Background: Adolescents and young adults (ages 13-24) account for >25% of new HIV infections i... more Background: Adolescents and young adults (ages 13-24) account for >25% of new HIV infections in the USA. The majority of these infections are behaviorally acquired and occur among young MSM and in communities of color. Multiple psychosocial stressors, including stigma, discrimination, substance use and poverty, negatively impact adherence to optimal care regimens. As adolescents transition to adult care programs, they encounter new barriers, including loss of trusted healthcare professionals and reduced psychosocial support. Callen-Lorde Health Center (CLCHC) predominantly serves the LGBT communities in New York City. The Center´s Health Outreach to Teens (HOTT) program is the largest adolescent clinic in NY and served over 1,500 youth, predominantly youth of color. In 2012 the clinic provided care to 174 HIV+ clients 13-24. An evaluation was undertaken to evaluate predictors of engagement and retention in care among clients transitioning to adult care programs. Methods: A retros...
The Network for LGBT Health Equity, the National LGBT Cancer Network, Memorial Sloan-Kettering Ca... more 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...
Background: Transgender women (TGW) continue to be vulnerable both socially and economically to H... more Background: Transgender women (TGW) continue to be vulnerable both socially and economically to HIV infection with global HIV+ prevalence approximating 20%. Initial studies show that 40-50% of TGW may be unaware of their HIV+ status, are less likely to be engaged in HIV care and less likely to achieve virologic suppression. There are few data on the HIV testing behaviors of transgender men (TGM) and gender nonconforming (GNC) persons, i.e., who identify as other than male or female. Data suggest that transgender individuals avoid preventive care, including HIV screening, due to healthcare barriers such as stigma and discrimination in healthcare settings, and that GNC people may face even more healthcare discrimination compared to transgender people. Callen-Lorde Community Health Center (CLCHC) in NYC predominantly serves the LGBT communities and has one of the largest transgender clinic populations in the USA. The center conducted a study to evaluate healthcare utilization, includin...
Background: FDA-approved 4th-generation HIV antigen/antibody immunoassays can detect HIV infectio... more 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,...
The International journal of artificial organs, 1996
Fungi have become an increasingly important cause of peritonitis in patients undergoing continuou... more 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.
Transgender and gender-nonconforming youth have unique medical and psychosocial needs that freque... more Transgender and gender-nonconforming youth have unique medical and psychosocial needs that frequently go unmet. For youth who wish to have their physical appearance congruent with their gender identity, treatment guidelines are available that advocate the use of gonadotropin-releasing hormone (GnRH) analogues (puberty blockers) and cross-sex hormone regimens. Although medical transition was once considered highly controversial, there is a mounting body of evidence that providing a supportive and affirming environment, as well as appropriate medical intervention, results in improved health outcomes. Primary care pediatricians may be unaware of current guidelines and consequently the need for treatment and/or timely referrals. Transgender youth often face other hurdles to initiation of therapy, including refusal of care and harassment in medical settings, denial of coverage by insurance plans, and the high cost of puberty blockers. Because transgender youth younger than 18 years depend on their families for medical decision making, they may be unable to access necessary medical treatment when parents do not support their transition plan. Medical transition impacts many aspects of the medical system, such as insurance coverage, billing, electronic health records, and preventive health care maintenance. These issues may become more apparent with the implementation of the Affordable Care Act (ACA) and increased use of electronic records and clinical decision support. The implementation of the ACA may also present new opportunities and protections for transgender individuals. Primary pediatricians are often the first providers families and youth reach out to for advice, and they can assist families with negotiating these complex medical, legal, social, and economic challenges and optimizing access to safe and appropriate health care services.
ABSTRACT Abstract Purpose: Transgender and gender non-conforming (TGNC) individuals face high lev... more ABSTRACT Abstract Purpose: 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. Methods: 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. Results: 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. Conclusions: 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.
Worldwide, transgender women who engage in sex work have a disproportionate risk for HIV compared... more Worldwide, transgender women who engage in sex work have a disproportionate risk for HIV compared with natal male and female sex workers. We reviewed recent epidemiological research on HIV in transgender women and show that transgender women sex workers (TSW) face unique structural, interpersonal, and individual vulnerabilities that contribute to risk for HIV. Only six studies of evidence-based prevention interventions were identifi ed, none of which focused exclusively on TSW. We developed a deterministic model based on fi ndings related to HIV risks and interventions. The model examines HIV prevention approaches in TSW in two settings (Lima, Peru and San Francisco, CA, USA) to identify which interventions would probably achieve the UN goal of 50% reduction in HIV incidence in 10 years. A combination of interventions that achieves small changes in behaviour and low coverage of biomedical interventions was promising in both settings, suggesting that the expansion of prevention services in TSW would be highly eff ective. However, this expansion needs appropriate sustainable interventions to tackle the upstream drivers of HIV risk and successfully reach this population. Case studies of six countries show contextspecifi c issues that should inform development and implementation of key interventions across heterogeneous settings. We summarise the evidence and knowledge gaps that aff ect the HIV epidemic in TSW, and propose a research agenda to improve HIV services and policies for this population.
Recent data on the high burden of HIV among transgender women have stimulated interest in address... more Recent data on the high burden of HIV among transgender women have stimulated interest in addressing HIV in this vulnerable population. This review situates the epidemiologic data on HIV among transgender women in the context of the social determinants of health and describes opportunities for effective interventions.
In December 2009, the Department of Health and Human Services guidelines for initiation of antire... more 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.
Background: Adolescents and young adults (ages 13-24) account for >25% of new HIV infections i... more Background: Adolescents and young adults (ages 13-24) account for >25% of new HIV infections in the USA. The majority of these infections are behaviorally acquired and occur among young MSM and in communities of color. Multiple psychosocial stressors, including stigma, discrimination, substance use and poverty, negatively impact adherence to optimal care regimens. As adolescents transition to adult care programs, they encounter new barriers, including loss of trusted healthcare professionals and reduced psychosocial support. Callen-Lorde Health Center (CLCHC) predominantly serves the LGBT communities in New York City. The Center´s Health Outreach to Teens (HOTT) program is the largest adolescent clinic in NY and served over 1,500 youth, predominantly youth of color. In 2012 the clinic provided care to 174 HIV+ clients 13-24. An evaluation was undertaken to evaluate predictors of engagement and retention in care among clients transitioning to adult care programs. Methods: A retros...
The Network for LGBT Health Equity, the National LGBT Cancer Network, Memorial Sloan-Kettering Ca... more 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...
Background: Transgender women (TGW) continue to be vulnerable both socially and economically to H... more Background: Transgender women (TGW) continue to be vulnerable both socially and economically to HIV infection with global HIV+ prevalence approximating 20%. Initial studies show that 40-50% of TGW may be unaware of their HIV+ status, are less likely to be engaged in HIV care and less likely to achieve virologic suppression. There are few data on the HIV testing behaviors of transgender men (TGM) and gender nonconforming (GNC) persons, i.e., who identify as other than male or female. Data suggest that transgender individuals avoid preventive care, including HIV screening, due to healthcare barriers such as stigma and discrimination in healthcare settings, and that GNC people may face even more healthcare discrimination compared to transgender people. Callen-Lorde Community Health Center (CLCHC) in NYC predominantly serves the LGBT communities and has one of the largest transgender clinic populations in the USA. The center conducted a study to evaluate healthcare utilization, includin...
Background: FDA-approved 4th-generation HIV antigen/antibody immunoassays can detect HIV infectio... more 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,...
The International journal of artificial organs, 1996
Fungi have become an increasingly important cause of peritonitis in patients undergoing continuou... more 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.
Transgender and gender-nonconforming youth have unique medical and psychosocial needs that freque... more Transgender and gender-nonconforming youth have unique medical and psychosocial needs that frequently go unmet. For youth who wish to have their physical appearance congruent with their gender identity, treatment guidelines are available that advocate the use of gonadotropin-releasing hormone (GnRH) analogues (puberty blockers) and cross-sex hormone regimens. Although medical transition was once considered highly controversial, there is a mounting body of evidence that providing a supportive and affirming environment, as well as appropriate medical intervention, results in improved health outcomes. Primary care pediatricians may be unaware of current guidelines and consequently the need for treatment and/or timely referrals. Transgender youth often face other hurdles to initiation of therapy, including refusal of care and harassment in medical settings, denial of coverage by insurance plans, and the high cost of puberty blockers. Because transgender youth younger than 18 years depend on their families for medical decision making, they may be unable to access necessary medical treatment when parents do not support their transition plan. Medical transition impacts many aspects of the medical system, such as insurance coverage, billing, electronic health records, and preventive health care maintenance. These issues may become more apparent with the implementation of the Affordable Care Act (ACA) and increased use of electronic records and clinical decision support. The implementation of the ACA may also present new opportunities and protections for transgender individuals. Primary pediatricians are often the first providers families and youth reach out to for advice, and they can assist families with negotiating these complex medical, legal, social, and economic challenges and optimizing access to safe and appropriate health care services.
ABSTRACT Abstract Purpose: Transgender and gender non-conforming (TGNC) individuals face high lev... more ABSTRACT Abstract Purpose: 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. Methods: 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. Results: 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. Conclusions: 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.
Worldwide, transgender women who engage in sex work have a disproportionate risk for HIV compared... more Worldwide, transgender women who engage in sex work have a disproportionate risk for HIV compared with natal male and female sex workers. We reviewed recent epidemiological research on HIV in transgender women and show that transgender women sex workers (TSW) face unique structural, interpersonal, and individual vulnerabilities that contribute to risk for HIV. Only six studies of evidence-based prevention interventions were identifi ed, none of which focused exclusively on TSW. We developed a deterministic model based on fi ndings related to HIV risks and interventions. The model examines HIV prevention approaches in TSW in two settings (Lima, Peru and San Francisco, CA, USA) to identify which interventions would probably achieve the UN goal of 50% reduction in HIV incidence in 10 years. A combination of interventions that achieves small changes in behaviour and low coverage of biomedical interventions was promising in both settings, suggesting that the expansion of prevention services in TSW would be highly eff ective. However, this expansion needs appropriate sustainable interventions to tackle the upstream drivers of HIV risk and successfully reach this population. Case studies of six countries show contextspecifi c issues that should inform development and implementation of key interventions across heterogeneous settings. We summarise the evidence and knowledge gaps that aff ect the HIV epidemic in TSW, and propose a research agenda to improve HIV services and policies for this population.
Recent data on the high burden of HIV among transgender women have stimulated interest in address... more Recent data on the high burden of HIV among transgender women have stimulated interest in addressing HIV in this vulnerable population. This review situates the epidemiologic data on HIV among transgender women in the context of the social determinants of health and describes opportunities for effective interventions.
In December 2009, the Department of Health and Human Services guidelines for initiation of antire... more 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.
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