Ex­tra care for trans­gen­der peo­ple

A Texas clinic wanted to stop HIV’s spread among a vul­ner­a­ble group, but found there was a big­ger con­cern.

Los Angeles Times - - THE NATION - By Alexan­dra Zavis alexan­dra.zavis @la­times.com

AUSTIN, Texas — When the Kind Clinic be­gan of­fer­ing free or low-cost hor­mone ther­apy for trans­gen­der peo­ple in March, word spread quickly here. Within days, the ser­vice was booked up un­til the end of June. Now the next avail­able ap­point­ment is in De­cem­ber.

For the pa­tients flock­ing to the clinic north of down­town — the first of its kind in central Texas — it’s a chance to be­gin a tran­si­tion many thought they could not af­ford. But for the doc­tors, the rush is a chance to start ad­dress­ing another ma­jor health prob­lem fac­ing the trans­gen­der com­mu­nity: the stag­ger­ing rates of HIV.

By of­fer­ing hor­mone ther­apy, the clinic aims to earn the trust of a pop­u­la­tion that of­ten feels alien­ated by main­stream medicine and per­suade those at high risk of ex­po­sure to HIV to start on a drug reg­i­men that can pre­vent in­fec­tion.

The U.S. Food and Drug Ad­min­is­tra­tion ap­proved a reg­i­men mar­keted as Tru­vada for use as a pre-ex­po­sure pro­phy­laxis against HIV in 2012, but it is not widely pre­scribed.

“Is that just avail­able to any­one?” Peter Haley, a 27year-old trans­gen­der pa­tient, asked a Kind Clinic doc­tor when she told him about Tru­vada.

The doc­tor, Cynthia Brinson, ex­plained that the clinic would first want to pro­vide coun­sel­ing about the medicine and do a se­ries of tests to rule out a pre­ex­ist­ing HIV in­fec­tion and other po­ten­tial com­pli­ca­tions. But if ev­ery­thing checked out, she said, the clinic would pro­vide a pre­scrip­tion and help fill­ing it at lit­tle or no cost.

Haley had come to the clinic be­cause he was no longer cov­ered by his mother’s in­sur­ance and couldn't af­ford the $100-a-month pre­scrip­tion for testos­terone in­jec­tions or rou­tine vis­its to the doc­tor.

Re­cently mar­ried, he didn’t think he was in any im­me­di­ate dan­ger from HIV. But he left the clinic with a stack of leaflets about pre­ex­po­sure pro­phy­laxis, or PrEP.

“I have a lot of friends who prob­a­bly should know about it,” he told the doc­tor.

A 2013 re­view of the lim­ited re­search es­ti­mated that as many as 22% of trans­gen­der women in the U.S. were liv­ing with the AIDS-caus­ing virus — a rate 27 times higher than for the gen­eral pop­u­la­tion of re­pro­duc­tive age (15 to 49). More than half of African Amer­i­can trans­gen­der women could be in­fected, ac­cord­ing to one study. The risk to trans­gen­der men is be­lieved to be lower, although there is even less data about them.

The pop­u­la­tion is so vul­ner­a­ble be­cause the stig­ma­tized place that trans­gen­der peo­ple oc­cupy in so­ci­ety trans­lates into ex­tremely high rates of poverty, sub­stance abuse, men­tal health dif­fi­cul­ties, home­less­ness and in­car­cer­a­tion — all of which in­crease the odds of hav­ing sex with­out con­doms or shar­ing nee­dles, the two most com­mon ways that HIV is spread in the U.S.

Find­ing a job can be es­pe­cially dif­fi­cult for some trans­gen­der women, so they may turn to sex work, which puts them at even greater risk. Many clients don’t want to use con­doms, they say, and as­saults are com­mon.

Many of those liv­ing with HIV refuse to get tested or treated be­cause of bad ex­pe­ri­ences at main­stream med­i­cal fa­cil­i­ties.

A sur­vey by the Na­tional Cen­ter for Trans­gen­der Equal­ity in 2015 found that 23% of the nearly 28,000 re­spon­dents hadn’t seen a doc­tor when they needed one in the last year, be­cause they were afraid of be­ing mis­treated. A third couldn’t af­ford to see one.

Of those who had con­sulted a health­care provider, a third re­ported be­ing re­fused treat­ment, ver­bally ha­rassed, as­saulted or sub­jected to some other mis­treat­ment.

“You go to the doc­tor to seek help, but they act like they’re dis­gusted by you some­times,” said Kelly Kline, one of the Kind Clinic’s first trans­gen­der pa­tients.

She re­called the New Year’s Eve that she came down with pneu­mo­nia and had to go to the emer­gency room.

“Ev­ery­one was so nice, un­til they asked for my ID,” she said. “Then the re­cep­tion­ist, in front of ev­ery­body, asked, ‘So, you’re a man?!’ ”

The doc­tor did a dou­ble take when he saw her and checked her chart.

“I’m so sorry,” she re­called him say­ing. “They told me there was sup­posed to be a man on my table.”

Kline, who hosts a pop­u­lar drag show at an Austin night­club, said she had lost count of the num­ber of friends who had died of AIDS-re­lated com­pli­ca­tions — “so many peo­ple.” Some refuse to get tested be­cause they can’t face the pos­si­bil­ity of an HIV di­ag­no­sis. But oth­ers are afraid of how they will be re­ceived.

Be­cause trans­gen­der peo­ple feel so un­wel­come at many med­i­cal fa­cil­i­ties, op­por­tu­ni­ties for pre­vent­ing the spread of HIV — the best hope for con­tain­ing the virus short of a cure or a vac­cine — are be­ing missed.

The Austin clinic be­gan in 2015 with the aim of mak­ing Tru­vada more eas­ily avail­able to those at high risk of con­tract­ing the virus. That in­cludes any­one who is in a re­la­tion­ship with an HIV-pos­i­tive per­son, gay and bi­sex­ual men who do not reg­u­larly use con­doms with part­ners whose HIV sta­tus they don’t know, and any­one who some­times shares equip­ment to in­ject drugs or hor­mones.

Taken daily, the medicine has been shown to re­duce the risk of in­fec­tion by more than 90%.

Though pub­lic health of­fi­cials in Texas and across the na­tion have made it a com­po­nent of their strate­gies against the virus, the U.S. Cen­ters for Dis­ease Con­trol and Preven­tion has said many pri­mary care doc­tors and nurses re­main un­aware of it.

The medicine has also faced op­po­si­tion from some doc­tors and AIDS ac­tivists who ar­gue that of­fer­ing peo­ple another way to block HIV trans­mis­sion would un­der­mine long-stand­ing ef­forts to pro­mote the use of con­doms, a method that is also ef­fec­tive against other sex­u­ally trans­mit­ted in­fec­tions. (The CDC is­sued guide­lines in 2013 stip­u­lat­ing that PrEP should be used with con­doms.)

Some doc­tors in Texas — which sees 4,000 new in­fec­tions each year — also ob­ject to the medicine on moral grounds, ar­gu­ing it en­cour­ages promis­cu­ity and in­tra­venous drug use.

Brinson, who in ad­di­tion to be­ing the clinic’s med­i­cal di­rec­tor pro­vides care at the county jail, re­called hav­ing to break the news to an in­mate that he was HIV-pos­i­tive. The man was stunned be­cause he had tested neg­a­tive just three months prior.

“Well, did they of­fer you PrEP?” she re­mem­bered ask­ing him. No, he had never heard of the reg­i­men.

“Just hav­ing peo­ple con­tin­u­ally come in to be tested but not of­fer­ing them a preven­tion seemed lu­di­crous,” she said.

Most of the peo­ple who work at the clinic are vol­un­teers, and the care is free, thanks to pub­lic and pri­vate fund­ing. The clinic can also help with the pre­scrip­tion costs for Tru­vada, which run as high as $1,600 a month with­out in­sur­ance.

By the end of last year, the clinic was pro­vid­ing the medicine to 800 pa­tients, most of them gay or bi­sex­ual men, who ac­count for the ma­jor­ity of new HIV in­fec­tions in the U.S.

But the doc­tors wor­ried about how few trans­gen­der peo­ple were com­ing in. So they reached out to com­mu­nity rep­re­sen­ta­tives, who pointed out that for many trans­gen­der peo­ple, HIV is a se­condary con­cern to ob­tain­ing the hor­mones they need to tran­si­tion. The ob­ser­va­tion was borne out by re­cent stud­ies that rec­om­mend com­bin­ing HIV and gen­der care ser­vices for these pa­tients.

And so the clinic be­gan of­fer­ing hor­mone ther­apy.

“Our strat­egy is around get­ting to zero [new in­fec­tions], and you can’t do that with­out ad­dress­ing the needs of the trans­gen­der com­mu­nity in a way that makes sense to them,” said Joe McA­dams, the Kind Clinic’s ex­ec­u­tive di­rec­tor.

At first, the clinic of­fered gen­der care ap­point­ments one evening a week. To meet the grow­ing de­mand, it re­cently added week­end hours and is plan­ning to move to larger premises in Au­gust.

More than a quar­ter of the trans­gen­der pa­tients de­cide to try Tru­vada, said McA­dams, who has been liv­ing with HIV him­self for 30 years.

One of them is Kline. She now takes a blue pill ev­ery morn­ing with her al­lergy medicine.

She loves com­ing to the clinic. On her first visit, she was of­fered a ques­tion­naire that asked about her gen­der iden­tity, the sex she was as­signed at birth and what pro­nouns she prefers.

“Other doc­tors have never, ever asked about it,” she said.

Pho­to­graphs by Katie Falken­berg Los An­ge­les Times

DR. CYNTHIA BRINSON talks to Peter Haley at the Kind Clinic in Austin. The clinic of­fers HIV preven­tion care and hor­mone ther­apy.

“OUR STRAT­EGY is around get­ting to zero” new HIV in­fec­tions, said Joe McA­dams, the Kind Clinic’s ex­ec­u­tive di­rec­tor, with pa­tient Ri­ley Cur­tis Steele.

KELLY KLINE, one of Kind’s first trans­gen­der pa­tients, says she doesn’t feel wanted at other clin­ics.

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