Characterizing the HIV Prevention and Care Continua in a Sample of Transgender Youth in the U.S

Characterizing Disparities in the HIV Care Continuum among Transgender and Cisgender Medicare Beneficiaries

Background

In the US, transgender and gender-diverse (TGD) individuals, particularly trans feminine individuals, experience a disproportionately high burden of HIV relative to their cisgender counterparts. While engagement in the HIV Care Continuum (e.g., HIV care visits, antiretroviral (ART) prescribed, ART adherence) is essential to reduce viral load, HIV transmission, and related morbidity, the extent to which TGD people engage in one or more steps of the HIV Care Continuum at similar levels as cisgender people is understudied on a national level and by gendered subgroups.

Methods and Findings

We used Medicare Fee-for-Service claims data from 2009 to 2017 to identify TGD (trans feminine and non-binary (TFN), trans masculine and non-binary (TMN), unclassified gender) and cisgender (male, female) beneficiaries with HIV. Using a retrospective cross-sectional design, we explored within- and between-gender group differences in the predicted probability (PP) of engaging in one or more steps of the HIV Care Continuum. TGD individuals had a higher predicted probability of every HIV Care Continuum outcome compared to cisgender individuals [HIV Care Visits: TGD PP=0.22, 95% Confidence Intervals (CI)=0.22-0.24; cisgender PP=0.21, 95% CI=0.21-0.22); Sexually Transmitted Infection (STI) Screening (TGD PP=0.12, 95% CI=0.11-0.12; cisgender PP=0.09, 95% CI=0.09-0.10); ART Prescribed (TGD PP=0.61, 95% CI=0.59-0.63; cisgender PP=0.52, 95% CI=0.52-0.54); and ART Persistence or adherence (90% persistence: TGD PP=0.27, 95% CI=0.25-0.28; 95% persistence: TGD PP=0.13, 95% CI=0.12-0.14; 90% persistence: cisgender PP=0.23, 95% CI=0.22-0.23; 95% persistence: cisgender PP=0.11, 95% CI=0.11-0.12)]. Notably, TFN individuals had the highest probability of every outcome (HIV Care Visits PP =0.25, 95% CI=0.24-0.27; STI Screening PP =0.22, 95% CI=0.21-0.24; ART Prescribed PP=0.71, 95% CI=0.69-0.74; 90% ART Persistence PP=0.30, 95% CI=0.28-0.32; 95% ART Persistence PP=0.15, 95% CI=0.14-0.16) and TMN people or cisgender females had the lowest probability of every outcome (HIV Care Visits: TMN PP =0.18, 95% CI=0.14-0.22; STI Screening: Cisgender Female PP =0.11, 95% CI=0.11-0.12; ART Receipt: Cisgender Female PP=0.40, 95% CI=0.39-0.42; 90% ART Persistence: TMN PP=0.15, 95% CI=0.11-0.20; 95% ART Persistence: TMN PP=0.07, 95% CI=0.04-0.10). The main limitation of this research is that TGD and cisgender beneficiaries were included based on their observed care, whereas individuals who did not access relevant care through Fee-for-Service Medicare at any point during the study period were not included. Thus, our findings may not be generalizable to all TGD and cisgender individuals with HIV, including those with Medicare Advantage or other types of insurance.

Conclusions

Although TGD beneficiaries living with HIV had superior engagement in the HIV Care Continuum than cisgender individuals, findings highlight notable disparities in engagement for TMN individuals and cisgender females, and engagement was still low for all Medicare beneficiaries, independent of gender. Interventions are needed to reduce barriers to HIV care engagement for all Medicare beneficiaries to improve treatment outcomes and reduce HIV-related morbidity and mortality in the US.

Latent class analysis of substance use typologies associated with mental and sexual health outcomes among sexual and gender minority youth

Little is known about sexual and gender minority youth (SGMY) who have sex with men's unique patterns of substance use, even though they are at risk for substance use and adverse mental and other health outcomes. We used latent class analysis to examine typologies of substance use and multinomial logistic regression to investigate mental health outcomes (depression and anxiety) and HIV/STI testing correlates associated with different classes of substance use in a sample of SGMY who have sex with men in the USA and use substances (n = 414) who participated in an online survey. The average age was 22.50 years old (SD = 3.22). A four-class solution was identified representing: 'depressant and stimulant use' (3.4%), 'high polysubstance use' (4.6%), 'low substance use with moderate cannabis use' (79.2%), and 'high cannabis, stimulant and alcohol use' (12.8%). Membership to a specified substance use class varied by age, previous arrest, gender identity, anxiety, and lifetime HIV testing. Multivariate logistic regression results indicated that participants in the high polysubstance use (AOR = 5.48, 95% CI 1.51, 19.97) and high cannabis use class (AOR = 3.87, 95% CI 1.25, 11.94) were significantly more likely than those in the low substance use with moderate cannabis use class to report previous arrest. Those in the high polysubstance use class were also significantly less likely to have been tested for HIV than those in the low substance use with moderate cannabis use class (AOR = 0.21, 95% CI 0.05, 0.93). Findings will guide the development and implementation of tailored approaches to addressing the intersection of substance use and HIV risk among SGMY.

Stigma, Discrimination, and Mental Health Outcomes Among Transgender Women With Diagnosed HIV Infection in the United States, 2015-2018

OBJECTIVE

Transgender women with diagnosed HIV experience social and structural factors that could negatively affect their overall health and HIV-related health outcomes. We describe estimates from the Centers for Disease Control and Prevention Medical Monitoring Project (MMP) of sociodemographic characteristics, HIV stigma, discrimination, and mental health outcomes among transgender women with diagnosed HIV.

METHODS

We analyzed pooled data of all transgender women with diagnosed HIV (N = 217) from the 2015 through 2018 MMP cycles. We reported unweighted frequencies, weighted percentages, and 95% CIs for all characteristics. We post-stratified data to known population totals by age, race and ethnicity, and sex at birth from the National HIV Surveillance System.

RESULTS

Approximately 46% of transgender women with diagnosed HIV identified as Black or African American, 67% lived at or below the federal poverty level, 18% had experienced homelessness in the past year, 26% experienced mild to severe symptoms of depression, 30% experienced mild to severe anxiety symptoms, 32% reported physical violence by an intimate partner, and 30% reported forced sex during their lifetime. Despite 80% being very satisfied with their current HIV care, 94% experienced current HIV stigma and 20% experienced health care-related discrimination since being diagnosed with HIV. Among transgender women with diagnosed HIV who experienced discrimination, 46% and 51% experienced health care discrimination attributed to their gender and sexual orientation or sexual practices, respectively.

CONCLUSIONS

Our findings underscore a need to address unmet ancillary services, such as housing, intimate partner violence, and mental health needs, and the need for strategies to reduce experiences with HIV stigma and discrimination in care for transgender women with diagnosed HIV in the United States.

Intersectional stigma and gender non-affirmation hinder HIV care engagement among transgender women living with HIV in India

Among transgender women living with HIV (TGWLH) in India, little is understood about the mechanisms through which multiple intersecting stigmas impact HIV care engagement, or intervention strategies that might mitigate this impact. We conducted focus groups with TGWLH (N = 30) in three Indian cities and analysed data using theoretical frameworks related to HIV stigma, gender affirmation, and syndemics. Findings revealed that enacted and anticipated stigma due to transgender identity, HIV, or sex work status, and lack of gender affirmation (e.g., misgendering) in healthcare settings delayed ART initiation and promoted care disengagement. Having supportive physicians and counsellors within ART centres and peer outreach workers facilitated ART initiation, adherence, and retention. Findings also revealed that HIV stigma within TGW communities led to concealment of HIV status or syndemic conditions such as depression and alcohol use, thereby affecting care engagement. However, the TGW community itself was also described as a resilience resource, offering emotional, psychological and tangible support that decreased the impact of discrimination on care engagement. HIV care engagement efforts among Indian TGWLH could be strengthened by reducing intersecting stigmas in healthcare settings and within TGW communities, providing gender-affirming and culturally competent healthcare, addressing psychosocial syndemic conditions, and strengthening support within transgender communities.

Structural Equation Modeling of Stigma and HIV Prevention Clinical Services Among Transgender and Gender Diverse Adults: The Mediating Role of Substance Use and HIV Sexual Risk

BACKGROUND

Transgender and gender diverse (TGD) adults experience high levels of stigma that contributes to elevated substance use and HIV sexual risk behaviors. Despite higher burdens of substance use and HIV compared to cisgender adults, TGD individuals may be less likely to engage in health care to avoid further discrimination.

SETTING

This analysis included 529 TGD adults in Massachusetts and Rhode Island who were HIV negative or had an unknown HIV serostatus and were purposively sampled between March and August 2019.

METHODS

We used structural equation modeling to test whether substance use, HIV sexual risk behaviors (ie, condom use, sex work, and multiple partners), and receiving gender-affirming hormone therapy mediate any observed association between TGD-related stigma and utilization of HIV prevention clinical services (ie, HIV prevention programs, PrEP use, and HIV testing).

RESULTS

Substance use and HIV sexual risk mediated the relationship between TGD-related stigma and utilization of HIV prevention clinical services (β = 0.08; 95% CI = 0.05, 0.17; P = 0.03 and β = 0.26; 95% CI = 0.14 to 0.37; P < 0.001). Having a hormone therapy prescription was not a mediator between TGD-related stigma and HIV prevention clinical services.

CONCLUSIONS

Future interventions that aim to improve HIV prevention clinical services among TGD adults should consider the impact of TGD-related stigma on participants' substance use and sexual risk behaviors. These efforts require that health care organizations and community organizations make a deliberate investment in the reach and success of interventions and programs.

Use of Stated Preference Methods in HIV Treatment and Prevention Research in the United States: A Systematic Review

Stated preference (SP) methods are increasingly being applied to HIV-related research and continuously provide researchers with health utility scores of select healthcare products or services that populations consider important. Following PRISMA guidelines, we sought to understand how SP methods have been applied in HIV-related research. We conducted a systematic review to identify studies meeting the following criteria: SP method is clearly stated, conducted in the United States, was published between 01/01/2012 and 02/12/2022, and included adults aged 18 and over. Study design and SP method application were also examined. We identified six SP methods (e.g., Conjoint Analysis, Discrete Choice Experiment) across 18 studies, which were categorized into one of two groups: HIV prevention and HIV treatment-care. Categories of attributes used in SP methods largely focused on: administration, physical/health effects, financial, location, access, and external influences. SP methods are innovative tools capable of informing researchers on what populations consider most beneficial when deciding on treatment, care, or prevention options for HIV.

Information, Motivation, Behavioral Skills Model in Youth Newly Starting Antiretroviral Treatment

An understanding of adherence among youth newly starting antiretroviral therapy (ART) is critical but understudied. The information-motivation-behavioral skills (IMB) model is often used to understand health behaviors, but has rarely been studied in youth with HIV. In a multi-site sample of 153 youth newly starting ART, structural equation modeling was utilized to test this model. The model was generally supported with information and behavioral skills directly related to the decision to adhere, while motivation was indirectly related through behavioral skills. Results suggest that interventions focusing on improving IMB constructs for medication adherence are important for preventing non-adherence in youth newly starting ART.

Barriers to uptake of PrEP across the continuum among transgender women: A global scoping review

BACKGROUND

Although preexposure prophylaxis (PrEP) has demonstrated high efficacy for HIV prevention, rates of PrEP uptake remain low among the transgender population, especially in transgender women (TGW). We conducted this scoping review to assess and characterize barriers to PrEP use along the PrEP care continuum among TGW.

METHODS

We conducted this scoping review by searching studies in Embase, PubMed, Scopus, and Web of Science. Eligibility criteria included: reporting a PrEP related quantitative result among TGW; peer-reviewed and published in English between 2010-2021.

RESULTS

Globally, high willingness (80%) to use PrEP was found, yet uptake and adherence (35.4%) were low. TGW experiencing hardship, including poverty, incarceration, and substance use, were associated with higher odds of PrEP awareness but lower odds of PrEP use. Structural and social barriers such as stigma, medical mistrust, and perceived racism can be important barriers for PrEP continuation. High social cohesion and hormone replacement therapy were associated with greater odds of awareness. In addition, our study confirmed prior research showing that PrEP does not lower feminizing hormone levels in TGW.

CONCLUSIONS

Significant demographic factors among TGW that are associated with PrEP engagement. It is imperative to focus on TGW as a population with independent needs, requiring specific PrEP care guidelines and tailored resource allocation, that fully considers individual-, provider-, and community/structural-level barriers and facilitators. The present review also indicates that combining PrEP care with GAHT or broader gender-affirmation care may facilitate PrEP use.

HIV Care Continuum Interventions for Transgender Women: A Topical Review

Transgender women experience a disproportionate prevalence of HIV and barriers to linkage to care, retention in care, medication adherence, and viral suppression. As part of a national cooperative agreement funded by the Health Resources and Services Administration's HIV/AIDS Bureau, we searched the literature from January 1, 2010, through June 1, 2020, for English-language articles on interventions designed to improve at least 1 HIV care continuum outcome or address 1 barrier to achieving HIV care continuum outcomes among transgender women diagnosed with HIV in the United States. To be included, articles needed to identify transgender women as a priority population for the intervention. We found 22 interventions, of which 15 reported quantitative or qualitative outcomes and 7 reported study protocols. Recent interventions have incorporated a range of strategies that show promise for addressing pervasive structural and individual barriers rooted in societal and cultural stigma and discrimination against transgender people. Cross-cutting themes found among the interventions included meaningful community participation in the design and implementation of the interventions; culturally affirming programs that serve as a gateway to HIV care and combine gender-affirming care and social services with HIV care; interventions to improve behavioral health outcomes; peer-led counseling, education, and navigation; and technology-based interventions to increase access to care management and online social support. Ongoing studies will further elucidate the efficacy and effectiveness of these interventions, with the goal of reducing disparities in the HIV care continuum and bringing us closer to ending the HIV epidemic among transgender women in the United States.

A scoping review of youth advisory structures in the United States: Applications, outcomes, and best practices

Although youth advisory structures (YASs) have proliferated internationally to facilitate the voice of young people, little is known about the practices of such groups, especially in the United States. To address this gap of knowledge, this study describes the findings of a scoping review of scholarly research on YAS in the United States. The review found that although the use of YAS is increasing, current scholarship offers little information about YAS processes or how youth are engaged. Most YAS in the review partnered with marginalized young people to inform research and programming around sensitive health topics, such as human immunodeficiency virus prevention. Youth who participated in YAS experienced positive outcomes such as leadership and skill development, healthier decision-making, and confidence. Although most studies involved youth in minimal ways, there is a growing body of literature where youth are engaged in long-term partnerships that support positive youth development. This review details other key characteristics of YAS and provides recommendations for best practices, such as building consensus around terms used to refer to YAS and promoting the dissemination of process details around YAS facilitation.

Using the Positive Peers Mobile App to Improve Clinical Outcomes for Young People With HIV: Prospective Observational Cohort Comparison

BACKGROUND

Disparities in HIV outcomes persist among racial, gender, and sexual minorities in the United States. Younger people face a greater risk of contracting HIV, often living without knowledge of their HIV status for long periods. The Positive Peers App (PPA) is a multifunctional HIV support tool designed to improve HIV-related clinical outcomes for young people with HIV. The app was designed according to the specifications of an in-care young adult HIV community in Northeast Ohio. Data provided in this study provide preliminary evidence of the usefulness of PPA as a relevant tool for engaging this clinical patient population in care and facilitating viral suppression.

OBJECTIVE

In this study, we aimed to describe variations in PPA use and examine the associations between use and HIV clinical outcomes between self-selected user and nonuser cohorts in the same clinical population.

METHODS

The PPA was offered free of charge to persons with HIV, aged 13 to 34 years of age, diagnosed with HIV within the last 12 months, out of care for 6 months during the last 24 months, or not virally suppressed (HIV viral load >200 copies/mL) in the prior 24 months. Baseline and 6- and 12-month surveys were administered via an audio computer-assisted self-interviewing system to all participants. The app's user activity was tracked natively by the app and stored in a secure server. Participant demographic and HIV care data were extracted from clinical records within 12 months before the start of the study and across the duration of the study period. HIV care outcomes of PPA users (n=114) were compared with those of nonusers (n=145) at the end of the study period (n=259).

RESULTS

The analysis showed that younger PPA users (aged 13-24 years) were more likely to obtain HIV laboratories (adjusted odds ratio 2.85, 95% CI 1.03-7.90) and achieve sustained viral suppression than nonusers (adjusted odds ratio 4.2, 95% CI 1.2-13.9).

CONCLUSIONS

The PPA appears to help younger users sustain HIV suppression. The app offers an important tool for addressing this critical population. The PPA remains in the field and is currently being adopted by other localities to facilitate their efforts to end the HIV epidemic. Although our reported observational results require additional validation and stringent ongoing surveillance, the results represent our best efforts in a pilot study to provide a measure of efficacy for the PPA. Next steps include a large-scale evaluation of the PPA acceptability and effectiveness. Given the building evidence of user reports and outcomes, the freely available PPA could be a helpful tool for achieving Ending the HIV Epidemic goals.

A qualitative study of how stigma influences HIV services for transgender men and women in Nigeria

INTRODUCTION

Transgender men and women in Nigeria experience many barriers in accessing HIV prevention and treatment services, particularly given the environment of transphobia (including harassment, violence and discrimination) and punitive laws in the country. HIV epidemic control in Nigeria requires improving access to and quality of HIV services for key populations at high risk, including transgender men and women. We assessed how stigma influences HIV services for transgender people in Lagos, Nigeria.

METHODS

In-depth interviews (IDIs) and focus group discussions were conducted with transgender men (n = 13) and transgender women (n = 25); IDIs were conducted with community service organization (CSO) staff (n = 8) and healthcare providers from CSO clinics and public health facilities (n = 10) working with the transgender population in March 2021 in Lagos. Content analysis was used to identify how stigma influences transgender people's experiences with HIV services.

RESULTS AND DISCUSSION

Three main findings emerged. First, gender identity disclosure is challenging due to anticipated stigma experienced by transgender persons and fear of legal repercussions. Fear of being turned in to authorities was a major barrier to disclose to providers in facilities not affiliated with a transgender-inclusive clinic. Providers also reported difficulty in eliciting information about the client's gender identity. Second, respondents reported lack of sensitivity among providers about gender identity and conflation of transgender men with lesbian women and transgender women with being gay or men who have sex with men, the latter being more of a common occurrence. Transgender participants also reported feeling disrespected when providers were not sensitive to their pronoun of preference. Third, HIV services that are not transgender-inclusive and gender-affirming can reinforce stigma. Both transgender men and women spoke about experiencing stigma and being refused HIV services, especially in mainstream public health facilities, as opposed to transgender-inclusive CSO clinics.

CONCLUSIONS

This study highlights how stigma impedes access to appropriate HIV services for transgender men and women, which can have a negative impact along the HIV care continuum. There is a need for transgender-inclusive HIV services and competency trainings for healthcare providers so that transgender clients can receive appropriate and gender-affirming HIV services.

Barriers and Facilitators to HIV Pre-Exposure Prophylaxis Uptake, Adherence, and Persistence Among Transgender Populations in the United States: A Systematic Review

HIV pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV; however, PrEP use among transgender individuals remains low. We conducted a systematic review to identify barriers and facilitators to PrEP uptake, adherence, and persistence among transgender individuals in the United States. We conducted a literature search in PubMed and CINAHL databases in March 2021 and followed PRISMA guidelines. Studies were eligible if they were published in a peer-reviewed journal and reported interest, uptake, adherence, and/or persistence of PrEP use among transgender individuals. Articles that did not disaggregate results for transgender participants were excluded. Data from included articles were coded using content analysis and narratively synthesized using a framework matrix. We screened 254 unique articles published after US Food and Drug Administration approval of PrEP, and 33 articles were included in the review. Five themes were identified in the literature, including (1) PrEP concentrations were lower among individuals taking feminizing hormones, but the difference did not appear clinically significant; (2) concerns regarding interactions between gender-affirming hormone therapy and PrEP remain a large barrier; (3) PrEP initiation may facilitate increased self-advocacy and self-acceptance; (4) lack of trust in medical institutions impacts PrEP uptake; and (5) social networks have a significant influence on PrEP knowledge, interest, and adherence. Additional research is needed involving transgender men and nonbinary persons, and efforts to improve PrEP persistence among the transgender community are needed. Training health care providers to provide inclusive and affirming care is perhaps one of the strongest areas for intervention to increase PrEP uptake and persistence.

Prevention-effective adherence trajectories among transgender women indicated for PrEP in the United States: a prospective cohort study

PURPOSE

Adherence to pre-exposure prophylaxis (PrEP) during periods of PrEP-indication (i.e., prevention-effective adherence) is critical for preventing HIV. We sought to describe factors associated with prevention-effective adherence trajectories among transgender women (TW) to inform PrEP implementation strategies.

METHODS

Using data from The LITE American Cohort (n = 728), we performed group-based multi-trajectory modeling (GBMTM) to identify clusters of TW with similar trajectories of PrEP adherence and indication, and sociodemographic, biobehavioral, and structural correlates of each trajectory.

RESULTS

We identified five trajectories: (1) consistent indication/no PrEP (15.3%), (2) initial indication/no PrEP (47.1%), (3) declining indication/discontinued PrEP (9.5%), (4) consistent indication/PrEP adherent (18.5%), and (5) increasing indication/initiated PrEP (9.6%). TW diagnosed with an STI were more likely to follow a consistent indication/no PrEP trajectory compared to consistent indication/PrEP adherent trajectory (adjusted Relative Risk Ratio [aRRR], 2.54; 95% confidence interval [CI], 1.16-5.57). TW who experienced homelessness were more likely to follow PrEP discontinuation and initiation trajectories relative to PrEP adherence (aRRR, 2.71; 95% CI, 1.10-6.70 and 2.83; 95% CI, 1.13-7.05, respectively).

CONCLUSIONS

Over a quarter of TW followed trajectories suggestive of prevention-effective adherence, while 15% did not initiate PrEP despite consistent indication. Findings highlight missed opportunities for PrEP engagement at STI diagnosis and suggest structural interventions addressing housing instability may improve prevention-effective adherence among TW.

HIV care outcomes among transgender persons with HIV infection in the United States, 2006-2021

OBJECTIVES

HIV prevalence is an estimated 14% among transgender women (TW) and 3% among transgender men (TM). HIV care is vital for viral suppression but is hindered by transphobia and HIV stigma. We assessed HIV care outcomes among transgender persons (TG) with HIV in the United States.

DESIGN

Systematic review and meta-analysis of peer-reviewed journal articles.

METHODS

We searched multiple electronic databases and Centers for Disease Control and Prevention's HIV Prevention Research Synthesis database for 2006-September 2020. Eligible reports were US-based studies that included TG and reported HIV care outcomes. Random-effects models were used to calculate HIV care outcome rates. The protocol is registered with PROSPERO (CRD42018079564).

RESULTS

Few studies reported outcomes for TM; therefore, only TW meta-analysis results are reported. Fifty studies were identified having low-to-medium risk-of-bias scores. Among TW with HIV, 82% had ever received HIV care; 72% were receiving care, and 83% of those were retained in HIV care. Sixty-two percent were currently virally suppressed. Among those receiving HIV care or antiretroviral therapy (ART), 67% were virally suppressed at last test. Sixty-five percent were linked to HIV care 3 months or less after diagnosis. Seventy-one percent had ever been prescribed ART. Approximately 66% were taking ART, and 66% were ART-adherent. Only 56% were currently adherent the previous year.

CONCLUSIONS

HIV care outcomes for TW were not ideal, and research gaps exists for TM. High heterogeneity was observed; therefore, caution should be taken interpreting the findings. Integrating transgender-specific health needs are needed to improve outcomes of transgender persons across the HIV care continuum.

A retrospective study of HIV pre-exposure prophylaxis counselling among non-Hispanic Black youth diagnosed with bacterial sexually transmitted infections in the United States, 2014-2019

INTRODUCTION

Youth account for a disproportionate number of new HIV infections; however, pre-exposure prophylaxis (PrEP) use is limited. We evaluated PrEP counselling rates among non-Hispanic Black youth in the United States after a bacterial sexually transmitted infection (STI) diagnosis.

METHODS

We conducted a retrospective cohort study of Black youth receiving care at two academically affiliated clinics in Philadelphia between June 2014 and June 2019. We compared PrEP counselling for youth who received primary care services versus those who did not receive primary care services, all of whom met PrEP eligibility criteria due to STI diagnosis per U.S. Centers for Disease Control and Prevention clinical practice guidelines. Two logistic regression models for receipt of PrEP counselling were fit: Model 1 focused on sexual and gender minority (SGM) status and Model 2 on rectal STIs with both models adjusted for patient- and healthcare-level factors.

RESULTS

Four hundred and sixteen patients met PrEP eligibility criteria due to STI based on sex assigned at birth and sexual partners. Thirty patients (7%) had documentation of PrEP counselling. Receipt of primary care services was not significantly associated with receipt of PrEP counselling in either Model 1 (adjusted OR (aOR) 0.10 [95% CI 0.01, 0.99]) or Model 2 (aOR 0.52 [95% CI 0.10, 2.77]). Receipt of PrEP counselling was significantly associated with later calendar years of STI diagnosis (aOR 6.80 [95% CI 1.64, 29.3]), assigned male sex at birth (aOR 26.2 [95% CI 3.46, 198]) and SGM identity (aOR 317 [95% CI 39.9, 2521]) in Model 1 and later calendar years of diagnosis (aOR 3.46 [95% CI 1.25, 9.58]), assigned male sex at birth (aOR 18.6 [95% CI 3.88, 89.3]) and rectal STI diagnosis (aOR 28.0 [95% CI 8.07, 97.5]) in Model 2. Fourteen patients (3%) started PrEP during the observation period; 12/14 (86%) were SGM primary care patients assigned male sex at birth.

CONCLUSIONS

PrEP counselling and uptake among U.S. non-Hispanic Black youth remain disproportionately low despite recent STI diagnosis. These findings support the need for robust investment in PrEP-inclusive sexual health services that are widely implemented and culturally tailored to Black youth, particularly cisgender heterosexual females.

Gender Affirmation as a Source of Resilience for Addressing Stigmatizing Healthcare Experiences of Transgender Youth of Color

BACKGROUND

Transgender and other gender diverse (TGD) youth of color experience stigma within healthcare. Gender affirmation can be a resilience resource; however, little is known about gender affirmation within healthcare.

PURPOSE

This study explores TGD youth of color's experiences of stigma and gender affirmation across the entire healthcare experience and their role on motivation to seek care.

METHODS

In 2015, cross-sectional surveys and individual in-depth interviews were conducted among 187 TGD youth ages 16-24 living in 14 U.S. cities. Analyses followed a mixed-methods design whereby 33 participants were purposively selected for a qualitative phenomenological analysis based on quantitatively reported gender affirmation needs. Subsequent quantitative analyses examined how healthcare use differed by access to gender affirmation.

RESULTS

Participants qualitatively described experiencing stigma across multiple healthcare settings (e.g., primary care, emergency care, medical gender affirmation), including before (finding providers, scheduling), during (waiting rooms, provider interactions), and after (pharmacy) healthcare visits. Participants who quantitatively reported access to gender-affirming healthcare still described negative healthcare experiences, either because they accessed multiple healthcare services or because of prior negative experiences. Stigma and gender affirmation (both inside and outside of healthcare) influenced motivation to seek care, with variation depending on the type of care. Quantitative analyses confirmed these findings; access to gender affirmation differed for participants who delayed primary care vs. those who did not, but did not vary based on participants' use of medical gender affirmation.

CONCLUSIONS

Findings highlight the importance of promoting gender-affirming healthcare environments to increase access to care for TGD youth of color.

Examining Sexual Behavior Among U.S. Transgender Adolescents

The health of transgender adolescents (i.e., those identifying with a gender other than their sex assigned at birth) is gaining attention from researchers, yet little work has examined normative sexual behaviors among this population. Self-identified gender minority adolescents, including those identifying as trans boys, trans girls, nonbinary, and questioning their gender identity (age range 14-18, M_age = 16, n = 1,223) from all 50 U.S. states responded to anonymous online surveys. Participants reported on their age of initiation and number of sexual partners for four sexual behaviors ranging in intimacy (i.e., sexual touching, oral sex, vaginal sex, and anal sex). Participants also indicated the gender of their sexual partners and experiences with sexually transmitted infections (STIs), STI tests, and pregnancy. Overall, transgender adolescents' age of initiating sexual behaviors and number of sexual partners are similar to those observed in prior studies of cisgender adolescents. No differences were found between gender identity subgroups on ever engaging, age of initiation, number of partners, and gender of partners across the four sexual behaviors, with some exceptions for anal sex. Participants reported low rates of STIs and pregnancy, but also low rates of STI testing. Implications for sex education and health care are discussed.

How Has HIV Pre-Exposure Prophylaxis (PrEP) Changed Sex? A Review of Research in a New Era of Bio-behavioral HIV Prevention

In 2012, the U.S. FDA approved the first drug for use as HIV Pre-Exposure Prophylaxis (PrEP), which is nearly 99% effective when taken as prescribed. Although the manifest function of PrEP is to prevent HIV infection in the event of exposure, the drug has also had a significant impact on various facets of sexuality. In this review, we focus on research that emerged in the near decade since PrEP's approval, with a specific focus on the ways in which different elements of sex and sexuality have been impacted by gay, bisexual, and other men who have sex with men (GBMSM), cisgender women, and transgender individuals. We highlight evidence showing how PrEP has enhanced sexual self-esteem, improved sexual pleasure, reduced sexual anxiety, and has increased sexual agency for those taking it. For many, PrEP also serves as a gateway to improve routine health and increase sexual health-care utilization. Additionally, we review the question of whether PrEP is associated with increased sexual risk taking (i.e. risk compensation), and note that, although some data are mixed, PrEP is not intended as an intervention to reduce condomless anal sex or STIs: it aims to prevent HIV. Finally, our review highlights that, although the volume of research on PrEP among GBMSM is robust, it is underdeveloped for cisgender women and transgender populations and insufficient for inclusion in such a review for cisgender heterosexual men was. PrEP research with these populations is an important direction for future research. Finally, from 2012 to 2019, a single PrEP formulation and delivery method was FDA approved (oral emtricitabine/tenofovir disoproxil fumarate). As additional drug formulations (ie.g., emtricitabine/tenofovir alafenamide) and delivery methods (e.g., microbiocides, vaginal ring, injectable) come to market, it will be important to examine how these, too, impact the spectrum of sexuality.

Text Messaging Improves HIV Care Continuum Outcomes Among Young Adult Trans Women Living with HIV: Text Me, Girl!

Young adult trans women living with HIV in the US exhibit suboptimal advancement through the HIV Care Continuum relative to national averages. From December 2016 through May 2018, 134 young adult trans women living with HIV enrolled in Text Me, Girl!, a theory-based, trans-specific text-messaging intervention designed to improve HIV Care Continuum outcomes. Participants (N = 130) averaged 29.5 years, were predominantly Latinx (43%) or African American/Black (40%). Clustered logistic and ordinal logistic multivariable models (n = 105; 366 observations) indicate that through 18-month follow-up, increased exposure to the text-messaging intervention was associated with significant (p < 0.05) increased retention to HIV care (adjusted odds ratio [aOR] 1.33) and biomarker-confirmed viral suppression (aOR 1.51); retention in the intervention was associated with significantly increased likelihood of ART uptake (aOR 2.95) and "excellent" ART adherence (aOR 10.44). Text Me, Girl! offers promising evidence that a unidirectional, automated text-messaging intervention can improve HIV care outcomes among young adult trans women living with HIV.

Young Transgender Women of Color: Homelessness, Poverty, Childhood Sexual Abuse and Implications for HIV Care

This study describes a sample of HIV+ young transgender women of color aged 18-24 and their experience with homelessness as part of a demonstration project of engagement and retention in HIV medical care funded by Health Resources and Services Administration. The study engaged transgender women of color in HIV care in nine sites across the US between 2012 and 2017. This analysis describes and compares transwomen who had been homeless in the last 6 months to those not homeless. We hypothesized that homelessness would compete with HIV care, food, shelter, and be associated with poverty. Variable domains included sociodemographic, mental health and substance use, HIV care, sexual risk behavior, social support from transgender and other friends, and childhood sexual abuse. There were 102 youth enrolled, 77 (75.5%) who had been homeless, and 25 (24.5%) who had not been homeless. Bivariate analyses showed that low income, sex work as source of income, inability to afford food, lack of viral load (VL) suppression, childhood sexual abuse, lower levels of social support, and higher levels of depression were associated with homelessness. A logistic regression model showed that being unable to afford food (AOR = 9.24, 95% CI 2.13-40.16), lack of VL suppression in last 6 months (AOR = 0.10, 95% CI .02-.57), and lack of transgender friend support (AOR = 0.09, 95% CI .02-.53) was associated with homelessness. Programs that place basic needs first-food and shelter-may be able to engage and assist young transgender women of color with HIV to survive and live healthier lives.

A designathon to co-create community-driven HIV self-testing services for Nigerian youth: findings from a participatory event

BACKGROUND

Youth are at high risk for HIV, but are often left out of designing interventions, including those focused on adolescents. We organized a designathon for Nigerian youth to develop HIV self-testing (HIVST) strategies for potential implementation in their local communities. A designathon is a problem-focused event where participants work together over a short period to create and present solutions to a judging panel.

METHODS

We organized a 72-h designathon for youth (14-24 years old) in Nigeria to design strategies to increase youth HIVST uptake. Proposals included details about HIVST kit service delivery, method of distribution, promotional strategy, and youth audience. Teams pitched their proposals to a diverse seven-member judging panel who scored proposals based on desirability, feasibility, potential impact and teamwork. We examined participants' socio-demographic characteristics and summarized themes from their HIVST proposals.

RESULTS

Forty-two youth on 13 teams participated in the designathon. The median team size was 3 participants (IQR: 2-4). The median age was 22.5 years (IQR: 21-24), 66.7% were male, 47.4% completed tertiary education, and 50% lived in Lagos State. Themes from proposals included HIVST integration with other health services, digital marketing and distribution approaches, and engaging students. Judges identified seven teams with exceptional HIVST proposals and five teams were supported for further training.

CONCLUSIONS

The designathon provided a structured method for incorporating youth ideas into HIV service delivery. This approach could differentiate HIV services to be more youth-friendly in Nigeria and other settings.

Pre-Exposure Prophylaxis (PrEP) for HIV Infection in Cisgender and Transgender Women in the U.S.: A Narrative Review of the Literature

Using a socioecological approach, this review describes the peer-reviewed literature on oral pre-exposure prophylaxis (PrEP) among both cisgender (cis women) and transgender women (trans women) in the U.S. A search of the PubMed database and HIV-related conference abstracts generated over 2,200 articles and abstracts. Of these, 103 fulfilled review inclusion criteria. Most of the existing research presents findings on individual-level factors associated with PrEP use such as willingness and perceived barriers. There was far less investigation of factors related to PrEP at more distal ecological levels. Though trans women are at greater risk of HIV infection than cisgender women, less is known about this population group with respect to PrEP despite their inclusion in many major clinical trials. Further, the literature is characterized by a persistent conflation of sex and gender which makes it difficult to accurately assess the reviewed research on HIV prevention and PrEP apart from risk group. Informed by these findings, we highlight specific opportunities to improve access to PrEP and reduce socioecological barriers to PrEP care engagement for cisgender and transgender women.

mHealth for transgender and gender-expansive youth: harnessing gender-affirmative cross-disciplinary innovations to advance HIV prevention and care interventions

Transgender and gender-expansive (TGE) youth endure stark disparities in health and wellbeing compared to their cisgender peers. A key social determinant of health for TGE adolescents and emerging adults is gender affirmation, which encompasses multidimensional validations of an individual's lived gender. Lacking available resources for one's gender affirmation, TGE young people may engage in high-risk maladaptive coping behaviors, linked to their disproportionately high HIV-acquisition risk. A range of innovative mobile technologies are guided by the Gender-Affirmative Framework to promote the health of TGE communities, including through HIV prevention and care continuum outcomes. The aim of this review was to examine key features of existing mobile technologies that can be leveraged to advance the field of TGE-responsive mHealth. We systematically searched scientific records, gray literature, and the iOS and Android app distribution services. To be eligible, platforms and interventions needed to be tailored exclusively to a TGE user base, incorporate gender-affirming features, and be optimized for or adaptive to mobile technologies. Eligible interventions (N=24) were compared on evidence of utility, core functionalities, and dimensions of gender affirmation. Smartphone applications (apps) and webapps (n=16) were the most common delivery modality. Many interventions (n=9) aimed to address HIV-related outcomes and integrated gender-affirmative features. The most common gender-affirmative features originated in fields of human-computer interactions and informatics, or were crowdfunded by TGE developers. HIV-focused interventions incorporated evidence-based health behavior change strategies and utilized rigorous evaluation methods. Across modalities and disciplines, behavioral self-monitoring and access to HIV prevention services were the most frequent features. Over two-thirds of the interventions reviewed aimed to provide medical gender affirmation (e.g, provided guidance on obtaining medically sanctioned hormone therapies, or safely practicing non-medical options such as chest-binding) or psychological gender affirmation (e.g, provided linkage to mental health counseling). Our results show that mHealth and other technology-mediated interventions offer a diverse range of both evidence-based and innovative features; however, many have not been rigorously evaluated in a randomized controlled trial to support TGE users. A continuing commitment to evidence-based health behavior change strategies, exemplified by the HIV-focused interventions included in this review, is essential to advancing gender-affirmative mHealth. The unique and highly innovative features of platforms originating outside the fields of HIV prevention and care suggest new directions for TGE-responsive mHealth, and the need for more conscientious models of knowledge exchange with investigators across scientific disciplines, private-sector developers, and potential users.

Perspectives on and preferences for on-demand and long-acting PrEP among sexual and gender minority adolescents assigned male at birth

INTRODUCTION

Sexual and gender minority (SGM) adolescents assigned male at birth who have sex with male partners are at increased risk for HIV. Daily oral pre-exposure prophylaxis (PrEP) is available for minor adolescents in the United States, who may have difficulty with adherence. Adolescents' perspectives toward emerging PrEP delivery methods that would not require daily pill-taking have not been well-explored.

METHODS

We conducted online surveys and focus groups in November 2018-February 2019 with 59 SGM adolescents assigned male at birth who reported sex with or attraction to male partners. Questions assessed their perspectives on and preferences for biomedical (on-demand, injection, implant) and non-biomedical HIV prevention options (condoms). Data were analyzed thematically.

RESULTS

Of all prevention options, the implant and condoms were rated highest, and participants preferred the implant over other biomedical options. Convenience, duration, and ease of access played important roles in adolescents' preferences. Parents were viewed as a barrier to taking PrEP regardless of delivery method due to their role in adolescents' ability to access healthcare.

CONCLUSIONS

SGM adolescents are interested in long-acting PrEP, yet also perceive substantial obstacles to using biomedical prevention that reflect adolescents' developmental contexts.

POLICY IMPLICATIONS

State laws expanding adolescents' access to HIV preventive services, sex education inclusive of PrEP information, and parent- and provider-initiated PrEP conversations can reduce barriers regardless of PrEP delivery method. Research to accelerate the availability of long-acting implants for adolescents is needed.

Medical Gender Affirmation and HIV and Sexually Transmitted Disease Prevention in Transgender Youth: Results from the Survey of Today's Adolescent Relationships and Transitions, 2018

Purpose: We assessed the association of receipt of medical gender affirmation services (e.g., hormones, surgery) with HIV and other sexually transmitted disease (STD) prevention and knowledge indicators among transgender youth. Methods: A United States online sample of sexually experienced transgender youth ages 13-24 years (N = 1029) in 2018 completed a cross-sectional survey, including questions about sociodemographics, medical gender affirmation, and HIV and STD prevention outcomes (HIV testing, STD testing, pre-exposure prophylaxis [PrEP] awareness, and nonoccupational postexposure prophylaxis [nPEP] awareness). Logistic regression models were fit to assess the association of medical gender affirmation with HIV and STD prevention outcomes. Interaction terms and stratified models assessed differences in the association between medical gender affirmation and outcomes by gender identity. Results: Participants' mean age was 19.1 (standard deviation = 2.7), 45% were transgender female, 29% transgender male, 26% nonbinary, 53% were youth of color, and 19% accessed medical gender affirmation services. Medical gender affirmation was associated with increased odds of STD testing (adjusted odds ratio [aOR] = 1.90; 95% confidence interval [CI] = 1.33-2.73) with no significant interactions by gender identity. Associations between medical gender affirmation and awareness of PrEP and nPEP varied by gender identity. Among transgender male youth, medical gender affirmation was associated with awareness of PrEP (aOR = 2.65; 95% CI = 1.50-4.71) and nPEP (aOR = 2.03; 95% CI = 1.12-3.71). Among nonbinary youth, medical gender affirmation was associated with awareness of PrEP (aOR = 3.47; 95% CI = 1.26-11.27). Conclusion: Medical gender affirmation was associated with uptake and awareness of sexual health services. Bolstering medical gender affirmation for transgender youth may also bolster preventive health services broadly.

A Scoping Review Examining Social and Legal Gender Affirmation and Health Among Transgender Populations

Purpose: Transgender (trans) populations experience health inequities. Gender affirmation refers to psychological, social, legal, and medical validation of one's gender and is a key social determinant of trans health. The majority of research has focused on medical affirmation; however, less is known about the role of social and legal affirmation in shaping trans health. This review aimed to (1) examine how social and legal gender affirmation have been defined and operationalized and (2) evaluate the association between these forms of gender affirmation and health outcomes among trans populations in the United States. Methods: We conducted a systematic search of LGBT Life, PsycInfo, and PubMed using search strings targeting transgender populations and gender affirmation. This review includes 24 of those articles as well as 1 article retrieved through hand searching. We used a modified version of the National Institute of Health Quality Assessment Tool to evaluate study quality. Results: All studies relied on cross-sectional data. Studies measured and operationalized social and legal gender affirmation inconsistently, and some measures conflated social gender affirmation with other constructs. Health outcomes related to mental health, HIV, smoking, and health care utilization, and studies reported mixed results regarding both social and legal gender affirmation. The majority of studies had serious methodological limitations. Conclusion: Despite conceptual and methodological limitations, social and legal gender affirmation were related to several health outcomes. Study findings can be used to develop valid and reliable measures of these constructs to support future multilevel interventions that improve the health of trans communities.

The ongoing HIV epidemic in American youth: challenges and opportunities

The incidence of human immunodeficiency virus (HIV) infection has been decreasing in the United States overall, except among youth, and in particular among Black and Latinx young men who have sex with men (MSM). In this review we summarize key drivers of the HIV epidemic among youth, as well as novel interventions geared specifically towards combating the epidemic among high-risk populations. Many factors driving the HIV epidemic among youth are related to systemic inequities, including lack of access to healthcare, inadequate education, and internalized and experience homophobia and racism. Developmentally, youth may feel that they are invulnerable and be willing to engage in risks. Moreover, HIV is often invisible for youth given advances in treatment and community stigma, limiting open discussion of risk and new preventive modalities. Outcomes from the HIV treatment cascade suggest that youth are less likely to be aware of their HIV infection status, less likely to link to and be engaged in care, and less likely to be virologically suppressed than older MSM and other populations of people living with HIV. Importantly, pre-exposure prophylaxis (PrEP) has been shown to be an effective tool for prevention of HIV infection that also appears to have disproportionately poor uptake among youth. Barriers to PrEP utilization appear to be quite heterogeneous, and include patient-, provider-, and structural-level barriers. Interventions important in improving HIV prevention will thus have to be multipronged and developed for culturally diverse populations. Cognitive behavioral therapy-based interventions are promising strategies as they are able to address a diverse array of barriers. New formulations of PrEP will also likely be instrumental in improving adherence. Since youth spend considerable amounts of time accessing digital media, the deployment of apps and other mobile phone-based interfaces offer unique opportunities to increase education and to facilitate HIV prevention for at risk youth. Multiple studies are underway to better inform the optimal delivery of treatment and prevention services for this complex and diverse population, and include novel sociobiological interventions and new modes of medication delivery that may lend themselves to overcoming obstacles specific to youth.

Transgender people living with HIV: characteristics and comparison to homosexual and heterosexual cisgender patients in two Italian teaching hospitals

Regarding people living with HIV (PLHIV), little is known about the epidemiological characteristics and management decisions for transgender individuals. This retrospective study compared transgender and cisgender (homosexual and heterosexual) PLHIV at both the S. Maria della Misericordia of Perugia and Careggi of Firenze Teaching Hospitals from 2000 to 2018. Multivariate logistic regression was performed to analyse possible relationships between viral suppression (dependent variable) and age, sexually transmitted infections (STIs), and hepatitis diagnosis (independent variables). After analysing and comparing epidemiological and clinical data for 124 transgender, 180 homosexual cisgender and 188 heterosexual cisgender PLHIV, we found that transgender PLHIV, mostly Latin American sex workers, were more likely to have other STIs. Likewise, this subgroup, on average, was younger at the time of HIV diagnosis and more likely to be less adherent to care, consequently jeopardizing the achievement of viral suppression. Finally, the use of hormone therapy and gender confirmation surgery in transgender PLHIV contributed to specific management issues. To date, major attention has focused on studying the epidemiological characteristics of homosexual and heterosexual PLHIV. Our analysis found that transgender PLHIV were the least likely group to be adequately retained in the continuum of care and presented specific issues in part due to social and behavioural realities.

Increasing HIV Testing and Viral Suppression via Stigma Reduction in a Social Networking Mobile Health Intervention Among Black and Latinx Young Men and Transgender Women Who Have Sex With Men (HealthMpowerment): Protocol for a Randomized Controlled Trial

BACKGROUND

Stigma and discrimination related to sexuality, race, ethnicity, and HIV status negatively impact HIV testing, engagement in care, and consistent viral suppression (VS) among young Black and Latinx men who have sex with men and transgender women who have sex with men (YBLMT). Few interventions address the effects of intersectional stigma among youth living with HIV and those at risk for HIV within the same virtual space.

OBJECTIVE

Building on the success of the HealthMpowerment (HMP) mobile health (mHealth) intervention (HMP 1.0) and with the input of a youth advisory board, HMP 2.0 is an app-based intervention that promotes user-generated content and social support to reduce intersectional stigma and improve HIV-related outcomes among YBLMT. The primary objective of this study is to test whether participants randomized to HMP 2.0 report improvement in HIV prevention and care continuum outcomes compared with an information-only control arm. We will also explore whether participant engagement, as measured by paradata (data collected as users interact with an mHealth intervention, eg, time spent using the intervention), mediates stigma- and HIV care-related outcomes. Finally, we will assess whether changes in intersectional stigma and improvements in HIV care continuum outcomes vary across different types of social networks formed within the intervention study arms.

METHODS

We will enroll 1050 YBLMT aged 15 to 29 years affected by HIV across the United States. Using an HIV-status stratified, randomized trial design, participants will be randomly assigned to 1 of the 3 app-based conditions (information-only app-based control arm, a researcher-created network arm of HMP 2.0, or a peer-referred network arm of HMP 2.0). Behavioral assessments will occur at baseline, 3, 6, 9, and 12 months. For participants living with HIV, self-collected biomarkers (viral load) are scheduled for baseline, 6, and 12 months. For HIV-negative participants, up to 3 HIV self-testing kits will be available during the study period.

RESULTS

Research activities began in September 2018 and are ongoing. The University of Pennsylvania is the central institutional review board for this study (protocol #829805) with institutional reliance agreements with the University of North Carolina at Chapel Hill, Duke University, and SUNY Downstate Health Sciences University. Study recruitment began on July 20, 2020. A total of 205 participants have been enrolled as of November 20, 2020.

CONCLUSIONS

Among a large sample of US-based YBLMT, this study will assess whether HMP 2.0, an app-based intervention designed to ameliorate stigma and its negative sequelae, can increase routine HIV testing among HIV-negative participants and consistent VS among participants living with HIV. If efficacious and brought to scale, this intervention has the potential to significantly impact the disproportionate burden of HIV among YBLMT in the United States.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03678181; https://clinicaltrials.gov/ct2/show/study/NCT03678181.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24043.

High risk and low HIV prevention behaviours in a new generation of young trans women in Brazil

Adult trans women in Brazil are highly impacted by HIV, but little is known about risk for young trans women. Our study was conducted to compare the HIV prevalence and correlates of risk for young trans women ages 18-24 years old to adult trans women in Brazil. Trans women were recruited from Rio de Janeiro and Baixada (the metropolitan area of Rio de Janeiro), Brazil (N = 345). Youth ages 18-24 years of age had significantly greater odds of being HIV negative than adults (OR 0.4, 95% CI 0.2-0.6, p = 0.0002), but significantly lower odds of having post-exposure prophylaxis (PEP) knowledge (OR 0.5, 95% CI:0.3-0.9, p = 0.02) and PrEP awareness (OR 0.5, 95% CI: 0.3-0.8, p = 0.01). Young trans women also had significantly higher odds of using substances (OR 1.8, 95% CI 1.1-2.9, p = 0.02) and condomless anal intercourse with their last three sexual partners (OR 1.8, 95% CI: 1.1-3.0, p = 0.03) compared to adults. Already by age 24, one in four trans women in Brazil were infected with HIV pointing to a new generation at high risk of acquiring HIV. HIV prevention interventions are needed to change the healthcare system to reach and engage young trans women.

Social-Environmental Resilience, PrEP Uptake, and Viral Suppression among Young Black Men Who Have Sex with Men and Young Black Transgender Women: the Neighborhoods and Networks (N2) Study in Chicago

Young black men who have sex with men (YBMSM) and young black transgender women (TGW) have experienced a stark disparity in HIV prevention and care. Resilience, collective resources to adapt stressors or adversities, may improve HIV prevention and care outcomes. The present study investigated the association of resilience-based factors with PrEP uptake and viral suppression from a socioecological perspective among YBMSM and young black TGW. Data were from the baseline cycle of the Neighborhoods and Networks (N2) Study, an ongoing cohort study of 16-34-year-old YBMSM and young black TGW in Chicago (n = 324). Confidant network-level and neighborhood affiliation variables were created to measure the social-environmental context of resilience. All analyses were stratified by participants' HIV status (184 HIV-negative participants and 140 HIV-positive participants). Among HIV-negative participants, having a parental figure within an individual's confidant network was significantly associated with a greater likelihood of PrEP use. Among HIV-positive participants, confidant network members' awareness of an individual's HIV status was associated with viral suppression. Social support resources from confidant networks could improve HIV prevention and care engagement among YBMSM and young black TGW. Understanding the social and environmental contexts of resilience resource is critical for HIV prevention and care engagement.

Sexual Behaviors, Referral to Sexual Health Services, and Use of Sexual Health Services Among Transgender High School Students

BACKGROUND

Transgender adolescents are at increased risk for negative sexual health outcomes compared to their cisgender peers.

METHODS

Using data from 10,231 students from 7 high schools in a large, urban school district, our analysis compared sexual behaviors, referral to sexual health services by school staff, and use of sexual health services between transgender and cisgender students. We used propensity score matching to create a comparable sample of transgender and cisgender students and logistic regression models to examine how gender identity was associated with aforementioned outcomes.

RESULTS

Transgender students were more likely to have ever had sex, less likely to have used a condom at last sex, and more likely to have been referred for human immunodeficiency virus (HIV) testing, sexually transmitted disease (STD) testing, and other sexual health services than cisgender students. Transgender students were no more likely than cisgender students to have tested for HIV or STDs.

CONCLUSIONS

These findings underscore the need for understanding the risk perceptions held by transgender students and for prevention efforts that are inclusive for all gender identities. Research is needed to understand if school-based sexual health interventions such as staff referrals for sexual health services are effective for transgender students.

HIV-related outcome disparities between transgender women living with HIV and cisgender people living with HIV served by the Health Resources and Services Administration's Ryan White HIV/AIDS Program: A retrospective study

BACKGROUND

In the United States, approximately one-fifth of transgender women are living with HIV-nearly one-half of Black/African American (Black) transgender women are living with HIV. Limited data are available on HIV-related clinical indicators among transgender women. This is because of a lack of robust transgender data collection and research, especially within demographic subgroups. The objective of this study was to examine retention in care and viral suppression among transgender women accessing the Health Resources and Services Administration's (HRSA) Ryan White HIV/AIDS Program (RWHAP)-supported HIV care, compared with cisgender women and cisgender men.

METHODS AND FINDINGS

We assessed the association between gender (cisgender or transgender) and (1) retention in care and (2) viral suppression using 2016 client-level RWHAP Services Report data. Multivariable modified Poisson regression models adjusting for confounding by age, race, health care coverage, housing, and poverty level, overall and stratified by race/ethnicity, were used to calculate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs). In 2016, the RWHAP served 6,534 transgender women (79.8% retained in care, 79.0% virally suppressed), 143,173 cisgender women (83.7% retained in care, 84.0% virally suppressed), and 382,591 cisgender men (81.0% retained in care, 85.9% virally suppressed). Black transgender women were less likely to be retained in care than Black cisgender women (aPR: 0.95, 95% CI: 0.92-0.97, p < 0.001). Black transgender women were also less likely to reach viral suppression than Black cisgender women (aPR: 0.55, 95%I CI: 0.41-0.73, p < 0.001) and Black cisgender men (aPR: 0.55, 95% CI: 0.42-0.73, p < 0.001). A limitation of the study is that RWHAP data are collected for administrative, not research, purposes, and clinical outcome measures, including retention and viral suppression, are only reported to the RWHAP for the approximately 60% of RWHAP clients engaged in RWHAP-supported outpatient medical care.

CONCLUSIONS

In this study, we observed disparities in HIV clinical outcomes among Black transgender women. These results fill an important gap in national HIV data about transgender people with HIV. Reducing barriers to HIV medical care for transgender women is critical to decrease disparities among this population.

Project Moxie: Results of a Feasibility Study of a Telehealth Intervention to Increase HIV Testing Among Binary and Nonbinary Transgender Youth

Transgender youth have low rates of engagement in HIV prevention, shaped in part by experiences of transphobia and lack of access to culturally competent care. Project Moxie tested the feasibility of an intervention that provides home-based HIV self-testing coupled with video-chat counseling. A diverse sample of 202 binary and nonbinary transgender youth (TY) were recruited online, and randomized 2:1 to receive the intervention or a control condition of only home-based HIV self-testing. TY were willing to order HIV self-testing kits and report their results. Half of those in the intervention arm opted to use the video-chat counseling and, among those who did, levels of satisfaction were high. Project Moxie demonstrates the ability to recruit TY online and provide them with access to home HIV testing. Further work is required to develop online interventions for youth who do not wish to receive counseling through video-chat formats.

A Gap Between Willingness and Uptake: Findings From Mixed Methods Research on HIV Prevention Among Black and Latina Transgender Women

BACKGROUND

Black and Latina transgender women (BLTW) face significant HIV disparities with estimated HIV prevalence up to 50% and annual incidence rates as high as 2.8 per 100 person-years. However, few studies have evaluated the acceptability and uptake of high-impact HIV prevention interventions among BLTW.

SETTING

Data collection took place in Baltimore, MD and Washington, DC from May 2015 to May 2017.

METHODS

This mixed methods study included quantitative interviewer-administered surveys, key informant interviews, and focus group discussions. Rapid HIV testing followed each survey. Logistic regression models tested associations between legal gender affirmation (ie, desired name and gender marker on identity documents), transgender pride, history of exchange sex, HIV risk perception, and willingness to take pre-exposure prophylaxis (PrEP). Transcripts of qualitative data were coded to identify common themes related to engagement in HIV prevention.

RESULTS

Among 201 BLTW, 56% tested HIV-positive and 87% had heard of PrEP. Only 18% who had heard of PrEP had ever taken it. Of the 72 self-reported HIV-negative or status-unknown BLTW who had never taken PrEP, 75% were willing to take it. In multivariable analyses, history of exchange sex was associated with willingness to take PrEP, whereas greater HIV knowledge and transgender pride were associated with lower likelihood of willingness to take PrEP. Concern about drug interactions with hormone therapy was the most frequently reported barrier to PrEP uptake.

CONCLUSIONS

Noting the disconnect between PrEP willingness and uptake among BLTW, HIV prevention programs could bridge this gap by responding to identified access barriers and incorporating community-derived strategies.

High Rates of PrEP Eligibility but Low Rates of PrEP Access Among a National Sample of Transmasculine Individuals

BACKGROUND

Transmasculine individuals have been largely ignored in HIV prevention research, and there is a lack of data regarding this population's eligibility for and utilization of HIV pre-exposure prophylaxis (PrEP).

SETTING

National online survey conducted in the United States.

METHODS

Between May and July 2017, we surveyed 1808 transmasculine individuals (aged 18-60 years; 30% people of color and/or Latinx), asking questions about sexual behavior and receipt of sexual health care, including PrEP. We examined the number of individuals who would meet eligibility criteria for PrEP and then used log-linked Poisson regression with robust variance estimation to examine predictors of PrEP eligibility.

RESULTS

Almost one-quarter of the sample (n = 439; 24.3%) met one or more criterion for PrEP eligibility. PrEP eligibility did not differ by age, race/ethnicity, education, or binary gender identity. PrEP eligibility was lower among heterosexual-identified and higher income participants, and was higher among participants who were in open relationships and reported substance use. Among PrEP-eligible individuals, 64.9% had received an HIV test in the past year, 33.9% had received PrEP information from a provider, and 10.9% (n = 48) had received a PrEP prescription. PrEP-eligible individuals who had received a PrEP prescription were more likely to have a binary gender identity, identify as gay, and be taking testosterone.

CONCLUSIONS

A substantial proportion of transmasculine individuals meet PrEP eligibility criteria, but few are receiving adequate PrEP services. Enhanced efforts should be made by providers, programs, and systems to assess HIV-related risk in transmasculine patients and engage them in comprehensive sexual health care.

Youth-Serving Professionals' Perspectives on HIV Prevention Tools and Strategies Appropriate for Adolescent Gay and Bisexual Males and Transgender Youth

INTRODUCTION

HIV disproportionally burdens adolescent men who have sex with men (AMSM) and transgender youth. This study explores barriers and facilitators that professionals face in delivering HIV preventive services and education.

METHODS

Adolescent health providers (nurse practitioners, physicians, and other), school nurses, youth workers, and school educators were recruited nationally for this qualitative study.

RESULTS

Thirty-four professionals participated. Common categories identified across professional group were (1) effective strategies for building trust with youth, (2) perceived barriers/facilitators to sexual health communication, (3) perceived barriers/facilitators to effective HIV prevention, and (4) preferred content for HIV prevention tools.

DISCUSSION

Key elements for developing multidisciplinary resources to support AMSM and transgender youth should include (1) web-based or easily accessible sexual health educational materials, (2) resources for referrals, (3) trainings to support competence in caring for sexual and gender minority youth, and (4) guidance for navigating policies or eliciting policy change.

Transgender stigma: A critical scoping review of definitions, domains, and measures used in empirical research

RATIONALE

A growing body of transgender (trans) health research has explored the relationship between stigma and health; yet, studies have conceptualized and operationalized anti-trans stigma in multiple ways.

OBJECTIVE

This scoping review aims to critically analyze quantitative measures of anti-trans stigma in the U.S. using a socioecological framework.

METHOD

We organized and appraised measures from 126 included articles according to socioecological level: structural, interpersonal, or individual.

RESULTS

Of the identified articles, 36 measured anti-trans stigma at the structural level (i.e., institutional structures and policies), 102 measured anti-trans at the interpersonal level (i.e., community interactions), and 44 measured anti-trans stigma at the individual level (i.e., internalized or anticipated stigma). Definitions of anti-trans stigma varied substantially across articles. Most measures were adapted from measures developed for other populations (i.e., sexual minorities) and were not previously validated for trans samples.

CONCLUSIONS

Studies analyzing anti-trans stigma should concretely define anti-trans stigma. There is a need to develop measures of anti-trans stigma at all socioecological levels informed by the lived experiences of trans people.

Digital HIV Care Navigation for Young People Living With HIV in San Francisco, California: Feasibility and Acceptability Study

BACKGROUND

HIV continues to be a public health challenge adversely affecting youth and young adults, as they are the fastest-growing group of new HIV infections in the United States and the group with the poorest health outcomes among those living with HIV. HIV prevention science has turned to mobile health as a novel approach to reach and engage young people living with HIV (YPLWH) experiencing barriers to HIV care.

OBJECTIVE

This study aimed to assess the feasibility and acceptability of a text message-based HIV care navigation intervention for YPLWH in San Francisco. Health eNavigation is a 6-month text message-based HIV care navigation where YPLWH are connected to their own HIV care navigator through text messaging to improve engagement in HIV primary care. Digital HIV care navigation included delivery of the following through SMS text messaging: (1) HIV care navigation, (2) health promotion and education, (3) motivational interviewing, and (4) social support.

METHODS

We evaluated the feasibility and acceptability of a text message-based HIV care navigation intervention among YPLWH. We assessed feasibility using quantitative data for the overall sample (N=120) to describe participant text messaging activity during the intervention. Acceptability was assessed through semistructured, in-depth interviews with a subsample of 16 participants 12 months after enrollment. Interviews were audio-recorded, transcribed, and analyzed using grounded theory.

RESULTS

Overall, the text message-based HIV care navigation intervention was feasible and acceptable. The majority of participants exhibited medium or high levels of engagement (50/120 [41.7%] and 26/120 [21.7%], respectively). Of the majority of participants who were newly diagnosed with HIV, 63% (24/38) had medium to high engagement. Similarly, among those who were not newly diagnosed, 63% (52/82) had medium to high engagement. The majority of participants found that the intervention added value to their lives and improved their engagement in HIV care, medication adherence, and viral suppression.

CONCLUSIONS

Text message-based HIV care navigation is a potentially powerful tool that may help bridge the gaps for linkage and retention and improve overall engagement in HIV care for many YPLWH. Our results indicate that participation in text message-based HIV care navigation is both feasible and acceptable across pervasive structural barriers that would otherwise hinder intervention engagement.

Adherence to Antiretroviral Therapy Among Transgender and Gender Nonconforming People Living with HIV: Findings from the 2015 U.S. Trans Survey

Purpose: This article includes an analysis of medication adherence among transgender and gender nonconforming (TGNC) people living with HIV (PLWH) from the 2015 U.S. Trans Survey (USTS), the largest survey of TGNC people in the United States.

Methods: Using data from the USTS, our analytic sample included 162 TGNC PLWH who had been prescribed antiretroviral (ART). We grouped respondents by adherent/nonadherent and compared demographic characteristics and potential adherence risk factors.

Results: Approximately 65.8% of participants reported “taking ART as prescribed” all the time (61.0% trans women and 85.7% of trans men). Black TGNC PLWH were more likely to be nonadherent than whites or Hispanics. Adherent participants reported higher rates of home ownership. Nonadherent PLWH reported higher rates of verbal harassment, sex work, and homelessness in the past year, and lower rates of visiting an HIV doctor for care in the past year.

Conclusions: USTS respondents living with HIV reported lower adherence than in other nationally representative studies of this population in medical care. HIV rates are higher among black individuals, and reported adherence is lower, suggesting this is a high-priority population. Findings also suggest that unstable sociostructural conditions (homelessness, sex work, etc.) compromise medication adherence. Future practice directions include integrating HIV treatment plans into larger support services for TGNC PLWH.

Underutilization of Pre-Exposure Prophylaxis Services Among Transgender and Nonbinary Youth: Findings from Project Moxie and TechStep

We use quantitative and qualitative data from two ongoing studies to describe pre-exposure prophylaxis (PrEP) awareness, willingness to use PrEP, barriers to facilitators of PrEP uptake, and PrEP use among 15- to 24-year-old transgender and gender nonbinary (TGNB) youth. Most youth were aware of PrEP, but only one participant across both studies reported current use. Uncertainty about willingness to take PrEP may be related to general (e.g., medication cost) and trans-specific (e.g., PrEP–hormone interactions) concerns. Intensified and sustained efforts are needed to engage TGNB youth along the PrEP continuum and the impact of new PrEP administration and dosing options should be examined for TGNB youth.

Antiretroviral Treatment Interruptions Among Black and Latina Transgender Women Living with HIV: Characterizing Co-occurring, Multilevel Factors Using the Gender Affirmation Framework

Black and Latina transgender women (BLTW) are disproportionately impacted by HIV but remain underrepresented in HIV and health services research. Between March 2016 and May 2017, BLTW (N = 201) were recruited in Baltimore, Maryland and Washington, DC through convenience sampling for a survey assessing multilevel determinants of HIV risk and treatment outcomes. Interviews concluded with a rapid oral HIV test. Bivariate and multivariable logistic regression modeling was performed to identify gender affirmation-related correlates of self-reported HIV treatment interruptions (HIVTIs) among BLTW living with HIV who had initiated antiretroviral therapy (ART) (n = 96). Among them, 57.3% (n = 55) reported at least one HIVTI. Unmet surgical needs (aOR = 1.6), past-year marijuana use (aOR = 14.6), and no current hormone use (aOR = 24.9) were significantly (p < 0.05) associated with HIVTIs in multivariable analysis. Unmet need for gender affirmation may inhibit ART adherence, highlighting opportunities to mitigate care interruptions in alignment with community needs and goals.

Technology use to facilitate health care among young adult transgender women living with HIV

Little is known about how young adult transgender women living with HIV use digital technologies to facilitate their health care. This study examined the use of digital technologies to search for health information and support HIV care among young adult transgender women living with HIV (N = 130) in Los Angeles County, California. About half used the Internet "all the time" to search for transgender-specific resources (TSR; 53.8%) and for sexual health information (SHI; 51.5%). Less than half (39.2%) received digital HIV care reminders and, of those taking ART medication (n = 63), 36.5% received digital medication reminders. Internet information search was associated with Hispanic/Latina ethnicity (TSR: OR = 0.23, 95% CI [0.09, 0.58]; SHI: OR = 0.29, 95% CI [0.12, 0.73]) and higher (≥ $500) past-month income (TSR: OR = 2.67, 95% CI [1.13, 6.34]; SHI: OR = 2.67, 95% CI [1.14, 6.26]); receiving digital medication reminders with post-secondary educational attainment (OR = 5.70, 95% CI [1.04, 31.19]) and higher income (OR = 6.73, 95% CI [1.52, 29.67]). Receiving analog, but not digital, HIV care reminders was associated with engagement in HIV care (OR = 2.37, 95% CI [1.13, 5.00]) and ART uptake (OR = 2.18, 95% CI [1.06, 4.48]. Digital technology use was common for health-related searches but not for supporting HIV care.

The HIV Care Cascade Among Transgender Women with HIV in Canada: A Mixed-Methods Study

Scant research has explored the engagement of transgender (trans) women living with HIV (WLWH) in the HIV care cascade, particularly in universal health care settings like Canada. This convergent parallel, mixed-methods study drew on cross-sectional quantitative data from 50 trans WLWH in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS) and qualitative semistructured interview data from a subsample of 11 participants. Descriptive analyses were used to describe proportions of trans WLWH at five steps of the HIV care cascade and bivariate analyses to determine associations between hypothesized barriers/facilitators and HIV care cascade outcomes. Framework analysis was used to describe barriers and facilitators to HIV care engagement. Quantitative and qualitative data were then compared and contrasted. While use of purposive sampling, including recruitment through AIDS Service Organizations and HIV clinics, may have led to oversampling of trans WLWH who already had access to care, gaps were still seen in antiretroviral therapy (ART) outcomes (current ART use: 78%; ≥95% adherence among those currently taking ART: 67%). The number of years living with HIV was positively associated with HIV care cascade engagement. Factors associated with lower engagement included: higher health-related quality of life, depressive and post-traumatic stress disorder symptoms, barriers to access to care, transphobia, HIV-related stigma, and housing insecurity. Qualitative findings converged and expanded on how physical health, and social and structural marginalization, influence trans WLWH's engagement in HIV care. Qualitative findings elaborated on the importance of ART-related factors in impeding or facilitating engagement, including concerns about feminizing hormone-ART drug-drug interactions. Mixed-methods findings reveal how trans WLWH experience barriers common to other people living with HIV, and also experience unique barriers as a result of trans and HIV experiences.

Human Immunodeficiency Virus in Transgender Persons

Worldwide, transgender populations are disproportionately affected by human immunodeficiency virus (HIV). Pervasive stigma and discrimination impact social and economic determinants of health, which perpetuate HIV disparities among transgender individuals. This article reviews the prevalence of HIV infection among transgender populations and presents psychosocial, behavioral, and individual level factors that contribute to HIV acquisition. The authors provide practical recommendations regarding a patient-centered approach to HIV/sexually transmitted infection risk assessment. The role of preexposure prophylaxis utilization in preventing the transmission of HIV is discussed as well as the current data on HIV treatment outcomes for transgender people living with HIV.