Social networks and social support among ball-attending African American men who have sex with men and transgender women are associated with HIV-related outcomes

Both/And: Mixed methods analysis of network composition, communication patterns, and socio-economic support within social networks of transgender women involved in sex work in Lima, Peru

INTRODUCTION

Social networks contribute to normative reinforcement of HIV prevention strategies, knowledge sharing, and social capital, but little research has characterized the social networks of transgender women (TW) in Latin America. We conducted a mixed methods analysis of three network clusters of TW in Lima, Peru, to evaluate network composition, types of support exchanged, and patterns of communication.

METHODS

We recruited TW residing in or affiliated with three "casas trans" (houses shared among TW) in Lima between April-May 2018. Eligible participants were 18 or older, self-reported HIV-negative, and reported recent intercourse with a cis-male partner. Participants completed demographic questionnaires, social network interviews, and semi-structured interviews to assess egocentric network structures, support exchanged, and communication patterns. Quantitative and qualitative data were analyzed using Stata v14.1 and Atlas.ti, respectively.

RESULTS

Of 20 TW, median age was 26 years and 100% reported involvement in commercial sex work. Respondents identified 161 individuals they interacted with in the past month (alters), of whom 33% were TW and 52% family members. 70% of respondents reported receiving emotional support from family, while 30% received financial support and instrumental support from family. Of the 13 (65%) respondents who nominated someone as a source of HIV prevention support (HPS), the majority (69%) nominated other TW. In a GEE regression analysis adjusted for respondent education and region of birth, being a family member was associated with lower likelihood of providing financial support (aOR 0.21, CI 0.08-0.54), instrumental support (aOR 0.16, CI 0.06-0.39), and HPS (aOR 0.18, CI 0.05-0.64). In qualitative interviews, most respondents identified a cis-female family member as their most trusted and closest network member, but other TW were more often considered sources of day-to-day support, including HPS.

CONCLUSION

TW have diverse social networks where other TW are key sources of knowledge sharing and support, and family members may also represent important and influential components. Within these complex networks, TW may selectively solicit and provide support from different network alters according to specific contexts and needs. HIV prevention messaging could consider incorporating network-based interventions with TW community input and outreach efforts for supportive family members.

HIV Prevention and Care Among Black Cisgender Sexual Minority Men and Transgender Women: Protocol for an HIV Status-Neutral Cohort Study Using an Observational-Implementation Hybrid Approach

BACKGROUND

Black cisgender gay, bisexual, and other sexual minority men (SMM) and transgender women (TW) continue to be heavily affected by HIV. Further research is needed to better understand HIV prevention and care outcomes in this population. In particular, there is a need for research examining the impact of substance use and sleep health on HIV prevention and treatment outcomes among Black SMM and TW.

OBJECTIVE

This paper outlines the study methods being used in the recently launched follow-up study to the Neighborhoods and Networks (N2) study, which we refer to as N2 Part 2 (N2P2). N2P2 aims to address this gap in the literature, build off the findings of the original N2 study, and identify socioenvironmental determinants of health, including whether neighborhood and network factors mediate and moderate these relationships.

METHODS

Building on the N2 cohort study in Chicago from 2018 to 2022, N2P2 used a prospective longitudinal cohort design and an observational-implementation hybrid approach. With sustained high levels of community engagement, we aim to recruit a new sample of 600 Black SMM and TW participants residing in the Chicago metropolitan statistical area. Participants are asked to participate in 3 study visits across an 18-month study period (1 visit every 9 months). Four different forms of data are collected per wave: (1) an in-person survey, (2) biological specimen collection, (3) a daily remote ecological momentary assessment for 14 days after each study visit, and (4) data from electronic health records. These forms of data collection continue to assess neighborhood and network factors and specifically explore substance use, sleep, immune function, obesity, and the implementation of potential interventions that address relevant constructs (eg, alcohol use and pre-exposure prophylaxis adherence).

RESULTS

The N2P2 study was funded in August 2021 by the National Institute of Drug Abuse (R01DA054553 and R21DA053156) and National Heart, Lung, and Blood Institute (R01HL160325). This study was launched in November 2022. Recruitment and enrollment for the first wave of data collection are currently ongoing.

CONCLUSIONS

The N2P2 study is applying innovative methods to comprehensively explore the impacts of substance use and sleep health on HIV-related outcomes among an HIV status-neutral cohort of Black SMM and TW in Chicago. This study is applying an observational-implementation hybrid design to help us achieve findings that support rapid translation, a critical priority among populations such as Black SMM and TW that experience long-standing inequities with regard to HIV and other health-related outcomes. N2P2 will directly build off the findings that have resulted from the original N2 study among Black SMM and TW in Chicago. These findings provide a better understanding of multilevel (eg, individual, network, and neighborhood) factors that contribute to HIV-related outcomes and viral suppression among Black SMM and TW.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48548.

Characteristics of Individuals Seen as Sources of Social Support in Populations at Increased Risk for HIV

Access to social support from one's social network can serve as a protective factor against HIV infection; however, research exploring the availability of support in diverse populations that include high proportions of people at increased risk for HIV and the characteristics of network members associated with access to such support is limited. Multi-level dyadic analyses of social network data collected from women at risk for HIV and their network members reveal which individual and relationship characteristics of network members are associated with providing emotional, material, and/or health informational support. Results indicate that access to all three types of support was associated with a network member being a friend, a member of a participant's 'core' group, someone whose opinion matters to the respondent, and the respondent trusting them. These findings have implications for interventions designed to increase access to support among individuals at risk for HIV.

Both/And: Mixed methods analysis of network composition, communication patterns, and socio-economic support within social networks of transgender women in Lima, Peru

Introduction

Social networks contribute to normative reinforcement of HIV prevention strategies, knowledge sharing, and social capital, but little research has characterized the social networks of transgender women (TW) in Latin America. We conducted a mixed methods analysis of three network clusters of TW in Lima, Peru, to evaluate network composition, types of support exchanged, and patterns of communication.

Methods

We recruited TW residing in or affiliated with three "casas trans" (houses shared among TW) in Lima between April-May 2018. Eligible participants were 18 or older, self-reported HIV-negative, and reported recent intercourse with a cis-male partner. Participants completed demographic questionnaires, social network interviews, and semi-structured interviews to assess egocentric network structures, support exchanged, and communication patterns. Quantitative and qualitative data were analyzed using Stata v14.1 and Atlas.ti, respectively.

Results

Of 20 TW, median age was 26 years and 100% reported involvement in commercial sex work. Respondents identified 161 individuals they interacted with in the past month (alters), of whom 33% were TW and 52% family members. 70% of respondents reported receiving emotional support from family, while 30% received financial support and instrumental support from family. Of the 13 (65%) respondents who nominated someone as a source of HIV prevention support (HPS), the majority (69%) nominated other TW. In a GEE regression analysis adjusted for respondent education and region of birth, being a family member was associated with lower likelihood of providing financial support (aOR 0.21, CI 0.08-0.54), instrumental support (aOR 0.16, CI 0.06-0.39), and HPS (aOR 0.18, CI 0.05-0.64). In qualitative interviews, most respondents identified a cis-female family member as their most trusted and closest network member, but other TW were more often considered sources of day-to-day support, including HPS.

Conclusion

TW have diverse social networks where other TW are key sources of knowledge sharing and support, and family members may also represent important and influential components. Within these complex networks, TW may selectively solicit and provide support from different network alters according to specific contexts and needs. HIV prevention messaging could consider incorporating network-based interventions with TW community input and outreach efforts for supportive family members.

"To feel supported in your community is to feel loved": Cultivating community and support for Black transmasculine people navigating anti-Black racism, transphobia, and COVID-19 pandemic

Background: Black transmasculine people are disproportionately affected by a myriad of intersecting stressors including racism (specifically anti-Black racism), sexism, and cissexism. Black transmasculine people are exposed daily to systemic oppression such as transphobia, dehumanization, and violence, making this community more vulnerable to mental health and physical health concerns. These experiences are further compounded by the lack of relevant research about the unique experiences of Black transmasculine people during the COVID-19 pandemic. Aims: Utilizing a critical intersectionality lens and Prilleltensky's psychopolitical validity as guiding frameworks, the present study investigates the need for support and community for Black transmasculine people when navigating anti-Black racism and transphobia during the COVID-19 pandemic. Methods: The researchers integrated intersectionality and Prilleltensky's psychopolitical validity as frameworks paired with the constructivist grounded theory paradigm outlined by Charmaz to analyze data. The researchers co-constructed meaning from participants' (N = 32) perspectives to provide a theoretical understanding of how Black transmasculine participants' perceived community and support during COVID-19 pandemic. Results: The researchers developed a model of pathways toward community and support. The model suggests two levels: (a) locating awareness of community and support, and (b) integrated action toward community and support. The approaches are integrated from within group actions that can be facilitated from outside the community on micro and macro sociological levels to provide holistic support and community for Black transmasculine people. Discussion: This model extends the current literature on liberation and community psychology regarding the different levels of support for Black transmasculine people. This intervention can provide awareness and insight about working alongside the Black transmasculine community to address their unique needs of support and community. These findings hope to enhance clinical practices and identify strategies to promote wellness among Black transmasculine people.

"Through the Things That Have Happened to Me, They've Made Me Stronger": Individual and Interpersonal Sources of Violence and Resilience Among a Diverse Sample of Transgender Women in Los Angeles

Within the United States, transgender women face a disproportionate burden of violence, experiencing increased rates of multiple forms of violence compared with cisgender women and other sexual/gender minority groups. Among transgender women, further racial/ethnic disparities in experiences of violence exist. Resilience has been shown to be protective against the adverse impacts of violence on mental and physical health outcomes, yet little is known about unique sources of resilience, coping, and strength among transgender women. Sixteen in-depth interviews were conducted with a racially diverse sample of transgender women between May and July, 2020 in Los Angeles. Participants were between the ages of 23 and 67 years. Four participants identified as African American/Black, four as Latina, four as White, two as Asian, and two as Native American. Participants were recruited from a local social service organization. Interview questions assessed social network characteristics, experiences of violence, coping mechanisms, and sources of resilience in response to violence. Deductive and inductive coding schemes were used to identify common themes, and data analysis focused upon experiences of violence and sources of resilience/coping. Violence was common among members of the sample, with every participant reporting a history of multiple forms of violence. Violence perpetration came from many sources, including cisgender male strangers, family members, intimate partners, and other transgender women. Women also reported multiple sources of strength and coping, including engaging in self-care and leisure activities, behavioral adaptations, mentorship/support from other transgender women, and striving to "pass" as cisgender. Despite having faced extensive violence, the participants in this sample were resilient, demonstrating many internal and external coping mechanisms and sources of strength. These findings can inform programs and services that target transgender women, providing participants with opportunities to build resilience and other coping mechanisms to buffer the harmful mental and physical health impacts of exposure to violence.

The Helping Networks of Transgender Women Living with HIV

Transgender women living with HIV face significant barriers to healthcare that may be best addressed through community-centered interventions holistically focused on their HIV-related, gender-related, and other important needs. Community health ambassador (CHA) interventions (education and training programs designed to engage communities and community leaders in health promotion) may be an effective option, though information about the natural helping networks of this vulnerable population is too limited to inform the implementation of this approach. This study uses social network analysis to describe the natural helping networks of transgender women living with HIV, their help-seeking patterns for HIV-related, gender-related, and ancillary resources, and the characteristics of potential network ambassadors. From February to August 2019, transgender women living with HIV in the US (N = 231) participated a 30-min online survey asking them to describe their natural helping networks (N = 1054). On average, participants were embedded within natural helping networks consisting of 4-5 people. They were more likely to seek help from informal network members vs. formal service providers (p < .01), and from chosen family and partners/spouses (p < .05) above other social connections. Older network members (p < .01), other transgender women (p < .05), and those with whom they regularly engaged face-to-face (p < .01) (vs. social technology) were identified as potential network ambassadors for HIV-, gender-related, and other important issues. These findings suggest an opportunity to develop CHA interventions that leverage existing help networks and potential network ambassadors to promote equitable access to HIV, gender-affirming, and other crucial resources among this medically underserved group.

Social networks, mobility, and HIV risk among women in the fishing communities of Lake Victoria

BACKGROUND

Population mobility is a demonstrated barrier to reducing HIV incidence. A clear understanding of social networks and their influence on mobility among women in the fishing communities of Lake Victoria may contribute to tailoring effective interventions that suit the needs of these mobile women.

METHODS

A cross-sectional qualitative methods study was conducted to understand mobility patterns among women resident and or working in fishing communities of Lake Victoria in Kenya, Tanzania, and Uganda. The study was conducted in six fishing communities from March 2018 to June 2019. The communities were purposively selected, based on population size (1000 people or more) and HIV prevalence of > 15% among women aged 18 years or older who had lived in the fishing community for at least six months. In-depth interviews were conducted with 24 key informants and 72 women from the sites in the three countries. Questions focused on women's social networks and other factors that fuelled or facilitated women's mobility as well as challenges they faced due to mobility. Data analysis followed a thematic framework approach.

RESULTS

Different social groupings/networks existed among women in the fishing communities of Lake Victoria. These included female sex workers, women fish processors/traders, women bar workers/owners, restaurant workers, and family networks. Networks encouraged mobility, supporting finding work opportunities, but also increased sexual risks through partner changes. The benefits of networks included information sharing, financial support, and group protection, especially against violence.

CONCLUSION

Social networks and groupings among women in the fishing communities of Lake Victoria could be useful in tailoring HIV prevention and HIV care interventions to suit the needs of these highly mobile populations.

Sexual and Gender Minority Youth in Foster Care: An Evidence-Based Theoretical Conceptual Model of Disproportionality and Psychological Comorbidities

Sexual and gender minority youth (SGMY) are overrepresented in the foster care system and experience greater foster-care-related stressors than their non-SGM peers. These factors may further elevate their risk of anxiety/depressive, post-traumatic stress disorder, self-harm, and suicidality. The system currently produces unequal and disproportionate adverse mental health outcomes for SGMY and needs points of intervention to disrupt this status quo. This article provides an empirically grounded conceptual-theoretical model of disproportionate representation and burden of psychological comorbidities experienced by SGMY in the foster care system. We apply findings from an integrated literature review of empirical research on factors related to overrepresentation and mental health burden among SGMY to minority stress theory to explicate how and why the foster care system exacerbates mental health comorbidities for SGMY. Searches were conducted in June 2020 in PubMed using MeSH terms and title/abstract terms for foster care, sexual or gender minorities, and psychological comorbidities. Inclusion criteria are studies conducted in the United States, published in English, focused on mental illness, and published between June 2010 and 2020. Developmental/intellectual and eating disorders were excluded. The initial search returned 490 results. After applying inclusion criteria, 229 results remained and are utilized to build our conceptual-theoretical model. We assert that the phenomenon of disproportionate psychological comorbidities for SGMY in foster care is best represented as a complex and dynamic system with multiple feedback loops. Extant empirical and theoretical literature identifies three critical areas for intervention: family acceptance, community belonging and queer chosen/constructed family, and affirming and nondiscriminatory child welfare policy.

Incarceration, Social Support Networks, and Health among Black Sexual Minority Men and Transgender Women: Evidence from the HPTN 061 Study

Support from social networks buffers against negative effects of stress but is disrupted by incarceration. Few studies examine incarceration, social support networks, and health among Black sexual minority men (BSMM) and Black transgender women (BTW). We conducted a secondary analysis using HIV Prevention Trials Network 061 (HPTN 061), a sample of BSMM/BTW recruited from six US cities. We measured associations between recent incarceration reported at six months follow-up and social support networks at twelve months follow-up, and cross-sectional associations between support networks and twelve-month health outcomes (e.g., sexual partnerships, substance use, healthcare access and depressive symptoms). Among the analytic sample (N = 1169), recent incarceration was associated with small medical support networks (adjusted risk ratio [aRR] 1.16, 95% CI 1.01, 1.34) and small financial support networks (aRR 1.18, 95% CI 1.04, 1.35). Support networks were associated with multiple partnerships (adjusted prevalence ratio [aPR] 0.77, 95% CI 0.65, 0.90), unhealthy alcohol use (aPR 1.20, 95% CI 0.96, 1.51), and depressive symptoms (aPR 1.16, 95% CI 0.99, 1.36). Incarceration adversely impacts social support networks of BSMM/BTW, and support networks were associated with a range of important health outcomes.

Exploring community enabling factors associated with recent HIV testing in a regional sample of gay, bisexual, and other men who have sex with men

HIV testing and diagnosis are the gateway into treatment and eventual viral suppression. With gay, bisexual, and other men who have sex with men (GBMSM) persistently over-representing new HIV diagnoses in Canada, combined with the evolving nature of community social connection, an exploration of factors associated with recent HIV testing is warranted. As most studies of GBMSM rely on samples obtained from larger metropolitan regions, examining HIV testing from an under-researched region is necessary. With data collected from an online survey of LGBTQ+ persons 16 or older living, working, or residing in the Region of Waterloo, Ontario, Canada, we used multinomial logistic regression to explore socio-demographic, behavioural, and psychosocial factors associated with recent HIV testing for GBMSM. In the final multivariate multinomial logistic regression model: sense of belonging was associated with more recently testing, as was having an increasing proportion of LGBT friends, app use to find sex partners in the past 12 months, access to the local AIDS service organization, and general sense of belonging to local community, among other. This analysis highlights the continued importance of enabling and need factors when accessing testing, and suggests areas for further testing promotion in physical and virtual spaces frequented by GBMSM.

Characterizing the PrEP Continuum for Black and Latinx Sexual and Gender Minority Youth

Pre-exposure prophylaxis (PrEP) rollout efforts thus far have inadequately reached young people from underrepresented backgrounds. This study explores PrEP engagement among young Black and Latinx men who have sex with men, transgender women, and gender diverse individuals in three U.S. cities using an adapted PrEP continuum measure. We analyze data from the recruitment phase of an ongoing PrEP engagement intervention (n = 319) using partial proportional odds logistic regression. Participants reported high willingness and intention to use PrEP, yet most (82%) were not currently taking PrEP. Being insured (aOR = 2.95, 95%-CI = 1.60-5.49), having one or more PrEP users in one's sexual network (aOR = 4.19, 95%-CI = 2.61-6.79), and higher individual HIV risk scores (aOR = 1.62, 95%-CI = 1.34-1.97) were each associated with being further along the PrEP continuum. Strategies are needed to address barriers to healthcare access and leverage connections within social and sexual networks in order to bolster PrEP engagement among marginalized young people from diverse backgrounds.

We are Family: A Feasibility and Acceptability Study of an HIV Prevention Intervention With the House Ball and Gay Family Communities

BACKGROUND

Black and Latinx sexual minority youth are disproportionately affected by HIV. The House Ball and gay family communities encompass sexual and ethnic minority youth who form chosen families that promote protective HIV-related health behaviors. We conducted a small-scale trial of the We Are Family intervention, leveraging these existing social dynamics to address HIV.

METHODS

From September 2018 to September 2019, we enrolled N = 118 for baseline and 6-month follow-up assessments. Eligible participants were 18 years or older, San Francisco Bay Area residents, members of a house or gay family or ball attendees in the past year, smartphone users, and sexually active. The intervention included one 2-hour in-person group session, community-level events, a mobile health app, and a dedicated service provider.

RESULTS

Ninety-seven percent of our participants were people of color, 94% were retained through follow-up. 73% attended at least 1 group session, 100% used the mobile health app, and 56% attended a community-level event. Modest changes were observed baseline to follow-up: among all participants, any condomless anal intercourse past 3 months (74.6%-66.7%, P = 0.064); among HIV-negative participants (N = 82) HIV testing past 6 months (80.7%-87.2%, P = 0.166); among HIV-positive participants (N = 34) receiving HIV primary care past 6 months (64.5%-78.8%, P = 0.139), and adherent to ART past 30 days (22.6%-28.1%, P = 0.712). 86% would be willing to refer a friend to the app, and 65% found the app to be personally relevant.

CONCLUSIONS

We Are Family reaches and retains its target population, is feasible, acceptable, and shows promise for improving HIV-related health behavior.

Non-parental Adults and Sexual Health Behaviors Among Young Minority Men: A Qualitative Examination

Young Black and Latino sexual minority men (YBLSM) exhibit disproportionately high rates of negative sexual health outcomes, including HIV and other sexually transmitted infections, compared to other groups, partly due to relatively higher rates of exposure to a host of socio-structural risk factors (e.g., unstable housing and under-employment). However, an under-studied interpersonal resource exists for many YBLSM, non-parental adults (NPAs, i.e., adults who act as role models and provide social support), who may be able to influence contextual (e.g., unemployment) and individual (e.g., reduced health expectations) factors underlying sexual health disparities.

Aims: This study sought to examine the role of NPAs in factors that affect sexual health behaviors and in supporting those health behaviors directly, among YBLSM living in a mid-sized city in the southern United States. A total of n=20 participants, n=10 YBLSM (ages 16 to 22), and n=10 NPAs (ages 26 to 52) were interviewed using semi-structured guides to examine NPA involvement in the lives of YBLSM from both sides of the relationship. The research team used a framework analysis approach to iteratively identify and define meaningful codes and sub-codes. Both YBLSM and NPAs described NPAs helping YBLSM through role modeling and social support in a variety of areas found to affect sexual health behaviors, such as housing instability and psychological distress, as well as in specific behaviors, such as condom use and HIV medication adherence. Given the multiple socio-structural obstacles facing YBLSM and their multifaceted relationships with NPAs, NPAs may be a promising resource to help address these impediments to health. Partnering more intentionally with NPAs is a potentially promising strategy to help reduce HIV-related disparities affecting YBLSM that is worthy of additional empirical attention.

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.

Characterizing Biomedical HIV Prevention Awareness and Use Among Black Transgender Women in the United States

Black transgender women (BTW) in the United States experience disproportionate rates of HIV despite biomedical prevention interventions such as pre-exposure prophylaxis (PrEP) and non-occupational post-exposure prophylaxis (nPEP). Using a sample of 490 BTW collected from 2014 to 2017, bivariate, multivariable, and multinomial analyses were conducted to determine factors associated with awareness and use of PrEP and nPEP. BTW living with HIV were more aware of PrEP than HIV-negative BTW. Structural, demographic, and trans-specific factors (e.g., experiences of homelessness, violence, and current hormone use) related to HIV risk were associated with PrEP and nPEP awareness. PrEP use was associated with behavioral HIV risks (e.g., STI diagnosis, having an HIV-positive partner, and needle-sharing) and may demonstrate risk recognition among BTW. Knowing someone using PrEP was significantly positively associated with PrEP use. Development of guidelines for PrEP and nPEP use for BTW should leverage the strengths of guidelines for other populations, while also acknowledging the unique risks for this population.

A Uniquely Targeted, Mobile App-Based HIV Prevention Intervention for Young Transgender Women: Adaptation and Usability Study

Background

Young transgender women (YTW) are a key population for HIV-related risk reduction, yet very few interventions have been developed to meet their needs. Mobile health interventions with the potential for both efficacy and wide reach are a promising strategy to reduce HIV risk among YTW.

Objective

This study aims to adapt an efficacious group-based intervention to a mobile app, Project LifeSkills, to reduce HIV risk among YTW, and to test its acceptability and usability.

Methods

The group-based intervention was adapted to a mobile app, LifeSkills Mobile, with input from an expert advisory group and feedback from YTW collected during user-centered design sessions. A beta version of the app was then tested in a usability evaluation using a think-aloud protocol with debriefing interviews, recordings of screen activity, and assessments of usability via the Post-Study System Usability Questionnaire (PSSUQ) and the Health Information Technology Usability Evaluation Scale (Health-ITUES).

Results

YTW (n=8; age: mean 24 years, SD 3 years; racial or ethnic minority: 7/8, 88%) provided feedback on the app prototype in design sessions and then tested a beta version of the app in a usability trial (n=10; age: mean 24 years, SD 3 years; racial or ethnic minority: 8/10, 80%). Both usability ratings (Health-ITUES: mean 4.59, SD 0.86; scale range: 1-5) and ratings for satisfaction and accessibility (PSSUQ: mean 4.64, SD 0.90; scale range 1-5) were in the good to excellent range. No functional bugs were identified, and all mobile activities were deployed as expected. Participant feedback from the usability interviews indicated very good salience of the intervention content among the focal population. Participants’ suggestions to further increase app engagement included adding animation, adding audio, and reducing the amount text.

Conclusions

We conclude that the LifeSkills Mobile app is a highly usable and engaging mobile app for HIV prevention among YTW.

Associations Between Social Support Availability and HIV Risk and Protective Factors in a U.S. Sample of Adults with Diverse Transgender Identities

Purpose: There is conflicting evidence on how different types of social support may attenuate human immunodeficiency virus (HIV) risk or may even promote health behaviors in transgender (trans) and nonbinary populations. Drawing on Social Support Theory, we assessed associations between emotional, instrumental, and informational social support and HIV risk and protective factors in a U.S. sample of trans and nonbinary adults. We investigated whether such associations differed for trans men, trans women, and nonbinary individuals. Methods: Data were drawn from the Transgender Stress and Health Study, an online survey (N = 300), conducted in 2014-2015. We used Poisson regressions to measure the relationship between social support availability and HIV testing, substance use, and sexual risk behaviors for each gender subgroup. Results: Multivariate analyses revealed that, controlling for social support availability, nonbinary individuals were less likely to report past year HIV testing (incidence rate ratio [IRR] = 0.56; 95% confidence interval [CI] 0.36-0.89) than trans men (ref). Instrumental support availability was associated with substance use (IRR = 1.3; 95% CI 1.01-1.6), and this association was stronger for trans women (IRR = 2.1; 95% CI 1.1-4.04). Trans women were more likely to report sexual risk behavior across all types of social support, controlling for social support availability. Conclusion: We found key differences in social support availability, HIV testing, substance use, and sexual risk behavior. Our results suggest that trans men, trans women, and nonbinary individuals may have unique HIV prevention needs, and should be treated as distinct study groups in further research.

Networks Among Racial and Ethnic Minority Men Who Have Sex With Men in HIV Research in the United States: A Concept Analysis

In the past 10 years, research has proliferated investigating the effects of sexual and social networks on the transmission of HIV, especially among racial/ethnic minority men who have sex with men (MSM). This research, however, has been inconsistent in its application of social network theory leading to variations in the measurement of networks and a lack of clarity in the interpretation of results from studies of network data. Efforts to delineate how networks are defined, measured, and interpreted are needed to advance the science of HIV prevention and promote health equity. The aims of this article are to review the literature around networks among racial/ethnic minority MSM, use concept analysis methods to clarify the definition and scope of the concept of networks, and to develop a network typology that can be used to guide measurement and interpretation of networks for HIV research with racial/ethnic minority MSM.

The Role of Networks in Racial Disparities in HIV Incidence Among Men Who Have Sex with Men in the United States

Network factors have been proposed as potential drivers of racial disparities in HIV among Black and Latino men who have sex with men (MSM). This review aimed to synthesize the extant literature on networks and racial disparities in HIV among MSM and identify potential directions for future research. We searched databases for peer-reviewed articles published between January 1, 2008 and July 1, 2018. Articles were included if the sample was comprised primarily of racial/ethnic minority MSM and measured one or more network characteristics. (n = 25). HIV prevalence in networks, social support, and structural barriers were linked to disparities in HIV for Black MSM. Future research should focus on intervention development around social support and other strategies for risk reduction within networks. Given the contribution of structural factors to racial/ethnic HIV disparities, network-level interventions should be paired with policies that improve access to housing, jobs, and education for MSM.

Individual and Social Network Factors Associated with High Self-efficacy of Communicating about Men's Health Issues with Peers among Black MSM in an Urban Setting

Black men who have sex with men (BMSM) bear a disproportionate burden of HIV in the USA. BMSM face stigma, discrimination and barriers to health care access, and utilization. Peers (male or female) may assist BMSM in navigating their health issues by engaging in communication to support in their health care needs. Individuals with high self-efficacy of communicating about men's health issues with peers can be trained as community popular opinion leaders (CPOLs) to change peer behaviors by promoting risk reduction communication. We examined the characteristics associated with high self-efficacy of communicating with peers about men's health issues among 256 BMSM from a behavioral HIV intervention conducted in Baltimore, Maryland. In the multivariate logistic model, gay identity (AOR: 2.10, 95% CI: 1.15,3.83), involvement in the house and ballroom community (AOR: 2.50, 95% CI: 1.14,5.49), larger number of network members who are living with HIV (AOR: 6.34, 95% CI: 1.48,27.11), and larger number of network members who would loan them money (AOR: 1.46, 95% CI: 1.05,2.03) were statistically significantly associated with high self-efficacy of communicating with peers about men's health issues. We also found that having depressive symptoms (AOR: 0.43, 95% CI: 0.24, 0.77) was negatively associated with high self-efficacy of communicating with peers about men's health issues. Findings from the current study can inform future studies to identify better CPOLs who are able to communicate effectively with peers about men's health issues for BMSM.

Exploring the role of LGBT-affirming churches in health promotion for Black sexual minority men

In the USA, Black sexual minority men (BSMM) remain disproportionately impacted upon by HIV and other sexual health issues. Individuals who attend church have lower rates of morbidity and mortality than those that do not; however, church attendance presents a paradox of being protective for some health outcomes and a risk for others among this population. Lesbian, gay, bisexual, and transgender (LGBT) affirming churches may offer support, but little is known about the role of LGBT-affirming churches in the lives of BSMM and how they may impact HIV and other health outcomes. This study explored the role of LGBT-affirming churches in the lives of BSMM. Nine focus groups (N = 52) were conducted in Baltimore City, Maryland between December 2017 and April 2018. Thematic analysis evaluated domains related to how men perceived, experienced, and engaged with LGBT-affirming churches. Three primary themes identified: (1) preferring traditional church environments over LGBT-affirming churches; (2) experiencing the LGBT-affirming church as a space of acceptance, emotional healing, and modelling loving same-sex relationships; and (3) perceiving LGBT-affirming churches as opportunities to engage community members to promote the well-being of BSMM. A secondary theme identified involvement in the house and ballroom community as an LGBT-affirming religious experience.

It's a Kiki!: Developmental benefits of the Kiki scene for Black gay/bisexual/transgender adolescents/emerging adults

Younger members of the House and Ball Community (HBC) have created an emerging social scene called "Kiki" that has shared elements with the HBC. Given the growing popularity of the Kiki scene in urban communities with large numbers of Black gay, bisexual, and transgender (GBT) adolescents and emerging adults, it is important to understand the developmental benefits of the Kiki scene. We conducted individual in-depth interviews with 30 GBT adolescents and emerging adults (ages 15-24) who attended Kiki-related events and 15 older opinion leaders affiliated with the HBC. Participants described how the Kiki scene provides them with a range of supportive and affirming functions and offers a place where they can achieve important developmental milestones. The results clustered into three primary thematic areas of development: Executive Functioning Development, Social-Emotional Development, and Physical and Emotional Safety during Development. Within each of these thematic areas are sub-themes that further explicate the ways in which these functions are supported. We believe this to be one of the first papers exclusively focused on the positive aspects of the Kiki scene for adolescent and emerging adult development, and we encourage other researchers to further explore this emerging socializing force and its potential benefits to development.

Associations Between Social Support and Social Media Use Among Young Adult Cisgender MSM and Transgender Women Living With HIV

Social media platforms offer the opportunity to develop online social networks. Use of these platforms has been particularly attractive to younger sexual and gender minority individuals as well as those living with HIV. This cross-sectional study examined the perceived level of social support and associations with social media use among youth and young adult cisgender men who have sex with men (MSM) and transgender (trans) women living with HIV and examined these associations by gender identity. The study drew from baseline data collected from 612 cisgender MSM and 162 trans women enrolling in one of 10 demonstration sites that were part of a Health Resources and Services Administration Special Projects of National Significance initiative. The individual projects were designed to evaluate the potential for social media/mobile technology-based interventions to improve retention in care and HIV health outcomes. The data used in this study came from baseline surveys completed when participants enrolled in a site between October 2016 and May 2018. Results demonstrated that a significantly greater proportion of MSM than trans women participants reported the use of social media platforms (e.g., Facebook: MSM = 86%, trans women = 62%; Instagram: MSM = 65%, trans women = 35%). Furthermore, increased social media use improved perceptions of social support only among MSM participants (direct adjusted OR = 1.49) and not trans women participants (gender identity interaction term adjusted OR = 0.64). These results revealed that MSM participants perceived greater social benefit from the use of social media platforms than trans women, which could be a result of generalized online transphobia experienced by trans women. More nuanced data on various social media platforms, that is, anonymous versus profile-based, and group differences, are needed to better understand how social media platforms can be best utilized to optimize health care outcomes among sexual and gender minority youth and young adults living with HIV.

Strategies for engaging transgender populations in HIV prevention and care

PURPOSE OF REVIEW

Transgender (trans) populations are heavily impacted by HIV, yet face structural, social, and individual barriers to engagement in HIV prevention and care. In this review, we summarize the data on barriers and facilitators and discuss evidence-informed strategies to facilitate access to and engagement in HIV prevention and care by trans communities.

RECENT FINDINGS

Intersectional stigma and discrimination at structural, community, individual levels present substantial impediments to HIV prevention and optimal care. Access to gender-affirming health care is a priority for trans communities. Where trans communities are highly networked, these networks may provide a strong infrastructure for disseminating HIV innovations and reaching individuals who are not engaged in HIV services. Efforts to engage trans people in HIV prevention and care must address stigma, provide gender-affirming services, and build on community strengths and priorities to ensure trans populations achieve maximum benefit from advances in HIV prevention and care.

SUMMARY

Combination approaches that respond to the complex drivers of HIV in trans communities represent promising strategies for engaging trans people and their partners in HIV prevention and care.

Barriers to syphilis testing among men who have sex with men: a systematic review of the literature

Men who have sex with men (MSM) represent the highest risk group for syphilis in the United States and several other countries. Improving uptake of syphilis testing among MSM requires understanding key barriers to testing in this population. Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, a systematic review to assess proportions of syphilis testing among MSM and identify social, structural, and individual barriers to syphilis testing was conducted. All searches were conducted through the University of Maryland world catalogue search engine. Studies that measured syphilis testing in a sample of MSM were included. All studies were assessed for bias using JBI-MAStARI instruments. Studies were synthesised based on sample size, years of data collection, study selection method (e.g. hospital or clinic-based, community/venue-based), location (e.g. USA-based, other countries) and results of the bias assessment. For studies measuring barriers associated with testing, the measure of association, point estimate and statistical significance was assessed. Of 848 studies found in the initial search, 24 were included in the final review. The largest difference in syphilis testing proportions was based on hospital or clinic-based sampling (50-87%) compared with venue/community-based and online sampling (31-38%). Socioeconomic factors (four items, four studies, OR 0.23 to 0.68), healthcare interactions six items, five studies, OR 0.09 to 0.69) and community/interpersonal factors (seven items, five studies, OR 0.07 to 0.58) were identified as barriers to testing. Barriers to syphilis testing among MSM include socioeconomic factors, healthcare-related factors and community/interpersonal factors. Improving overall routine utilisation of healthcare services is an especially important focal point in testing promotion.

Identifying Opportunities for Collaboration Across the Social Sciences to Reach the 10-10-10: A Multilevel Approach

BACKGROUND

The national and global strategy to combat HIV, often referred to as the "90-90-90," aims to diagnose 90% of people living with HIV, get 90% of those diagnosed onto antiretroviral treatment (ART), and achieve viral suppression in 90% of those on ART. The remaining 10-10-10 who will be undiagnosed, not on ART, or not virally suppressed, include vulnerable persons and populations most affected by social determinants of health. Given their foci on the social determinants of health at the individual, social, and structural levels, social scientists are in a prime position to help reach the 10-10-10. A potentially effective way for social scientists to achieve this goal is to examine the issues that affect the 10-10-10 using a multilevel framework, to understand at what levels their own approaches fit within such a multilevel framework, and to seek intentional collaborations with other social scientists who may work at different levels but whose approaches may complement their own within multilevel collaborations.

APPROACH

The present article describes how a multilevel framework can guide collaboration across disciplines within the social sciences toward the common goal of reaching the 10-10-10.

CONCLUSIONS

Within a multilevel framework, social scientists can work collaboratively to address the needs of individuals among the 10-10-10 within the social and structural contexts (eg, social norms, stigma, poverty, and barriers to care) that affect their health. Such an approach draws on the unique strengths and approaches of different social-science disciplines while also building capacity for individuals most affected by social determinants of health.

'I want the heart of fierceness to arise within us': maintaining public space to promote HIV-related health with House Ball Community members in an era of gentrification

The House Ball Community consists of sexual, gender and ethnic minority youth who form family-like houses and compete in balls. Many rely on community-based organisations as venues for socialising and accessing health-related resources. In recent years, urban gentrification has challenged the economic survival of the organisations that serve this community and its members. Between 2016 and 2017, we conducted 45 in-depth interviews with houses and gay families in the San Francisco Bay Area and regular participant observation at community events, including balls. In addition to forcing community organisations to close or move, rising rents have increased housing instability among Ballroom Community members, with some moving to distal locations. Participants felt nostalgia for organisations that provided HIV-related services and hosted balls in previous years, feeling the loss of space keenly. To maintain community and generate employment, the San Francisco Ballroom Community now offers Vogue classes at private dance studios. This allows participants to recruit new house members, welcoming a broader array of individuals into the community than those who have historically participated. However, accessing culturally appropriate sexual health services remains difficult. Health advocates should recognise that community organisations are necessary for diverse youth to build community and access sexual health services.

Social Support Networks Among Young Men and Transgender Women of Color Receiving HIV Pre-Exposure Prophylaxis

PURPOSE

The aim of the study was to characterize perceived social support for young men and transgender women who have sex with men (YM/TWSM) taking HIV pre-exposure prophylaxis (PrEP).

METHODS

Mixed-methods study of HIV-negative YM/TWSM of color prescribed oral PrEP. Participants completed egocentric network inventories characterizing their social support networks and identifying PrEP adherence support figures. A subset (n = 31) completed semistructured interviews exploring adherence support and qualities of PrEP support figures. We calculated proportions of role types (e.g., family), individuals disclosed to regarding PrEP use, and PrEP-supportive individuals within each participant network. Interviews were analyzed using an inductive approach.

RESULTS

Participants (n = 50) were predominately African American men who have sex with men. Median age was 22 years (interquartile range: 20-23). Biologic family were the most common support figures, reported by 75% of participants (mean family proportion .37 [standard deviation (SD): .31]), followed by 67% reporting friends (mean friend proportion .38 [SD: .36]). Most network members were aware (mean disclosed proportion .74 [SD: .31]) and supportive (mean supportive proportion .87 [SD: .28]) of the participants' PrEP use. Nearly all (98%) participants identified ≥1 figure who provided adherence support; more often friends (48%) than family (36%). Participants characterized support as instrumental (e.g., transportation); emotional (e.g., affection); and social interaction (e.g., taking medication together). Key characteristics of PrEP support figures included closeness, dependability, and homophily (alikeness) with respect to sexual orientation.

CONCLUSIONS

Although most YM/TWSM identified family in their support networks, friends were most often cited as PrEP adherence support figures. Interventions to increase PrEP adherence should consider integrated social network and family-based approaches.

Social Networks Moderate the Syndemic Effect of Psychosocial and Structural Factors on HIV Risk Among Young Black Transgender Women and Men who have Sex with Men

The interaction between the cumulative effect of psychosocial and structural factors (i.e. syndemic effect) and social networks among young Black transgender women and men who have sex with men (YBTM) remains understudied. A representative cohort of 16-29 year-old YBTM (n = 618) was assessed for syndemic factors [i.e. substance use; community violence; depression; poverty; justice system involvement (JSI)], social network characteristics, condomless anal sex (CAS), group sex (GS), and HIV-infection. The syndemic index significantly increased the odds of CAS, GS, and HIV-infection, and these effects were moderated by network characteristics. Network JSI buffered the effect on CAS, romantic network members buffered the effect on GS, and network age and proportion of family network members buffered the effect on HIV-infection. The proportion of friend network members augmented the effect on GS and HIV-infection. Future research to prevent HIV among YBTM should consider social network approaches that target both structural and psychosocial syndemic factors.

We are family: designing and developing a mobile health application for the San Francisco bay area House Ball and Gay Family communities

BACKGROUND

The House Ball community (HBC) and its affiliated Gay Families (GFs) consist of predominantly African American and Latinx sexual, gender, and ethnic minorities (SGEM), who form chosen families often as a way to provide support, and in the case of the HBC, to constitute houses that then compete in performative categories in balls. Members of both communities are disproportionately impacted by HIV. Although public health professionals have engaged with the HBC and GFs to improve HIV testing and clinical care, most intervention activities have relied on in-person modes of outreach and delivery. Little research has been conducted with the members of the HBC and GFs to develop and produce culturally-informed mobile health (mHealth) applications that would enable them to increase HIV-related knowledge, connect to HIV-related resources, receive HIV health support, and to celebrate their unique identities and communities in a safe space.

METHODS

We conducted 45 in-depth interviews with HBC and GF members who attended balls. Topics included HIV-related health needs, suggestions for mHealth components, current usage of apps and desirable features, and wishes around privacy and security. Following analysis of the interview data, we convened a series of four workshops with N=15 participants who were split into two groups. The purpose of the workshops was to co-design a digital tool to help provide information, reduce HIV-related stigma, and locate HIV resources for participants. Each group attended two workshops. Data were analyzed by a team of social scientists, community members, and mobile health experts. Findings were used to design an mHealth app related to HIV prevention and care.

RESULTS

Participants requested an app that clearly reflected the community. The desired features of the app included accurate information and education on HIV transmission; links to resources such as HIV testing, lube and condoms, PrEP, and other health-related services; and the ability to rate and review local resources. In workshops, participants proposed several design elements and functions for the app. It had to be 'Mobile and Modern', 'Relatable, Raw, and "Reflective of Me"', 'Positive and Fun', feature community-generated content, and provide a safe space for users. Using these clear directives, the team designed an mHealth tool to be fielded as part of the larger "We Are Family" intervention that would provide HIV-specific information, resources, and support in a platform that was congruent with community norms and expectations.

CONCLUSIONS

Designing and fielding an mHealth app as part of a larger HIV prevention intervention that reflects the social support and relationships within existing House Ball and Gay Family communities allows those youth most at risk for HIV-related health disparities to gain access to HIV testing, or link and re-engage young people to care.

PrEP indicators, social capital and social group memberships among gay, bisexual and other men who have sex with men

Efforts to reduce HIV among gay, bisexual and other men who have sex with men include increasing awareness and uptake of pre-exposure prophylaxis (PrEP). Social capital may facilitate engagement in HIV prevention. Membership of social groups including chosen families (i.e. friends as family relationships) - one potential indicator of social capital - may be protective against HIV risk and infection. In this cross-sectional quantitative study, we examined social capital items and social group membership in association with PrEP outcomes. In 2014, the New Orleans arm of the National HIV Behavioral Surveillance recruited 353 HIV-negative men, of whom 46% identified as Black, Latino or Other Race and 54% as Non-Hispanic White, using venue-based sampling to complete a structured survey. Multivariable logistic regression models tested the relations between social group membership and social capital with PrEP indicators. Men who reported community group participation were more likely to be aware of PrEP compared to those who did not. Men in chosen families associated with a family name were least likely to be aware of and willing to take PrEP compared to those not in any other social groups. Social group membership is a potential social capital indicator for assessing HIV prevention among men.

"Housing Insecurity Seems to Almost Go Hand in Hand with Being Trans": Housing Stress among Transgender and Gender Non-conforming Individuals in New Orleans

Housing is an important social determinant of physical and mental health. Transgender and gender non-conforming individuals (T/GNCI) face a unique constellation of discrimination and compromised social services, putting them at risk for housing insecurity, homelessness, and its associated public health concerns. This study explores housing insecurity among T/GNCI in New Orleans, LA, where the infrastructural landscape is marked by an underinvestment in housing stock and disaster capitalism. In-depth interviews were conducted with T/GNCI (n = 17) living in New Orleans, identified through purposive sampling. Semi-structured guides were used to elicit personal stories and peer accounts of insecure housing experiences and coping strategies. Interviews were audio recorded and transcribed. Data was coded, sorted, and analyzed for key themes using NVIVO 11. Respondents discussed an array of circumstances that contribute to housing insecurity, including intersectional stigma and discrimination coupled with gentrification and a changing housing landscape in the city. Housing was intricately intertwined with employment and other structural issues; vulnerability in one realm was closely tied to insecurity in the others. Social support and queer family structures emerged as a key source of resilience, coping, and survival. The study supports an increase of resources for T/GNC housing access and interventions that address the cyclical discrimination, housing, and employment issues this population faces with a consideration of the historical and current structural barriers impeding their access to safe, stable, long-term housing.

Psychological resilience among transfeminine adolescents and emerging adults living with HIV

OBJECTIVES

The current study sought to examine factors that promote psychological resilience related to engagement in the HIV continuum of care (CoC) among transfeminine adolescents and emerging adults (TF AEA) living with HIV in the U.S. using a qualitative approach.

DESIGN

The parent study from which these data came utilized a concurrent transformative mixed-methods research design grounded in Gender Affirmation and Gender Minority Stress Theory that focused on advancing our understanding of transgender youth's experiences with healthcare generally and their experiences across the HIV CoC.

METHODS

Semi-structured in-depth qualitative interviews with 66 TF AEA living with HIV were analysed using a two-stage interpretive phenomenological analytic approach that allowed for both inductive and deductive explorations of the data.

RESULTS

When discussing health-promoting psychological resilience factors, participants described both interpersonal resources (i.e. support or assistance via interactions with others) and intrapersonal assets (i.e. positive internal cognitive processes) that encouraged their engagement in the HIV CoC. The interpersonal resources described by participants included three main types of support: emotional support, gender support and instrumental-informational support. Three thematic categories describe the intrapersonal assets that participants discussed: health awareness and HIV acceptance; health motivation and health responsibility; and psychological well being and inner strength.

CONCLUSION

Despite experiences of HIV-related stigma and transphobia, TF AEA living with HIV demonstrate psychological resilience, as they navigate engagement in the HIV CoC. Results highlight possibilities for implementing public health interventions at individual, community and systems levels to bolster resilience among TF AEA living with HIV.

Network Properties Among Gay, Bisexual and Other Men Who Have Sex with Men Vary by Race

The HIV burden among gay, bisexual, and other men who have sex with men (GBM) may be related to variations in network characteristics of the individual's social and sexual network. This study investigates variations in network properties among 188 Black and 295 White GBM recruited in New Orleans during the National HIV Behavioral Surveillance in 2014. Participants described up to five people who provided social support and five sex partners in the past 3 months. Network properties and network dissimilarity indicators were aggregated to the participant level as means or proportions and examined using PROC GLM. White participants reported larger networks (p = 0.0027), had known network members longer (p = 0.0033), and reported more substance use (p < 0.0001) within networks. Black participants reported networks with fewer men (p = 0.0056) and younger members (p = 0.0110) than those of White GBM. Network properties among GBM differ by race in New Orleans which may inform prevention interventions.

Network Properties Among Gay, Bisexual and Other Men Who Have Sex with Men Vary by Race

The HIV burden among gay, bisexual, and other men who have sex with men (GBM) may be related to variations in network characteristics of the individual's social and sexual network. This study investigates variations in network properties among 188 Black and 295 White GBM recruited in New Orleans during the National HIV Behavioral Surveillance in 2014. Participants described up to five people who provided social support and five sex partners in the past 3 months. Network properties and network dissimilarity indicators were aggregated to the participant level as means or proportions and examined using PROC GLM. White participants reported larger networks (p = 0.0027), had known network members longer (p = 0.0033), and reported more substance use (p < 0.0001) within networks. Black participants reported networks with fewer men (p = 0.0056) and younger members (p = 0.0110) than those of White GBM. Network properties among GBM differ by race in New Orleans which may inform prevention interventions.

Improving communication about HIV prevention among people living with HIV and their at-risk social network members in Dar es Salaam, Tanzania

Although a number of HIV prevention programs have been implemented, such as mass media campaigns, high rates of unprotected and concurrent sexual partnerships, as well as low uptake HIV testing and limited HIV knowledge, persist in Tanzania. We examined the effect and predicting factors of HIV prevention communication among people living with HIV (PLH) exposed to NAMWEZA intervention, and their at-risk social network members (NMs) Quantitative data were collected from 326 participants at baseline and 24 months of follow-up. In-depth interviews with 20 PLH were conducted at follow-up. Results indicated specific communication about condom use and HIV testing increased; (mean increase of 0.28 (SD = 0.14) scores, P = 0.012 and 0.42 (SD = 0.11) scores, p < 0.001 respectively while general discussion about protecting other people from HIV did not change significantly; mean increase was 0.01 scores (SD = 0.005), p = 0.890. Positive predictors of communication included being single; OR = 1.10, p = 0.01, female; OR = 1.15, p = 0.03, aged 30 years or older; OR = 1.23, p < 0.01, HIV knowledge, dose of NAMWEZA participation; OR = 1.01, p < 0.001, and high self-efficacy for condom use; OR = 1.4, p < 0.001. Stigma demonstrated a significant but negative association with communication for condom use; OR = 1.01, p < 0.01.Qualitative data reflected perceived possession of more individual skills and ability to address some personal/cultural obstacles to communicating about HIV prevention including those observed in the quantitative data. NAMWEZA improved communication about HIV prevention among PLH with their at-risk-NMs. The approach is a promising complement to media campaigns in similar populations. Future research and program evaluation efforts should explore how communities perceive and communicate about protecting others from HIV.

Transgender persons' HIV care (dis)engagement: a qualitative evidence synthesis protocol from an ecological systems theory perspective

INTRODUCTION

There seems to be little information on interactional patterns of enabling and constraining factors contributing to HIV care engagement across systems and across time. Understanding these patterns from a (micro-meso-macro-exo) systems perspective can provide rich insights on relevant social networks affecting transgender populations. In this review, we will synthesise the wealth of literature on transgender persons' engagement in the HIV care continuum.

METHODS AND ANALYSIS

We will perform a networked systems approach to qualitative evidence synthesis of relevant qualitative research data generated from primary qualitative, mixed-method and evaluation studies exploring HIV care engagement among diverse transgender populations. Studies not using qualitative methods and studies not published in English will be excluded from this review. Empirical studies will be identified via a search in major databases such as PubMed, Scopus, ERIC, Embase, Web of Science, Sociological Abstracts, PsychInfo and Social Services Abstract in January 2019. Two reviewers will independently screen the studies for inclusion, assess their quality and extract data. In case some of the system levels in the network are ill-covered by empirical studies, non-empirical studies will be considered for inclusion. The qualitative evidence synthesis includes a summary of descriptive data (first order), an exploration of relationships between system levels or their components (second order) and a structured summary of research evidence through narrative synthesis. The narrative synthesis will be extended with an overall social network analysis that visualises important nodes and links cutting across ecological systems.

ETHICS AND DISSEMINATION

Ethical approval is not required to conduct this review. Review findings will be disseminated via peer-reviewed academic journals and a targeted information campaign towards organisations that work with our population of interest.

PROSPERO REGISTRATION NUMBER

CRD42018089956.

The Social and Sexual Networks of Black Transgender Women and Black Men Who Have Sex with Men: Results from a Representative Sample

Background: Little research has evaluated the social and sexual network-related health outcomes of young black transgender women (TGW) or compared these outcomes with those of black men who have sex with men (MSM). Social network analysis offers one potent means of understanding the dynamics driving the broad spectrum of adverse outcomes experienced by these subgroups.

Methods: We examined the social and sexual health network traits of 618 black individuals assigned male at birth who have sex with men, 47 (7.6%) of whom identified as TGW. Using respondent-driven sampling, data collection occurred over three waves between 2013 and 2016, in Chicago, Illinois. Univariate, logistic regression, and confidant and sexual network analyses were conducted to characterize dynamic network features.

Results: TGW's mean age was 22.1 (standard deviation ±2.6). TGW's sexual networks were significantly less stable (stability ratio of 0.175 vs. 0.278 among MSM, p=0.03) and had greater network turnover (turnover ratio of 0.825 vs. 0.735, p=0.04). TGW also had significantly more sex partners (7.6 vs. 4.0, p=0.0002) and exchange sex (odds ratio=2.97; 95% confidence interval: 1.66–5.32, p<0.001), lower rates of employment (39.6% vs. 71.1%, p<0.001), and more reported an income <$20,000 (93.5% vs. 80.8%, p=0.029). Within confidant networks, TGW had a borderline significantly higher network turnover ratio (0.703 vs. 0.625, p=0.06). Furthermore, both TGW and MSM had high, but similar, HIV rates (42.3% vs. 30.6%, respectively; p=0.17). There were no significant structural network differences vis-à-vis mean degree (p=0.46), betweenness centrality (p=0.40), closeness centrality (p=0.18), or average shortest path length (borderline statistically significant at p=0.06).

Conclusion: Using data from a representative sample of younger black individuals, we observed black TGW have less sexual network stability in contrast to black MSM but comparable structural network features. We further observed that both groups, and black TGW especially, possess considerable system-level, socioeconomic, and sexual health burdens.

Development of a social capital scale for constructed families of gay, bisexual, and other men who have sex with men

Despite previous empirical studies which have linked social capital to a number of health outcomes, few studies have investigated sub-group specific social capital among populations at increased risk for HIV infection such as gay, bisexual and other men who have sex with men (GBM). Many GBM of color belong to constructed families in which friends refer to each other with kinship terms such as parents and children. No studies have measured social capital provisions within constructed family networks. This study developed a preliminary instrument for assessing social capital among constructed families. The network level social capital scale incorporated the following theoretical domains hypothesized to define social capital derived from network membership: social influence, multiplex ties, heterogeneity, social cohesion, trust, quality of support, and compositional quality. A cross-sectional survey administered an eight-item scale to 131 GBM who belonged to constructed families. The factor structure and confirmatory factor analysis were assessed. Reliability was evaluated using Cronbach's alpha to measure internal consistency. A final single factor solution was obtained which was comprised of six items with high factor loadings. The resulting measures were highly correlated with an alpha of 0.84 and each factor loading was well above 0.3. This study assessed the psychometric properties of a preliminary network level social capital instrument among GBM in constructed families. Future studies may utilize or adopt this scale to measure network-level social capital within other populations.

Co-Occurring Psychosocial Problems and Multiple Sexual Partners among Men Who Have Sex with Men in Shanghai, China: A Syndemic Approach

We aimed to apply syndemic theory to verify the association and reinforcing effects between psychosocial problems and multiple sexual partners (MSP) of men who have sex with men (MSM) in Shanghai, China. A cross-sectional study was conducted among 547 MSM in Shanghai, China using a face-to-face survey. Sociodemographic and psychosocial data were collected, as well as information on MSP and condomless anal sex. In the 6 months prior to the survey, 54.3% of the MSM sample had had MSP. Univariate analysis showed that self-esteem, depression, loneliness, sexual compulsivity, and involuntary subordination (IS) were associated with MSP. Sexual compulsivity (multivariate odds ratio [ORm] = 2.94, 95% CI = 1.76-4.91) and IS (ORm = 1.79, 95% CI = 1.14-2.81) remained significant in multivariate analysis. MSM with five or more psychosocial problems had greater odds of (adjusted odds ratios = 3.06, 95% CI = 1.49-6.25) having MSP in the previous 6 months than the non-syndemic group. Our findings provide preliminary confirmation of the additive relationship of syndemic psychosocial health conditions and MSP among MSM in Shanghai, China. An integrated intervention with special focus on sexual compulsivity and IS is needed.

Understanding health decision making: An exploration of homophily

The phenomenon of homophily first was described in Lazarsfeld and Merton's classic 1954 friendship analysis as a tendency for friendships to form between those who are alike in some respect. Although theories of decision making address a host of factors that affect the process, the influence of individuals with homophilic ties remains unaccounted for and unexplained. The purpose of this paper is to review theories relevant to decision making and describe what is known about the relationship between homophily and health care decision making. Further, we provide new evidence suggesting the influence of homophily on decision making in results from a randomized, multi-center clinical trial of American men with localized prostate cancer. A diverse sample of 293 men with a new diagnosis of localized prostate cancer reported relevant personal factors influencing the care management decision before randomization to a decision aid or usual care, between 2013 and 2015. Among these personal factors were the level of influence or importance ascribed to various individuals at the time of the treatment decision. One month later, participants reported how prepared they were for decision making. 123 men (42%) reported friends and/or coworkers as information sources, of which 65 (53%) indicated that friends and/or coworkers influenced the care decision. Men who reported friends/coworkers as information sources had significantly higher one-month preparation scores. Our review of decision making theories and practical applicability suggests the influence of homophilic relationships manifests in health care decision making. Faced with a list of options to manage health conditions, decision makers turn to known individuals in their environments, particularly those individuals with whom the decision maker can identify. Clinicians may solicit information from patients about influential others and explain how that support fits into the health decision at hand without dishonoring the importance of the homophilic relationship.

"Tiptoeing Around the System": Alternative Healthcare Navigation Among Gender Minorities in New Orleans

Purpose: Gender Minority (GM) individuals experience healthcare access barriers, including financial concerns and discrimination, which influence their health seeking behaviors. This study explores the alternative navigation strategies used by GM individuals to cope with these barriers and access care, both biomedical and complementary and alternative medicine (CAM). Methods: In-depth interviews were conducted with GM individuals (n=18) and healthcare providers (n=5) identified through purposive sampling. Semistructured guides were used to elicit information about healthcare seeking strategies and experiences. Transcribed interview data were coded, sorted, and analyzed for key themes. Results: Commonly discussed healthcare access barriers included the following: identifying a competent provider, costs and insurance obstacles, and anticipated discrimination. Respondents expressed a need for gender-affirming care within the biomedical system, and alternative navigation strategies to overcome access barriers, including travelling abroad for surgical procedures, ordering hormones online, and sharing with friends. Respondents discussed CAM principally related to emotional health, preferring CAM to biomedical offerings. Utilizing social networks to access all care modalities was common. Conclusions: The healthcare-seeking behavior of GM individuals demonstrates great resilience. This population is committed to accessing gender-affirming care regardless of the associated risks of care outside of provider supervision. The healthcare community needs to eliminate access barriers and support harm reduction strategies. CAM for emotional health support and the role of social networks in accessing care resources should be better integrated into care for this population.

Who counts as family? Family typologies, family support, and family undermining among young adult gay and bisexual men

Gay and bisexual men may form chosen families in addition to or in place of families of origin. However, the characteristics of these diverse families remain largely unexamined in the quantitative literature. The purpose of this study was to develop a family typology based on responses from a racially and ethnically diverse sample of young adult gay and bisexual men (YGBM) recruited from the Detroit Metropolitan Area (N=350; 18-29 years old). To explore the role of family, we then examined family social support and social undermining in relation to YGBM psychological distress within different family types. A series of multivariate regressions were used to examine associations between family social support and social undermining with depression and anxiety outcomes. The majority (88%) of YGBM included family of origin in their definitions of family and 63% indicated having chosen families. Associations between family social processes and psychological outcomes varied by type of family, suggesting that family composition shapes how perceptions of support and undermining relate to experiencing symptoms of depression and anxiety. Chosen families play a prominent role in the lives of YGBM and should not be overlooked in family research. Findings also highlight the importance of examining co-occurring family social support and social stress processes to further address psychological distress symptoms among YGBM.

A longitudinal examination of factors associated with social support satisfaction among HIV-positive young Black men who have sex with men

This study examined the long-term predictors of social support satisfaction among HIV-positive young Black men who have sex with men (YBMSM). Data were collected across three waves between October 2012 and November 2014 as part of the baseline assessment from Project nGage, a preliminary efficacy randomized control study examining the role of social support in improving HIV care among YBMSM. The sample included 92 YBMSM aged 18-29. Major results controlling for age, education and intervention effects indicated that psychological health, social network size, and education at baseline predicted differences in social support satisfaction at Wave 3, with no significant effects based on length of HIV diagnosis. Therefore, interventions that are intended to promote the quality of life for YBMSM and their engagement and retention in HIV care must focus on their psychological health concerns and network size.

Social-structural properties and HIV prevention among young men who have sex with men in the ballroom house and independent gay family communities

The endogenous social support systems of young Black men who have sex with men (YBMSM), like surrogate families and social networks, are considered crucial assets for HIV prevention in this population. Yet, the extent to which these social systems foster sexual health protections or risks remains unclear. We examine the networked patterns of membership in ballroom houses and independent gay families, both Black gay subcultures in the United States, and how these memberships are related to HIV protective and risk traits of members. Drawing from a population-based sample of 618 YBMSM living in Chicago between June 2013 and July 2014, we observe a suite of protective and risk traits and perform bivariate analyses to assess each of their associations with being a member of a house or family. We then present an analysis of the homophilous and heterophilous mixing on these traits that structures the patterns of house and family affiliations among members. The bivariate analyses show that members of the house and family communities were more likely than non-members to report protective traits like being aware of PrEP, having health coverage, having a primary care doctor, and discouraging sex drug use among peers. However, members were also more likely to engage in the use of sex drugs. With respect to how these traits inform specific house/family affiliations, results show that members who had a recent HIV test, who were PrEP aware, or who engaged in exchange sex were more likely to belong to the same house or family, while HIV positive individuals were less likely to cluster within houses or families. These findings provide insights regarding the strengths and vulnerabilities of the house and gay family communities that can inform more culturally specific interventions that build on the existing human and social capital in this milieu.