HIV-Related Sexual Risk Among Transgender Men Who Are Gay, Bisexual, or Have Sex With Men

Latent Constructs of Economic Marginality Associated with Sexual Behavior, Healthcare Access and HIV Outcomes Among Transgender and Nonbinary People in Three U.S. Cities

Transgender and nonbinary people (TNB) in the U.S. experience high HIV prevalence and diverse economic hardships. Yet a comprehensive understanding of how multiple, simultaneously occurring hardships-termed economic marginality-are together associated with healthcare and HIV outcomes is needed. Leveraging survey data from a sample of 330 TNB people in three U.S. cities, we conducted an exploratory mixed-source principal component analysis of latent factors of economic experience, then estimated their associations with sexual behavior, access to healthcare, HIV status, and HIV testing frequency. Two factors emerged: a traditional socioeconomic factor related to income, education, and employment (SES), and one related to housing precarity and (lack of) assets (Precarity). Higher Precarity scores were associated with sexual behavior, cost-based healthcare avoidance, discrimination-based healthcare avoidance, and more frequent HIV testing. Findings highlight the importance of understanding profiles of economic marginalization among trans and nonbinary people and can inform efforts to address upstream, structural factors shaping healthcare access and HIV outcomes in this key population.

Racial/Ethnic Differences in Sexually Transmitted Infection Testing Among Transgender Men and Nonbinary Assigned Female at Birth Young Adults in the United States: a National Study

BACKGROUND

Sexually transmitted infections (STIs) cause a major burden of disease in the United States (US)-especially among structurally marginalized populations, including transgender and nonbinary people, individuals assigned female at birth (AFAB), Black and Latinx/e individuals, and young adults. Although screening can help detect and prevent STIs, research on STI testing among populations at diverse intersections of multiple forms of structural marginalization, including Black, Latinx/e, and other racially/ethnically minoritized transgender men and nonbinary AFAB US young adults, is extremely scarce.

METHODS

We conducted a national cross-sectional online survey of transgender and nonbinary US young adults from February to July 2019. Using Poisson regression, we estimated prevalence ratios (PR) and 95% confidence intervals (CI) for the associations between race/ethnicity-which we conceptualized as a system of structural inequality that shapes individuals' and groups' exposure to racism-and lifetime and past-year STI testing among transgender men and nonbinary AFAB US young adults aged 18-30 years with at least one-lifetime sexual partner (N = 378).

RESULTS

Approximately 74% of participants had received an STI test in their lifetime, and, among those, 72% with a past-year sexual partner had been tested for an STI in the last 12 months. We observed no statistically significant association between race/ethnicity and lifetime STI testing among transgender and nonbinary AFAB young adults with a lifetime sexual partner. In contrast, Black (PR = 1.32; 95%: 1.03, 1.68) and Latinx/e (PR = 1.39; 95% CI: 1.11, 1.75) transgender men and nonbinary AFAB young adults who ever received an STI test and had a past-year sexual partner were significantly more likely to have received an STI test in the last 12 months relative to their White counterparts, adjusting for demographic factors. Further adjustment for lifetime STI diagnosis and health insurance status did not appreciably attenuate these observed adjusted differences; however, the adjusted difference in the prevalence of past-year STI testing between Black (but not Latinx/e) and White transgender men and nonbinary AFAB young adults was no longer statistically significant upon further adjustment for educational attainment and employment status, possibly due to small sample sizes.

CONCLUSION

The higher adjusted prevalence of past-year STI testing among Black and Latinx/e compared to White transgender men and nonbinary AFAB US young adults may reflect racist and xenophobic sexual stereotypes about Black and Latinx/e people among health care providers and institutions, the history of hyper-surveillance of Black and Latinx/e people by public health institutions in the context of infectious disease containment, and/or agency and resistance among Black and Latinx/e transgender men and nonbinary AFAB young adults with regard to sexual health promotion in the face of multiple compounding systems of oppression.

Heterogeneity in HIV/Sexually Transmitted Infection Prevalence and Prevention Among the Partners of Transgender and Nonbinary People

BACKGROUND

Transgender and nonbinary (TNB) people are diverse in their sexual orientation and partnerships. We describe the epidemiology of HIV/sexually transmitted infection (STI) prevalence and prevention utilization among the partners of TNB people in Washington State.

METHODS

We pooled data from five 2017 to 2021 cross-sectional HIV surveillance data sources to generate a large sample of TNB people and cisgender people who had a TNB partner in the past year. We described characteristics of recent partners of trans women, trans men, and nonbinary people and used Poisson regression to assess if having a TNB partner was associated with self-reported HIV/STIs prevalence, testing, and preexposure prophylaxis (PrEP) use.

RESULTS

Our analysis included 360 trans women, 316 trans men, 963 nonbinary people, 2896 cis women, and 7540 cis men. Overall, 9% of sexual minority cis men, 13% of sexual minority cis women, and 36% of TNB participants reported having any TNB partners. There was significant heterogeneity in HIV/STI prevalence, testing, and PrEP use among the partners of TNB people by study participant gender and the gender of their sex partners. In regression models, having a TNB partner was associated with a higher likelihood of HIV/STI testing and PrEP use but was not associated with higher HIV prevalence.

CONCLUSIONS

We observed significant heterogeneity in HIV/STI prevalence and preventative behaviors among the partners of TNB people. Given that TNB people are diverse in their sexual partnerships, there is a need to better understand individual-, dyad-, and structural-level factors that facilitate HIV/STI prevention across these diverse partnerships.

Cisnormativity as a structural barrier to STI testing for trans masculine, two-spirit, and non-binary people who are gay, bisexual, or have sex with men

Trans masculine, two-spirit, and non-binary people who are gay, bisexual or otherwise have sex with men (TGBM) are under-tested for sexually transmitted infections (STI) and may face complex, intersectional barriers that prevent them from accessing STI testing. As part of a study on gay, bisexual and other men who have sex with men's (GBM) experiences of current STI testing systems in Ontario, Canada, this paper reports on the findings from TGBM participants' experiences with in-person STI testing in a range of venues (i.e. Family doctors, walk-in clinics, and community-based organizations) to explore testing barriers specific to TGBM. Using a community-based research approach, between June 2020 and December 2021 peer researchers who identified as GBM conducted focus groups and interviews with 38 cis and trans GBM, 13 of whom identified as TGBM. Data were analyzed following grounded theory. When questioned about past experiences with testing, TGBM participants reported several barriers to STI testing within current testing models in Ontario due to cisnormativity and heteronormativity. Cisnormativity is the assumption that everyone identifies as the gender they were assigned at birth, and those who do not are considered "abnormal", while heteronormativity is when it is assumed that everyone is heterosexual. From our research we identified three overarching themes concerning testing barriers among TGBM participants: (1) non-inclusive clinic environments, (2) lack of provider knowledge and competency, and (3) legal documentation. Inherent cis and heteronormativity in healthcare institutions appear to be factors shaping the historical under-testing for STI in the TGBM population. These findings suggest the relevance of implementing trans-specific clinical practices that reduce the stigma and barriers faced by TGBM in STI testing contexts, including: hosting all-gender testing hours, opening more LGBTQ+ clinics, offering training in transgender health to testing providers, and conducting a review of how gender markers on health documents can be more inclusive of trans, two-spirit, and non-binary communities.

Kinky Sex and Deliberate Partner Negotiations: Case Studies of Canadian Transgender Men Who Have Sex with Men, Their HIV Risks, Safer Sex Practices, and Prevention Needs

Growing research in the last two decades has begun to investigate the HIV risks and sexual health practices of transgender men, especially as a subpopulation of men who have sex with men (MSM) that likely shares certain HIV risks and sexual health practices with cisgender MSM, the sociodemographic group that continues to be at highest risk for HIV in many developed countries since the start of the epidemic. As part of our Community-Based Participatory Research project and larger strengths-based qualitative study that was dedicated to examine multiple factors that promote resilience to HIV utilizing the perspectives and lived experiences of middle-aged and older MSM, the case studies we present in this article feature the distinct insights and experiences of three HIV-negative transgender MSM from Downtown Toronto, Ontario, Canada, who participated in our one-on-one interviews. The three case studies provide not only an enlightening snapshot of some of the specific contexts, HIV risks, safer sex practices, and HIV prevention needs of transgender MSM, but also a unique opportunity to critically reflect on the potential implications of the insights and experiences that were shared by our participants, particularly for adapting and developing current and future HIV services and programs to maximally benefit transgender MSM.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

"Making a Way Out of No Way:" Understanding the Sexual and Reproductive Health Care Experiences of Transmasculine Young Adults of Color in the United States

Research focusing on the specific and unique sexual and reproductive health care experiences of transmasculine young adults of color are extremely scarce. We conducted five focus group discussions with 19 Black, Latinx, Asian, Native, and other transmasculine individuals of color aged 18-25 years in the greater Boston area. Using thematic analysis, we found that transmasculine young adults of color experienced cissexism, heterosexism, and racism in accessing and utilizing sexual and reproductive health services. These multiple forms of discrimination undermined participants' receipt of high-quality sexual and reproductive health information and care from competent health care providers who shared their lived experiences. Participants relied on support from their lesbian, gay, bisexual, transgender, and queer peers to obtain needed sexual and reproductive health resources and minimize harm during clinical encounters. Multilevel interventions are needed to promote access to person-centered and structurally competent sexual and reproductive health care among transmasculine young adults of color.

Living conditions, HIV and gender affirmation care pathways of transgender people living with HIV in France: a nationwide, comprehensive, cross-sectional, community-based research protocol (ANRS Trans&HIV)

INTRODUCTION

Transgender identity is poorly accepted in France, and data on living conditions and the daily difficulties transgender people encounter are scarce. This lack of data reinforces their invisibility in social life, contributes to their stigmatisation and probably increases the burden of HIV infection, especially for HIV-positive transgender people (TRHIV). The main objective of the community-based research study ANRS Trans&HIV is to identify personal and social situations of vulnerability in TRHIV, the obstacles they encounter in terms of access to and retention in medical care, and their gender affirmation and HIV care needs.

METHODS AND ANALYSIS

ANRS Trans&HIV is a national, comprehensive, cross-sectional survey of all TRHIV currently being followed in HIV care units in France. TRHIV women are exclusively included in the quantitative component, and TRHIV men in the qualitative component. Data are collected by community-based interviewers and will be analysed to explore patient care pathways and living conditions in the TRHIV population with regard to gender affirmation and HIV. Data collection began in October 2020 and should be completed in December 2021. The statistical analyses techniques used will be adapted to each of the study's objectives and to the type of data collected (cross-sectional (questionnaires) and retrospective (biographical trajectory)). The study's results will provide a greater understanding of TRHIV health needs in order to suggest possible national recommendations for comprehensive HIV and gender affirmation medical care.

ETHICS AND DISSEMINATION

ANRS Trans&HIV was approved by Inserm's Ethical Evaluation Committee (no 20-694 on 12 May 2020) and is registered with the National Commission on Informatics and Liberty under number 2518030720. Potential participants are informed about the study through an information note provided by their attending HIV physician. All results published in peer-reviewed journals will be disseminated to the HIV transgender community, institutional stakeholders and healthcare providers.

TRIAL REGISTRATION NUMBER

NCT04849767.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Violence Inflicted on Latina Transgender Women Living with HIV: Rates and Associated Factors by Perpetrator Type

Many transgender individuals report violence directed against them. This study examined violence inflicted on transgender Latinas with HIV by primary partners, sexual partners and acquaintances/strangers. Logistic regression was used for analysis. 150 transgender Latinas were recruited. Rates of violence from different perpetrator types were 47-50%. For violence by primary partners, social support from cisgender people was associated with a lower likelihood of violence (AOR 0.56; CI 0.32, 0.98; p < 0.05). For violence by sexual partners, a history of childhood sexual abuse was associated with a higher likelihood of violence (AOR 2.64; CI 1.10, 6.34; p < 0.05). For violence by acquaintances/strangers, discrimination was associated with a higher likelihood of violence (AOR 2.84; CI 1.16, 6.94; p < 0.05) and social support from cisgender people with a lower likelihood (AOR 0.58; CI 0.37, 0.92; p < 0.05). Interventions are needed at individual, institutional and systemic levels to eradicate such violence.

HIV burden and correlates of infection among transfeminine people and cisgender men who have sex with men in Nairobi, Kenya: an observational study

BACKGROUND

Transgender people are disproportionately affected by HIV and other sexually transmitted infections (STIs) worldwide, and culturally competent prevention and treatment services are often unavailable or inaccessible. Despite recent improvements in national HIV responses for many key populations in east Africa, evidence of effective responses informed by transgender sexual health needs is sparse. We aimed to assess gender identity among men and transgender people who have sex with men in Kenya, and to explore its associations with sexual health-related outcomes, risk behaviours, and uptake of HIV prevention and care interventions.

METHODS

We did a cross-sectional study in Nairobi, Kenya, and recruited adult cisgender men and transfeminine people who reported having sex with men, through respondent-driven sampling. Inclusion criteria were possession of a valid study coupon, being aged 18 years or older, having male sex assignment at birth or male gender identification currently, living within 50 km of Nairobi, and having had consensual anal or oral sexual activity with a man in the previous 12 months. Seed participants were identified by three community organisations that provide targeted health-care services to gay, bisexual, or other men who have sex with men (MSM) communities in Nairobi. We assessed gender identity, sociodemographics, sexual behaviour, and HIV prevention and care uptake, by self-completed survey. Participants were tested for HIV, syphilis, and rectal and urethral gonorrhoea and chlamydia. We compared prevalence of sexual health outcomes, risk behaviour, and HIV prevention and care service uptake among transfeminine and cisgender participants, using multivariable robust Poisson regression models, with gender identity as the independent variable.

FINDINGS

Between May 4 and Dec 8, 2017, we enrolled 618 participants. Six participants did not answer the questions on sex assigned at birth and gender identity and so were excluded from the analyses. 522 (sample-weighted percentage 86%) of 612 participants were classified as cisgender men, 70 (11%) as transfeminine, and three (<1%) as transmasculine. 17 participants (2%) did not identify as male, female, or transgender. Compared with cisgender men, transfeminine people were more likely to be HIV-positive (28 [41%] of 70 transfeminine vs 151 [25%] of 521 cisgender men; p=0·0009) and to report current symptoms consistent with a rectal STI (eight [16%] of 67 vs 38 [7%] of 518; p=0·014). Transfeminine people reported higher numbers of recent male sexual partners (22 [27%] of 70 transfeminine people reported four or more male sexual partners in the past 3 months vs 112 [13%] of 522 cisgender men; p=0·042) and were more likely to report condomless anal intercourse with men (43 [62%] of 70 vs 208 [39%] of 522; p=0·0009) and receptive anal intercourse (54 [76%] of 70 vs 252 [46%] of 522; p<0·0001) in the past 3 months, and transactional sex with men (42 [57%] of 69 vs 240 [42%] of 518; p=0·023) and experience of sexual assault (16 [23%] of 69 vs 65 [11%] of 520; p=0·019) in the past 12 months. Use of pre-exposure prophylaxis and post-exposure prophylaxis was low in both groups.

INTERPRETATION

Transfeminine people who have sex with men have a higher burden of HIV and associated risk behaviours compared with cisgender MSM in the same context, yet their uptake of prevention and care services is poor. Policies should acknowledge the specific needs of transfeminine people as distinct from cisgender MSM, and support health-care providers to address these needs.

FUNDING

Evidence for HIV Prevention in Southern Africa (EHPSA), UK Aid.

The persistent and evolving HIV epidemic in American men who have sex with men

Men who have sex with men (MSM) in the USA were the first population to be identified with AIDS and continue to be at very high risk of HIV acquisition. We did a systematic literature search to identify the factors that explain the reasons for the ongoing epidemic in this population, using a social-ecological perspective. Common features of the HIV epidemic in American MSM include role versatility and biological, individual, and social and structural factors. The high-prevalence networks of some racial and ethnic minority men are further concentrated because of assortative mixing, adverse life experiences (including high rates of incarceration), and avoidant behaviour because of negative interactions with the health-care system. Young MSM have additional risks for HIV because their impulse control is less developed and they are less familiar with serostatus and other risk mitigation discussions. They might benefit from prevention efforts that use digital technologies, which they often use to meet partners and obtain health-related information. Older MSM remain at risk of HIV and are the largest population of US residents with chronic HIV, requiring culturally responsive programmes that address longer-term comorbidities. Transgender MSM are an understudied population, but emerging data suggest that some are at great risk of HIV and require specifically tailored information on HIV prevention. In the current era of pre-exposure prophylaxis and the undetectable equals untransmittable campaign, training of health-care providers to create culturally competent programmes for all MSM is crucial, since the use of antiretrovirals is foundational to optimising HIV care and prevention. Effective control of the HIV epidemic among all American MSM will require scaling up programmes that address their common vulnerabilities, but are sufficiently nuanced to address the specific sociocultural, structural, and behavioural issues of diverse subgroups.

Health and well-being of trans and non-binary participants in a community-based survey of gay, bisexual, and queer men, and non-binary and Two-Spirit people across Canada

There is a paucity of population health data on the experiences of transgender, non-binary, and other gender minority gay, bisexual, and queer men, and Two-Spirit people in Canada. To address this gap, this article presents a socio-demographic and health profile of trans and non-binary participants from the community-based bilingual 2018 Sex Now Survey. Participants were recruited in-person from Pride festivals in 15 communities to self-complete an anonymous paper-and-pen questionnaire. To be eligible, participants needed to be at least 15 years old, live in Canada, either report a non-heterosexual sexual identity or report sex with a man in the past 5 years, and not report gender identity as a woman. Through community consultations the survey was inclusive of trans men, non-binary people, and Two-Spirit people. Three gender groups (cisgender, transgender, and non-binary) were created, and trans and non-binary participants were compared with their cisgender peers across a variety of demographic, mental health, sexual health, and general health indicators. Odds ratios were calculated to determine initial significance for categorical variables, and adjusted odds ratios were calculated to control for five possible confounders (age, ethnoracial identity, country of birth, sexual identity, and financial strain). Significant differences emerged across all sets of indicators, with many of these findings remaining significant after adjusting for confounding variables, including significantly higher reported rates of mental health challenges and sexual health service barriers for trans and non-binary participants compared to the cisgender group. Trans and non-binary participants were also more likely to be in polyamorous relationships. Collectively, our findings demonstrate that trans and non-binary people experience significant disadvantages compared with cisgender sexual minority men. Improved educational supports and employment protections, access to queer and gender affirming healthcare, and trauma-informed mental health services are needed to improve the health wellbeing of trans and non-binary people in Canada.

The Pre-Exposure Prophylaxis Cascade in At-Risk Transgender Men Who Have Sex with Men in the United States

Purpose: This analysis was designed to characterize the pre-exposure prophylaxis (PrEP) cascade in a U.S. national sample of transgender men and trans masculine adults who have sex with cisgender men (trans MSM) at-risk for HIV acquisition. Methods: From November to December 2017, 843 HIV-negative trans MSM self-reporting past-6-month receptive sex with a cisgender man were recruited via peer referrals, dating apps, listservs, and social media. A computer-assisted self-interview assessed demographics, health care, and the PrEP cascade. Descriptive statistics and multivariable regression models evaluated factors associated with PrEP uptake and persistence. Results: Mean age was 28.1 years (standard deviation = 7.1); 4.8% were Black, 21.7% Latinx, and 25.6% another race/ethnicity. A total of 84.1% had heard of PrEP, with 67.3% reporting interest. More than half (55.2%) were PrEP indicated, of which 50.8% were PrEP naive. Approximately 1/4 (28.0%) reported PrEP use, of which 65.3% were PrEP persistent. PrEP modality preferences were injectable (51.2%), daily oral pill (22.1%), and anal gel/lube (14.6%). Reasons for PrEP noninterest were no HIV risk (68.5%), cost (24.2%), and side effects (20.1%). Surgical gender affirmation, no health care discrimination, and social media as a primary health information source were associated with increased odds of PrEP uptake and persistence (all p < 0.05). PrEP adherence difficulties were reported by 52.6%, due to busy/inconsistent schedule (53.1%), side effects (27.4%), and too many medical visits (11.6%). Conclusion: PrEP uptake was modest among the trans MSM sampled, given prevalent HIV risk behaviors. The limited PrEP uptake in at-risk trans MSM suggests the need to develop culturally tailored community education and interventions.

Impact and acceptability of HIV self-testing for trans men and trans women: A mixed-methods subgroup analysis of the SELPHI randomised controlled trial and process evaluation in England and Wales

BACKGROUND

Globally, trans people are disproportionately affected by HIV, but research on strategies to increase testing are limited. SELPHI is a randomised-controlled-trial (RCT) of 10,135 cis men, trans men, and trans women reporting lifetime anal intercourse with male partners (cis or trans), evaluating whether the offer of free HIV self-testing (HIVST) increases diagnosis. This subgroup analysis from the SELPHI RCT aims to describe key HIVST outcomes and HIVST acceptability for trans people.

METHODS

SELPHI recruited using social networking and trans focused social media. Participants were randomised 60/40 to baseline HIVST (Biosure™) (BT) vs no baseline HIVST (nBT); and at 3-months (if completed the survey and reported recent CAI) 50/50 to 3-monthly HIVST (RT) vs no repeat HIVST (nRT). Outcomes were self-reported through online surveys. We conducted a qualitative study of semi-structured peer-led participant interviews (n = 20) exploring HIVST motivations and experiences. These were analysed using a framework approach.

FINDINGS

SELPHI recruited and randomised 118 trans men and trans women (94 trans men, 24 trans women), of whom 20 (16 trans men, 4 trans women) underwent the second randomisation. Median age at baseline was 29 (IQR: 22, 37), 79% were white, 79% were UK born, 37% had degree level education, and 31% had never tested for HIV. 62% (n = 59) of trans men completed the 3-month survey, but survey completion by trans women in nBT was too low (1/11) for randomised comparison. In trans men HIV testing uptake by 3 months was significantly higher in BT (95% 36/38) vs nBT (29%, 6/21) (RR=3.32 (1.68, 6.55) p<0.001). Trans people randomised to RT reported 3 times higher rate of HIV testing compared to nRT during the two-year follow-up (IRR 3.66 (1.86, 8.01) p<0.0001). STI testing frequency (mean number of tests during each 13 week period/ 2-year follow-up) was not significantly different across interventions: RT (0.03) and nRT (0.01) (IRR=1.86 95%CI; 0.77, 5.15; p = 0.15). Social harms were rare. Acceptability was very high in BT: 97% (38/39) found instructions easy to understand, 97% (37/38) found the HIVST simple to use and 100% (39/39) reported good overall experience. In interviews, reported HIVST benefits included increased autonomy, privacy, convenience and avoidance of health care providers perceived to be discriminatory and services that increased dysphoria. Minor lancet and test processing issues were reported.

INTERPRETATION

HIVST significantly increased testing uptake and frequency in trans men and trans people overall, although recruitment and retention of trans women was low. HIVST acceptability was high and indicates easy access to this novel technology may increase HIV testing access for this key population.

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.

Sexual and Mental Health Inequalities across Gender Identity and Sex-Assigned-at-Birth among Men-Who-Have-Sex-with-Men in Europe: Findings from EMIS-2017

Some men who have sex with men (MSM) were assigned female at birth (AFB) and/or identify as trans men. Little is known about how these men differ from other MSM. We compared sexual and mental health indicators from the European MSM Internet Survey (EMIS-2017), comparing men AFB and/or currently identifying as trans men with those assigned male at birth (AMB) who identified as men. EMIS-2017 was an opportunistic 33-language online sexual health survey for MSM recruiting throughout Europe. We used regression models adjusting for age, country of residence and employment status to examine differences across groups. An analytic sample of 125,720 men living in 45 countries was used, of which 674 (0.5%) were AFB and 871 (0.7%) identified as trans men. The two sub-groups were not coterminous, forming three minority groups: AFB men, AFB trans men and AMB trans men. Minority groups were younger and more likely unemployed. Anxiety, depression, alcohol dependence and sexual unhappiness were more prevalent in sex/gender minority men. Conversely HIV and STI diagnoses were less common. AMB trans men were most likely to have sexual risk behavior with steady partners and to have unmet health promotion needs, and were least likely to be reached by interventions. Sex assigned at birth and trans identification were associated with different sexual and mental health needs. To facilitate service planning and to foster inclusion, sex-assigned-at-birth and current gender identity should be routinely collected in health surveys.

Identifying Health Differences Between Transgender and Cisgender Gay, Bisexual and Other Men Who Have Sex With Men Using a Community-Based Approach

In this article, we describe a community-based research (CBR) approach to making a national online survey of gay, bisexual, and other men who have sex with men (GBMSM) inclusive of transgender GBMSM by working with members of the transgender community at all stages of the research process. This collaboration resulted in 209 transgender GBMSM completing our survey and we contrasted their health experiences with 7439 cisgender GBMSM. We found that transgender GBMSM were less likely than cisgender GBMSM to report intercourse without a condom (AOR 0.43; 95% CI: 0.28-0.66) and to have had an HIV test (AOR 0.64; 95% CI 0.49-0.85). Transgender GBMSM were more likely to report discrimination in the health care system in their lifetime (AOR 4.17; 95% CI 3.03-5.73), to self-rate their health as poor (AOR 3.47; 95% CI 2.52-4.80), and to have discussed depression (AOR 3.47; 95% CI 262-4.59) or anxiety (AOR 3.27; 95% CI 2.47-4.33) with a health care provider. Our experience highlights the feasibility of including transgender individuals in GBMSM research, while the results affirm the need for GBMSM health services to take into account the unique experiences of transgender GBMSM.

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.

Sociodemographic and behavioural factors associated with testing for HIV and STIs in a US nationwide sample of transgender men who have sex with men

OBJECTIVES

Transgender men who have sex with men (TMSM) represent an understudied population in relation to screening for HIV and sexually transmitted infections (STIs). We examined HIV and STI testing prevalence among TMSM along with the factors associated with testing in a diverse US nationwide sample of TMSM.

METHODS

Data from a cross-sectional online convenience sample of 192 TMSM were analysed using multivariable binary logistic regression models to examine the association between sociodemographic and behavioural factors and lifetime testing for HIV, bacterial STIs and viral STIs, as well as past year testing for HIV.

RESULTS

More than two-thirds of TMSM reported lifetime testing for HIV (71.4%), bacterial STIs (66.7%), and viral STIs (70.8%), and 60.9% had received HIV testing in the past year. Engaging in condomless anal sex with a casual partner whose HIV status is different or unknown and having fewer than two casual partners in the past 6 months were related to lower odds of lifetime HIV, bacterial STI, viral STI and past year HIV testing. Being younger in age was related to lower probability of testing for HIV, bacterial STIs and viral STIs. Furthermore, TMSM residing in the South were less likely to be tested for HIV and viral STIs in their lifetime, and for HIV in the past year. Finally, lower odds of lifetime testing for viral STIs was found among TMSM who reported no drug use in the past 6 months.

CONCLUSIONS

These findings indicate that a notable percentage of TMSM had never tested for HIV and bacterial and viral STIs, though at rates only somewhat lower than among cisgender MSM despite similar patterns of risk behaviour. Efforts to increase HIV/STI testing among TMSM, especially among those who engage in condomless anal sex, are needed.

Chlamydia, Gonorrhea, and Human Immunodeficiency Virus Infection Among Transgender Women and Transgender Men Attending Clinics that Provide Sexually Transmitted Disease Services in Six US Cities: Results From the Sexually Transmitted Disease Surveillance Network

BACKGROUND

Transgender women and transgender men are disproportionately affected by human immunodeficiency virus (HIV) infection and may be vulnerable to other sexually transmitted diseases (STDs), but the lack of surveillance data inclusive of gender identity hinders prevention and intervention strategies.

METHODS

We analyzed data from 506 transgender women (1045 total visits) and 120 transgender men (209 total visits) who attended 26 publicly funded clinics that provide STD services in 6 US cities during a 3.5-year observation period. We used clinical and laboratory data to examine the proportion of transgender women and transgender men who tested positive for urogenital and extragenital chlamydial or gonococcal infections and who self-reported or tested positive for HIV infection during the observation period.

RESULTS

Of the transgender women tested, 13.1% tested positive for chlamydia and 12.6% tested positive for gonorrhea at 1 or more anatomic sites, and 14.2% were HIV-infected. Of transgender men tested, 7.7% and 10.5% tested positive for chlamydia and gonorrhea at 1 or more anatomic sites, and 8.3% were HIV-infected. Most transgender women (86.0% and 80.9%, respectively) and more than a quarter of transgender men (28.6% and 28.6%, respectively) with an extragenital chlamydial or gonococcal infection had a negative urogenital test at the same visit.

CONCLUSIONS

Publicly funded clinics providing STD services are likely an important source of STD care for transgender persons. More data are needed to understand the most effective screening approaches for urogenital, rectal, and pharyngeal Chlamydia trachomatis and Neisseria gonorrhoeae infections in transgender populations.

Cervical gonorrhea in a transgender man post hysterectomy

A 40-year-old transgender man presented to the Hawaii Department of Health with a one-day history of vaginal discharge. Testing of all exposed sites revealed vaginal and rectal gonorrhea. While he reported a total hysterectomy, pelvic examination revealed a cervix. Review of medical records documented a subtotal hysterectomy; however, the patient had not been screened for cervical cancer or sexually transmitted infections (STIs) for several years after surgery. Transgender men who have sex with cisgender men are at increased risk for HIV and STIs and should be screened at least annually for HIV and STIs from all exposed sites. STI data on transgender men are extremely limited. This case report highlights unmet needs of this population.

High risk and low uptake of pre-exposure prophylaxis to prevent HIV acquisition in a national online sample of transgender men who have sex with men in the United States

INTRODUCTION

Trans masculine people who have sex with cisgender ("cis") men ("trans MSM") may be at-risk for HIV infection when they have cis MSM partners or share needles for hormone or recreational drug injection. Limited data are available characterizing indications and uptake of pre-exposure prophylaxis (PrEP) in trans MSM. The aim of this study was to assess PrEP indication and uptake as a means of primary HIV prevention for adult trans MSM in the U.S.

METHODS

Between November and December 2017, a national convenience sample of trans MSM in the U.S. (n = 857) was recruited using participatory methodologies and completed an online survey of demographics, HIV risk, PrEP, behavioural and psychosocial factors. Self-reported receptive anal sex or frontal/vaginal sex (with or without a condom) with a cis male sex partner in past six months was an eligibility criterion. A multivariable logistic regression procedure was used to model PrEP indications (yes/no) per an interpretation of U.S. Centers of Disease Control and Prevention recommendations among those without HIV (n = 843).

RESULTS

The diverse sample was 4.9% Black; 22.1% Latinx ethnicity; 28.4% non-binary gender identity; 32.6% gay-identified; 82.7% on testosterone. Overall, 84.1% had heard of PrEP. Of these, 33.3% reported lifetime PrEP use (21.8% current and 11.5% past). Based on HIV behavioural risk profiles in the last six months, 55.2% of respondents had indications for PrEP. In a multivariable model, factors associated with PrEP indication included where met sex partners, not having sex exclusively with cismen, higher perceived HIV risk, greater number of partners and high cis male partner stigma (all p < 0.05).

DISCUSSION

The majority of trans MSM in this sample had a PrEP indication. Stigma was associated with risk for HIV acquisition and represents a critical target for HIV biobehavioural prevention interventions for trans MSM, who appear to be underutilizing PrEP.

CONCLUSIONS

Results from this study support the full inclusion of trans MSM in HIV biobehavioural prevention efforts. Public health interventions and programmes are needed to reach trans MSM that attend to general MSM risk factors as well as to vulnerabilities specific to trans MSM, including the context of stigma from cis male sexual partners.

Managing sexually transmitted infections: Beyond the 2015 guidelines

Guidelines for the prevention and management of sexually transmitted infections (STIs) are updated periodically while new science is continuously developed. Advanced practice registered nurses implement clinical decisions based on current guidelines and evidence. This article provides recent updates on managing STIs.

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.

Human Immunodeficiency Virus and Trans Women: A Literature Review

Trans women are a key, yet under-researched, population in the HIV epidemic. However, there remains a paucity of data on the health and wellbeing of trans women at risk of, or living with, HIV in the United Kingdom. This article provides a narrative review of key empirical research into HIV among trans women. In an effort to explore individual and social factors in relation to HIV in this population, we outline key tenets of identity process theory from social psychology and the concept of structural violence from medical anthropology. We focus on published studies around the following themes: (1) epidemiological data, (2) syndemic factors (3) barriers to social support, (4) HIV and gender transitioning, and (5) access to and engagement with health care. We identify lacunae and thus call for United Kingdom-based research in the following areas: (1) the prevalence and incidence of HIV in trans women, (2) the impact of syndemic factors on HIV risk and acquisition in trans women, (3) the nature of social support for coping with syndemic factors, (4) the interface of gender transitioning and HIV, and (5) barriers to accessing HIV prevention and care services. There is great scope (and urgency) for research into HIV among trans women, especially in the United Kingdom, to reduce incidence in this group, to enhance engagement in HIV care across the care continuum, and to improve the health and wellbeing of those living with HIV. A tentative model for HIV prevention and care is presented in this article.

Towards Providing Culturally Aware Nutritional Care for Transgender People: Key Issues and Considerations

Transgender people are an important group for whom access to healthcare is often problematic. Dietitians need to be aware of key issues in transgender health to provide culturally competent clinical nutritional care. This article serves as a primer, clarifying key terms and concepts, exploring the impact of stigma and discrimination on health and nutrition for people from transgender communities, and offering practical advice for nutritional and other related issues. Education for dietitians both pre- and postqualification is an important part of improving care and building skills and awareness of cultural humility. Transgender people may be at increased nutritional risk due to increased risk of cardiovascular disease, HIV, body image issues, and food insecurity. This risk profile, along with the history of trauma both outside and related to the medical community means that there is an urgent need for dietitians to develop practice tools for assessment, care, and referral to improve the nutritional status and well-being of this client group.

HIV Prevention Among Transgender Populations: Knowledge Gaps and Evidence for Action

PURPOSE OF REVIEW

The purpose of this review is to summarize the available evidence-based HIV prevention interventions tailored for transgender people.

RECENT FINDINGS

A limited number of evidence-based HIV prevention interventions have been tested with transgender populations. Most existing interventions target behavior change among transgender women, with only one HIV prevention program evaluated for transgender men. Studies addressing biomedical interventions for transgender women are ongoing. Few interventions address social and structural barriers to HIV prevention, such as stigma, discrimination, and poverty. Evidence-based multi-level interventions that address the structural, biomedical, and behavioral risks for HIV among transgender populations, including transgender men, are needed to address disparities in HIV prevalence. Future research should address not only pre-exposure prophylaxis uptake and condom use but also structural barriers that limit access to these prevention strategies.

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

In the U.S., transgender and other gender minority (TG) youth are an at-risk group understudied in HIV prevention and treatment. This study sought to characterize the HIV prevention and care continua in a diverse sample of 181 sexually-active TG ages 16-24 years (mean age = 20.7 years; 76.8% trans feminine; 69.1% youth of color) recruited July-December 2015 in 14 U.S. cities. Overall, 30.9% reported living with HIV, of which 71.4% were on antiretroviral therapy (ART) and 55.0% were medication adherent; 65.6% were known to be virally suppressed. In multivariable models, medical gender affirmation was associated with lower odds of viral suppression. Medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. Among at-risk TG youth not living with HIV, only 8.2% had accessed pre-exposure prophylaxis (PrEP). Early biobehavioral prevention and treatment interventions are needed for TG youth.

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

In the U.S., transgender and other gender minority (TG) youth are an at-risk group understudied in HIV prevention and treatment. This study sought to characterize the HIV prevention and care continua in a diverse sample of 181 sexually-active TG ages 16-24 years (mean age = 20.7 years; 76.8% trans feminine; 69.1% youth of color) recruited July-December 2015 in 14 U.S. cities. Overall, 30.9% reported living with HIV, of which 71.4% were on antiretroviral therapy (ART) and 55.0% were medication adherent; 65.6% were known to be virally suppressed. In multivariable models, medical gender affirmation was associated with lower odds of viral suppression. Medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. Among at-risk TG youth not living with HIV, only 8.2% had accessed pre-exposure prophylaxis (PrEP). Early biobehavioral prevention and treatment interventions are needed for TG youth.