A Latent Class Analysis of Chronic Health Conditions Among HIV-Positive Transgender Women of Color

Identifying Effective Strategies for Improving Engagement in HIV Prevention and Care Among Transgender Persons in the United States: A Systematic Review

This systematic review synthesized published literature (2000 - 2023) to identify HIV interventions specifically designed for transgender persons in the United States (PROSPERO registration number: CRD42021256460). The review also summarized strategies for improving outcomes related to the four pillars of the Ending the HIV Epidemic (EHE) initiative in the United States: Diagnose, Treat, Prevent, and Respond. A comprehensive search was conducted using the Centers for Disease Control and Prevention's HIV Prevention Research Synthesis Project database, which included over 120,000 citations from routine systematic searches in CINAHL, EMBASE, Global Health, MEDLINE, PsycInfo, and Sociological Abstracts. Of 23 interventions that met inclusion criteria, 94% focused on transgender women of color and 22% focused on young transgender persons aged 15-29 years old. Most interventions focused on Treat or Prevent, few focused on Diagnosis, and none focused on Respond. Twenty interventions (87%) showed improvement in at least one EHE related outcome and a quarter of these effective interventions were tested with randomized controlled trials. Common strategies observed in effective interventions include the following: engaging the community in intervention development; pilot-testing with the focus population to ensure appropriateness and acceptability; addressing social determinants of health (e.g. stigma, discrimination, violence) through empowerment and gender-affirming approaches; increasing access to care, prevention, and services through co-location and one-stop shop models; and utilizing peer-led counseling, education, support, and navigation. Continuous effort is needed in addressing gaps, including more research for transgender men and rural settings and for how best to adopt and adapt best practices for subgroups of transgender population.

An evaluation of nine culturally tailored interventions designed to enhance engagement in HIV care among transgender women of colour in the United States

INTRODUCTION

Transgender women (TW) worldwide have a high prevalence of HIV, and TW with HIV encounter numerous healthcare barriers. It is critical to develop evidence-informed interventions to improve their engagement in healthcare to achieve durable viral suppression (VS). We evaluated whether participation in one of nine interventions designed specifically for TW was associated with improved engagement in HIV care among transgender women of colour (TWC).

METHODS

Between 2013 and 2017, nine US organizations implemented nine distinct and innovative HIV care engagement interventions with diverse strategies, including: individual and group sessions, case management and navigation, outreach, drop-in spaces, peer support and/or incentives to engage TWC with HIV in care. The organizations enrolled 858 TWC, conducted surveys, captured intervention exposure data and extracted medical record data. Our evaluation of the interventions employed a pre-post design and examined four outcomes-any HIV care visit, antiretroviral therapy (ART) prescription, retention in HIV care and VS (both overall and among those with a clinic visit and viral load test), at baseline and every 6 months for 24 months. We employed logistic generalized estimating equations to assess the relative odds of each outcome at 12 and 24 months compared to baseline.

RESULTS

Overall, 79% of participants were exposed to at least one intervention activity. Over 24 months of follow-up, participants received services for a median of over 6 hours (range: 3-69 hours/participant). Compared to baseline, significantly (p<0.05) greater odds were demonstrated at both 12 and 24 months for three outcomes: prescription of ART (ORs: 1.42 at 12 months, 1.49 at 24 months), VS among all participants (ORs: 1.49, 1.54) and VS among those with a clinic visit and viral load test (ORs: 1.53, 1.98). The outcomes of any HIV care visit and retention in HIV care had significantly greater odds (ORs: 1.38 and 1.58, respectively) only at 12 months compared to baseline.

CONCLUSIONS

These evaluation results illustrate promising approaches to improve engagement in HIV care and VS among TWC with HIV. Continued development, adaptation and scale-up of culturally tailored HIV care interventions for this key population are necessary to meet the UNAIDS 95-95-95 goals.

HIV awareness and prevention strategies among transgender women in the Eastern and Southern United States: findings from the LITE Study

INTRODUCTION

Transgender women (TW) experience an increased risk of human immunodeficiency virus (HIV) acquisition. This study identified patterns of HIV awareness and prevention strategies used by TW who were not living with HIV.

METHODS

Data were drawn from a baseline survey of the LITE Study, a multi-site cohort of TW in Eastern and Southern United States (March 2018-August 2020). We conducted a latent class analysis to identify classes of HIV awareness and prevention strategies among TW who reported past 12-month sexual activity (N = 958) using 10 variables spanning HIV knowledge, receipt and use of HIV prevention strategies, and sexual practices. Due to differences across the cohort arms, classes were estimated separately for TW enrolled in site-based versus online study arms. We identified demographic characteristics, gender-affirming indicators and HIV vulnerabilities associated with class membership.

RESULTS

Four parallel classes emerged: class 1 "limited strategies-less sexually active" (15% and 9%, site-based and online, respectively), class 2 "limited strategies-insertive sex" (16%/36%), class 3 "limited strategies-receptive sex" (33%/37%) and class 4 "multiple strategies-insertive and receptive sex" (36%/18%). Across all classes, condomless sex, pre-exposure prophylaxis (PrEP)/post-exposure prophylaxis (PEP) prevention knowledge and awareness were high but reported PrEP/PEP use was low. Compared with class 1, membership in class 4 was associated with being a person of colour (site-based OR = 2.15, 95% CI = 1.15-4.00, online OR = 4.54, 95% CI = 1.09-18.81) increased odds of self-perceived medium-to-high HIV risk (site-based OR = 4.12, 95% CI = 2.17-7.80, online OR = 11.73, 95% CI = 2.98-46.13), sexually transmitted infections (STI) diagnosis (site-based OR = 6.69, 95% CI = 3.42-13.10, online OR = 8.46, 95% CI = 1.71-41.78), current sex work (site-based OR = 6.49, 95% CI = 2.61-16.11, online OR = 10.25, 95% CI = 1.16-90.60) and 2-4 sexual partners in the last 3 months (site-based OR = 2.61, 95% CI = 1.33-5.13). Class 3, compared with class 1, had increased odds of current sex work partners (site-based OR = 3.09, 95% CI = 1.19-8.07) and of having 2-4 sexual partners in the last 3 months (site-based OR = 3.69, 95% CI = 1.85-7.39).

CONCLUSIONS

TW have varied HIV awareness and prevention strategy utilization, with clear gaps in the uptake of prevention strategies. Algorithms derived from latent class membership may be used to tailor HIV prevention interventions for different subgroups and those reached through facility-based or digital methods.

Development of a computable phenotype to identify a transgender sample for health research purposes: a feasibility study in a large linked provincial healthcare administrative cohort in British Columbia, Canada

OBJECTIVES

Innovative methods are needed for identification of transgender people in administrative records for health research purposes. This study investigated the feasibility of using transgender-specific healthcare utilisation in a Canadian population-based health records database to develop a computable phenotype (CP) and identify the proportion of transgender people within the HIV-positive population as a public health priority.

DESIGN

The Comparative Outcomes and Service Utilization Trends (COAST) Study cohort comprises a data linkage between two provincial data sources: The British Columbia (BC) Centre for Excellence in HIV/AIDS Drug Treatment Program, which coordinates HIV treatment dispensation across BC and Population Data BC, a provincial data repository holding individual, longitudinal data for all BC residents (1996-2013).

SETTING

British Columbia, Canada.

PARTICIPANTS

COAST participants include 13 907 BC residents living with HIV (≥19 years of age) and a 10% random sample comparison group of the HIV-negative general population (514 952 individuals).

PRIMARY AND SECONDARY OUTCOME MEASURES

Healthcare records were used to identify transgender people via a CP algorithm (diagnosis codes+androgen blocker/hormone prescriptions), to examine related diagnoses and prescription concordance and to validate the CP using an independent provider-reported transgender status measure. Demographics and chronic illness burden were also characterised for the transgender sample.

RESULTS

The best-performing CP identified 137 HIV-negative and 51 HIV-positive transgender people (total 188). In validity analyses, the best-performing CP had low sensitivity (27.5%, 95% CI: 17.8% to 39.8%), high specificity (99.8%, 95% CI: 99.6% to 99.8%), low agreement using Kappa statistics (0.3, 95% CI: 0.2 to 0.5) and moderate positive predictive value (43.2%, 95% CI: 28.7% to 58.9%). There was high concordance between exogenous sex hormone use and transgender-specific diagnoses.

CONCLUSIONS

The development of a validated CP opens up new opportunities for identifying transgender people for inclusion in population-based health research using administrative health data, and offers the potential for much-needed and heretofore unavailable evidence on health status, including HIV status, and the healthcare use and needs of transgender people.

Non-HIV chronic disease burden among transgender populations globally: A systematic review and narrative synthesis

Chronic disease is a growing concern for research, policy and clinical care. While the global burden of HIV for transgender populations has been comprehensively covered in recent systematic reviews, the same is not true for the burden of other chronic disease. The objective of this study was to review the literature on non-HIV chronic disease burden for transgender populations worldwide. A systematic review was conducted of Medline, Embase, CINAHL, PsycINFO and LGBT Life bibliographic databases for peer-reviewed scientific studies with non-HIV chronic disease prevalence data for transgender populations published any date up to February 15, 2019 without restriction on country or study design. A total of 93 studies and 665 datapoints were included in this review, comprising 48 distinct chronic disease outcomes in seven groups (cancer, cerebro/cardiovascular conditions, chronic liver and kidney disease, mental health and substance use conditions, metabolic and endocrine disorders, musculoskeletal and brain disorders, respiratory conditions, and unspecified and other conditions). The empirical literature on chronic disease among global transgender populations focuses on mental health morbidity, demonstrating an evidence gap on chronic physical health morbidity, particularly beyond that of sexual health. This review identified important gaps including in age-related conditions, inflammation-related disease and studies designed explicitly to investigate chronic disease burden among transgender populations. There is a need for high quality evidence in this area, including longitudinal population-based studies with appropriate comparison groups, and consistent measurement of both transgender status and chronic conditions.

Use of latent class analysis to identify multimorbidity patterns and associated factors in Korean adults aged 50 years and older

Introduction

Multimorbidity associated with significant disease and economic burdens is common among the aged. We identified chronic disease multimorbidity patterns in Koreans 50 years of age or older, and explored whether such patterns were associated with particular sociodemographic factors and health-related quality-of-life.

Methods

The multimorbidity patterns of 10 chronic diseases (hypertension, dyslipidemia, stroke, osteoarthritis, tuberculosis, asthma, allergic rhinitis, depression, diabetes mellitus, and thyroid disease) were identified via latent class analysis of data on 8,370 Korean adults aged 50+ years who participated in the sixth Korean National Health and Nutrition Examination Survey (2013–2015). The associations between multimorbidity patterns, and sociodemographic factors and health-related quality of life, were subjected to regression analysis.

Results

Three patterns of multimorbidity were identified: 1) a relatively healthy group (60.4% of the population); 2) a ‘cardiometabolic conditions’ group (27.8%); and, 3) an ‘arthritis, asthma, allergic rhinitis, depression, and thyroid disease’ group (11.8%). The female (compared to male) gender was associated with an increased likelihood of membership of the cardiometabolic conditions group (odds ratio [OR] = 1.32, 95% confidence interval [CI] = 1.15–1.51) and (to a much greater extent) the arthritis, asthma, allergy, depression, and thyroid disease group (OR = 4.32, 95% CI = 3.30–5.66). Low socioeconomic status was associated with membership of the two multimorbidity classes. Membership of the arthritis, asthma, allergy, depression, and thyroid disease group was associated with a significantly poorer health-related quality-of-life than was membership of the other two groups.

Conclusion

The co-occurrence of chronic diseases was not attributable to chance. Multimorbidity patterns were associated with sociodemographic factors and quality-of-life. Our results suggest that targeted, integrated public health and clinical strategies dealing with chronic diseases should be based on an understanding of multimorbidity patterns; this would improve the quality-of-life of vulnerable multimorbid adults.

Psychosocial Syndemic Risks Surrounding Physical Health Conditions Among Sexual and Gender Minority Individuals

Purpose: The high prevalence of physical health conditions among sexual and gender minority (SGM) individuals could be explained, in part, by SGM individuals' disparate exposure to interconnected psychosocial syndemic risks, including substance use, depression, posttraumatic stress disorder, intimate partner violence, and sexual assault. We utilized a syndemic framework to understand the overlapping and potentially synergistic association between psychosocial syndemic risks and physical health conditions among SGM adults. Methods: A sample of 298 self-identified SGM adults (M age = 28.03, SD = 9.86; 47.0% racial/ethnic minority, 41.6% transgender or gender nonconforming) completed an online survey from May 2016 through May 2017. Results: Three (1.0%) participants reported no syndemic risks, 19 (6.4%) reported one, 52 (17.4%) reported two, 85 (28.5%) reported three, 89 (29.9%) reported four, and 50 (16.8%) reported all five syndemic risks. The number of psychosocial syndemic risks was positively associated with the number of physical health conditions and synergistically (i.e., more than additively) increased the overall health burden on SGM individuals. Conclusion: We found evidence for psychosocial syndemic risks as predictors of SGM individuals' physical health. This study is novel in providing evidence for syndemics surrounding a comprehensive set of physical health outcomes among individuals identifying along a full spectrum of SGM identities. The study controlled for HIV to examine syndemic conditions surrounding physical health outcomes beyond this well-established syndemically determined condition. Comprehensive intervention and policy efforts that address co-occurring psychosocial risks for physical health conditions are needed to reduce health disparities affecting SGM populations.