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Q&A: Tackling HIV among youth, transgender people
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The CDC reported that in 2014, 22% of new HIV diagnoses in the United States occurred among young people aged 13 to 24 years, 80% of whom were gay and bisexual men. A 2013 study estimating the prevalence rate among transgender women found that 22% were infected with HIV in five high-income countries, including the U.S. Prior research has also found that compared with other races and ethnicities, African American transgender women are more likely to test positive for HIV.
These latest statistics of high-risk populations suggest new approaches to prevent and reduce the rates of HIV infection among youth and transgender people in the U.S. are still needed. Infectious Disease News spoke with Jeffrey Klausner, MD, MPH, professor of medicine in the division of infectious diseases at UCLA’s David Geffen School of Medicine, and professor of public health at the UCLA Fielding School of Public Health, to discuss the latest HIV statistics, prevention methods and treatment recommendations. – by Savannah Demko
Why are youth at such increased risk of becoming infected with HIV?
Youth are at increased risk of becoming infected with HIV due to increased sexual risk behavior and increased exposure to HIV–infected sex partners. The transmission of sexually transmitted infections like HIV are driven by the number and infectiousness of sexual contacts and the frequency of condom use. Young people tend to have more sex partners, more condomless sex and more contact with older adults who are more likely to be infected and infectious. Because young people have not experienced the devastating effects of the AIDS epidemic in the 1980s and 1990s, there is less fear and more risk taking. Fear of dying from AIDS was a powerful motivator to practice safer sex. Now, thanks to the tremendous advances in HIV therapy, that fear is gone. Motivating young people now to practice safer sex is much more difficult.
How can youth and transgender people prevent the spread of HIV infection?
There are several highly effective ways for youth and transgender people to prevent becoming infected. One of the best is condom use. Condoms are highly effective in preventing the spread of sexually transmitted infections like HIV. A second effective way is to use pre-exposure prophylaxis, or PrEP, the combination HIV medication regimen that when taken daily is very effective at preventing HIV. A third and more difficult way is to have sex only with partners who are noninfectious — uninfected or successfully treated. A fourth and underappreciated way is to get regular sexually transmitted disease checkups and screening tests. Sexually transmitted diseases like gonorrhea, syphilis and chlamydia increase the risk of getting HIV infection anywhere from 100% to 500%. Identifying and treating those sexually transmitted diseases will reduce one’s risk of getting HIV.
Transgender women, especially black transgender women, seem to be at increased risk of acquiring HIV. Why?
Certain populations, in particular historically disadvantaged populations like African Americans or transgender women, are at increased risk for HIV because of ongoing challenges with access to care and access to interventions like PrEP and prevention education. Additionally, the capacity to negotiate safer sex is less and there is a greater likelihood that their sex partners will be infectious either because their partners are unaware of their infection status or their infected partners are not treated. It’s a real crisis that many African Americans and some transgender populations have limited knowledge of HIV status and very poor access to testing and treatment.
Can you discuss the role of stigma among youth and transgender people in the HIV epidemic?
Stigma is a powerful and potent poison that prevents people from getting tested and seeking care. Youth, transgender people and people of color suffer from multiple sources of stigma due to their age, sexuality, gender and skin color. Add on top of that the stigma of HIV and no wonder it’s so difficult for people to access prevention or treatment services. Sexually transmitted diseases remain highly stigmatized. People are OK today discussing their cancer but never would discuss their herpes infection. Our society has a long way to go in order to make sexuality something acceptable to discuss. I do not see us moving in the right direction. Understanding the severity of stigma, however, has led many groups to take advantage of the internet and social media. Through private and often anonymous communication strategies, we can deliver prevention services like PrEP, mail condoms, home-based STD screening collection kits and even home-based tests for HIV detection. Unfortunately, although those approaches have demonstrated acceptability, feasibility and even cost-effectiveness in research studies, those activities have not been brought to scale to realize a population-level impact.
What can clinicians do to reduce the number of new HIV infections among youth and transgender people? Are there any resources you recommend for clinicians?
To reduce the number of new HIV infections among youth and transgender people, clinicians must improve their own capacity to provide nonjudgmental care, to routinely ask every patient about his or her sexual behavior including sex of sex partners and to make no assumptions. Simple interventions like having posters of same sex couples in the waiting or examination rooms, including sexual history questions on office visit, self-completed health assessments and training staff in cultural competency can make a big difference. I have a telemedicine project where we provide PrEP through an internet-based and telephone assessment, and I am always surprised that the young men on the phone are not talking to their doctors about their sex lives, and the main reason is that doctors are not asking. There are a variety of HIV prevention resources available from state governments, the CDC and local community-based organizations. The Black AIDS Institute specifically has materials and training for those serving African Americans.
Is our national approach to reduce the incidence of HIV among youth and transgender people working? If not, what can we do to make it better?
Overall, there has been a favorable but slow trend demonstrating a decline in HIV incidence in certain populations in certain geographic areas. There is a national strategy based on sound science, but implementation of that strategy has lagged. The great recession of 2008-2009 resulted in reductions in public health activities at the federal, state and local levels that have not been restored. Few jurisdictions have adequate resources to maintain effective prevention programs, and not many engage in basic HIV control activities like interviewing new cases, notifying and testing recent sex partners, and following up on new cases to ensure linkage and retention in care. I was struck by recent data presented at [the Conference on Retroviruses and Opportunistic Infections] that a large proportion of those with known HIV infection in the U.S. are not in care and successfully treated. Given the public health implications — that is, the ongoing spread of infection in those untreated individuals not in care — it should be our highest priority to help get those folks back in care and successfully treated. That has to be a combined effort of clinicians and local health departments. We’ve come a long way over the past 20 years in terms of the prioritization of the public health response to HIV versus the individual issues of autonomy and civil rights. When I started at the San Francisco Department of Public Health in 1995, it was OK if newly positive patients did not come back for their test results. It took many years to convince colleagues of the public health value of making sure patients learned their status and were helped to get treatment. We must double down on those public health efforts today and locate people out of care and help them get back into care. That’s good for both public health and good for the individual. We can do that in a manner that respects individual rights.
References:
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a5.htm?s_cid=mm6347a5_w
Disclosure: Klausner reports receiving funds from Gilead Sciences.