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

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.

Housing instability among young men who have sex with men in a US national sample

Background

Youth, including those experiencing housing instability, are among the fastest growing groups of individuals with new STI diagnoses, including HIV. The unpredictable nature of the lives of youth experiencing housing instability often leads to inconsistent or non-existent health care and preventive follow up, leaving gaps in our knowledge about the most prominent needs for intervention.

Methods

Using data from the Together 5000 (T5K) study, we examined factors associated with housing instability in a sample of 2,228 youth between the ages of 16-24 who identified as sexual and gender minority (SGM) men having sex with men. Logistic regression was used to assess the most prominent factors associated with housing instability. The model included seven significant factors - former peer victimization, gender, age, sex work, IPV, social support, and health insurance status.

Findings

Participants who reported more behavioral risk factors for STI and those who reported sex work in the last three months were more likely to experience housing instability (OR = 2.5 and 2.76 respectively). Youth with higher levels of reported social support, health insurance, and older age were more likely to report stable housing (OR = .98, 1.61, and 1.13 respectively). Surprisingly, youth with stable housing were more likely to report intimate partner violence than those experiencing housing instability (OR = .89).

Discussion

Implications for addressing STIs among adolescent SGM men having sex with men are discussed including bolstering support systems and addressing basic needs deficits and trauma associated with sex work and behavioral risk factors for STI.

Implications and contributions statement

The study examines correlates of housing instability among a sample of young sexual and gender minority men who have sex with other men. Correlates of housing instability included behavioral risk factors for sexually transmitted infection and reporting sex work in the last three months. Health insurance, older age, and higher levels of social support were correlated with more stable housing.

Transgender Women Experiencing Homelessness - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020

Transgender women experience high prevalence of homelessness, which can affect their likelihood of acquiring HIV infection and can lead to poor medical outcomes. CDC analyzed data from the National HIV Behavioral Surveillance Among Transgender Women to identify whether personal characteristics and social factors affecting transgender women were associated with duration of homelessness during the past 12 months. Longer duration and chronic homelessness might indicate greater unmet needs, which increases their likelihood for acquiring HIV infection. Ordinal logistic regression was conducted to calculate adjusted prevalence odds ratios and 95% CIs for transgender women from seven urban areas in the United States experiencing homelessness 30-365 nights, 1-29 nights, and zero nights during the past 12 months. Among 1,566 transgender women, 9% reported 1-29 nights homeless and 31% reported 30-365 nights homeless during the past 12 months. Among participants who reported physical intimate partner violence or forced sex, 50% and 47%, respectively, reported experiencing 30-365 nights homeless. Furthermore, 55% who had been evicted or denied housing because of their gender identity and 58% who had been incarcerated during the past year experienced 30-365 nights homeless. The odds of transgender women experiencing longer duration of homelessness was associated with being younger and having a disability; higher psychological distress scores were associated with longer duration of homelessness. Analysis of social determinants of health found transgender women experiencing longer homelessness to be less educated, living below the Federal poverty level, and having lower social support. Therefore, focusing on HIV prevention and interventions addressing housing instability to reduce the duration of homelessness among transgender women is important. Further, integrating housing services with behavioral health services and clinical care, specifically designed for transgender women, could reduce HIV acquisition risk and improve HIV infection outcomes.

Structural and Psychosocial Syndemic Conditions and Condomless Anal Intercourse Among Transgender Women - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020

Psychosocial and structural syndemic conditions, including polydrug use and experiencing homelessness, frequently co-occur and might jointly increase HIV risk. Limited studies have assessed racial and ethnic differences in exposure to syndemic conditions and behaviors associated with HIV transmission among transgender women. This report examines the relation between syndemic conditions and condomless anal intercourse (CAI) among transgender women in seven urban areas in the United States to develop HIV prevention interventions for transgender women. During 2019-2020, transgender women in seven urban areas were recruited using respondent-driven sampling for a biobehavioral survey. Reported syndemic conditions (psychosocial: polydrug use, sexual violence, and psychological distress; structural: homelessness, incarceration, and exchange sex) were summed to create a syndemic score. Using modified Poisson regression to account for RDS, the study assessed whether the strength of the association between syndemic score and CAI differed by race and ethnicity. To assess additive interaction, the relative excess prevalence owing to interaction (REPI) and 95% CIs for selected pairs of syndemic conditions on CAI prevalence stratified by race and ethnicity were estimated. Of 1,348 transgender women (Black = 546, White = 176, and Hispanic = 626), 55% reported CAI; and 24% reported ≥3 syndemic conditions. Reporting additional syndemic conditions was associated with CAI for White, Hispanic, and Black participants. The association was significantly stronger for White than Black and Hispanic participants. Limited significant superadditive interactions were found, although the majority were between structural syndemic conditions. Racial and ethnic differences in REPI estimates were observed. Reporting more syndemic conditions was associated with increased CAI across racial and ethnic groups, demonstrating that HIV prevention efforts for transgender women should address structural and psychosocial syndemic conditions. Results differed by race and ethnicity, indicating that syndemic-focused interventions for transgender women should be tailored to racial and ethnic groups.

When Ethics and the Law Collide: A Multicenter Demonstration Cohort Study of Pre-Exposure Prophylaxis Provision to Adolescent Men Who Have Sex With Men and Transgender Women in Brazil

PURPOSE

To explore legal and ethical challenges related to adolescents' participation in human immunodeficiency virus (HIV) research that may affect their best interests.

METHODS

We analyzed the ethical principles and legal aspects of the participation of 15-17-year-old men who have sex with men and transgender women in the pre-exposure prophylaxis (PrEP) 1519 study, a PrEP demonstration cohort study in three Brazilian cities. The analyses of ethics review committees' (ERCs) evaluations and court decisions followed ethical and human rights principles. An HIV vulnerability score was created, and descriptive statistics and multivariate logistic regression were performed using data from 347 participants.

RESULTS

The ERCs evaluated the benefits and risks of research participation, all finding that the benefits outweighed the risks. ERCs deferred responsibility for decisions about waiving parental consent to the judiciary. State courts reached different decisions about waiving parental consent, reflecting variation in recognition of adolescents' evolving capacities and the adolescent as a subject of sexual rights and the primary agent capable of deciding on their health and best interests. The most vulnerable adolescent participants were found in sites where the blanket waiver was in place.

DISCUSSION

Judicializing the ethical review process is detrimental to fulfilling the ethical principle of justice and vulnerable adolescents' access to health research. ERCs must be sufficiently independent and autonomous and have the capacity to respect, protect, and help fulfill the rights of participants while ensuring the generation of adequate evidence to inform public health practice.

Socio-ecological Barriers to Viral Suppression Among Transgender Women Living with HIV in San Francisco and Los Angeles, California

Troubling disparities in viral suppression persist among transgender (trans) women living with HIV in the US. We utilized baseline data from a randomized controlled trial of a behavioral intervention among trans women living with HIV in San Francisco and Los Angeles, to identify the socio-ecological correlates of biologically confirmed viral suppression (< 200 HIV-1 RNA copies/mL). Among 253 participants, the mean age was 43 (SD = 11), 46% identified as Black or African American and 35% were virally non-suppressed. In adjusted Poisson regression models, the following barriers to viral suppression were identified: injection drug use [adjusted risk ratio (aRR) 0.78, 95% CI 0.65-0.93, Z = - 2.64, p = 0.008], methamphetamine use (aRR 0.65, 95% CI 0.51-0.83, Z = - 3.45, p = 0.001), amphetamine use (aRR 0.62, 95% CI 0.44-0.87, Z = - 2.75, p = 0.006), homelessness (aRR 0.79, 95% CI 0.63-0.98, Z = - 2.06, p = 0.039), and sex work (aRR 0.60, 95% CI 0.41-0.86, Z = - 2.77, p = 0.009). These findings underscore the importance of interventions that address the socio-ecological barriers to viral suppression among trans women in urban settings.

Stressors Associated with Tobacco Use Among Trans Women

Purpose

Tobacco use is prevalent among sexual and gender minorities (SGM), yet few studies have examined the specific drivers of tobacco use among trans women. The purpose of this study is to examine the impact of proximal, distal, and structural stressors associated with tobacco use among trans women.

Methods

This study is based on a cross-sectional sample of trans women (n=162) living in Chicago and Atlanta. Analyses were conducted to examine the association between stressors, protective factors, and tobacco use using a structural equation modeling framework. Proximal stressors (transgender roles scale, transgender congruence scale, internalized stigma, and internalized moral acceptability) were operationalized as a higher order latent factor, while distal stressors were operationalized as observed variables (discrimination, intimate partner violence, sex work, rape, child sexual abuse, HIV, and violence). Protective factors included social support, trans-related family support, and trans-related peer support. All analyses adjusted for sociodemographic variables (age, race/ethnicity, education, homelessness and health insurance).

Results

The prevalence of smoking among trans women in this study was 42.9%. In the final model, homelessness (odds ratio [OR]: 3.78; 95% confidence interval [CI]: 1.97, 7.25), intimate partner violence (OR: 2.14; 95% CI: 1.07, 4.28), and commercial sex work (OR: 2.22; 95% CI: 1.09, 4.56) were all associated with tobacco use. There was no association between proximal stressors and tobacco use.

Conclusion

Among trans women, tobacco use prevalence was high. Tobacco use was associated with homelessness, intimate partner violence, and commercial sex work. Targeted tobacco cessation programs should account for the co-occurring stressors that trans women face.

Structural Needs, Substance Use, and Mental Health Among Transgender and Nonbinary Young Adults in the San Francisco Bay Area: Findings from the Phoenix Study

Transgender and nonbinary (trans) young adults report high rates of substance use and adverse mental health outcomes; however, few studies have examined how social, economic, and legal factors may contribute to health inequities in this population. Guided by the structural vulnerability framework, this study sought to explore structural needs and whether these needs were associated with substance use and mental health outcomes among trans young adults. Between 2019 and 2021, 215 trans young adults aged 18-29 from San Francisco Bay Area were recruited into a longitudinal study. Baseline data were used to examine bivariate and multivariable associations between structural needs and substance use and mental health outcomes. There were bivariate differences in the number of structural needs by education, income source, incarceration history, and ethnicity, and the number of unmet structural needs was associated with education and income source. After adjusting for sociodemographics, the number of structural needs was associated with daily marijuana use (AOR 1.29, 95% CI: 1.10-1.49) and suicidal ideation (AOR 1.24, 95% CI: 1.06-1.45), and the number of unmet structural needs was associated with daily marijuana use (AOR 1.30, 95% CI: 1. 10-1.55) and depressive symptoms (β 2.00, 95% CI: 1.00-3.00). Additionally, both numbers of structural needs and unmet structural needs mediated the relationship between income source (traditional employment vs. other income only) and depressive symptoms (TIE β 2.51, 95% CI: 0.99-4.04; β 1.37, 95% CI: 0.23-2.52, respectively). Findings highlight a need for multisector efforts to address structural vulnerabilities among trans young adults.

Disparities in HIV Testing, Condom Use, and HIV Education Between Transgender and Not Transgender High School-Aged Youth: Findings From the 2019 Youth Risk Behavior Survey

Transgender individuals are disproportionately affected by HIV in the United States. Given increased risk of HIV among youth, there is a need to understand HIV risk and protective factors among transgender individuals who are 18 years and younger. Patterns of HIV testing, HIV education, and condom use have known associations with HIV outcomes among youth in general, but are understudied among transgender youth. This study assessed these outcomes by developing a series of sex-stratified multivariable logistic regression models using pooled Youth Risk Behavior Survey data. Results indicate female and male transgender youth as well as males who were not sure they were transgender were more likely have tested for HIV compared with their not transgender peers. Male transgender youth were significantly less likely to have received HIV education compared with not transgender males. Females not sure if they were transgender and male transgender youth were significantly less likely to have used condoms compared with, respectively, not transgender female and not transgender male counterparts. In sum, condom use and HIV education both remain lower among transgender individuals relative to their not-transgender peers. This highlights the need for the promotion of culturally appropriate HIV education and HIV prevention supports among transgender youth.

The prevalence of childhood sexual experiences and intimate partner violence among transgender women in China: Risk factors for lifetime suicidal ideation

Objective

Several studies highlighted childhood sexual experiences (CSEs) and intimate partner violence (IPV) as risk factors that affected lifetime suicidal ideation. TW had higher rates of CSEs and IPV than cisgender people. The aim of this study was to comprehensively assess the prevalence of CSEs and IPV among TW and their association with lifetime suicidal ideation.

Methods

A cross-sectional survey was conducted among 247 TW in Shenyang and Kunming, China, from April to September 2018. CSEs, IPV, and lifetime suicidal ideation were assessed. Logistic regression models were used to examine the association between self-reported CSEs under 18 years of age, IPV in adulthood, and lifetime suicidal ideation.

Results

In the study, 14.2% (35/247) of the sample participants reported CSEs under 18 years of age; 44.9% (111/247) reported experiencing IPV in adulthood, including 18.6% (44/247) of physical IPV, 27.1% (67/247) of trans-specific identity IPV, 31.6% (78/247) of verbal IPV, and 19.4% (48/247) of sexual IPV; and 26.3% (65/247) had thought about attempting suicide at least one time. CSEs and any form of IPV were significantly associated with suicidal ideation in this sample population. A final stepwise multivariate logistic regression model found that both physical and verbal IPVs were significantly associated with suicidal ideation when controlling for other factors (ORm₁ = 2.58, 95% confidence interval (CI) = 1.163-5.724; ORm₂ = 2.72, 95% CI = 1.334-5.547).

Conclusions

The findings highlight the effects of CSEs and IPV among TW and suggest the need for research on suicide in the future. Suicide prevention efforts for this invisible and vulnerable population should focus on those with physical and verbal IPV.

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&lt;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.

The Use of Photovoice Methodology to Assess Health Needs and Identify Opportunities Among Migrant Transgender Women in the U.S.-Mexico Border

Psychosocial, social and structural conditions have rarely been studied among transgender women in the U.S.-Mexico Border. This study used Photovoice methodology to empower migrant transgender women of color (TWC) to reflect on realities from their own perspectives and experiences and promote critical dialogue, knowledge, and community action. Sixteen participants documented their daily experiences through photography, engaged in photo-discussions to assess needs and identify opportunities, and developed a community-informed Call to Action. Four major themes emerged from the participants' photographs, discussions, and engagement: (1) mental health, (2) migration experiences and challenges, (3) stigma, discrimination, and resiliency, and (4) impact of the COVID-19 pandemic. Through active community engagement, a Call to Action was developed. A binational advisory committee of decision makers and scholars reviewed a set of recommendations to better respond to the needs of TWC in the U.S.-Mexico Border. Photovoice served as an empowerment tool for TWC to assess the myriad of syndemic conditions, including mental health, stigma, discrimination and COVID-19, affecting them daily and identify initiatives for change.

"It Made Me so Vulnerable": Victim-blaming and Disbelief of Child Sexual Abuse as Triggers of Social Exclusion Leading Women to Homelessness

Although the association between child sexual abuse (CSA) and homelessness among women is well documented, few studies have investigated this topic from a feminist standpoint, examining the impact of sociocultural factors such as rape culture. Based on a qualitative life course approach, individual interviews were conducted with 21 women who experienced both CSA and homelessness. Participants were between 29 to 60 years old (M = 45 years of age). Analyses revealed that CSA disclosure experiences were characterized by victim-blaming and disbelief. Women's traumatic experiences were further aggravated by these types of reactions. Finally, CSA and negative social reactions to women's disclosures of CSA were perceived as the onset of social exclusion, which lead to their homelessness. This study shows how traumatic CSA experiences and negative social reactions to their disclosure can both contribute to social exclusion and isolation, and to homelessness through the internalization of rape myths. These findings support the importance of focusing on CSA prevention to reduce social exclusion and homelessness.

Providing Affirmative Care to Transgender and Gender Diverse Youth: Disparities, Interventions, and Outcomes

PURPOSE OF REVIEW

This paper reviews the evolving body of research on the mental health of transgender and gender diverse (TGD) youth. Minority stress experiences in families, schools, and the community impact the health and well-being of this population due to experiences of stigma, discrimination, and rejection. Poor healthcare access and outcomes may be compounded in youth with intersectional identities.

RECENT FINDINGS

There is increasing evidence that gender-affirming interventions improve mental health outcomes for TGD youth. TGD youth report worse mental health outcomes in invalidating school and family environments and improved outcomes in affirming climates. TGD youth experience significant healthcare disparities, and intersectional clinical approaches are needed to increase access to affirmative care. Providers can best support TGD youth by considering ways they can affirm these youth in their healthcare settings, and helping them access support in schools, family systems, and communities. Understanding the intersection of multiple minority identities can help providers address potential barriers to care to mitigate the health disparities seen in this population.

Overview of Factors Associated with HIV Viral Load Suppression in Transgender Women

BACKGROUND

Transgender women face a significantly higher HIV burden than their cisgender counterparts around the world with worse treatment outcomes in almost all categories.

CONTENT

A mini-review of the available literature discussing HIV risk and factors associated with HIV viral load suppression in transgender women.

SUMMARY

This review discusses the disparities transgender women face that contribute to both of these factors including race as well as social determinants of health and how they affect the HIV treatment cascade in this population.