Dana D. Hines, PhD, MSN, RN

Assistant Professor of Nursing

George Washington University

Acknowledgements

This research was supported by the:

• National Institutes of Health/National Institute of Nursing Research (F31 NR013864-01) and T32NR0706

• Indiana University School of Nursing Research Incentive Fund

• Midwest Nursing Research Society

• Sigma Theta Tau International

Introduction

• Transwomen are disproportionately impacted by HIV– 28% of transwomen in the US are HIV-positive

• Uptake of HIV testing is low among transwomen

• Have poor outcomes at each step along the HIV Care Continuum

• Dearth of trans-specific, evidence-based/informed interventions

Background

• Indiana moderate HIV incidence state, but has low levels of public health prevention and investment in prevention services

• Delays in linkage to care common in publicly funded testing sites

• 45% of people living with HIV in Indiana not linked to medical care

• HIV increasing among transwomen in Indiana

Aims

• Describe circumstances by which transwomen in Indiana receive HIV testing

• Identify factors that facilitate and impeded linkage to care

Methods

• Network Episode Model

– Sociological health model

• Research Design

– Qualitative Descriptive

• Data Collection

– Face-to-face, in-depth interviews

• Data Analysis

– Content analysis

• Members of the coding team read transcripts in their entirety

• Segments of transcripts related to study aims were highlighted

• Text units coded• Data display tables used to organize codes by

aims• Narrative descriptions written for each topic• Coding team met regularly to verify codes,

discuss topics, and reach consensus on categories

Data Analysis

Participant Demographics

56%22%

5%

6%

11%

Race/Ethnicity

Black

White

Latina

Native American/Pacific Islander

Multi-racialN=18

Participant Demographics

• Ranged in age from 21-60

• Almost half (n=8) diagnosed between the ages of 20-29

• Most (n=10) were unemployed

• Most (n=10) identified as heterosexual

• Almost (n=17) all insured

• Majority (n=17) on ART

Participant Demographics

61% (n=11) 50%(n=9)61% (n=11)

39% (n=7) 83% (n=15)

Circumstances Prompting Routine Testing

Routine Testing Pathway(n=10)

Intake processfor prison/jail

Illness symptoms

Other health screening procedures

Prison/jailn=4 Hospital

n=4

Plasma centern=2

Circumstances PromptingSelf-Initiated Testing

Self-Initiated Testing Pathway

(n=4)

Self-perceived riskSexual identity Knowing someone with HIVDid not feel wellNew romantic relationship

Physician office =2HIV CTS=2

Circumstances PromptingRecommended Testing

Recommended Testing Pathway

(n=4)

Romantic partner tested positive

Health care provider suggested testing

Physician office =2HIV CTS=2

Linkage to Care

• 61% (n=11) linked to care right away (within 3 months of diagnosis)

• 39% (n=7) delayed linkage to care

• Delays occurred among participants tested in clinical and non-clinical sites

• No delays were reported by participants in the recommended testing pathway

Hospital/EDHIV CTSPrisons/jailsPlasma CentersPhysician offices

Psychosocial supportVerbal encouragementGuidance from friend or partnerDirect referrals to care

Facilitated linkage to care

Hospital/EDHIV CTSPrisons/jailsPlasma CentersPhysician offices

Unready to face new diagnosisConcerns about lack of privacy & confidentialityLack of informational support• post-test counseling and direct referralsAdverse life events

Interrupted linkage to care

Unready to face new diagnosisConcerns about lack of privacy & confidentialityLack of informational support• post-test counseling and direct referralsAdverse life events

Delayers Psychosocial SupportEducational/informational supportIllnessSeeing others diePersistence from HCPSubstance abuse treatment

Motivating Factors

Finally connect to care

Discussion

• Social circumstances (romantic relationships, social network characteristics, sexual identity) prompt HIV testing

• Routine testing is an good approach for increasing HIV testing and early diagnosis among transwomen

• Women whose routine testing was prompted by illness symptoms had advanced disease

Discussion

• Psychosocial support, peer guidance, and direct referrals support timely linkage to care

• Lack of privacy/confidentiality, denial and lack of education delay linkage to care

• Transwomen with greater adverse life circumstances need ongoing and continuous support for entering care

Practice Implications

• Findings related to barriers to care may help:

– Inform a categorization or alert system to identify transwomen who are at high risk for entering care

– Clinicians prioritize those patients who could benefit from early and persistent support with linking to HIV care

Policy Implications

• In 2013 transgender people in Indiana accounted for the fewest HIV tests administered by federally funded testing sites

– Reportedly had no positive tests

• In June 2015 HRSA crosswalk outlined services most likely to advance the care continuum

Conclusions

• HIV testing and linkage to care are closed tied to social characteristics, behaviors, and relationships

• Transwomen should be screened for barriers to care at each step along the continuum

• Federal funded agencies aimed at increasing uptake of HIV testing and linkage to care should include a peer-led component

• HIV crosswalks may need to be adapted to meet the unique needs of transwomen

Contact Information

Dana D. Hines, PhD, MSN, RN1919 Pennsylvania NW, Suite 500

Washington, DC 20006dana_hines2@gwu.edu