Risk for HIV and unprotected sexual behavior in male primary partners of transgender women

Enhanced Cohort Methods for HIV Research and Epidemiology (ENCORE): Protocol for a Nationwide Hybrid Cohort for Transgender Women in the United States

BACKGROUND

In the United States, transgender women are disproportionately impacted by HIV and prioritized in the national strategy to end the epidemic. Individual, interpersonal, and structural vulnerabilities underlie HIV acquisition among transgender women and fuel syndemic conditions, yet no nationwide cohort monitors their HIV and other health outcomes.

OBJECTIVE

Our objective is to develop a nationwide cohort to estimate HIV incidence, identify risk factors, and investigate syndemic conditions co-occurring with HIV vulnerability or acquisition among US transgender women. The study is informed by the Syndemics Framework and the Social Ecological Model, positing that stigma-related conditions are synergistically driven by shared multilevel vulnerabilities.

METHODS

To address logistical and cost challenges while minimizing technology barriers and research distrust, we aim to establish a novel, hybrid community hub-supported digital cohort (N=3000). The digital cohort is the backbone of the study and is enhanced by hubs strategically located across the United States for increased engagement and in-person support. Study participants are English or Spanish speakers, are aged ≥18 years, identify as transgender women or along the transfeminine spectrum, reside in 1 of the 50 states or Puerto Rico, and do not have HIV (laboratory confirmed). Participants are followed for 24 months, with semiannual assessments. These include a questionnaire and laboratory-based HIV testing using self-collected specimens. Using residential zip codes, person-level data will be merged with contextual geolocated data, including population health measures and economic, housing, and other social and structural factors. Analyses will (1) evaluate the contribution of hub support to the digital cohort using descriptive statistics; (2) estimate and characterize syndemic patterns among transgender women using latent class analysis; (3) examine the role of contextual factors in driving syndemics and HIV prevention over time using multilevel regression models; (4) estimate HIV incidence in transgender women and examine the effect of syndemics and contextual factors on HIV incidence using Poisson regression models; and (5) develop dynamic, compartmental models of multilevel combination HIV prevention interventions among transgender women to simulate their impact on HIV incidence through 2030.

RESULTS

Enrollment launched on March 15, 2023, with data collection phases occurring in spring and fall. As of February 24, 2024, a total of 3084 individuals were screened, and 996 (32.3%) met the inclusion criteria and enrolled into the cohort: 2.3% (23/996) enrolled at a hub, and 53.6% (534/996) enrolled through a community hub-supported strategy. Recruitment through purely digital methods contributed 61.5% (1895/3084) of those screened and 42.7% (425/996) of those enrolled in the cohort.

CONCLUSIONS

Study findings will inform the development of evidence-based interventions to reduce HIV acquisition and syndemic conditions among US transgender women and advance efforts to end the US HIV epidemic. Methodological findings will also have critical implications for the design of future innovative approaches to HIV research.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59846.

Practices and preferences for HIV testing and treatment services amongst partners of transgender women in Lima, Peru: An exploratory, mixed methods study

BACKGROUND

In Peru, one-third of transgender women (TW) are estimated to be living with HIV. While TW are recognized as a priority population, their sexual partners are an at-risk hidden population with unmet needs for HIV services. We conducted a study examining the practices and preferences for HIV services among partners of transgender women (PTW), as compared to TW, to better understand the needs of PTW and inform HIV service delivery for them in Peru.

METHODS

Between July-October 2022 we conducted a cross-sectional mixed methods study among PTW and TW in Lima, Peru. Using an explanatory sequential design, we administered online surveys to PTW (n = 165) and TW (n = 69), then interviewed a subset of participants (n = 20: 16 PTW, 4 TW). We quantitatively and qualitatively described PTW practices/perspectives on HIV testing and treatment and compared them to TW practices/preferences; we also compared practices/preferences among PTW based on their relationship with TW.

RESULTS

Overall, PTW and TW shared similar experiences and preferences for HIV testing/treatment, but fewer PTW reported accessing non-traditional HIV testing options and PTW expressed less strong preferences for HIV services. PTW practices/preferences varied by type of relationship with TWs. Surveys and interviews highlighted a need to prioritize efficiency for HIV testing, eliminate gender/sexuality-based discrimination in healthcare settings, increase privacy when delivering HIV services, and increase awareness of pre-exposure prophylaxis.

CONCLUSION

PTW identified many aspects related to the location, convenience, and privacy of HIV services as important. Next steps could include a discrete choice experiment to further clarify priorities for HIV services for PTW in Peru.

Men's Sexual Interest in Feminine Trans Individuals across Cultures

Feminine trans individuals (i.e., individuals who were assigned male at birth but who have a feminine gender presentation and identity) are present in many cultures. In some cultures, these individuals identify as (trans) women. Many of these individuals undergo medical treatments to feminize their bodies (e.g., breast augmentation), but most do not undergo vaginoplasties and therefore have penises. In many non-Western cultures, feminine trans individuals identify as a non-binary gender (i.e., neither man, nor woman). Many of these individuals do not surgically augment their bodies. Across cultures, some men express sexual interest in feminine trans individuals. Are manifestations of sexual interest in feminine trans individuals consistent across Western and non-Western cultural settings? Our review suggests that, across cultures, most of these men are also sexually attracted to cisgender individuals. Many are sexually attracted to cisgender women or to cisgender members of both sexes. A small subset is sexually attracted to cisgender men. Men who are sexually interested in feminine trans individuals commonly report being primarily insertive during anal sex. Additionally, they tend to report that their sexual interest in these individuals is motivated by attraction to femininity or to the combination female- and male-typical characteristics.

Exploring HIV risk behavior and sexual/gender identities among transgender women and their sexual partners in Peru using respondent-driven sampling

HIV prevalence is high among transgender women, but little is known about cisgender men who have sex with transgender women (MSTW). The objective of this study was to investigate characteristics and behavior of MSTW compared to transgender women and men who have sex with men (MSM) using a modified respondent-driven sampling design. Seed participants completed a survey and invited up to three sex partners. Forward recruitment continued in waves through the referral of sex partners. Cross-sectional data were assessed using mixed effects models. From February to July 2018, 479 participants in Lima, Peru enrolled (n = 199 transgender women, n = 196 MSTW, and n = 45 MSM). MSTW behavior and identity differed significantly from that of transgender women and MSM. MSTW primarily identified as bisexual (69%) or heterosexual (15%) and only 6% reported male partners. Insertive condomless anal intercourse was reported by 61% of MSTW; 46% did not know their HIV serostatus. Compared to MSTW without male partners, those with recent male partners were more likely to sell sex (OR 15.7, 95% CI 4.1-60.5), and report condomless receptive anal intercourse (OR 89.0, 95% CI 19.1-414.8). This evidence suggests that MSTW are a distinct population from MSM, and highlights the critical need to include MSTW in HIV research and interventions.

In Their Own Words: How Trans Women Acquired HIV Infection

Despite high HIV prevalence, the reasons trans women acquire HIV are not well understood. Trans women are often mis-classified or aggregated with men who have sex with men (MSM) in epidemiologic studies and HIV surveillance data. Trans women enrolled in the 2019/2020 National HIV Behavioral Surveillance Study in San Francisco were asked an open-ended question about how they were infected with HIV. The most common responses were "Sex with a straight cisgender man partner when the respondent identified as a trans woman" (43.0%); "Sexual assault" (13.9%); "Injection drug use (IDU)" (10.1%); "IDU or sexual contact" (7.6%) and "Sex with a partner who injected drugs" (7.6%). Sex with a cisgender man partner prior to identifying as a trans women (MSM contact) was not mentioned by any respondent. HIV prevention strategies targeting MSM will fail to reach trans women and many of their cisgender men partners.

Brief Report: Self-Reported Knowledge of HIV Status Among Cisgender Male Sex Partners of Transgender Women in Lima, Peru

BACKGROUND

Knowledge of HIV status is a critical first step in the HIV care cascade. Cisgender male sex partners of transgender women (MSTW) are at a disproportionately high risk of HIV, but little is known about their access to HIV testing or knowledge of HIV status.

METHODS

We used cross-sectional data from a respondent-driven sampling study to analyze self-reported HIV status and predictors of knowledge of HIV status among MSTW in Lima, Peru. Mixed-effects models were used to generate crude and adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) for the association between knowledge of HIV status and predictors of interest, including sociodemographics and recent sexual behavior.

RESULTS

From February to July 2018, 196 eligible MSTW enrolled, of which 90 (46%) reported not knowing their HIV status. Recent casual or 1-time partners were reported by 84% of MSTW and 54% reported purchasing sex. In adjusted analyses, MSTW participants were less likely to know their HIV status if they reported buying sex (aPR 0.43, 95% CI: 0.32 to 0.59) or reported ≥16 recent sex partners compared with ≤5 partners [aPR 0.32, (0.20 to 0.50)]. Those who reported male sex partners were 80% more likely to know their status [aPR 1.80, (1.33 to 2.44)].

CONCLUSIONS

Reported knowledge of HIV status was low among MSTW in Lima, and unknown HIV status was associated with behaviors linked to HIV acquisition. MSTW who reported male partners were more likely to know their status, potentially indicating that HIV testing is more accessible to men who have sex with men.

HIV transmission patterns among transgender women, their cisgender male partners, and cisgender MSM in Lima, Peru: A molecular epidemiologic and phylodynamic analysis

BACKGROUND

Transgender women (TW) in Peru are disproportionately affected by HIV. The role that cisgender men who have sex with TW (MSTW) and their sexual networks play in TW's risk of acquiring HIV is not well understood. We used HIV sequences from TW, MSTW, and cisgender men who have sex with men (MSM) to examine transmission dynamics between these groups.

METHODS

We used HIV-1 pol sequences and epidemiologic data collected through three Lima-based studies from 2013 to 2018 (n = 139 TW, n = 25 MSTW, n = 303 MSM). We identified molecular clusters based on pairwise genetic distance and used structured coalescent phylodynamic modeling to estimate transmission patterns between groups.

FINDINGS

Among 200 participants (43%) found in 62 clusters, the probability of clustering did not differ by group. Both MSM and TW were more likely to cluster with members of their own group than would be expected based on random mixing. Phylodynamic modeling estimated that there was frequent transmission from MSTW to TW (67·9% of transmission from MSTW; 95%CI = 52·8-83·2%) and from TW to MSTW (76·5% of transmissions from TW; 95%CI = 65·5-90·3%). HIV transmission between MSM and TW was estimated to comprise a small proportion of overall transmissions (4·9% of transmissions from MSM, and 11·8% of transmissions from TW), as were transmissions between MSM and MSTW (7·2% of transmissions from MSM, and 32·0% of transmissions from MSTW).

INTERPRETATION

These results provide quantitative evidence that MSTW play an important role in TW's HIV vulnerability and that MSTW have an HIV transmission network that is largely distinct from MSM.

Stress and coping amongst cisgender male partners of transgender women

The cisgender male partners of transgender women have received little attention beyond their sexual behaviour. This is an issue, as marginalisation and social environments determine sexual behaviour and subsequent health outcomes. This article assesses in-depth interviews with cisgender male partners of transgender women in Atlanta and Baltimore, USA. Analysis suggests men experience minority stress that may lead to ameliorative coping processes such as coming out and LGBTQ group affiliation. Specifically, the interviews identify stressful, marginalising reactions from family and friends concerning men's relationships with transgender women. In turn, men described uniquely supportive ties to LGBTQ communities, which included ongoing relationships with transgender women, having close sexual and gender minority friends, and occupying notably LGBTQ spaces such as Pride events. The LGBTQ social connectivity of the cisgender male partners of transgender women could prove critical to future targeted HIV prevention efforts.

Heterosexual Cisgender Men Partnered with Transgender Women Exhibit Higher HIV/STI Sexual Risk than Their Gay, Bisexual, and Queer Counterparts: Findings from a U.S.-Based Convenience Sample Recruited Online

Cisgender men are frequently vectors for HIV transmission among transgender women. Despite this, the correlates of sexual risk among these men remain under-examined. The purpose of the present study was to explore potential differences in relationship characteristics, sexual risk-taking, and risk-reduction strategies among cisgender men partnered with transgender women. The study utilized secondary screening data provided by adult cis men who reported being in a primary relationship with a trans woman (N = 710). Gay men (18%) were comparatively older, and most likely to report both HIV seropositivity and committed pairings. Heterosexual men (14%) were more likely to report exchange sex, briefer relationships, extra-dyadic sex, lesser serostatus awareness or PrEP uptake. Queer men (7%) were youngest, and most likely to access PrEP. Heterosexual cis men with trans women partners may be subject to unique socio-cultural drivers of sexual risk, such as heteronormative pressures and relationship stigma.

Consideration of Human Immunodeficiency Status in Patients Seeking Facial Feminization Surgery

ABSTRACT

Facial feminization surgery (FFS) with its proven safety and efficacy has become a mainstay surgical approach for those desiring gender-specific perceived feminine facial aesthetics. To date, specific characteristics of patients seeking FFS have been limited, with no studies investigating the role of the Human Immunodeficiency Virus (HIV) on FFS outcomes. The potential clinical implications of HIV and more specifically HIV-associated lipodystrophy, which can cause facial lipoatrophy, require further investigation. Given the importance of midface projection in feminizing the face, the authors aimed to investigate any associations HIV or Highly Active Antiretroviral Therapy may have on outcomes, including clinical consequences of facial lipoatrophy. The authors performed a retrospective chart review of all patients with a diagnosis of gender dysphoria referred to the senior author (EDR) for FFS between 2017 and 2020. Patients were grouped based on HIV status and demographics, history, and outcomes were assessed. Seventy-seven patients were included, with 28 patients (36.4%) having a diagnosis of HIV. A total of 25 (32.5%) and 23 (29.9%) patients underwent malar fat grafting and cheek implants, respectively. No significant difference was found between HIV-positive and HIV-negative patients when looking at the use of malar fat grafting, cheek implants, age, or complication rates. To the best of our knowledge, this study presents the largest cohort of HIV status assessment of FFS patients to date. Future studies, particularly on the long-term outcomes, are warranted, as is continued information sharing among providers and centers performing FFS, in order to continue advancing the literature and subsequently patient care.

Self-Identity, Beliefs, and Behavior Among Men Who Have Sex with Transgender Women: Implications for HIV Research and Interventions

While transgender women have been identified as a global priority population for HIV prevention and treatment, little is known about the cisgender male partners of transgender women, including their sexual behavior and HIV prevalence. Previous research has suggested that these male partners have varied identities and sexual behavior, which make identifying and engaging them in research difficult. This paper describes interviews conducted with fifteen cisgender men who reported recent sexual activity with transgender women in Lima, Peru. The purpose of this research was to explore how these men reported their identities and sexual behavior, to better understand how they would interact with HIV outreach, research, and care. The major themes were sexual orientation and identity; view of transgender partners; social ties to transgender women and other men with transgender women partners; disclosure of relationships; HIV knowledge and risk perception; and attitudes toward interventions. We found that language used to assess sexual orientation was problematic in this population, due to lack of consistency between orientation and reported behavior, and unfamiliarity with terms used to describe sexual orientation. In addition, stigma, lack of knowledge of HIV prevention methods, and fear of disclosure of sexual behavior were identified as barriers that could impact engagement in HIV research, prevention, and care. However, participants reported social relationships with both transgender women and other men who have transgender partners, presenting possible avenues for recruitment into HIV research and healthcare services.

HIV Prevention Among Cisgender Men Who have Sex with Transgender Women

Cisgender men who have sex with transgender women face elevated risk for HIV, yet are understudied in prevention research. We conducted in-depth interviews with 19 men who have sex with transgender women in Baltimore, Maryland and Atlanta, Georgia to explore perspectives on HIV prevention. Participants used several strategies to reduce HIV risk: condoms, frequent HIV testing, communication about HIV status with partners, and limiting the types of sex acts performed. While condom use was inconsistent, it was preferred over pre-exposure prophylaxis, in part due to medical distrust. HIV self-testing was generally viewed unfavorably. Although most participants were referred to the study by their transgender women partners, they recommended reaching other men who have sex with transgender women in bars, nightclubs, online, and through social media. HIV prevention interventions should be inclusive of the needs and experiences of men who have sex with transgender women.

A Novel Adaptation of Peer Health Navigation and Contingency Management for Advancement Along the HIV Care Continuum Among Transgender Women of Color

Transgender women, particularly racial/ethnic minority transgender women, evidence disproportionately high rates of untreated HIV infection and disproportionately low rates of HIV viral suppression. The Alexis Project was a combined peer health navigation (PHN) and contingency management (CM) intervention that targeted HIV milestones associated with advancement along the HIV care continuum. From February 2014 through August 2016, 139 transgender women of color (TWOC) enrolled and received unlimited PHN sessions and an escalating CM rewards schedule for confirmed achievement of both behavioral (e.g., HIV care visits) and biomedical (e.g., viral load reductions and achieved/sustained viral suppression) HIV milestones. Results demonstrated that increased attendance to PHN sessions was associated with significant achievement of both behavioral (coef. range 0.12-0.38) and biomedical (coef. = 0.10) HIV milestones (all p ≤ 0.01); 85% were linked to HIV care, and 83% who enrolled detectable and achieved the minimum 1 log viral load reduction advanced to full viral suppression. The combined PHN and CM intervention successfully promoted advancement along the HIV Care Continuum, with particularly robust effects for behavioral HIV milestones.

Discrimination and Risky Sexual Behavior, Substance Use, and Suicidality among Transgender Individuals

Transgender identities are becoming increasingly common in the United States, and existing research provides ample evidence that risky sexual behaviors, substance use, and suicidality are prevalent experiences among transgender persons. Yet, prior research provides little insight into understanding the specific mechanisms that may promote deviant outcomes among transgender persons. Drawing from an aspect of general strain theory, the goal of this study is to examine the extent to which transwomen and transmen vary in risky sexual behaviors, substance use, and suicidality, and to explore the degree to which discrimination - as a source of strain - plays a role within this process. An analysis of data from transgender individuals from the Virginia Transgender Health Initiative Study (THIS) demonstrates that transwomen and transmen significantly diverge in self-reported risky sexual behaviors, substance use, and suicidality. Greater discrimination based on transgender identity relates to significantly increased odds of suicidality and elevated levels of substance use, but does not relate to risky sexual behavior. Overall, effects of discrimination on each outcome are similar for both transwomen and transmen.

Couples-based approach to HIV prevention for transgender women and their partners: study protocol for a randomised controlled trial testing the efficacy of the 'It Takes Two' intervention

INTRODUCTION

HIV transmission and acquisition risk among transgender women is particularly high in the context of primary partnerships. This project extends a previous pilot couples-focused HIV intervention programme, which was shown to be feasible, acceptable and promising in reducing sexual risk behaviour among transgender women and their partners. This randomised controlled trial (RCT) tests the efficacy of this culturally sensitive HIV prevention programme for HIV-serodiscordant and HIV-negative seroconcordant transgender women and their partners.

METHODS AND ANALYSIS

To finalise the protocol for trial, we used qualitative methods to hone eligibility criteria, refine the intervention and control manuals, and name and brand the intervention ('It Takes Two'). The RCT investigates the effects of the It Takes Two intervention on Composite Risk for HIV (CR-HIV) among 100 couples. CR-HIV is a binary indicator of couple HIV risk using validated measures of sexual behaviour, pre-exposure prophylaxis use among HIV-negative participants and viral suppression among participants living with HIV. Using a two-arm RCT, we will examine intervention effects on CR-HIV at 12-month follow-up comparing transgender women and their partners randomised to the intervention versus control (HIV prevention information only).

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the University of California, San Francisco (19-28624) and the University of Michigan (HUM00147690) Institutional Review Boards. Participants provide informed consent before taking part of the study activities. Results will be published in peer-reviewed journals and presented at scientific conferences. We will make our results available to the community of researchers and general public interested in transgender health to avoid unintentional duplication of research, as well as to others in the health and social services community, including LGBT community-based organisations, AIDS service organisations and other transgender-serving organisations. The full de-identified dataset and codebook will be shared at the University of Michigan Digital Repository.

TRIAL REGISTRATION NUMBER

NCT04067661.

HIV Testing and Linkage to Care Among Transgender Women Who Have Sex with Men: 23 U.S. Cities

Transgender women face unique barriers to HIV testing and linkage to care. This article describes the results of a national testing initiative conducted by 36 community-based and other organizations using a variety of recruitment and linkage-to-care strategies. A total of 2191 HIV tests were conducted with an estimated 1877 unique transgender women, and 4.6% of the transgender women had confirmed positive results. Two thirds (66.3%) were linked to care within approximately three months of follow-up, and the median time to linkage was 7 days. Transgender women tested at clinical sites were linked to care faster than those tested at non-clinical sites (median: 0 vs. 12 days; P = .003). Despite the use of a variety of linkage-to-care strategies, the proportion of transgender women successfully linked to care was below national goals. Tailored programs and interventions are needed to increase HIV testing and improve timely linkage to care in this population.

Understanding disclosed and cryptic HIV transmission risk via genetic analysis: what are we missing and when does it matter?

PURPOSE OF REVIEW

To discuss the recent HIV phylogenetic analyses examining HIV transmission patterns among and within risk groups.

RECENT FINDINGS

Phylodynamic analysis has recently been applied to multiple HIV outbreaks among people who inject drugs to determine whether HIV transmission is ongoing. Large-scale analyses of datasets of HIV sequences collected for drug-resistance testing provide population-level insights into transmission patterns. One focus across world regions has been to investigate whether age-disparity is a driver of HIV transmission. In sub-Saharan Africa, researchers have examined transmission between heterosexuals and MSM and between high prevalence fishing communities and inland communities. In the US and the UK, cryptic risk groups such as nondisclosed MSM and the partners of transgender women are increasingly being uncovered based on their position in densely sampled molecular transmission networks.

SUMMARY

Analysis of HIV genetic sequence can resolve viral transmission patterns between risk groups at unprecedented scales and levels of detail. Future research should focus on understanding the effect of missing data on inferences and the biases of different methods. Uncovering groups and patterns obscured from traditional epidemiolocal analyses is exciting but should not compromise the privacy of the groups in question.

Characterizing Men Who Have Sex with Transgender Women in Lima, Peru: Sexual Behavior and Partnership Profiles

HIV prevalence is high among transgender women (TW), but how HIV is transmitted to this population is not well understood. This analysis aims to characterize sexual partners of TW (PTW) to understand how their behavior contributes to HIV risk among TW. We examined baseline data from TW, PTW, and men who have sex with men (MSM) from a treatment-as-prevention study in Lima, Peru. Individual and partnership characteristics were compared across groups, and Poisson regression was used to calculate prevalence ratios for associations between sexual concurrency and potential correlates. We found that 81% of PTW had no cisgender male partners. Prevalence of alcohol dependency, concurrency, and condomless anal intercourse was high and HIV testing was low compared to the other groups. Our results suggest that PTW are a distinct population from MSM and TW, engage in behavior associated with HIV transmission, and are likely not well reached by HIV prevention interventions.

Understanding HIV risk and vulnerability among cisgender men with transgender partners

In the HIV pandemic, cisgender (ie, non-transgender) men with transgender partners are an underserved population. Complexities of sexuality and gender affect HIV vulnerability for this group, including not identifying with conventional sexual orientation categories (eg, bisexual, heterosexual, or gay) and having attractions based on gender role or expression rather than genital anatomy. Only one HIV prevention interventional study in this population was identified, and one study that assessed the perceived acceptability of an intervention. We found no data for interventions using pre-exposure prophylaxis, interventions for cisgender men with transgender men partners, or cisgender men with casual or transactional sexual partnerships with transgender people. Cisgender men with transgender partners are not easily categorised using traditional HIV risk categories. Additional research is needed to understand stigma and other structural drivers of HIV vulnerability, sexual networks and practices, substance use patterns, and biomedical prevention interest and uptake for this group. Studies that use an intersectional lens and syndemic framework could offer key insights.

Social Network Organization, Structure, and Patterns of Influence Within a Community of Transgender Women in Lima, Peru: Implications for Biomedical HIV Prevention

Understanding social network structures can contribute to the introduction of new HIV prevention strategies with socially marginalized populations like transgender women (TW). We conducted 20 semi-structured interviews and four focus groups (n = 32) with TW from selected social networks in Lima, Peru between May and July, 2015. Participants described layers of social influence from diverse actors in their social networks. The majority identified a close relative as their primary social support, with whom they confided secrets but avoided issues of transgender identity, sexuality, and sex work. Participants described close circles of TW friends with whom they shared information about gender identity, body modification, and sexual partners, but avoided issues like HIV. Community leadership included political leaders (who advocated for transgender rights) as well as social leaders (who introduced TW to hormone therapy, body modification, and commercial sex). Detailed analysis of TW social networks can contribute to implementation and acceptability of new HIV prevention technologies.

Relationship Stigma and HIV Risk Behavior Among Cisgender Men Partnered with Transgender Women: The Moderating Role of Sexual Identity

Cisgender men partnered with transgender women are an understudied and hard to engage population in HIV prevention efforts. Relationship stigma-the anticipation of negative treatment based on having a relationship with a member of a stigmatized group-has been linked to adverse health behaviors, but it remains unclear whether different sources of relationship stigma (i.e., family, friends, and the general public) are associated with HIV risk behaviors and whether these associations may vary by men's sexual identities (e.g., gay, bisexual, and heterosexual). The current study examined associations between relationship stigma and HIV risk behaviors and whether these associations were moderated by sexual identity. We recruited a convenience sample of 185 cisgender men in primary partnerships with transgender women to participate in a one-time survey. Gay identified men reported greater levels of relationship stigma from the general public compared with heterosexually identified men. In multivariable models, higher levels of relationship stigma from the public were associated with increased odds of engaging in drug use prior to having condomless sex and receiving an STI diagnosis in the last 30 days. There were significant interaction effects such that higher levels of relationship stigma from the public were associated with both indicators of HIV risk for gay identified men but not for heterosexually identified men. Findings support the importance of HIV prevention approaches accounting for relationship stigma from the general public and the diverse sexual identities of men partnered with transgender women when seeking to increase linkage to and engagement in HIV prevention services, including biomedical prevention strategies.

American Cohort to Study HIV Acquisition Among Transgender Women in High-Risk Areas (The LITE Study): Protocol for a Multisite Prospective Cohort Study in the Eastern and Southern United States

BACKGROUND

In the United States, transgender women (TW) are disproportionately burdened by HIV infection. Cohort studies are needed to evaluate factors driving HIV acquisition among TW over time. These will require implementation strategies that are acceptable to the TW community and feasible to implement.

OBJECTIVE

This study aims to investigate the rate and correlates of HIV acquisition and other health outcomes among TW in eastern and southern United States.

METHODS

LITE is a multisite prospective cohort in 6 eastern and southern US cities, which will be followed across 24 months of technology-enhanced biobehavioral follow-up. Adult TW, regardless of HIV status, are recruited via convenience sampling (eg, peer referrals, social media, and dating apps). Participants are enrolled in a baseline study visit, complete a sociobehavioral survey, and test for HIV and sexually transmitted infections. Participants who are not living with HIV at baseline are offered enrollment into the cohort (N=1100); follow-up assessments occur quarterly.

RESULTS

Cohort assembly was informed by synchronous Web-based focus group discussions with TW (n=41) and by continuing engagement with community advisory board members from each site. Enrollment launched in March 2018. The study is underway in the Atlanta; Baltimore; Boston; Miami; New York City; and Washington, DC, metro areas. As of March 2019, 795 TW completed a baseline visit (mean age 35 years). The majority of the participants are racial/ethnic minorities, with 45% of the TW identifying as black and 28% of the TW identifying as Hispanic/Latinx. More than one-quarter (28%) of the TW are living with HIV infection (laboratory-confirmed). Online recruitment methods support engagement with TW, although peer referral and referral through trusted health facilities and organizations remain most effective.

CONCLUSIONS

This study is responsive to increasing research interest in technology-enhanced methods for cohort research, particularly for hard-to-reach populations. Importantly, the diversity of literacy, technology use, and overall socioeconomic situations in this sample of TW highlights the need to leverage technology to permit a flexible, adaptive methodology that enhances engagement of potential participants living in marginalized contexts while still ensuring rigorous and sound study design.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14704.

The HIV-Related Risk Factors of the Cisgender Male Sexual Partners of Transgender Women (MSTW) in the United States: A Systematic Review of the Literature

Cisgender male sexual partners of transgender women (MSTW) may be at risk for HIV infection. We performed a review of HIV risk factors among MSTW. We searched PubMed database for empirical quantitative U.S.-based studies that included MSTW and were published in English up to November 2018. Of the 4,680 total papers identified, 6 unique studies were included. MSTW displayed heterogeneity in HIV risk factors (e.g., condom use, sexual partners, sexual positions, substance use). In our exploratory meta-analyses, estimated prevalence of self-reported HIV positive status among MSTW was 30.6%, HIV unknown status was 8.8%, and self-reported condomless anal sex with transgender women was 46.1%. Reports of sexual health communication with transgender women was low. More research on MSTW populations is needed to better understand this population's unique needs in the context of recent advancements in HIV prevention.

A Multilevel Analysis of Social Network Characteristics and Technology Use on HIV Risk and Protective Behaviors Among Transgender Women

This study examined the empirical structure (i.e., size, density, duration) of transgender women's social networks and estimated how network alters' perceived HIV risk/protective behaviors influenced transgender women's own HIV risk/protective behaviors. From July 2015 to September 2016, 271 transgender women completed surveys on sociodemographic characteristics, HIV risk/protective behaviors, and social networks. Hierarchical generalized linear models examined the associations of social network alter member data 'nested' within participant data. Analyses revealed that social network factors were associated with HIV risk/protective behaviors, and that the gender identity of the alters (cisgender vs. transgender), and social network sites and technology use patterns ("SNS/tech") moderated these associations. Among network alters with whom the participant communicated via SNS/tech, participants' HIV risk behavior was positively associated with alters' HIV risk behavior (cisgender alters aOR 4.10; transgender alters aOR 5.87). Among cisgender alters (but not transgender alters) with whom the participant communicated via SNS/tech, participants' HIV protective behavior was positively associated with alters' HIV protective behavior (aOR 8.94).

HIV transmission networks among transgender women in Los Angeles County, CA, USA: a phylogenetic analysis of surveillance data

BACKGROUND

Transgender women are among the groups at highest risk for HIV infection, with a prevalence of 27·7% in the USA; and despite this known high risk, undiagnosed infection is common in this population. We set out to identify transgender women and their partners in a molecular transmission network to prioritise public health activities.

METHODS

Since 2006, HIV protease and reverse transcriptase gene (pol) sequences from drug resistance testing have been reported to the Los Angeles County Department of Public Health and linked to demographic data, gender, and HIV transmission risk factor data for each case in the enhanced HIV/AIDS Reporting System. We reconstructed a molecular transmission network by use of HIV-TRAnsmission Cluster Engine (with a pairwise genetic distance threshold of 0·015 substitutions per site) from the earliest pol sequences from 22 398 unique individuals, including 412 (2%) self-identified transgender women. We examined the possible predictors of clustering with multivariate logistic regression. We characterised the genetically linked partners of transgender women and calculated assortativity (the tendency for people to link to other people with the same attributes) for each transmission risk group.

FINDINGS

8133 (36·3%) of 22 398 individuals clustered in the network across 1722 molecular transmission clusters. Transgender women who indicated a sexual risk factor clustered at the highest frequency in the network, with 147 (43%) of 345 being linked to at least one other person (adjusted odds ratio [aOR] 2·0, p=0·0002). Transgender women were assortative in the network (assortativity 0·06, p<0·001), indicating that they tended to link to other transgender women. Transgender women were more likely than expected to link to other transgender women (OR 4·65, p<0·001) and cisgender men who did not identify as men who have sex with men (MSM; OR 1·53, p<0·001). Transgender women were less likely than expected to link to MSM (OR 0·75, p<0·001), despite the high prevalence of HIV among MSM. Transgender women were distributed across 126 clusters, and cisgender individuals linked to one transgender woman were 9·2 times more likely to link to a second transgender woman than other individuals in the surveillance database. Reconstruction of the transmission network is limited by sample availability, but sequences were available for more than 40% of diagnoses.

INTERPRETATION

Clustering of transgender women and the observed tendency for linkage with cisgender men who did not identify as MSM, shows the potential to use molecular epidemiology both to identify clusters that are likely to include undiagnosed transgender women with HIV and to improve the targeting of public health prevention and treatment services to transgender women.

FUNDING

California HIV and AIDS Research Program and National Institutes of Health-National Institute of Allergy and Infectious Diseases.

Characterizing HIV risk among cisgender men in Latin America who report transgender women as sexual partners: HIV risk in Latin America men

Cisgender men (CM) who report transgender women (TW) as sexual partners are an understudied population in the HIV epidemic in Latin America. The current study sought to characterize this group in a 2012 cross-sectional online survey of Latin American CM who were members of a sexual networking website for men who have sex with men (N = 11,847). Multivariable logistic regression models were fit to estimate demographic, behavioral, and psychosocial correlates of having a TW sexual partner and engaging in condomless sex. Overall, 0.9% (n = 106) reported a TW sexual partner in the last 12 months; of these, 76.4% (n = 81) reported condomless sex in the last three months. Identifying as bisexual or heterosexual compared to gay, and specifying a versatile sexual role preference compared to insertive were associated with reporting a recent TW sex partner (all p < 0.05). HIV-negative serostatus, lifetime STI history, and alcohol dependence were associated with recent condomless sex (all p < 0.05). CM with TW sexual partners have distinct HIV-related vulnerabilities. Future research is needed to understand CM who report TW sexual partners, including their sexual preferences and practices, sexual networks, exposure to stigma, biomedical prevention interest and uptake, and acceptability of integrating alcohol abuse screening into sexual health services.

Optimizing HIV prevention and care for transgender adults

: Transgender women have recently been acknowledged as a unique and important risk group in HIV research and care. Although transgender men also face specific problems related to HIV infection, less is known about the risk behaviours and HIV prevalence of this important population. This article highlights key issues relating to the epidemiology, prevention, treatment and management of complications of HIV infection in transgender adults living with HIV, and explores future areas for HIV-related research, with the ultimate goal of improving healthcare provision and quality of life for transgender persons worldwide.

"Unspoken Agreements": Perceived Acceptability of Couples HIV Testing and Counseling (CHTC) Among Cisgender Men with Transgender Women Partners

Transgender women (TW) are one of the highest risk groups for HIV infection globally; however, the HIV testing needs of their cisgender (non-transgender) male partners remain largely unknown. This study sought to examine the perceived acceptability of couples HIV testing and counseling (CHTC) for TW-male dyads from the perspective of cisgender men who partner with TW. Between September 2016 and June 2017, 19 cisgender men (mean age = 40.1, SD = 12.8) who currently have, or have ever had a TW partner completed an in-depth semi-structured phone interview and brief survey to gather data on acceptability of CHTC, as well as perceived barriers and facilitators to CHTC for TW-male couples. Qualitative data were thematically analyzed and integrated with survey data. Acceptability of CHTC was high in the sample (89.5%) but was complex and largely contingent on: (1) monogamy and commitment as critical precursors to CHTC acceptability; (2) risk perception and level of comfort with CHTC; (3) understandings of sexual agreements; and (4) personal relationships versus other TW-male relationships. Findings have implications for culturally-adapting and implementing CHTC in real-world settings for TW-male couples, as well as for meeting the individual HIV testing needs of cisgender men who partner with TW.

The impact and cost-effectiveness of combined HIV prevention scenarios among transgender women sex-workers in Lima, Peru: a mathematical modelling study

Background

HIV incidence remains high among transgender women in Lima, Peru, most of whom report sex work. On the basis of a stakeholder analysis and health system capacity assessment, we designed a mathematical model to guide HIV programmatic planning among transgender women sex workers (TWSW) in Lima.

Methods

Using a deterministic compartmental model, we modelled HIV transmission among TWSW, their stable partners, and their clients to estimate the impact and cost-effectiveness of combinations of interventions compared with the standard of care on reducing HIV incidence over a 10-year period. We simulated HIV transmission accounting for differences in sexual positioning in anal intercourse and condom use by partner type and fitted the model to HIV surveillance data using Latin hypercube sampling. The interventions we considered were 15% relative increase in condom use with clients and 10% relative increase with stable partners; increase in antiretroviral treatment (ART) coverage at CD4 count lower than 500 cells per mm³ and greater than or equal to 500 cells per mm³; and 15% pre-exposure prophylaxis (PrEP) coverage using generic and branded formulations. We considered a basic scenario accounting for current limitations in the Peruvian HIV services and an enhanced scenario assuming achievement of the UNAIDS 90–90-90 targets and general improvements in HIV services. The 50 best fits according to log-likelihood were used to give the minimum and maximum values of intervention effect for each combination. We used disability-adjusted life-years (DALYs) to measure the negative health outcomes associated with HIV infection that could be averted through the interventions investigated and calculated incremental cost-effectiveness ratios to compare their cost-effectiveness.

Findings

Under the basic scenario, combining the four interventions of increasing condom use with clients and stable partners, extending ART to people with CD4 count greater than or equal to 500 cells per mm³, and 15% PrEP coverage with generic drugs would avert 47% (range 27–51) of new infections in TWSW, their clients, and their stable partners over 10 years, with an incremental cost-effectiveness ratio of US$509 per DALY averted. Under the enhanced scenario, this strategy would avert 61% (44–64) of new infections among this population with an incremental cost-effectiveness ratio of $1003 per DALY averted. Under both scenarios, implementation of this strategy approaches or surpasses the 50% incidence reduction goal and would represent a cost-effective use of country resources if generic PrEP drugs are used. The total cost of implementing this strategy under the enhanced scenario would be approximately $1·2 million per year over 10 years, corresponding to 10% of the current Global Fund’s yearly contribution in Peru.

Interpretation

Investments in HIV services among TWSW in Lima would be cost-effective, even under stringent cost-effectiveness criteria when accounting for setting-specific resource constraints. Notable improvements in HIV testing rates, innovative interventions to increase condom use, and reduced PrEP costs will be key to achieving the 50% incidence reduction goal. Modelling studies incorporating stakeholders’ perspectives and health system assessments can bring added value to HIV policy making.

Composite Risk for HIV: A New Approach Towards Integrating Biomedical and Behavioral Strategies in Couples-Based HIV Prevention Research

A substantial number of new HIV infections among gay, bisexual, and other men who have sex with men and transgender women occurs in the context of primary partnerships. Given the diversity of risk reduction needs and various approaches available for reducing risk within couples, condomless sex is no longer the gold standard HIV outcome. We present a novel, comprehensive, and flexible Composite Risk for HIV (CR-HIV) approach for integrating evolving biomedical and behavioral HIV prevention strategies into couples-based HIV prevention intervention and survey research. We provide illustrative examples of the utility of the CR-HIV approach based on couples' HIV status.

Health and Well-Being of Cisgender, Transgender and Non-Binary Young People

Young transgender and non-binary individuals (TNBI) are exposed to situations of discrimination and have a greater risk of violence. The purpose of this study is to analyze which protective, violence and health and well-being factors have more influence on TNBI compared to cisgender people. The sample comprised 856 youth between 14 and 25 years old. A survey including questions about sociodemographic information and protective, violence and health and well-being factors was designed ad hoc for this study. The results show the non-binary group received the least support from family and friends, higher risk of suffering cyberbullying, and many feel isolated and unhappy. TNBI have suffered more verbal attacks both inside and outside their school and physical attacks at school than cisgender young. These results are important because they may contribute to the promotion of public policies and clinical interventions that favor the integration of TNBI in our society.

Differences in Experiences of Discrimination in Accessing Social Services Among Transgender/Gender Nonconforming Individuals by (Dis)Ability

Transgender and gender nonconforming (GNC) individuals frequently experience discrimination and potentially a lack of respect from service providers, suggesting they have decreased access to professionals with cultural competency. Similarly, people with disabilities experience higher levels of discrimination in social services than their nondisabled counterparts. From an intersectional perspective, this study examines rates of discrimination in accessing social services faced by transgender and GNC people, comparing across ability. Data indicate that although transgender and GNC individuals of all abilities experience gender-based discrimination when accessing social services, those with disabilities experience higher levels of antitransgender discrimination in mental health centers, rape crisis centers, and domestic violence shelters.

Couples-Focused Prevention Program to Reduce HIV Risk Among Transgender Women and Their Primary Male Partners: Feasibility and Promise of the Couples HIV Intervention Program

HIV risk among transgender women has been attributed to condomless sex with primary male partners. This study pilot tested a couples-focused HIV intervention program for transgender women and their primary male partners. We analyzed data from 56 transgender women and their male partners (n = 112 participants) who were randomized as a couple to one of two groups. Participants in the intervention group (27 couples) received 3 counseling sessions: 2 couples-focused sessions, which discussed relationship dynamics, communication, and HIV risk, and 1 individual-focused session on HIV prevention concerns. Participants in the control group (29 couples) received 1 session on general HIV prevention information delivered to both partners together. At 3-month follow-up, participants in the intervention reported lower odds of condomless sex with primary partners (OR 0.5, 95 % CI 0.3-1.0), reduced odds of engaging in sex with a casual partner (OR 0.3, 95 % CI 0.1-1.0), and reduction in the number of casual partners (B = -1.45, SE = 0.4) compared with the control group. Findings provide support for the feasibility and promise of a couples-focused HIV prevention intervention for transgender women and their primary male partners.

Transgressing gender norms in addiction treatment: Transgender rights to access within gender-segregated facilities

Despite having disproportionately high rates of substance use disorder and co-occurring health and mental health issues compared to the general population, transgender individuals experience significant barriers to accessing and engaging in addiction treatment programs. Inpatient addiction treatment centers were originally designed to treat substance-dependent heterosexual cisgender populations and, as such, feature gender-segregated housing, bathrooms, and treatment sessions. The heteronormative structural and programmatic barriers, combined with exposures to stigmatic and prejudicial attitudes, may dissuade transgender populations from benefiting from the addiction treatment they so direly need. The purpose of this article is to examine the current policy debate surrounding the rights of transgender individuals in public accommodations in the context of inpatient addiction treatment centers.

Global Epidemiology of HIV Infection and Related Syndemics Affecting Transgender People

INTRODUCTION

Transgender populations have been underrepresented in HIV epidemiologic studies and consequently in HIV prevention, care, and treatment programs. Since 2012, there has been a dramatic increase in research focused on transgender people. Studies highlight the burden of HIV and risk determinants, including intersecting stigmas, as drivers of syndemics among transgender populations. This review synthesizes the most recent global epidemiology of HIV infection and describes current gaps in research and interventions to inform prioritization of HIV research for transgender populations.

METHODS

A systematic review was conducted of the medical literature published between January 1, 2012 and November 30, 2015. The data focused on HIV prevalence, determinants of risk, and syndemics among transgender populations.

RESULTS

Estimates varied dramatically by location and subpopulation. Transfeminine individuals have some of the highest concentrated HIV epidemics in the world with laboratory-confirmed prevalence up to 40%. Data were sparse among trans masculine individuals; however, they suggest potential increased risk for trans masculine men who have sex with men (MSM). No prevalence data were available for transgender people across Sub-Saharan Africa or Eastern Europe/Central Asia. Emerging data consistently support the association of syndemic conditions with HIV risk in transgender populations.

DISCUSSION

Addressing syndemic conditions and gender-specific challenges is critical to ensure engagement and retention in HIV prevention by transgender populations. Future research should prioritize: filling knowledge gaps in HIV epidemiology; elucidating how stigma shapes syndemic factors to produce HIV and other deleterious effects on transgender health; and understanding how to effectively implement HIV interventions for transgender people.

The conflation of gender and sex: Gaps and opportunities in HIV data among transgender women and MSM

Historically, HIV studies have conflated men who have sex with men (MSM) with transgender (trans) women, explicitly excluded trans individuals, or included sample sizes of trans people that are too small to reach meaningful conclusions. Despite the heavy burden of HIV among trans women, conflation of this population with MSM has limited the information available on the social and behavioural factors that increase HIV vulnerability among trans women and how these factors may differ from MSM. Using data sets from quantitative studies among MSM (n = 645) and trans women (n = 89), as well as qualitative in-depth interviews with 30 trans women in Baltimore, we explore what these data tell us about similarities and differences in HIV vulnerability between the two groups and where they leave gaps in our understanding. We conclude with implications for data collection and intervention development.

Dyadic dynamics of HIV risk among transgender women and their primary male sexual partners: the role of sexual agreement types and motivations

Transgender women - individuals assigned a male sex at birth who identify as women, female, or on the male-to-female trans feminine spectrum - are at high-risk of HIV worldwide. Prior research has suggested that transgender women more frequently engage in condomless sex with primary cisgender (i.e., non-transgender) male partners compared with casual or paying partners, and that condomless sex in this context might be motivated by relationship dynamics such as trust and intimacy. The current study examined sexual agreement types and motivations as factors that shape HIV risk behaviors in a community sample of 191 transgender women and their cisgender primary male partners who completed a cross-sectional survey. Overall, 40% of couples had monogamous, 15% open, and 45% discrepant sexual agreements (i.e., partners disagreed on their type of agreement). Actor-partner interdependence models were fit to examine the influence of sexual agreement type and motivations on extra-dyadic HIV risk (i.e., condomless sex with outside partners) and intra-dyadic HIV serodiscordant risk (i.e., condomless sex with serodiscordant primary partners). For male partners, extra-dyadic risk was associated with their own and their partners' sexual agreement motives, and male partners who engaged in extra-dyadic HIV risk had an increased odds of engaging in HIV serodiscordant intra-dyadic risk. Study findings support inclusion of the male partners of transgender women into HIV prevention efforts. Future research is warranted to explore the interpersonal and social contexts of sexual agreement types and motivations in relationships between transgender women and their male partners to develop interventions that meet their unique HIV prevention needs.

A scoping review and thematic analysis of social and behavioural research among HIV-serodiscordant couples in high-income settings

BACKGROUND

While HIV incidence has stabilized in many settings, increases in health and wellbeing among many people living with HIV/AIDS suggest that the number of HIV-serodiscordant relationships is growing. Given the deficit of reviews addressing social and behavioural characteristics of HIV-serodiscordant couples within high-income settings, our objective was to understand the scope of the published literature, identify evidence gaps, and suggest future research needs.

METHODS

Ten electronic databases were searched. Studies were included if they were reported in English, used primary data, were from the combination antiretroviral (cART) era (>1996), reported on social or behavioural aspects, included any fraction of primary (i.e., stable) relationships, and were conducted in high-income settings. Studies that identified their unit of analysis as either the dyad or individual member of the couple were included. Studies were coded according to a thematic framework.

RESULTS

Included studies (n = 154) clustered into eight themes: risk behaviours (29%), risk management (26%), reproductive issues (12%), relationship quality (9%), serostatus disclosure (7%), adherence to antiretroviral therapy (7%), vulnerability (5%), and social support (3%). The proportion of studies conducted among heterosexual couples, same-sex male couples, and mixed cohorts were 42%, 34%, and 24%, respectively. Most studies (70%) were conducted in the United States, 70% of all studies were quantitative (including interventions), but only one-third were focused on couples (dyads) where both partners are recruited to a study. Over 25% of studies focused on sexual risk among same-sex male couples.

CONCLUSIONS

Future research efforts should focus on the interrelationship of risk management strategies and relationship quality, social determinants of health and wellbeing, HIV testing, vulnerable populations, reproductive issues among same-sex couples, disclosure of serodiscordant status to social networks, dyadic studies, population-based studies, and interventions to support risk management within couples. Additional population-based studies and studies among marginalized groups would be helpful for targeting research and interventions to couples that are most in need. As HIV-positive partners are typically the link to services and research, innovative ways are needed for reaching out to HIV-negative partners. Our review suggests that significantly more research is needed to understand the social and behavioural contexts of HIV-serodiscordant relationships.

A systematic review of the psychometric properties of the Sexual Relationship Power Scale in HIV/AIDS research

The Sexual Relationship Power Scale (SRPS) was developed over a decade ago to address the lack of reliable and valid measures of relationship power in social, behavioral and medical research. The SRPS and its two subscales (relationship control [RC], decision-making dominance [DMD]) have been used extensively in the field of HIV prevention and sexual risk behavior. We performed a systematic review of the psychometric properties of the SRPS and subscales as reported in the HIV/AIDS literature from 2000 to 2012. A total of 54 published articles were identified, which reported reliability or construct validity estimates of the scales. Description of the psychometric properties of the SRPS and subscales is reported according to study population, and several cross-population trends were identified. In general, the SRPS and RC subscale exhibited sound psychometric properties across multiple study populations and research settings. By contrast, the DMD subscale had relatively weak psychometric properties, especially when used with specific populations and research settings. Factors that influenced the psychometric properties of the various scales and subscales included the study population, mean age of the sample, number of items retained in the scale, and modifications to the original scales. We conclude with recommendations for (1) the application and use of the SRPS and subscales, (2) reporting of psychometric properties of the scales in the literature, and (3) areas for future research.

HIV risk and preventive interventions in transgender women sex workers

Worldwide, transgender women who engage in sex work have a disproportionate risk for HIV compared with natal male and female sex workers. We reviewed recent epidemiological research on HIV in transgender women and show that transgender women sex workers (TSW) face unique structural, interpersonal, and individual vulnerabilities that contribute to risk for HIV. Only six studies of evidence-based prevention interventions were identified, none of which focused exclusively on TSW. We developed a deterministic model based on findings related to HIV risks and interventions. The model examines HIV prevention approaches in TSW in two settings (Lima, Peru and San Francisco, CA, USA) to identify which interventions would probably achieve the UN goal of 50% reduction in HIV incidence in 10 years. A combination of interventions that achieves small changes in behaviour and low coverage of biomedical interventions was promising in both settings, suggesting that the expansion of prevention services in TSW would be highly effective. However, this expansion needs appropriate sustainable interventions to tackle the upstream drivers of HIV risk and successfully reach this population. Case studies of six countries show context-specific issues that should inform development and implementation of key interventions across heterogeneous settings. We summarise the evidence and knowledge gaps that affect the HIV epidemic in TSW, and propose a research agenda to improve HIV services and policies for this population.

Sexual mixing and the risk environment of sexually active transgender women: data from a respondent-driven sampling study of HIV risk among transwomen in San Francisco, 2010

Background

Research on the sexual networks of transwomen is central to explaining higher HIV risk for this population. This study examined HIV risk behaviors and sexual mixing patterns of transwomen by demographic and HIV-related risk behaviors.

Methods

Data were obtained from a 2010 study of HIV risk for transwomen in San Francisco. Assortativity by race, partner type, HIV serostatus, and IDU across sexual networks was calculated using Newman’s assortativity coefficient (NC). Multivariable generalized estimating equations (GEE) logistic regression models were used to evaluate associations between unprotected anal intercourse with race and HIV serostatus, partner-IDU status and relationship type discordance while adjusting for the HIV status of transwomen.

Results

There were 235 sexually active transwomen in this study, of whom 104 (44.3%) were HIV-positive and 73 (31.1%) had a history of injection drug use. Within the 575 partnerships, African American/black and Latina transwomen were the most racially assortative (NC 0.40, 95% CI 0.34-0.45, and NC 0.43, 95% CI 0.38-0.49, respectively). In partnerships where the partner’s HIV status was known (n = 309, 53.7%), most transwomen were in sexual partnerships with people of their same known serostatus (71.8%, n = 222). In multivariable analyses, unprotected anal intercourse was significantly associated with primary partners, having a sexual partner who was an injection drug user, and sexual partner seroconcordance.

Conclusions

Public health efforts to reduce transwomen’s HIV risk would likely benefit from prioritizing prevention efforts to risk reduction within IDU-discordant and primary partnerships, determining risks attributable to sexual network characteristics, and actively addressing injection drug use among transwomen.

HIV risk behaviors in the U.S. transgender population: prevalence and predictors in a large internet sample

To study the influence of gender on HIV risk, a sample of the U.S. transgender population (N = 1,229) was recruited via the Internet. HIV risk and prevalence were lower than reported in prior studies of localized, urban samples but higher than the overall U.S. population. Findings suggest that gender nonconformity alone does not itself result in markedly higher HIV risk. Sex with nontransgender men emerged as the strongest independent predictor of unsafe sex for both male-to-female (MtF) and female-to-male (FtM) participants. These sexual relationships constitute a process that may either affirm or problematize gender identity and sexual orientation, with different emphases for MtFs and FtMs, respectively.

A comparison of mental health, substance use, and sexual risk behaviors between rural and non-rural transgender persons

The aim of this study was to compare the mental health, substance use, and sexual risk behaviors of rural and non-rural transgender persons. Online banner advertisements were used to recruit 1,229 self-identified rural and non-rural transgender adults (18+ years) residing in the United States. Primary findings include significant differences in mental health between rural and non-rural transmen; relatively low levels of binge drinking across groups, although high levels of marijuana use; and high levels of unprotected sex among transwomen. The results confirm that mental and physical health services for transgender persons residing in rural areas are urgently needed.

Reducing HIV risk among transgender women in Thailand: a quasi-experimental evaluation of the sisters program

Transgender women are particularly at risk of HIV infection, but little evidence exists on effective HIV prevention strategies with this population. We evaluated whether Sisters, a peer-led program for transgender women, could reduce HIV risks in Pattaya, Thailand. The study used time-location sampling to recruit 308 transgender women in Pattaya into a behavioral survey in 2011. Coarsened exact matching was used to create statistically equivalent groups of program participants and non-participants, based on factors influencing likelihood of program participation. Using multivariable logistic regression, we estimated effects of any program participation and participation by delivery channel on: condom use at last sex; consistent condom and condom/water-based lubricant use in the past 3 months with commercial, casual, and regular partners; and receipt of HIV testing in the past 6 months. Program coverage reached 75% of the population. In a matched sub-sample (n = 238), participation in outreach was associated with consistent condom/water-based lubricant use with commercial partners (AOR 3.22, 95% CI 1.64-6.31). Attendance at the Sisters drop-in center was associated with receiving an HIV test (AOR 2.58, 95% CI 1.47-4.52). Dedicated transgender-friendly programs are effective at reducing HIV risks and require expansion to better serve this key population and improve HIV prevention strategies.

Decision Processes about Condom Use among Shelter-Homeless LGBT Youth in Manhattan

Health behavior interventions based on Theory of Planned Behavior address participants' personally-held beliefs, perceived social norms, and control over the behavior. New data are always needed to "member check" participants' decision processes and inform interventions. This qualitative study investigates decision processes around condom use among 81 homeless LGBT youth ages 18-26. Findings indicated considerable endorsement of the conventional policy of always using condoms, promulgated in HIV prevention education targeting this population. Although some participants reported risk behavior in contexts of sex work, survival sex, casual encounters, open relationships, and substance use, most were aware of these risks and consistently safe in those situations. Condoms use boundaries became vulnerable in states of emotional need and negative mood. The only effect participants acknowledged of homelessness on condom use was indirect, through negative mood states. The most prevalent context of condom non-use was with long-term primary partners, a potential area of vulnerability because, of 13 participants for HIV or HCV, nine mentioned how they had been infected, and all nine believed they had acquired it from a primary partner. Findings imply programs should emphasize HIV risk potential within long-term romantic partnerships and mental health services to remediate negative mood states.