#YourVaccineIsWaiting Public Awareness Campaign Targets Marginalized Groups Living with HIV/AIDS

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

The ADAP Advocacy Association recently launched its public awareness campaign - 'Your Vaccine Is Waiting' - targeting marginalized groups living with HIV/AIDS on their need to get vaccinated against Covid-19. Designed to raise awareness, it came in response to learning that numerous segments of the HIV community were among those characterized as vaccine hesitant. The campaign includes four public service announcements, produced by Brandagement, LLC. 

According to the World Health Organization, HIV increases the risk for severe Covid-19 by six percent (6%) and the risk of dying of Covid-19 in the hospital by thirty percent (30%).[1] Yet, vaccine hesitancy among the HIV community remains a very real issue in the United States, as well as abroad in other countries.

#YourVaccineIsWaiting continues our organization's commitment to focusing on the intersection between these two ongoing epidemics. Earlier this year, we blogged about the importance of the immunocompromised getting vaccinated against Covid-19. Fast-forward to now, four amazing advocates living with HIV/AIDS were asked to share their personal perspectives on why getting the jab was important to them, but also for the marginalized groups they represent. 

Tez Anderson, a long-term survivor living with HIV, shares why he decided to get vaccinated against Covid-19. He resides in San Francisco, California. Tez’s message aims to help convince long-term survivors to get vaccinated and further protect themselves.

In urban cities with large LGBTQ communities, HIV and Covid-19 has presented dual challenges for older residents. Listen to his message to the long-term survivor community: https://www.youtube.com/watch?v=s9Z0qiwoe00. 

Jen Laws, a transgender community organizer living with HIV, shares why he decided to get vaccinated against Covid-19. He resides in Slidell, Louisiana. Jen’s message aims to help convince the transgender community to get vaccinated and further protect themselves. 

According to the Williams Institute, among transgender people 25.9% report being in poor health, 32.2% have not seen a medical provider in the last year due to cost, and 34.6% expressed their gender identity could result in denial of quality care. Listen to his message to the transgender community: https://www.youtube.com/watch?v=8W_ZmVDxO74&t=259s.

Michelle Anderson, a community activist and policy associate living with HIV, shares why she decided to get vaccinated against Covid-19. She lives in Waxahachie, Texas. Michelle’s message aims to help convince African Americans to get vaccinated and further protect themselves.

In states with large urban communities, Covid-19 has disproportionately impacted African Americans. Listen to her message to the African American community: https://www.youtube.com/watch?v=7AJ440_kE68&t=213s.

Jonathan J. Pena, MSW, licensed clinical social worker associate living with HIV, shares why he decided to get vaccinated against Covid-19. He lives in Morrisville, North Carolina.

There are over 250,000 Hispanic/Latino Americans living with HIV/AIDS in the United States. One in five new HIV diagnosis in the United States were among Hispanic/Latino men (22%). Listen to his message to the Hispanic/Latino community: https://www.youtube.com/watch?v=mPWXIonBtTI&t=233s.

Why is our ongoing public awareness campaign important? According to research conducted by Johns Hopkins Medicine, Pfizer/BioNTech's vaccine induces a robust immune response in people living with HIV.[2] 

“Previous research has suggested a suboptimal response to COVID-19 vaccines in people living with HIV; however, these studies did not fully characterize and define that response, both for cellular [where the immune system directly attacks infected cells] and humoral [where the immune system circulates virus-fighting antibodies] immunity,” says study senior author Joel Blankson, M.D., Ph.D., professor of medicine at the Johns Hopkins University School of Medicine. “What we found with the widely used Pfizer/BioNTech vaccine was just the opposite, as it induces robust immune responses in people living with HIV comparable to those seen in healthy people.”[3]

The HIV community has waited decades for the development of a vaccine to defend against acquiring the human immunodeficiency virus, and yet we have one available for the other ongoing epidemic. SARS-CoV-2 has already taken 659,813 souls (and counting) from us in the United States, alone. Our community must meet the challenges presented by Covid-19 with the same intensity and rigor that we've done in the fight against HIV/AIDS over the last forty years. That is why, #YourVaccineIsWaiting.

[1] World Health Organization (2021, July 15). WHO warns that HIV infection increases risk of severe and critical COVID-19. Retrieved online at https://www.who.int/news/item/15-07-2021-who-warns-that-hiv-infection-increases-risk-of-severe-and-critical-covid-19.
[2] Johns Hopkines Medicine (2021, August 11). COVID-19 NEWS: Johns Hopkins Medicine Study Shows Vaccine Likely Protects People with HIV. Retrieved online at https://www.hopkinsmedicine.org/news/newsroom/news-releases/covid-19-news-johns-hopkins-medicine-study-shows-vaccine-likely-protects-people-with-hiv.
[3] Johns Hopkines Medicine (2021, August 11). COVID-19 NEWS: Johns Hopkins Medicine Study Shows Vaccine Likely Protects People with HIV. Retrieved online at https://www.hopkinsmedicine.org/news/newsroom/news-releases/covid-19-news-johns-hopkins-medicine-study-shows-vaccine-likely-protects-people-with-hiv.

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

Reflections from an HIV Advocate's Journey: Jen Laws

By: Jen Laws, Board Member, ADAP Advocacy Association, and HIV/transgender health advocate

There’s a long way to go from being 19 at Covenant House in north Philadelphia to being 34 and a public health policy consultant going back and forth between New Orleans and South Florida.

That 15 year path includes a great deal of good luck, a persistent outlook of good will, and a commitment to patient centered systemic change.

“You’ve got a brain like a computer and I intend to use it,” – Joey Wynn.

Having dabbled in fundraising and being deeply involved in a sex-positive community building culture, I was gifted with a chance to subcontract about a decade ago. Over a few months I expanded my knowledge of payment systems, in particular those changing due to the then recently passed Patient Protection and Affordable Care Act. It was a stroke of luck, opportunity meeting preparedness, that became my basis of knowledge and involvement on policy matters affecting people living with HIV and, in particular, transgender people. Soon after, joining South Florida AIDS Network and becoming half of a dynamic duo, Mr. Wynn saw an opportunity in me he regularly seeks out and fosters – the “next generation” of advocate.

You should know, he bit off more than he could chew.

“I’m gonna need you to watch your language,” – Brandon M. Macsata.

Six years later, deeply immersed in advocating for systemic changes in Florida and regularly offering commentary on legislative and regulatory policy changes aimed at demystifying the process for community members and reminding policy influencers of the need to focus on patient experiences, I had the distinct pleasure of being invited to join the board of directors for ADAP Advocacy Association. I’ve gained a reputation for being frank and sometimes profane in urging funders and influencers to remember the human nature of where HIV thrives and the programming needs to ensure patients thrive. “We’re never going to end any epidemic if we keep sanitizing our programming, our language, and ignoring or avoiding sex.” This is true even for ADAPs. Effective outreach and education of available assistance programs must also speak to the holistic experiences of patients.

“Promoting Access to Care Among Transgender Men and Women Living with HIV/AIDS” became the first major project I got to work on for the ADAP Advocacy Association. Teaming up with RAD Remedy, the white paper, infographic, and Twitter chat aimed to shift the conversation around treatment priorities for transgender people living with HIV. The project is something I’m still deeply proud of and have used in advocating for systemic change. Along with informing the Human rights Watch project “Living at Risk: Transgender Women, HIV, and Human Rights in South Florida”, Florida’s ADAP program recently added certain hormone replacement therapies to their formulary, recognizing that an effective program doesn’t seek to prioritize care for a patient, but empowers a patient to prioritize their own care – reducing barriers and increasing access.

“I’m glad you exist,” – Tiffany Stringer

Systems change begins with humanizing the very real experiences of frustration and sometimes impossible barriers people living with HIV face in seeking the care we need to survive. PLWH are more than our lab work but we rarely acknowledge that in policy success metrics. Essential to patient driven changes is an oft forgotten notion of empathy; not the concerted sigh and nod but the willingness to take a chance – a risk of investment.

I still find myself in awe anyone cares much what I think much less seeks out my opinion on matters. And yet, at state meetings and in planning, I get a great deal of “what do you think?” I like to think it’s because I’m stubborn and bold. There’s no harm in asking and if I get told “no”, I’m back in the same spot I was before asking. Pointing out needs to planning bodies in states with bans on syringe funding as we approach the age of injectables, the logistical needs for staffing, opportunities to extend education via lab hours (hopefully solving both needs in “one swoop”), and informing policy positions and goals by leveraging existing payment systems – all of this work is my passion because it serves as a reminder “the boat rises from the bottom”. Until those with the least means, the most affected, are safe and happy and healthy, all of us face the risk of losing. Our systems cannot be devoid of the humanity they seek to affect.

As much as my colleagues hound me about pursuing an advanced degree, I’ve refused. In a nation with a seemingly impossible student loan crisis on the horizon, why would I seek additional debt? Every ounce of payment systems education I have, from 340B to ADAPs to ACA implications and implementation, is self-taught; webinars, fact sheets, diligent reading and memorization of statute, ruling, and regulation, case studies, pilot projects, endless listening to committees. I’m a voracious reader with a talent to translate lawyered language and legalese into plain, digestible, applicable language – a necessary tool for community engagement and education. I stand on this position as a matter of principle as well as the well-studied fact most people learn the necessary skills for their employment on the job. In an environment of advocacy, where a need for diversity of thought matters, it is an issue of principle to demand that if an employer or potential contract wishes for me (or anyone) to have an advanced degree, they include that as part of the offered compensation. We’re never going to break the molds laid before us and reach our goals by training out different approaches to problem solving. Additionally, integration of lived experience and work experience matters in patient advocacy and in much of non-medical service provision. I will absolutely die on the hill that demands our funders and our advocacy and service organizations hire from affected community and stop demanding an unreasonable and unnecessary institutional educational background. Employment and housing are the core issues PLWH face as barriers to care. So take this recount of my history as a reminder, should you be a funder or in a position of hiring for an organization, that your greatest opportunity to take a risk and “win” is all around you.

As the US has plateaued in declining HIV transmission rates, as our own federal government has given a weak nod at “Ending the HIV Epidemic”, I’d like to take a moment for the agencies, funders, and influencers reading this:

Take risks. Read the room, if you will. Today’s environment, in the age of COVID, our work hasn’t stopped; to the contrary, it’s more important now than ever. But our organizations are also struggling now more than they have in years. As we face a mounting jobless and eviction crisis, our community and industry’s historical positions will be exacerbated.

So leap. Take a big jump and hire someone interesting you wouldn’t traditionally hire. Fund the idea or agency who submitted a rushed grant proposal. Find and fund contractors who have left aging agencies due to their refusal to adapt and modernize.

******************************************

I wanted to include some background as to how this profile came about and what I find important in my work.

Brandon tells me I’ve provided leadership on trans issues and advocated for meaningful, systemic changes in access to care, providing program and policy insights and analysis. He’s been asking me to write this profile 3 months. Never one to decline a writing opportunity, I had to ask myself why I avoided this one.

There’s likely a whole post-doctoral class to be written on trans guys who maintain cultural standards of survival cisgender women are acculturated to, from doubting the impact of one’s work to prefacing expertise with “I think”. And while there’s some of that mixed up in my hesitancy to talk about myself, there’s more and I think…know it’s important to share with the advocates reading this.

You matter more than you know. Your humility and reminder to remain empathetic and ethical is critical to ensuring PLWH drive our own determination. Your story matters and you need to make sure someone else isn’t telling it for you. You get to talk about the “by chance” moments without viewing your work as “less than”. We all got here by a series of chances – some great, some not so great – and a great deal of hard work. Touting your successes is something you’ve earned. And not sharing them isn’t an issue of humility. It’s doubting your value because in this world, if we struggle, we are taught to doubt the earned nature of our successes and fear the rug being pulled out from underneath us should be “brag too much.”

You don’t have to do that. You deserve and have earned your success. Brag a little.

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

ADAP Open Drug Formulary Programs Improve Access to Care & Treatment; So why are there so few?

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

Each State AIDS Drug Assistance Program ("ADAP") is unique in that "it decides which medications will be included in its drug formulary, and how those medications will be distributed to eligible consumers."[1] It clearly presents a conundrum between payers and consumers. Ask any payer of health benefits, and controlling costs is probably paramount to them. Ask any consumer of health benefits, and most important is the unrestricted access to all the supports, services and/or therapies that should be afforded to them. Therein is the divide between closed and open drug formulary programs, including ADAP.

(Editor's Note: This blog is not intended to be an endorsement of any product made by any pharmaceutical company but rather acknowledge the unique health needs experienced by people living with HIV/AIDS, as they attempt to access care and treatment that is appropriate, culturally competent, and timely)

Photo Source: COMP Blog

In March 2015, Managed Healthcare Executive published an article, Closed formularies hold the line on costs, which accurately summed up the challenges faced by health plans. Though health plans are quite different from State AIDS Drug Assistance Programs, in general, they nonetheless do share an important thing in common. They often employ cost containment strategies in an effort to not only control costs, but also ensure plan sustainability. It provides little comfort, however, for consumers living with chronic health conditions, such as HIV/AIDS, who require access to numerous drug therapies.

According to the National Alliance of State & Territorial AIDS Directors ("NASTAD"), only approximately one in five (1:5) ADAPs employ an open drug formulary program. The Online AIDS Drug Assistance Program Formulary Database (2018 version) reports the following states offer open drug formularies: Illinois, Iowa, Massachusetts, Minnesota, Nebraska, New Hampshire, New Jersey, Ohio, Oregon, and Washington State. Only Washington State reports no drug exclusions under its open drug formulary program.[2]

To be fair, ADAPs aren't unique in this area. ADAPs mirror private health plans (and many other public health plans) in that they have closed drug formularies. Yet, open drug formulary programs are advantageous to consumers because they provide additional coverage for medications. So why are there so few?

The Ryan White HIV/AIDS Treatment Extension Act of 2009 (Public Law 111-87) dictates that "each ADAP must cover at least one drug from each class of HIV antiretroviral medications ("ARVs") on their ADAP formulary. RWHAP funds may only be used to purchase FDA-approved medications."[3] Otherwise, State ADAPs are pretty much left to their own fruition on which ARVs to include on their formularies, as well as non-ARV medications to treat other conditions and medication side effects.

Eddie Hamilton, founder of the Ohio-based ADAP Educational Initiative, summarized his support for open drug formulary programs:

“One of the leading barriers to care is the lack of access to the non-ARV medications for various reasons, such as co-pays or non-covered medications. Open formularies enhance ARV regimen compliance as it enables people living with HIV/AIDS to deal with the various side effects and co-morbidities associated with HIV. While the Ryan White program covers mostly HIV related services, it is counter-intuitive to fix only one medical issue while leaving other potential life threatening medical issues that would be preventable on the table. One may have a undetectable viral load but succumb to a heart attack because of the lack of access to a statin!”

It is disheartening when people living with HIV/AIDS are denied access to numerous non-ARV medications, especially when the medications could treat a litany of other health-related conditions. Some of the conditions commonly identified by consumers are lipodystrophy, diarrhea, hormone therapy, and co-infection with Hepatitis C ("HCV").

For example, HIV-related lipodystrophy remains an important health issue confronted by consumers yet often it is characterized by payers as cosmetic. Research has shown that between 20% and 30% of HIV-positive patients are experiencing excess visceral adipose tissue ("VAT"). For years, there's been a common misconception that this belly fat is just a physical cosmetic issue that is a side effect of earlier HIV treatments — something that must be accepted as a reality of now living longer with HIV-infection. Recent research dispels that myth so that even with newer anti-retro viral regimens this condition continues to exist.

An ADAP Blog posted in late 2016 highlighted the success by Massachusetts in expanding treatment options for people living with HIV-associated lipodystrophy. The Treat Lipodystrophy Coalition fought tirelessly for the law to require insurance coverage for treatment of a debilitating and disfiguring side effect of HIV medications. Patients living with HIV-associated lipodystrophy are now demanding the same is done with public payers, such as ADAP and Medicaid.[4]

Photo Source: Treat Lipodystrophy Coalition

Carl Sciortino, executive director for the AIDS Action Committee, and former representative in the Massachusetts Legislature who introduced the aforementioned legislation, then summarized the effort to expand treatment access: "Some of our long-term survivors carrying the physical scars of earlier life-saving treatments have been denied the dignity and medical treatment they are entitled to for far too long. Lipodystrophy affects our veterans, and as a country we have effectively turned our backs on their need to treat their epidemic-inflicted wounds. I'm proud of our step forward in providing insurance coverage in Massachusetts, and I'm grateful for any interest it sparks in providing care to people living with HIV across the country."[5]

Tesamorelin (common brand name: Egrifta) is the only FDA-approved therapy to combat HIV-related lipodystrophy. Yet, as of December 31, 2017, only 11 ADAPs reported that they do include Tesamorelin on their drug formularies, including: Colorado, District of Columbia, Illinois, Louisiana, Massachusetts, New Hampshire, New Jersey, North Carolina, North Dakota, South Carolina, and Washington. Thanks to the ADAP Crisis Task Force, that soon could be changing after a discounted drug pricing agreement for ADAPs was reached with the drug's manufacturer.

One of the most common side effects causing angst for people living with HIV/AIDS is diarrhea. It is a widely held opinion that HIV-related diarrhea is a thing of the past with the advent of the newer ARVs. The "runs" impact long-term survivors quite often, according to a patient survey released in December 2017.[6]

Josh Robbins, Founder of the HIV Scoop, isn't known for being shy, and as such he become a vocal spokesman on how this common HIV-related side effect personally impacted his life. His advocacy on the issue has given hope to others like him. Robbins characterized the struggle as follows:

“Before I found the drug to help normalize my gastro issues related to living with HIV, I was at a crossroads with HIV treatment. Everyone preached the importance of adherence to ARVs and staying in care, but I was exhausted of the process because of diarrhea and me not finding relief from it or support medically. When I saw the information on the drug, I knew I wanted to give it a try. What could I lose as I tried everything else? After starting it, there wasn’t a magic moment that I knew it was working for me—but I did notice that I didn’t dread taking my ARVs anymore and I stopped missing doses because they made me feel bloated and the diarrhea was brutal. All of that slowed down to where I don’t even think about it anymore. Can I give all the credit to this drug? Maybe not, but I can say that I finally feel normal in my stomach, I don’t spend tons of time in the bathroom anymore, and I’m finally adherent to my HIV meds. At least for me, this drug makes my journey living undetectable possible, because it normalized my gastro issues. So, yea, this drug changed my journey living with HIV.”

The medication in reference is Mytesi. Unfortunately, currently only 22 State ADAP drug formulary programs cover Mytesi, and as such people living with HIV/AIDS suffering from diarrhea are forced to rely on less potent over-the-counter therapies. These therapies often provide little or no relief. Once again, thanks to the ADAP Crisis Task Force, that soon could be changing after a discounted drug pricing agreement for ADAPs was reached with the drug's manufacturer.[7]

Evidence suggests that HIV-infections disproportionately impact the transgender communities.[8] In its recent issue brief on transgender health, NASTAD acknowledged the need to adopt a holistic approach to providing health services to this underserved population. The issue brief reads, in part, "...it is imperative that ADAPs ensure that their interventions are informed by a robust understanding of the unique personal, societal, and structural barriers that impede access to care and treatment for transgender people."[9]

The Centers for Disease Control & Prevention (CDC) has documented the unique needs set facing the transgender communities in the United States. CDC data suggests there is a need for gender-variant, culturally competent awareness and guidelines designed to better serve this underserved community enrolled in public health programs, as well as those persons eligible, but not enrolled (including ADAP).[10]

The CDC concluded, “Insensitivity to transgender identity can be a barrier for those who are diagnosed with HIV and seek quality treatment and care services. Research shows transgender women with diagnosed HIV infection are less likely to be on antiretroviral therapy (ART) or achieve viral suppression. Furthermore, few health care providers receive adequate training or are knowledgeable about transgender health issues and their unique needs.”[11]

Furthermore, NASTAD echoed this concern in its issue brief, making a compelling case for open drug formulary programs that are more liberalized to serve transgender consumers: "ADAP formulary composition presents another opportunity to promote trans- inclusive care and treatment. Beyond the provision of ARVs, ADAPs play a critical role in supporting the availability of medications for many co-occurring needs of PLWH, including transgender transition-related medications."[12]

As of December 31, 2015, unfortunately only 16 ADAPs covered one or more FDA-approved transgender transition-related medications on their formulary.[13]

According to Marcus J. Hopkins, Project Director of the Community Access National Network's HIV/HCV Co-Infection Watch, there are 43 State ADAPs offering some form of coverage for HCV treatment. Of those programs, 36 have expanded their HCV coverage to include the regimens that serve as the current Standard of Care (SOC) for Hepatitis C treatment. Eight (8) programs offer only Basic Coverage and 13 programs offer No Coverage. Three (3) territories – American Samoa, Marshall Islands, and Northern Mariana Islands – are not accounted for in this data.

HCV is a common co-infection in people with HIV/AIDS. An estimated 200,000-300,000 people in the United States are co-infected with both HIV and HCV infections. Experts believe that about 25% of Americans with HIV also have HCV; conversely some 10% of people with HCV are thought to also have HIV.

In most states, people living with HIV/AIDS are well served by their ADAP but that doesn't mean consumers should settle on the status quo. According to Jen Laws, an independent policy consultant and an ADAP Advocacy Association board member, expanding the efficacy of the State AIDS Drug Assistance Programs requires both modernization in systems and expansive formularies to meet the health needs of target populations; from heart disease and diabetes to gender confirming hormone replacement therapies, ADAPs can help us close the gaps in care clients face else where and realize the true potential of the programs in working to end HIV.

Laws argued, "Today, we understand comprehensive approaches to chronic health needs result in greater client adherence and positive overall health outcomes, directly impacting efficacy of HIV specific treatment. We know meeting target population health needs is a necessary step in combating the epidemic, especially in an environment where these same populations are unlikely to get their health needs met in traditional markets. In the age of treatment as prevention, ADAPs have a unique opportunity to function at the corner of both prevention and patient care."

Related articles of potential interest:

• Don't Take VAT, sponsored by Theratechnologies
• Keep Your Pants On, sponsored by Napo Pharmaceuticals
• Talking to your Doctor About Symptoms, online survey of patients living with HIV conducted Oct 25-Nov 6, 2017, sponsored by Napo Pharmaceuticals
• TRANSGENDER HEALTH: Improving Access to Care Among Transgender Men & Women Living with HIV/AIDS under the AIDS Drug Assistance Program: Model Policy for Ryan White/ADAPs Serving Transgender Clients, published in April 2017 by the ADAP Advocacy Association
• INFOGRAPHIC: Improving Access to Care Among Transgender Men & Women Living with HIV/AIDS under the AIDS Drug Assistance Program, published in April 2017 by the ADAP Advocacy Association
• CROSSROADS: ADAP CONSIDERATIONS FOR TRANSGENDER HEALTH, published in August 2016 by the National Alliance of State & Territorial AIDS Directors
• HIV/HCV Co-Infection Watch – March 2018, published in March 2018 by the Community Access National Network

__________

[1] Health Resources & Services Administration (2017, October). Part B: AIDS Drug Assistance Program. U.S. Department of Health & Human Services. Retrieved from https://hab.hrsa.gov/about-ryan-white-hivaids-program/part-b-aids-drug-assistance-program.
[2] National Alliance of State & Territorial AIDS Directors (2018, February 1); 2018 ADAP Formulary Database; National Alliance of State & Territorial AIDS Directors (NASTAD). Retrieved from https://www.nastad.org/adap-formulary-database.
[3] Health Resources & Services Administration (2017, October). Part B: AIDS Drug Assistance Program. U.S. Department of Health & Human Services. Retrieved from https://hab.hrsa.gov/about-ryan-white-hivaids-program/part-b-aids-drug-assistance-program.
[4] Macsata, Brandon M. (2016, October 28). ADAP Blog. Why HIV Medical Treatment Guidelines Matter. ADAP Advocacy Association. Retrieved from http://adapadvocacyassociation.blogspot.com/2016/10/why-hiv-medical-treatment-guidelines.html.
[5] Macsata, Brandon M. (2016, October 28). ADAP Blog. Why HIV Medical Treatment Guidelines Matter. ADAP Advocacy Association. Retrieved from http://adapadvocacyassociation.blogspot.com/2016/10/why-hiv-medical-treatment-guidelines.html.
[6] Yahoo Finance (2017, December 12). HIV With Diarrhea Often Suffer in Silence. Business Wire. Retrieved from https://finance.yahoo.com/news/survey-finds-people-living-hiv-140000800.html.
[7] Yahoo Finance (2017, April 10). Jaguar Subsidiary Napo Pharmaceuticals Signs Agreement with the ADAP Crisis Task Force for Mytesi. Business Wire. Retrieved from https://finance.yahoo.com/news/jaguar-subsidiary-napo-pharmaceuticals-signs-130000636.html.
[8] U.S. Centers for Disease Control and Prevention (2016, April 18). HIV Among Transgender People. Retrieved from http://www.thebody.com/content/63509/hiv-among-transgender-people.html?ap=1200.
[9] Pund, Britten, Et al. (2016, August). CROSSROADS: ADAP CONSIDERATIONS FOR TRANSGENDER HEALTH. National Alliance of State & Territorial AIDS Directors. Retrieved from https://www.nastad.org/sites/default/files/Crossroads-Trans-Health.pdf.
[10] U.S. Centers for Disease Control and Prevention (2016, April 18). HIV Among Transgender People. Retrieved from http://www.thebody.com/content/63509/hiv-among-transgender-people.html?ap=1200.
[11] U.S. Centers for Disease Control and Prevention (2016, April 18). HIV Among Transgender People. Retrieved from http://www.thebody.com/content/63509/hiv-among-transgender-people.html?ap=1200.
[12] Pund, Britten, Et al. (2016, August). CROSSROADS: ADAP CONSIDERATIONS FOR TRANSGENDER HEALTH. National Alliance of State & Territorial AIDS Directors. Retrieved from https://www.nastad.org/sites/default/files/Crossroads-Trans-Health.pdf.
[13] Pund, Britten, Et al. (2016, August). CROSSROADS: ADAP CONSIDERATIONS FOR TRANSGENDER HEALTH. National Alliance of State & Territorial AIDS Directors. Retrieved from https://www.nastad.org/sites/default/files/Crossroads-Trans-Health.pdf.