PrEP for the Transgender Community

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En provenance du cours de Johns Hopkins University

PrEParing: PrEP for Providers and Patients

31 notes

Johns Hopkins University

PrEParing: PrEP for Providers and Patients

31 notes

Pre-Exposure Prophylaxis (PrEP) using the antiretroviral medication emtricitibine/tenofovir approved in countries around the world is a highly effective means of reducing transmission of HIV through sexual encounters and needle sharing. This Johns Hopkins University course PrEPares you with essential information, concepts and practical advice regarding PrEP from leaders in the field. A first of its kind learning opportunity, both providers and patients learn from the same experts through content that meets the needs of both audiences, while facilitating the opportunity for a shared community space. Lessons for healthcare workers provide background on foundational and cutting-edge research and PrEP guidelines, how to initiate a PrEP program, clinical management and providing culturally sensitive sexual health and primary care to diverse communities. Lessons for PrEP enthusiasts, PrEP users or the PrEP curious provide information regarding who can benefit from PrEP, how to access services, what to expect and how to stick with your PrEP program long-term. The Association of Nurses in AIDS Care is providing 9.1 contact hours, 1.2 of which can be use towards pharmacology contact hours for this course. The Association of Nurses in AIDS Care is an approved provider of continue nursing education by the American Nurses Credentialing Center's Commission on Accreditation OBJECTIVES: At the conclusion of the session, the participant will be able to: 1. Describe the differences between foundational PrEP studies and demonstration projects 2. Describe the basic pharmacodynamics of tenofovir/emtricitibine including mechanism of infection prevention and time to protective concentration in mucosal tissues 3. List recommendations from PrEP for Prevention of HIV Infection in the United States clinical practice guidelines, USPHS and CDC, including initial and ongoing screening and testing 4. Describe the need for PrEP as an HIV prevention tool for priority in often stigmatized populations 5. Indicate the components for integrating PrEP services into clinical practice 6. Outline guidelines for screening and treatment of sexually transmitted infections 7. Describe how to take a thorough sexual history and to engage with clients around sex in an affirming and non-judgmental manner 8. List the baseline and follow-up laboratory monitoring required 9. Explain key aspects of patient education for HIV prevention and sexual health 10. Describe protocols for ongoing PrEP services and when to discontinue FACULTY/ CREDENTIALS: Jason E. Farley, PhD, MPH, ANP-BC, FAAN, Associate Professor Johns Hopkins University School of Nursing Chris Beyrer, MD, MPH, Professor Johns Hopkins University Bloomberg School of Public Health Yusuf Ariyibi, BA, Disease Intervention Specialist Baltimore City Health Department Joyce Jones, MD, MS, Clinical Associate Johns Hopkins University School of Medicine Neha Sheth Pandit, PharmD, AAHIVP, BCPS, Associate Professor University of Maryland School of Pharmacy Pierre-Cedric Crouch, PhD, ANP-BC, ACRN, Director of Nursing San Francisco AIDS Foundation Renata Arrington Sanders, MD, Assistant Professor Johns Hopkins University School of Medicine Jenell Coleman, MD, MPH, Associate Professor Johns Hopkins University School of Medicine Michele Decker, ScD, MPH, Associate Professor Johns Hopkins University Bloomberg School of Public Health Deborah Dunn, PA-C, MBA, Physician Assistant Chase Brexton Health Care Jordan White, MS, Desmond Tutu Fellow of Public Health and Human Rights Johns Hopkins University Bloomberg School of Public Health Gregory Lucas, MD, PhD, Professor Johns Hopkins University School of Medicine Demetre Daskalakis, MD, MPH, Acting Deputy Commissioner, Division of Disease Control, NYC Dept. of Health and Mental Hygiene David Dowdy, MD, PhD, Associate Professor Johns Hopkins University Bloomberg School of Public Health Jessica LaRicci, PrEP Coordinator Johns Hopkins University School of Nursing Susan Tuddenham, MD, MPH, Assistant Professor Johns Hopkins University School of Medicine Joseph Cofrancesco, MD, MPH, FACP, Associate Professor of Medicine Johns Hopkins University School of Medicine Jill Crank, CRNP, MSN/MPH, Nurse Practitioner Evergreen Healthcare Paul Sacamano, MPH, ANP-BC, ACRN, PrEP Project Lead Johns Hopkins University School of Nursing Shima Ge, BS, PrEP Peer Navigator Johns Hopkins University School of Nursing ORIGINATION DATE: October 2, 2017 RENEWAL DATE: EXPIRATION DATE: October 2. 2019 URL: https://www.coursera.org/learn/prep/ HARDWARE/SOFTWARE: Computer Hardware; Internet connection; Browser MATERIALS: None TARGET AUDIENCE: physicians, physician assistants, nurse practitioners, registered nurses, pharmacists, health education specialists, public health workers, social workers, case managers PREREQUISITES: None FORMAT: These seminars are enduring video presentations with online discussion forum and resources. CONTACT INFORMATION: Office of The REACH Initiative, Johns Hopkins University School of Nursing (888) 788-7737 ACCREDITATION STATEMENTS: CME activities with Joint Providers: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the Centers for Disease Control and Prevention and Johns Hopkins University School of Nursing. The Centers for Disease Control and Prevention is accredited by the (ACCME®) to provide medical education for physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The Centers for Disease Control and Prevention designates this enduring material for a maximum of 10.75 AMA PRA Category 1 Credits™. CEU: The Centers for Disease Control and Prevention is authorized by IACET to offer 1.1 CEU's for this program. CECH: Sponsored by the Centers for Disease Control and Prevention, a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is designated for Certified Health Education Specialists (CHES) and/or Master Certified Health Education Specialists (MCHES) to receive up to 10.5 total Category I continuing education contact hours. Maximum advanced level continuing education contact hours available are 0. CDC provider number 98614. The Centers for Disease Control and Prevention is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This program is a designated event for pharmacists to receive 1.05 CEUs in pharmacy education. The Universal Activity Number is 0387-9999-17-232-H01-P. Category: This activity has been designated as Knowledge-Based. Once credit is claimed, an unofficial statement of credit is immediately available on TCEOnline. Official credit will be uploaded within 60 days on the NABP/CPE Monitor. For Certified Public Health Professionals (CPH) The Centers for Disease Control and Prevention is a pre-approved provider of Certified in Public Health (CPH) recertification credits and is authorized to offer 11 CPH recertification credits for this program. CDC is an approved provider of CPH Recertification Credits by the National Board of Public Health Examiners. Effective October 1, 2013, the National Board of Public Health Examiners (NBPHE) accepts continuing education units (CEU) for CPH recertification credits from CDC. Please select CEU as your choice for continuing education when registering for a course on TCEOnline. Learners seeking CPH should use the guidelines provided by the NBPHE for calculating recertification credits. For assistance please contact NBPHE at http://www.NBPHE.org. DISCLOSURE: In compliance with continuing education requirements, all presenters must disclose any financial or other associations with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use. CDC, our planners, our content experts and their spouses/partners wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters with the exception of Dr. Jason Farley and he wishes to disclose that he received grant from Gilead. Planning committee discussed conflict of interest with Dr. Farley to ensure there is no bias. Content will not include any discussion of the unlabeled use of a product or a product under investigational use with the exception of Dr. Arrington Sander’s discussion of PrEP for adolescents, PrEP is not approved for adolescents < 18 years old; and Dr. Tuddenham’s discussion of STI screening, she will be discussing extra genital screening with NAAT currently recommended by CDC. CDC did not accept commercial support for this continuing education activity. To receive continuing education (CE): Complete the activity Complete the Evaluation at www.cdc.gov/TCEOnline Pass the posttest at 80% at www.cdc.gov/TCEOnline FEES: No fees are charged for CDC’s CE activities.

À partir de la leçon

Module 3

In this module, we review issues related to accessing and navigating the healthcare system that are relevant to priority populations for PrEP, including men who have sex with men (MSM), women, sero-different couples, adolescents, transgender persons, sex workers and persons who inject drugs or experience coercive sex. For patients, content covers self-advocacy and population-focused concerns and resources for PrEP services. For providers, we discuss the need and approach for tailoring PrEP for priority and often under-served communities with cultural humility.

Introduction0:38

PrEP for the Transgender Community34:57

Rencontrer les enseignants

Dr. Jason Farley, PhD, MPH, CRNP
Associate Professor
School of Nursing

>> Hi. My name is Deborah Dunn.

I'm a family practice PA at Chase Brexton Health Services.

I specialize in gender, medicine, transgender,

and gender nonconforming.

Also, I was part of a team

that helped write a program called Gender JOY,

which serves the trans youth and families.

We just had over-- hit over 700.

My patient start at age six and they go all the way

up to seniors, up to 70s and 80s.

So what I'd like to do today is talk to you as one practitioner

to another, as a practitioner and you are the patient.

There's-- You're going to see a lot of slides

and the slides are going to have a lot of studies.

But you can read them as I talk but I would--

I think it's more important that I educate you about the--

what happens face to face in the doctor's office.

For two reasons.

First of all, we all know

that transgender medicine is not taught

in any medical curriculum.

Reports have shown that transgender people--

a lot of studies have been done and the studies are showing

that transgender people just aren't comfortable or feel

like their practitioners are knowledgeable.

And so that acts as a barrier for transgender

to people come to see us.

So it's important that you get educated that you go

to conferences, that you read, there's a lot

of evidence-based medicine now.

There's websites like WPATH which is a-- WPATH, wpath.org,

where you can find like treatment guidelines

for transgender people.

There's the LGBT health resource websites that you can go to

and you can watch webinars.

So I encourage you to do that.

If you are a patient or if you're a transgender person,

it's very important that you find a practitioner

who makes you feel affirmed.

People ask me all the time, "So what is transgender?"

And I really don't like to use definitions.

I really don't because we--

as we all know, we identify [inaudible] gender

and we identify what the gender not because it's the gender

that we were told we are when we were born

or because we have a certain genital being female for me.

If I have breast or not, I'd still be gendered female.

And just I love my transgender children because they get it.

They-- I am a girl.

I am girl.

A child psychiatrist tells us

that people know their gender from age three.

If you ask a girl or a boy what their gender is,

they could tell you I'm a girl or a boy.

And, you know, they get it right.

And so, a lot of their parents are coming to me saying,

you know, is it something I did, is it because of divorce?

You know, if you think about it, is there anything,

any life event that could happen

that could make you change your gender, probably not.

And let us start encouraging everyone to start looking

at gender in a non-binary way that there's no longer the male

and a female, almost male, almost female,

trying to be male, trying to be female, a male trapped

in a female body, a female trapped in a male body,

we're all free to gender-express.

And how do we know that gender?

We just do.

We just do.

If you ask-- We're going to over some basic definitions.

But if you ask a person a gender now,

they may not identify as male or female.

There's now-- A lot of my patients are saying queer,

or non-binary, genderfluid, these are all terms

that we're going to start hearing now.

And what it just simply means is that somewhere on a spectrum,

someone's gender-- and identifying as a certain gender

that they feel deep-- from somewhere inside that they are.

Same thing with pronouns, I ask patients.

When I walk in the room, "I'm Deborah Dunn."

And your gender, I ask people their gender.

And so-- And then I ask the pronouns or preferred pronoun.

It may no longer just be he/she, it could be they.

And there's an umbrella, large numbers of terms for people

that use pronouns now.

And the same thing with sexual orientation,

we're no longer hearing people just say

that they're gay, straight, bisexual.

People now are saying pansexual, poly,

demi, there's lots of them.

And so what we have to get in the habit

of doing is making sure that people have opportunities

to express their gender and their gender

and their sexual orientation.

And in just a minute, I will show you how to do that on forms

and your electronic medical records.

A couple of things, though, before I start

that I think is important that you know

that Healthy People 2020 says that transgender people are

at the top six for health disparities.

And a lot of this is because of discrimination,

social and economic marginalization.

Because of these things,

transgender people experience higher rates of substance use,

violence, harassment, mental illness which a large number

of people have said or reported suicidal thoughts and attempts.

The second thing that I think is really important for you

to know is that it's-- that we have to do a better job

at documenting data and tracking data, gender.

Just as 2011, the CDC just added gender identity

to reporting forms.

So in other words, doctor's offices are places

where people were diagnosed with HIV,

people who are being reported as their gender at birth

and not the gender that they are identified with.

It's so important that we start documenting proper gender,

because it will help us to design programs

that target this group of people.

And it will also help us to know what the health disparities are,

so we can know what needs to be addressed.

Starting this year, it's going to be kind of mandated

that we start collecting sexual orientation and gender identity

in our electronic medical records.

And again, you know, who not--

who doesn't wanted to be counted?

It's important that we're documenting gender properly

so that we can set up programs,

so that we can address different health disparities.

And if you're a transgender person, I want to say to you

that I want to advocate for yourself.

If you walk into a practitioner's office

or wherever you are, because if you're at the Department

of Housing, we need to start getting this data

so that we can-- you know, even the Department of Housing needs

to know about programs aware what groups

of people need to be addressed.

But if you're a transgender person, you really--

it's important that your practitioner is reporting your

gender properly and your sexual orientation properly.

So advocate for yourself.

If they're not asking you questions

and if you're not seeing it on the forms, then I want you

to volunteer that information to them.

When you walk in for-- from like the front desk to the back,

from the call center, you know, we got to get used

to not using pronouns, he, she, mister, miss , please come back

for your appointment now.

I recommend using sign-in sheets.

Put name on one side and use preferred names

on the other side, and start calling people

by their preferred name until you know or you're able

to identify the-- their gender.

And for-- some examples on forms that you need to say,

is not husband and wife but use words like spouse and partners.

Instead of using mother and father, use parent and parent

because we know that they're the same sex partners,

couples now that have children.

So try to stay gender mutual.

It's really important.

The minute your patient feels like you're not being welcome

in a firm and they won't come back, I ask what is your--

When I walk in a room of a patient,

I'm like "I'm Deborah Dunn.

I ask your name.

Is this how you would like for me to address you?"

I ask about gender and then I ask about preferred pronouns.

And I write it down, and that's what I address them by.

We have had several examples of patients or seen

or heard several examples

of people they misgender or not using name.

For example, I had a small child that--

well, eighth grader who fully transitioned.

And whatever grade, third grade, and, you know,

we accidentally went to the waiting room

and call by the boy gender.

And she was suicidal.

We have to do better.

We have to try to get it right every time.

We have to realize that the name

on the insurance card maybe different

than the name a person identifies with.

So, set up systems that you get it right,

because we as health care practitioners, we need to be

in a business of helping people and not damaging people.

Don't make it hard for your patients to figure

out what bathroom they should go to.

It's-- You know, a family bathrooms, you know,

have neutral-- gender-neutral bathrooms.

Because imagine if, you know, your patient and trans patients,

I want to really strongly encourage you

to not allow your doctors or practitioners

or people not use your name and your gender.

So, let's get it right and let's get it right every time.

You know, I hear people say it's hard, it's new for me,

but you don't like to be called by the [inaudible] name.

No one does, right?

So, let's start calling--

let's start being sensitive about that.

In our electronic medical records at Chase Brexton,

this is what our form looks like under the gender history.

If you go down to the bottom, under gender identity,

that dropdown is not just male/female now,

it's other options, for example that one says transgender female

to male, also transgender male to female.

So we give people other options.

And in your intake forms,

if you're not comfortable asking people their gender

or sexual orientation, have that--

those questions on your forms

and then let your patients fill them out,

and then you can read them.

If your patient-- Again, if your patient--

if people aren't asking you, you have to let them know,

you should be telling them.

This is our sexual history.

I'm going to take a minute really on this form,

because this is how I identify my patients who need PrEP,

pre-exposure prophylaxis.

I ask, are you in a relationship?

People say yes or no.

And I'll ask, are you sexually active?

And people say or no.

I'll ask, how many sexual partners have you had

in the last two months?

They could say zero to over 20, is I hear all the time.

And I'll ask, in a year, the same thing.

And if my patient tells me that they've had over two partners,

multiple partners,

then I immediately start talking about PrEP.

I explain how it's an HIV medication

that have taken once a day for HIV negative people,

it can help prevent you from getting HIV.

I also-- If you look on the right-hand corner of this form,

we also ask about gender.

I ask the gender of your partner.

If people tell me they're sexual active, I'll say,

what is the gender of your partner?

Again, they may say nonconforming, non-binary,

genderfluid, but our dropdown has more than just male

and female or man and woman.

It has several different options.

People are saying they're active trans.

So, it's important to ask the questions

and if you're a trans person, make sure you tell them.

Don't worry about people being bias.

It's important because it will help us

to better know how you should be tested

and how we should counsel you about things like pregnancy.

And behavior, sexual behaviors, you got to ask people

if they're having oral sex, anal sex, vaginal sex.

You have to ask.

This is another way we're going to identify people

who are at higher risk.

I've seen people who have come back to me several times

with this chronic sore throat.

They've been in the emergency room.

They've been to doctor's offices.

Everyone is testing for strep.

No one is asking, are you having an oral sex?

And some people are.

And I'm testing them and it's chlamydia.

And as you know, penicillin is not the treatment for chlamydia.

Patient-- I mean, trans people, patients,

when you go to the doctor's office,

you have to disclose this to your doctor.

If you're having oral to anal, tongue, mouth, lips,

anything around the anal area, you know, you have to know

that there are some infections that are associated with that.

If you're having some diarrhea or some stomach cramping,

things like that, then, you know, you may need to tell them

that there's an incident of GI bugs that you can get that way.

If you're having vaginal sex, you know, vaginal, oral,

and anal, you should be testing,

more screenings regularly for GC and chlamydia.

We should still be teaching our people about barriers.

It's up to us, health care practitioners,

to help lower the transmission of HIV.

People are always talking about condoms.

People are always talking about condoms

but we should be teaching our people about dental dams.

I've seen dental dams in several doctor's offices,

were not teaching.

And they're just sitting there.

They can sit there for a year and rot people or not--

you know, if you taught your patients how

to use them, they would use them.

I don't keep these in my exam rooms.

Dental dam looks like this.

It stretches against their genitals and--

you know, it protects as oral barrier against oral, you know?

So, people do got to lick on top of this.

Also, women who have sex with women, it stops the transmission

of body fluids for people who don't like things like grinding.

But the number one use for this, my patients, is oral to anal.

Spread the cheeks, put this across

and lick on top, you know?

So, also, there're now the female condoms.

I've seen this everywhere.

They go into the vagina like this.

This hook goes along the cervix.

Again, the number use for it in my patients is anal.

The ring stays in or comes out.

It goes into the rectum like that

and the anal sphincter holds it in touch.

And you don't have to be a practitioner

to teach your patients.

It could be your friends, staff,

people should be teaching their children.

Also, if you're a trans patient or a person,

go to your doctor's offices and ask about these barriers.

Ask if they have them.

You can buy them at stores.

But it's very important to help protect you

against getting sexually transmitted.

There's HPV of the throat.

Doctors, providers, dentist look in the mouth.

Do Google images that look like.

It's doesn't look like warts, it just looks like raised areas.

So get yourself familiar.

A little bit about the epidemiology,

HIV in trans women.

What a lot of people-- People are constantly hearing that men

who have sex with men are the number one people with HIV.

Well, I can tell you now that recent studies now are showing

that trans women are taking the lead, more than two times.

And black trans women are more likely

to have HIV than non-black.

So these are the latest studies

that are showing these or showing this.

Why such a high HIV prevalence among trans women?

Again, think about it, you know, think about it.

If the studies are showing that people

who are substance abusers, promiscuous sex, marginalized,

depression, things like that, are at higher risk of HIV,

then it kind of explains it.

Because if you've being rejected by family, churches,

things like that, you're going to, you know, find comfort

where you can find comfort.

You're going to find comfort in maybe substances,

in maybe drinking, maybe in promiscuous sex.

You think about it, you know, that person, you know,

accepts me for who I am.

And I just think it's important for--

if you're trans that you realize

that this increases your risk of getting HIV.

These are just some studies.

This is one I took the slide

from your doctor telling [inaudible] who practices here

at Johns Hopkins of 47 people in Baltimore.

And this study, you know, it shadows other studies.

Trans people are having difficulty getting jobs.

People are going to job interviews and they're like, oh,

they may be trans, you know, I'm not going to hire.

People are losing jobs.

People are getting kicked out of, you know, housing.

People are getting--

having problems getting access to HIV services.

Physical abuse, harassment.

Studies are just showing, you know,

that there's a disproportionate number of trans people

who are sexually assaulted, being arrested, abused.

And I can tell you from my practice that families

that are opening and affirming and practitioners

who are opening and affirming that are helping the transition

of trans people definitely have improvement in quality of life

that there's lower rates in incidence of all

of these in any of these.

So again, it's another reason why you need to identify

who your patients are and that you help address the issues

that causes these things as physical abuse,

harassment, things like that.

Then I have to move a little bit.

Transgender women, younger women,

very little studies are done but I can tell you from my practice

in this study that you're seeing on the screen right now,

that there are some increased--

younger and younger people are getting HIV now.

My 16 to 24-year-olds have just blowing up all of a sudden,

getting one to two diagnoses a week sometimes.

So, we-- it's really important

that we do start doing HIV testing very early.

Start early.

Start identifying the patients early, I can't say that enough,

and then start testing earlier.

Ask about age when you start having sex,

teach our young people about barriers and test them.

It's not-- They're not too young to test at age 13 and 14--

12, 13, and 14, start testing.

But if you're not asking, you're not going to test.

So, it's really important that you start young--

which are younger people.

And through the slide in here,

a transgender women getting tested, they are

but the studies are showing more

that that they're undiagnosed people with HIV.

So, we need to go where we need to develop programs

where people will comfort testing but also we need to go.

We need to get involved in a community.

We need to go to [inaudible] events, set up tables,

bring your-- we have a power project van.

And we're testing.

You know, we're targeting the group--

the community that we know are high risk

and we're testing them on the sites.

We're parking in front of clubs.

When we know there's a drag show, you know, these are places

where you can do testing.

I'm part of a group called trans action group in Baltimore City

that actually outreaches trans women that are sex workers.

That's 11:00 p.m. to 4:00 a.m. And we have a van

and we're given Target gift cards for people that come test.

If you're a transgender person, please go get tested.

Look for opportunities where you can go get tested.

It's very important.

Because studies do tell us that there's a large number of you

that are HIV positive but don't know it.

And then move along.

What is the main mode by which transgender women

become infected?

All right, again, there's not a lot of place

where you can go and read this.

I'm going to do this based on my practice.

So, we still know that people are getting HIV

through receptive and insertive anal intercourse.

And through IV drug abuse, we know that blood transfusions,

having sex obviously with a person who is HIV--

unprotected that is HIV positive.

But what I want to say to you is, again, the importance

of doing sexual behavior histories.

Because we have to ask our transgender patients,

gender nonconforming, genderfluid,

and when I say transgender, it's all inclusive about receptive

and insertive anal intercourse.

The terminology that they've--

that our patients may be more familiar with are top

and bottom, so sometimes you have to use to language

that people understand.

It's important that you know transgender women are top

and bottom.

OK. It's just, you know, that a lot of people think

that transgender women are not top, but they are.

You know, it's-- we can't--

we have to stop classing people based on stereotypes.

There are sharing of needles to give estrogen to one another.

One night I had the privilege of following one

of the trans outreach who was with us

at the trans action group.

She took me into a place that was a pump house.

I saw this non-medical person use a vial,

use the same needle and syringe.

Went into the vial, drew out, injected in one girl,

told a woman that it was estrogen.

I don't know what was in there.

And took that same needle and syringe and went back to into

that vial, went to the second person and did it three times.

And you could see that the fluid or whatever it was in there,

I'm not sure was estrogen,

it could have been water, was blood-tinged.

Same thing with silicon.

Silicon was bought from Home Depot.

I could see it on the on the can, using a needle

and syringe drawing from that and injecting

and feminizing cheeks, breast, hips,

thighs not using any kind of incasing.

So this is another way that our patients are being--

are transmitting HIV.

And you have to ask.

You have to ask, are you using-- getting hormones off the street

and how are you getting it?

You know, are you using and sharing needles?

There are some IV drug use with transgender women,

most of the substances, is crack cocaine that I'm seeing a lot

of alcohol, not as much heroin.

I do see some heroin though.

Trans men is mainly alcohol.

A lot of our patients are having sex

with known positive partners.

And, you know, they're being told, I'm on HIV medicines

or my viral was undetected.

They're doing what's called barebacking anal intercourse

without using condoms or any barrier.

And, you know, it's up to us to educate our patients

about how they can get HIV.

And transgender males, females to males, they are not--

There's no data, no studies.

And so, I can tell you in my practice that transgender males,

I'm seeing more and more that are HIV positive.

You have to do sex behavior course setting.

Ask about using-- having vaginal intercourse,

anal and oral testing of all of those size

but most importantly doing HIV testing.

And that another group of people that I think we're going

to start seeing of higher rates of HIV.

PrEP and the transgender community,

there have been studies--

The iPrEX, I won't go into that study.

The bottom line is that PrEP can work but inherence is crucial.

The studies are showing that when there is Truvada,

which is the medication for PrEP, in the system,

then they are protective.

You see a lower rates of HIV transmitted.

However, compared to men who have sexual with men,

transgender women are, you know, not taking the PrEP

at the same amount that men who have sex with men.

So, I have a script that I give every time to my trans women,

trans men, gender nonconforming, genderfluid that you have

to take it for to work.

You have to take it everyday.

You can't take it as a day after pill.

It doesn't-- You know, you can develop resistance.

You can-- You have to take it everyday to be protected.

It has to be in your system for a period of time for it to work.

Again, if you give me a history that you've had unprotected sex,

anal, all of the things that we know increases your risk

of getting HIV, I immediately put you on PEP,

that's post-exposure prophylaxis, for like 28 days

and then I go to PrEP.

I'll just write the prescriptions.

I do the test and I will write the prescriptions.

Studies have shown that if women

at least taking them four doses per week, they're protected.

Doctors is so important, health care providers.

It's important that you are comfortable prescribing PrEP.

You have to.

It's easy, you know?

You prescribe Truvada.

You do the test for HIV and hepatitis, all the hepatitis.

I do a CMP.

Check kidney, renal functions, and you just prescribe it.

You have your patients come back every three months.

Transgender-- My trans patients, trans people out there listening

to this, go get prescription for PrEP.

If you know you fall in this class, this category,

then ask your doctor about it.

Find places that prescribe it.

Some of the things I hear--

Some of the reasons I hear our trans women saying why they

don't take PrEP or they're not taken HIV medicines,

because they feel that it lowers the effectiveness

of their hormones.

And if you feel like it's going to impact your transition,

then you may not be likely to take it.

But I'm here to tell you that PrEP, Truvada does not--

has been shown through studies not

to lower the efficacy of your estrogens.

So it is important that you explain

that to your patients when they come in.

And compliance is very important.

Then I'll quickly go through some key messages here.

Number one, please be open in affirming, learn,

go to conferences, read, go to different web places.

WPATH is definitely one that you wanted to go to so

that your patients they'll be comfortable around you.

Make sure you're using proper names and pronouns.

My trans patients, please advocate for yourself.

Make sure you're doing-- you're documenting,

you're collecting data of proper gender and sexual orientation

on your forms, in your electronic medical records.

Make sure that you're doing sexual histories

and gender histories, get comfortable with it.

Get your staff comfortable with it.

Don't forget about barriers.

We've stopped teaching people about how to block

but it's important that we still.

And it's not just condoms that come in every flavor or size,

but there are other barriers.

It's important that you ask people about sexual behaviors,

you're testing, and that you're finding to your T group

of people, you target your group of people

that you know are high risk.

And now that you know that trans people are at high risk,

then definitely do testings, start doing testing

at a much earlier age.

Just start doing.

I mean, just do it.

And get comfortable prescribing PrEP, very important.

And explain about the efficacy of the importance

of taking it everyday.

Explain about the importance of--

that you still have to use a protective.

You still have to use condoms.

You can still get sexually transmitted diseases.

And also it's important that you design

and that you become allies and you develop programs

that allow people to come in for testing that allow your patients

to come in to be prescribe PrEP.

Again, I'm Deborah Dunn.

My email address is ddunn@chasebrexton.org.

And thank you very much.

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