Asa Radix

Background: Public Health Advisors (PHAs) play a vital role in comprehensive syphilis elimination efforts through investigative contact epidemiology, partner elicitation, patient education, and risk-reduction counseling. Historically PHAs are situated in state and local health departments. The National Plan to Eliminate Syphilis underscored the need for alliances with organizational partners, including involvement of community health centers (CHC) and other agencies in provision of culturally competent interventions for persons at highest risk. Objectives: This presentation will illustrate the successful implementation of the PHA role in a CHC setting. Project Description: Callen-Lorde (CLCHC), a CHC that serves primarily lesbian, gay, bisexual, and transgender individuals, reports the second highest incidence of primary and secondary syphilis in NYC. In November of 2010 the CDC, in conjunction with the NYC Department of Health and Mental Hygiene (NYCDOHMH), funded the placement of ...

The Network for LGBT Health Equity, the National LGBT Cancer Network, Memorial Sloan-Kettering Cancer Center and Callen Lorde co-organized the first Cancer in the LGBT Communities Summit to develop an action plan to decrease disparities, and improve care across the cancer continuum (prevention, screening, treatment, survivorship) in LGBT populations. Over 2 days, 60 leaders in LGBT cancer research, policy, care and advocacy met to identify gaps in the care continuum for LGBT peoples, and define action steps to close these gaps. Day One: Attendees were divided into subgroups: (1) researchers, care providers, survivor/ advocates, and policy makers; (2) prevention, screening, diagnosis/ treatment, and survivorship; (3) Lesbians/ Bisexual Women, Gay/ Bisexual Men, and Transgender people. Day Two: attendees analyzed Day One findings, developed a conceptual statement about methodology and overarching concepts, and organized information into metathemes. Attendees recognized disparities, in...

Studies have shown that transgender women (TGW) are disproportionately affected by HIV, with an estimated HIV prevalence of 19.1% among TGW worldwide. After receiving a diagnosis, HIV-positive TGW have challenges accessing effective HIV treatment, as demonstrated by lower rates of virologic suppression and higher HIV-related mortality. These adverse HIV outcomes have been attributed to the multiple sociocultural and structural barriers that negatively affect their engagement within the HIV care continuum. Guidelines for feminizing hormonal therapy among TGW recommend combinations of oestrogens and androgen blockers. Pharmacokinetic studies have shown that certain antiretroviral therapy (ART) agents, such as protease inhibitors (PIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs) and cobicistat, interact with ethinyl estradiol, the key oestrogen component of oral contraceptives (OCPs). The goal of this article is to provide an overview of hormonal regimens used by TGW, to ...

Transgender medicine presents a particular challenge for the development of evidence-based guidelines, due to limitations in the available body of evidence as well as the exclusion of gender identity data from most public health surveillance activities. The guidelines that have been published are often based on expert opinion, small studies, and data gathered outside the US. The existence of guidelines, however, helps legitimate the need for gender-affirming medical and surgical interventions. Research conducted on transgender populations should be grounded in gender-affirming methodologies and focus on key areas such as health outcomes after gender-affirming interventions.

Transgender (trans) communities worldwide, particularly those on the trans feminine spectrum, are disproportionately burdened by HIV infection and at risk for HIV acquisition/transmission. Trans individuals represent an underserved, highly stigmatized, and under-resourced population not only in HIV prevention efforts but also in delivery of general primary medical and clinical care that is gender affirming. We offer a model of gender-affirmative integrated clinical care and community research to address and intervene on disparities in HIV infection for transgender people. We define trans terminology, briefly review the social epidemiology of HIV infection among trans individuals, highlight gender affirmation as a key social determinant of health, describe exemplar models of gender-affirmative clinical care in Boston MA, New York, NY, and San Francisco, CA, and offer suggested "best practices" for how to integrate clinical care and research for the field of HIV prevention. Holistic and culturally responsive HIV prevention interventions must be grounded in the lived realities the trans community faces to reduce disparities in HIV infection. HIV prevention interventions will be most effective if they use a structural approach and integrate primary concerns of transgender people (eg, gender-affirmative care and management of gender transition) alongside delivery of HIV-related services (eg, biobehavioral prevention, HIV testing, linkage to care, and treatment).

Transgender persons suffer significant health disparities and may require medical intervention as part of their care. The purpose of this manuscript is to briefly review the literature characterizing barriers to healthcare for transgender individuals and to propose research priorities to understand mechanisms of those barriers and interventions to overcome them. Current research emphasizes sexual minorities' self-report of barriers, rather than using direct methods. The biggest barrier to healthcare reported by transgender individuals is lack of access because of lack of providers who are sufficiently knowledgeable on the topic. Other barriers include: financial barriers, discrimination, lack of cultural competence by providers, health systems barriers, and socioeconomic barriers. National research priorities should include rigorous determination of the capacity of the US healthcare system to provide adequate care for transgender individuals. Studies should determine knowledge a...

This article describes methodological challenges, gaps, and opportunities in US transgender health research. Lack of large prospective observational studies and intervention trials, limited data on risks and benefits of sex affirmation (e.g., hormones and surgical interventions), and inconsistent use of definitions across studies hinder evidence-based care for transgender people. Systematic high-quality observational and intervention-testing studies may be carried out using several approaches, including general population-based, health systems-based, clinic-based, venue-based, and hybrid designs. Each of these approaches has its strength and limitations; however, harmonization of research efforts is needed. Ongoing development of evidence-based clinical recommendations will benefit from a series of observational and intervention studies aimed at identification, recruitment, and follow-up of transgender people of different ages, from different racial, ethnic, and socioeconomic backgr...

Transgender and gender non-conforming (TGNC) individuals face high levels of discrimination and mistreatment, including within social and medical service settings, which may lead to negative health and psychosocial sequelae. Given the many barriers to competent care, we sought to determine points of intervention by assessing the current needs, satisfaction, and health care utilization of TGNC individuals in New York City as reported by TGNC individuals. In January 2013, fifty TGNC individuals were recruited via flyers and direct referrals from healthcare professionals within community spaces and pertinent venues. We administered a brief survey and conducted four focus groups exploring participants' health care utilization and perceived barriers to care, routine care, hormone and silicone use, and recommendations for improving transgender services. Participants were 18- to 64-years-old, racially/ethnically diverse, and the majority were medically insured, underwent routine health care in the last year, and received an HIV test in their lifetime. A significant proportion reported taking hormones prescribed by a medical provider and were in the care of knowledgeable providers. Participants perceived four areas where barriers persisted: utilization of preventive services, access to transition-related procedures, access to legal assistance, and inclusion of TGNC individuals in public health education and campaigns. Structural interventions are needed, such as comprehensive provider training programs for all level staff to better serve the needs of TGNC individuals, increase service utilization and improve wellbeing, while effecting lasting institutional change. Service provision establishments should hire more TGNC staff and integrate transgender care into existing practices.

Background: FDA-approved 4th-generation HIV antigen/antibody immunoassays can detect HIV infection earlier than traditional confirmatory tests (i.e., Western blot). Screening and confirmatory test results (4th-generation reactive / Western blot negative) that are discordant may be misclassified as HIV-negative by clinicians. Use of an algorithm with HIV-1 Nucleic Acid Amplification Testing (NAAT) for confirmation enables proper classification of reactive 4th-generation test results. We report a prospective evaluation of a testing algorithm using HIV-1 NAAT to confirm reactive 4th-generation results. Methods: The STOP study is an ongoing, multi-site study comparing methods to detect acute HIV infection. In New York City, participants at three STD clinics and two community-based testing programs were screened for HIV with a 4th-generation antigen/antibody immunoassay (Architect, Abbott). Specimens with a reactive 4th-generation result were tested with a qualitative HIV-1 NAAT (APTIMA,...

Fungi have become an increasingly important cause of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis. The most common cause of fungal peritonitis is Candida. However, in recent years unusual and "nonpathogenic" fungi have been reported as etiologic agents of CAPD-associated peritonitis. We are reporting the first case of CAPD-associated peritonitis caused by Monilia sitophila. This organism had previously been considered to be non-pathogenic, and a troublesome laboratory contaminant. Our patient was successfully managed with intravenous and intraperitoneal amphotericin B, followed by oral itraconazole, without removal of her Tenckhoff catheter.

Background: MSM are an at-risk group for chlamydia (CT) and gonorrhea (GC) infections, including extra-genital (EG) CT/GC. However, studies show that EG infections may be underdiagnosed due to lack of screening. We examined the prevalence of EG CT/GC screening at a Federally-Qualified- Health-Center (FQHC) that primarily serves lesbian, gay, bisexual, and transgender (LGBT) communities to identify opportunities for improvement. Methods: We randomly sampled 10% of 3,000 HIV+ MSM with ≥1 clinic visit during 2011. Anatomic sites of CT/GC testing in the year prior to visit were abstracted from medical records, as were demographic factors: age, residential zip code, race/ethnicity, and insurance type. Results: In our sample (n=300), the median age was 39 years, 47% (141/300) were Manhattan residents, 18% were Black and most had either government subsidized insurance (78%) or were privately insured (21%). The prevalence of urethral, rectal and pharyngeal CT/GC testing in the past year was...

In December 2009, the Department of Health and Human Services guidelines for initiation of antiretroviral therapy (ART) changed to include patients with CD4 counts between 350 and 500 cells/µL. The aims of this study were to assess uptake of this recommendation in ART-naive youth with human immunodeficiency virus (HIV) and to describe the epidemiology of transmitted genotypic drug resistance mutations (DRMs) in this population. A multicenter, retrospective cohort study of ART initiation in ART-naive youth was performed. Eligible subjects were 13-25 years of age, were diagnosed with HIV within 1 year of presentation to care at the study sites, and presented to care from January 2007 to June 2011. Of 685 potential subjects identified, 331 (49%) fulfilled inclusion criteria. Mean CD4 count at presentation to care was 452 cells/µL. Overall, 191 (58%) subjects started ART. The mean CD4 count at ART initiation was 261 cells/µL before and 363 cells/µL after the 2009 guideline change (P < .0001). Of 212 (64%) subjects with resistance testing available prior to ART initiation, 38 (18%) subjects had a major DRM and an increased proportion of resistance was seen in later study years. Our study demonstrated an uptake in recently changed guideline recommendations to treat HIV-infected individuals at higher CD4 counts and reinforces the importance of performing resistance testing at entry into care, as 18% of our population had major DRMs prior to initiation of ART.