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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 [email protected]