UCSF

Transgender women (transwomen) experience innumerable challenges and disparities fixed in social inequities. Transwomen are people who identify as female, but were assigned the sex of male at birth. The high prevalence of HIV among transwomen is further complicated by transwomen’s low engagement to HIV care. The purpose of this dissertation is to examine clinical and social factors associated with HIV care among transwomen living with HIV. Guiding this dissertation is the intersectionality framework, which employs a multidimensional view of the various roles that transwomen embody. Three studies are presented in this dissertation. A literature review explored past studies in which stigma, discrimination or transphobia impacts a transwomen’s decision to engage in or not engage in HIV care. The remaining studies utilize secondary data that recruited 318 transwomen in San Francisco using respondent driven sampling. A subset of 123 transwomen was included in two original studies. One study is exploratory and included variables informed by the literature review. This study analyzes factors that were associated with the transwomen in San Francisco that did not access HIV care, was not currently on antiretroviral therapy (ART) and was not virally suppressed or had an unknown viral load. The final study looked at the role of cross-sex hormone therapy (HRT) among transwomen living with HIV and for any associations with transwomen’s HRT. The literature review found 9 studies that transwomen’s HIV care continuum—a sequential step-by step treatment model—was affected by stigmatization and discrimination at every step. The second study found that the experience of multiple discrimination (gender and race) was associated with detectable or unknown viral load. Hormone use was found to be associated with not being on ART. Unstable housing was associated with detectable viral load. The third study found that transwomen living with HIV who stated that their gender identity was validated by relationships had lower odds of not using HRT. Modifying the HIV care continuum to include treatment of the social and economic challenges as well as inclusion of trans-specific health care may positively impact the engagement of transwomen in their HIV care continuum.