Signature May/June 2015 - 3


B EST P R ACT I C ES
BY ROBERT GAROFALO, MD, MPH and
MADELINE DEUTSCH, MD MPH

Demystifying HIV Care for
Transgender Persons

A

BONOTOM STUDIO , INC .
P U B L I C AT I O N D E S I G N

CCORDING TO RECENT ESTIMATES AND STATISTICS issued by the Centers for Disease Control and

Prevention (CDC), transgender persons, and in particular transgender women are the highest risk demographics group in the United States for the acquisition of HIV.

According to the CDC, in 2010, the highest percentage
of newly identified HIV-positive test results was among
transgender people (2.1%), with the highest percentages of
newly identified positives occurring among racial and ethnic
minorities, most notably black transgender women.1
Due to a lack of standardized collection of gender identity data, detailed information is lacking on the number
of transgender people in the United States infected with
HIV or seeking HIV-related health services across the care
continuum.1 A meta-analysis and review of available data
reported a mean HIV prevalence of 27.7% in transgender
females in four studies, where HIV testing was performed
in this population. HIV prevalence was highest among black
transgender women, with a mean estimate of 56.3%.2
In addition, a recent review of studies of HIV infection
in countries with data available for transgender people
estimated that HIV prevalence for transgender women was
nearly 50 times higher than for other adults of reproductive
age.1 Yet despite their well-documented risk, this population
remains often overlooked, poorly understood, and at-risk for
the receipt of suboptimal or inadequate health care services.
In this article, we outline a five-point plan to help clinicians
care for transgender people who seek care for HIV-related
prevention and treatment services.

1. Understanding the Complexity of HIV Risk
and Barriers to Care

When working with transgender persons within a clinical
environment, it is important to recognize that a broad range of
psychosocial and environmental challenges often complicates
the social realities of these patients.
Transgender persons, in particular transgender women,
often report limited sources of social support, high rates of
unstable housing, economic instability, and limitations on
mobility relating to the use of public transportation.3 These
factors underlie an increased risk of psychological distress
that often manifests in the form of depression, anxiety,
post-traumatic stress, or suicidal ideation.

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MARCH 2016

HIVSpecialist

For the HIV care specialist,
it is essential to recognize that
gender-affirming health care,
such as the prescribing of
hormone therapy, need not be
done by an endocrinologist.
In fact, bundling and co-location
of gender affirming treatments
with HIV primary care
facilitates both linkage to
and retention in care.

Each of these factors as well as a denial of gender affirmation can be linked to alcohol and substance use and risky
sexual activities and challenge access and retention to health
care services.4
For some, an inability to obtain or maintain adequate
employment in the context of societal stigma or a lack of legal
protections results in high rates of commercial sex work and
other transactional sex to obtain food, shelter, and income.
In addition to the inherent HIV risk associated with sex
work, transgender women may face additional risks such as
earning more money for condomless receptive anal sex-as
well as increased risk of interpersonal violence.5
Sex work is a particularly difficult risk factor to modify
due to the strong financial incentives, as well as the gender
affirmation many transgender women receive from such
activity.4 Understanding the social realities facing transgender
persons, ideally in conjunction with community engagement,
can help inform the development of risk reduction messages
that are non-judgmental and with adequate cultural humility.

2. Integration of Health Care Services

Barriers to accessing HIV primary care and antiretroviral
treatment (ART) among HIV-positive transgender people
are well-documented.6 Discrimination from health care
providers, a lack of knowledge about transgender needs, and
the outright refusal of many health insurance providers to
cover the cost of gender-related care all represent barriers
to adequate care.
For the HIV care specialist, it is essential to recognize
that gender-affirming health care, such as the prescribing of
hormone therapy, need not be done by an endocrinologist.
In fact, bundling and co-location of gender affirming treatments with HIV primary care facilitates both linkage to and
retention in care. Even for those transgender patients who do
not seek hormones or surgery, other basic steps to support
gender affirmation, such as a system to identify patients
by their preferred name and pronoun can have a profound
impact on retention in care.7

www.aahivm.org

www.aahivm.org

SHUTTERSTOCK

FIRE PROTECTION

HIVSpecialist

MARCH 2016

29

Q2 2016 / ISSUE #70

The Environmental Impacts of Fire
BY BRIAN MEACHAM, PH.D., P.E, FSFPE, DREW MARTIN AND MAI TOMIDA

Residential
Fire Safety

What Are They
and How Do We
Address Them?

WHILE RESEARCHERS HAVE CONDUCTED CONSIDERABLE STUDIES into the impacts of fire in terms of human life, property loss, business
interruption, and costs to society, relatively little research has been conducted on the impacts of fire on the natural environment. However, this topic is
gaining new attention with global concerns associated with climate change
potential as resulting from carbon emissions: a by-product of most fires.
To gain a better and broader understanding of the environmental impacts
of fire-what they are, how they are being quantified, how big the problem
might be, and how impacts of concern might be mitigated-a literature review was undertaken by researchers at Worcester Polytechnic Institute (WPI)
under a grant from the Fire Protection Research Foundation (FPRF).1 The primary objectives of this effort were to review the existing literature, provide an
overview of the major concerns, and document the knowledge gaps. Consideration was also given to impact assessment techniques and steps that could
be taken to mitigate impacts of concern.

A GLOBAL
ROUNDTABLE
DISCUSSION

Broadly speaking, environmental impacts of fire relate to any fire outcome
that affects the physical, chemical, biological, cultural or socioeconomic components of the environment. Impacts can be direct or indirect. In addition to
carbon emissions and the associated impact on climate change potential,
direct impacts can include non-carbon contamination of the air by-products
of combustion distributed via a fire plume, contamination of soil and water
from the decomposition of products of combustion, and contamination from
fire suppression agents and firefighting water runoff containing toxic products. These, in turn, can result in harm to ecosystems, wildlife, and people, as
well as cleanup and recovery costs. The impacts can be local (e.g., as associated with a vehicle or small building fire), regional (e.g., as associated with a
chemical facility fire or small wildland fire) or even global (e.g., as associated
with a large wildland fire), with the magnitude of the impact being a function of the type and quantity of materials burning, size and duration of the
fire, contributions from fire suppression and control agents and techniques,
weather conditions, and environmental susceptibility in the impacted area.

TED BRELLISFORD/HAMPTON SPECTATOR

What Are Environmental Impacts of Fire?

1990 tire fire in
Hagersville, Canada

The Official Magazine of SFPE

MORTALITY of Hollywood Actors
EXPERIENCE

I

37

FIRE PROTECTION ENGINEERING | magazine.sfpe.org | Q2 2016

A M E R I C A N AC A D E M Y O F AC T UA R I E S ■ M A R | A P R ■ 2015

By Philip J. Lehpamer

MAY+JUNE.16

36

N A F S A : A S S O C I AT I O N O F I N T E R N AT I O N A L E D U C AT O R S

f you do a simple Web search on the topics of deaths
or lifespans of Hollywood actors, you will find many
articles documenting tragic deaths of film actors and
actresses, several of them at young ages. Here are two
examples ranging from the sensational to the scholarly:

■ There is a documentary video titled Death in Hollywood that
starts by looking at the 1955 film Rebel Without a Cause, whose

Smoke and
Mirrors

three stars all died from unnatural causes-James Dean (automobile accident), Natalie Wood (a suspicious boating accident),
and Sal Mineo (murdered). A fourth actor in that film, Nick Adams, died from a prescription drug overdose that may have been
a suicide. The documentary then continues for nearly 90 minutes
detailing suicides, drug overdoses, accidents, and murders that
took the lives of American film actors and actresses.

Marijuana Use and
Underwriting

■ A 2013 study done by Australian researchers looked at 1,000
New York Times obituaries from 2009 to 2011 covering a full range

TOWARD A
BETTER

World

of professions and occupations. The study concluded that fame
and achievement in performance-related careers such as acting
may come at the cost of a shorter life expectancy.
As a retired life and health actuary intrigued by this narrative
and these findings, I decided to gather the necessary data on ac-

Internships abroad centered on
social justice issues inspire ideas that
can change the world.

tors and actresses who starred in American films during the 20th
century and to conduct a mortality study to see what information
would come out of the classic actuarial science methodology that
produces mortality ratios by number of lives. Would the data bear
out the classic "Live fast, die young" story that exists as conventional wisdom?

36

CONTINGENCIES

MAY | JUN.16

MAY | JUN.16

WWW.CONTINGENCIES.ORG

CONTINGENCIES

37

n

Foreign Language for Global Competency

n

Increasing Diversity Abroad

n

Recruiting in India

Using the

CONSUMER COMPLAINT DATABASE

MAY | JUNE 2016

to Stay Ahead
of Regulatory
Trends

Bank
Cybersecurity
Regulations and Resources

BY JOSEPH DURHAM, CRCM, CAMS, AND
PAUL R. OSBORNE, CPA, CPO, AMLP, CAMS

T
 

HE EXPANDING ROLE of the Consumer Financial
Protection Bureau (CFPB) as a regulatory player in the
financial services industry is bringing shifts in the risks
financial institutions face regarding compliance. Perhaps
most notably, regulatory enforcement actions now are being driven
not only by examinations but also by consumer complaints, as
reported to the CFPB's Consumer Complaint Database (CCD).
The CFPB's complaint database's influence can be seen in regulators' growing interest in violations of the unfair, deceptive, or abusive
acts or practices (UDAAP) laws prohibiting consumer harm, as
opposed to traditional laws and regulations such as the Truth in
Lending Act,(TILA), Real Estate Settlement Procedures Act (RESPA), Fair Credit Reporting Act (FCRA), and Fair Debt Collection
Practices Act (FDCPA). Between July 2015 and January 2016, 32
different companies were subjected to UDAAP-related enforcement
actions with penalties and restitution totaling a whopping $1.2 billion.
It seems regulators largely are using complaints to determine
whether consumer harm has occurred, as evidenced by the correlation between the companies and practices that are the target
of a high volume of complaints and the companies and practices
that are the target of enforcement actions. For example, among the
institutions with the 20 highest complaint volumes in 2015, six were
hit with CFPB enforcement actions during the 2015 calendar year,
and 11 of the 20 have been penalized by the CFPB since its inception.
With the potential cost of UDAAP violations so high, banks
can't afford to overlook the CCD in their compliance efforts. Indeed, the complaint database can provide critical guidance that
banks can use to help avoid enforcement actions.

Background of Consumer Complaint Database
The CCD stems from the creation of the CFPB in 2011 under
the Dodd-Frank Wall Street Reform and Consumer Protection
Act. The law explicitly highlights collecting and tracking complaints as one of the bureau's core objectives.
Since its creation, the CFPB has received more than 700,000
complaints; in the 12 months preceding January 31, 2016, more
than 167,000 were submitted according to the CFPB website. The
CFPB doesn't publish every complaint but, as of January 31, 2016,
516,000 had been published. While not all complaints contain a
full narrative, 52,000 do describe the consumer harm fully.
Publishing complaints represents a dramatic change to the visibility of regulatory issues. Previously, a consumer could complain
to the Office of the Comptroller of the Currency, Federal Deposit
Insurance Corporation, Federal Reserve, or other regulatory agency,
and the respective agency would pass the complaint on to the
financial institution and see that it responded-but the regulator's
involvement essentially ended there. Complaints weren't tracked
or recorded across regulators, so a complaint never made it outside
any regulator's silo, meaning broader issues could escape notice
if there were numerous complaints across regulatory agencies
from the same or multiple consumers.

Consumer Compliant Database
Fair Lending Monitoring
Measuring Risk Appetite
6

SPRING 2016

P O W E R & I N T E G R AT E D B U I L D I N G S Y S T E M S

A PUBLICATION FOR MEMBERS OF THE FOUNDATION FIGHTING BLINDNESS
❮ QUOTABLE ❯

Not Just "The Blind Kid"
Dartanyon Crocket, an international judo champion affected by a retinal
disease, will deliver the keynote address at VISIONS 2016, FFB's annual
conference, this summer.

I

"
"I'm giving toward
the future. I'm
investing in the
research so that
future generations
can have even
better treatments
or a cure."
Kathryn Birch, FFB donor
receiving treatments for
age-related macular
degeneration

➾WHAT'S
INSIDE
Pg. 2 | Donor Spotlight:
The Reeds
Pg. 4 | Q&A with VISIONS
2016 Researcher
Pg. 6 | Gunds Receive
Prestigious Award
Pg. 7 | Tyler Millard &
FFB's Theme Song

WANT TO USE MY STORY to
inspire others with retinal disease," says Paralympian Dartanyon
Crockett. Crockett, 24, who was born with
Leber's disease and is legally blind, will
be the keynote speaker at VISIONS 2016,
FFB's annual conference, June 30-July 3, in
Baltimore, Maryland. (For more information about the conference, check out
www.blindness.org/visions/.)
Crockett grew up in an impoverished
neighborhood in Cleveland, Ohio. At a
turning point in his adolescence, he joined
his high school wrestling program. There
he found acceptance, a unique friendship
and the opportunity to beat low expectations. He went on to become a world
champion judo Paralympian and is currently in training for the 2020 Paralympic
Games in Tokyo.
In Focus staff recently spoke with Crockett.
Q: You obviously have not allowed your
blindness to limit you. What advice do you
have for others who have impaired vision?
A: Never use your disability as an excuse
for why you didn't succeed. My visual
impairment made things like school and
athletics challenging. I had to find different ways of doing things. I had to learn to

accept help. But there is no one in this life
who does not have a challenge of some
sort. The important question is whether or
not you will let yours hold you back.
Also, align yourself with people who believe in you and who see past your impairment and into your potential.
Q: Do you see yourself as a role model for
young people with retinal disease?
A: I spent much of my life trying to hide
my impairment. In school, the blind kids
were always separated from the rest of the
school. Kids and even adults would comSee CROCKETT, page 6

>> Help end blindness. Use the enclosed envelope to make a life-changing gift.
www.fightblindness.org 1

SAFETY

CONTRAC
CONTRA
ONTRAC
CTOR

ELECTRICAL
LECTRICAL

5 .1 6

| ABA BANK COMPLIANCE | MAY-JUNE 2016

THE OFFICIAL PUBLICATION OF THE NATIONAL GUARD ASSOCIATION OF THE UNITED STATES

MAY-JUNE 2016 | ABA BANK COMPLIANCE |

7

THE
LEGISLATIVE
ISSUE
APRIL 2016
WWW.NGAUS.ORG

Unfinished
Business
NGAUS returns to
the Hill to finalize
vet status, other
key legislation

26

Budget Adds, Subtracts 20 | Q&A with Top SASC Democrat 40

WWW . BONOTOM . COM
INFO @ BONOTOM . COM
http://www.aahivm.org http://www.aahivm.org http://magazine.sfpe.org http://WWW.CONTINGENCIES.ORG http://WWW.NGAUS.ORG http://www.bonotom.com http://www.blindness.org/visions/ http://www.fightblindness.org
Table of Contents for the Digital Edition of Signature May/June 2015
