modified from the homophobia scale 17 Needs for Social Support – Perceived needs for 5 types of social support from 3 sources (family, transgender friends and non-transgender friends) Social Support Received – Frequency of 5 types of social support received from family, transgender friends, and non-transgender friends

7. www.aids2014.org Results Selected a total of 161 participants who self- reported living with HIV from the parent sample of 573 transgender women in San Francisco and Oakland/Alameda County. Ethnicity African American = 62.7% (n=101) Latino = 15.5% (n=25) API = 8.7% (n=14) Caucasian = 13.0% (n=21)

8. www.aids2014.org Results - Demographics

9. www.aids2014.org Results – Unmet Needs P-value ≤ 0.05

10. www.aids2014.org Results – Risk Behaviors P-value ≤ 0.05

11. www.aids2014.org Results – Risk Behaviors Drinking Alcohol Before Sex Using Drugs Before Sex URAS with Primary Partner URAS with Casual Partners URAS with Commercial Customers Depression (Scale Sum) Drinking Alcohol Before SexPearson Correlation 0.6620.361.0710.252-.103 Sig. (2-tailed).000.418.003.241 N 133 132 Using Drugs Before SexPearson Correlation 0.2840.2040.168-.056 Sig. (2-tailed).000.009.034.482 N 161 160 URAS with Primary PartnerPearson Correlation.1520.256-.024 Sig. (2-tailed).054.001.767 N 161 160 URAS with Casual PartnersPearson Correlation 0.253-.095 Sig. (2-tailed).001.234 N 161160 URAS with Commercial Customers Pearson Correlation.114 Sig. (2-tailed).152 N 160 Depression (Scale Sum)Pearson Correlation Sig. (2-tailed) N

12. www.aids2014.org Results – Risk Behaviors x Unmet Needs Basic Assistance Unmet Needs Mental Health Unmet Needs Substance Abuse Treatment Unmet Needs Health Care Unmet Needs Total Unmen Needs Drinking Alcohol Before SexPearson Correlation.1090.188.114.031.069 Sig. (2-tailed).212.031.193.724.433 N 133 Using Drugs Before SexPearson Correlation.0940.16.137.023.095 Sig. (2-tailed).236.043.084.774.232 N 161 URAS with Primary PartnerPearson Correlation.035.072.043.094.042 Sig. (2-tailed).658.366.586.238.597 N 161 URAS with Casual PartnersPearson Correlation.129-.041-.110-.133.084 Sig. (2-tailed).102.606.164.092.288 N 161 URAS with Commercial Customers Pearson Correlation 0.1950.164.053.077.154 Sig. (2-tailed).013.038.506.333.052 N 161 Depression (Scale Sum)Pearson Correlation.065.115-.0320.166.049 Sig. (2-tailed).416.146.689.036.535 N 160

13. www.aids2014.org Results - Depression

14. www.aids2014.org Results – Psychosocial Measures

15. www.aids2014.org Results – Social Support Received

16. www.aids2014.org Summary of Multiple Linear Regression of Number of Unmet Needs Model Unstandardized Coefficients Standardized Coefficients tSig. BStd. ErrorBeta 1 (Constant) 3.6741.781 2.062.041 African American 1.217.649.2571.876.063 White.945.769.1411.229.221 Latino -.290.746-.046-.389.698 Age -.074.022-.258-3.359.001 TGCI -.554.297-.153-1.869.064 Transphobia.601.241.2112.496.014 Social Support Need 1.192.418.2392.849.005 Social Support Received from Family -.481.293-.133-1.641.103 Social Support Received from TG Friends.220.260.089.843.400 Social Support Received from non-TG Friends -.294.280-.115-1.049.296 Self-Esteem -.092.291-.029-.316.752 Depression -.282.387-.061-.729.467 Dependent Variable: Total Number of Unmet Needs; Ethnicity Referent group: API Results – Regression Analysis

17. www.aids2014.org Conclusion The study clearly showed that transgender women living with HIV had high unmet needs for basic assistance, such as employment, housing, and job training. The overall unmet needs, as well as basic assistance and mental health needs significantly differed between racial/ethnic groups; African American and Caucasian transgender women reported higher unmet needs than Latina and API transgender women. Transgender women living with HIV had engaged in risk behaviors, such as URAS with primary partners and drug and alcohol use before having had sex. African American and Caucasian transgender women were more likely to engage in these risk behaviors. Also, these risk behaviors were significantly inter-correlated (e.g., URAS with commercial sex partners was correlated with alcohol and drug use before having had sex and URAS with primary and casual partners).

18. www.aids2014.org Conclusion It should be noted that transgender women living with HIV who expressed higher needs for basic assistance were more likely to engage in URAS with commercial sex partners. Also, those who expressed unmet needs for mental health services were more likely to engage in substance use before having had sex and URAS with commercial partners.

19. www.aids2014.org Conclusion Compared with APIs, Latina, African American, and Caucasian transgender women living with HIV reported higher levels of depressive symptoms and depression was significantly correlated with higher unmet needs for health care, including HIV primary care.

20. www.aids2014.org Conclusion Multiple regression analysis revealed that ethnicity (African American), younger age, exposure to transphobia, and needs for social support were significantly and independently correlated with unmet needs. Limitation: Study participants were recruited based on purposive sampling in two different sampling periods.

21. www.aids2014.org Recommendations Future programs for transgender women living with HIV must address their basic needs, such as employment, housing, and job training. Also the programs must target specific groups: Latina, African American, and Caucasian, younger age group, and those expressed exposure to transphobia, to address and fulfill their unmet needs.

22. www.aids2014.org Recommendations Mental health issues among transgender women living with HIV must be addressed because unmet needs for health care including HIV primary care were significantly correlated with depression. Most of all, individual and institutional transphobia must be eliminated through education for service providers, as well as media campaigns for general populations because transphobia prevents transgender women living with HIV from seeking help and utilizing health and social services.

23. www.aids2014.org References 1.Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav. Jan 2008;12(1):1-17. 2.Clements-Nolle K, Marx R, Guzman R, Katz M. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: implications for public health intervention. Am J Public Health. Jun 2001;91(6):915-921. 3.Sugano E, Nemoto T, Operario D. The impact of exposure to transphobia on HIV risk behavior in a sample of transgendered women of color in San Francisco. AIDS Behav. Mar 2006;10(2):217-225. 4.San Francisco 2010 HIV Prevention Plan HIV Prevention Planning Council 5.Rose V, Sheer S, Balls J, al. e. Investigation of the high HIV prevalence in the African American transgender community in San Francisco. 14th International Conference on AIDS. Barcelona, Spain 2002. 6.Sevelius JM, Reznick OG, Hart SL, Schwarcz S. Informing interventions: the importance of contextual factors in the prediction of sexual risk behaviors among transgender women. AIDS Education And Prevention: Official Publication Of The International Society For AIDS Education. 2009;21(2):113-127. 7.Clements-Nolle K, Marx R, Katz M. Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. J Homosex. 2006;51(3):53-69. 8.Nemoto T, Sausa LA, Operario D, Keatley J. Need for HIV/AIDS education and intervention for MTF transgenders: responding to the challenge. J Homosex. 2006;51(1):183-202. 9.Lombardi EL, Wilchins RA, Priesing D, Malouf D. Gender violence: transgender experiences with violence and discrimination. J Homosex. 2001;42(1):89-101. 10.Dutton L, Koenig K, Fennie K. Gynecologic care of the female-to-male transgender man. J Midwifery Womens Health. Jul-Aug 2008;53(4):331-337. 11.Kenagy GP. Transgender Health: Findings From Two Needs Assessment Studies in Philadelphia. Health Soc Work. Feb 2005;30(1):19-26. 12.Burdge BJ. Bending gender, ending gender: theoretical foundations for social work practice with the transgender community. Soc Work. Jul 2007;52(3):243-250. 13.Nemoto, T., Bodeker, B., Iwamoto, M Social Support, Esposure to Violence and Transphobia, and correlates of Depression among Male-to-Female Transgender Women with a History of Sex Work. AJPH. Oct 2011; 101(10):1980-1988. 14.Radloff, L. (1977). "The CES-D scale: A self-report depression scale for research in the general population." Applied Psychological Measurement 1(3): 385-401. 15.Rosenberg, M. (1965). Society and the Adolescent Self-Image. Princeton, New Jersey, Princeton University Press. 16.Luhtanen, R. and J. Crocker (1992). "A collective self-esteem scale: Self-evaluation of one's social identity " Personality and Social Psychology Bulletin 18(3 ): 302-318. 17.Diaz, R. M., et al. (2001). "The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: findings from 3 US cities." Am J Public Health 91(6): 927-932.

24. www.aids2014.org Acknowledgements We thank transgender community members, AIDS service organizations, and the San Francisco Department of Public Health for their continuous support on our HIV prevention studies and service projects for transgender communities in the Bay area. This study was supported by the National Institute on Drug Abuse (Grant No.: R01 DA011589; PI: Tooru Nemoto). The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the National Institute on Drug Abuse.

25. www.aids2014.org Thank you very much!