Characterising HIV and STIs among transgender female sex workers: a longitudinal analysis

Prevalence of Sexually Transmitted Infections Among Transgender Women With and Without HIV in the Eastern and Southern United States

BACKGROUND

Data on the epidemiology of sexually transmitted infections (STIs) among transgender women (TGW) with and without human immunodeficiency virus (HIV) are limited.

METHODS

We analyzed baseline data collected from a cohort of adult TGW across 6 eastern and southern US cities between March 2018 and August 2020 (n = 1018). Participants completed oral HIV screening, provided self-collected rectal and urogenital specimens for chlamydia and gonorrhea testing, and provided sera specimens for syphilis testing. We assessed associations with ≥1 prevalent bacterial STI using modified Poisson regression.

RESULTS

Bacterial STI prevalence was high and differed by HIV status: 32% among TGW with HIV and 11% among those without HIV (demographic-adjusted prevalence ratio = 1.91; 95% confidence interval = 1.39-2.62). Among TGW without HIV, bacterial STI prevalence differed by geographic region, race and ethnicity, and gender identity, and was positively associated with reporting >1 sexual partner, hazardous alcohol use, homelessness, having safety concerns regarding transit to health care, and no prior receipt of gender-affirming health services. Among TGW with HIV, older age was inversely associated with bacterial STI.

CONCLUSIONS

TGW had a high prevalence of bacterial STIs. The prevalence and correlates of bacterial STI differed by HIV status, highlighting the unique needs and risks of TGW with and without HIV. Tailored interventions may reduce sexual health-related inequities.

Determinants of HIV Pre-Exposure Prophylaxis (PrEP) Retention among Transgender Women: A Sequential, Explanatory Mixed Methods Study

Transgender women (TW) face inequities in HIV and unique barriers to PrEP, an effective biomedical intervention to prevent HIV acquisition. To improve PrEP retention among TW, we examined factors related to retention using a two-phase, sequential explanatory mixed methods approach. In Phase I, we used data from a trial of 170 TW who were provided oral PrEP to examine predictors of 24-week retention. In Phase II, we conducted 15 in-depth interviews with PrEP-experienced TW and used thematic analysis to explain Phase I findings. In Phase I, more participants who were not retained at 24 weeks reported sex work engagement (18% versus 7%) and substantial/severe drug use (18% versus 8%). In Phase II, participants reported drug use as a barrier to PrEP, often in the context of sex work, and we identified two subcategories of sex work. TW engaged in "non-survival sex work" had little difficulty staying on PrEP, while those engaged in "survival sex work" struggled to stay on PrEP. In Phase I, fewer participants not retained at 24 weeks reported gender-affirming hormone therapy (GAHT) use (56% versus 71%). In Phase II, participants prioritized medical gender affirmation services over PrEP but also described the bidirectional benefits of accessing GAHT and PrEP. TW who engaged in "survival sex work" experience barriers to PrEP retention (e.g., unstable housing, drug use) and may require additional support to stay in PrEP care.

Epidemiology and determinants of reemerging bacterial sexually transmitted infections (STIs) and emerging STIs in Europe

In this scoping review, we offer a comprehensive understanding of the current and recent epidemiology, challenges, and emerging issues related to bacterial sexually transmitted infections (STIs) in the WHO European Region. We endeavour in collating data from both EU/EEA and non- EU/EEA countries, thereby giving a complete picture of the region which highlights the higher notification rates in Northern and Western countries than other regions, likely due to differences in testing, access to testing, and surveillance capacity. We provide an up-to-date review on the current knowledge of determinants and persistent inequities in key populations as well as the use of molecular epidemiology for identifying transmission networks in gonorrhoea and syphilis, and detecting chlamydia mutations that evade molecular diagnosis. Finally, we explore the emerging STIs in the region and the evolving transmission routes of food and waterborne diseases into sexual transmission. Our findings call for harmonized STI surveillance systems, proactive strategies, and policies to address social factors, and staying vigilant for emerging STIs.

Type of Exchange Sex and Associated Behaviors and Outcomes Among Cisgender Men and Women at Increased Risk for HIV via Heterosexual Transmission in Six U.S. Metropolitan Areas

Exchange sex is associated with sexual risk behaviors and poor outcomes and different types may incur different levels of risk. We assessed risk profiles of different types of exchange sex among non-injecting cisgender men and women who participated in the 2019 National HIV Behavioral Surveillance project at six sites. Six percent of men and 19% of women reported exchange sex in the past year; most engaged in non-commercial exchange sex for drugs/money with smaller percentages reporting formal sex work or non-commercial exchange sex for goods or services other than drugs/money. Exchange sex was associated with sexual risk and prevention behaviors and psychosocial and sexual health outcomes and associations varied by type of exchange sex. Efforts to improve access to STI/HIV testing and PrEP may benefit from tailoring based on type of exchange sex. Findings indicate value in a broader definition of exchange sex with follow-up assessment of exchange sex typology.

Providing gender-affirming care to transgender and gender-diverse individuals with and at risk for HIV

Transgender and gender-diverse populations have unique medical and psychosocial needs. It is important that clinicians address these needs with a gender-affirming approach in all aspects of health care for these populations. Given the significant burden of HIV experienced by transgender people, such approaches in providing HIV care and prevention are essential both to engage this population in care and to work toward ending the HIV epidemic. This review presents a framework for practitioners caring for transgender and gender-diverse individuals to deliver affirming, respectful health care in HIV treatment and prevention settings.

Increasing incidence rates of sexually transmitted infections from 2010 to 2019: an analysis of temporal trends by geographical regions and age groups from the 2019 Global Burden of Disease Study

Background

World Health Organization announced its goal of ending sexually transmitted infection (STI) epidemics by 2030. To provide a reference for tailored prevention strategies, we analyzed trends and differences in STIs by geographical regions and age groups from 1990 to 2019.

Methods

Annual number of new infections and age-standardized incidence rates (ASRs) of syphilis, chlamydia, gonorrhea, trichomoniasis, and genital herpes were recorded from the 2019 Global Burden of Disease study. We quantified the temporal trends of STIs by calculating changes in new infections and estimated annual percentage changes (EAPCs) of ASR.

Results

The ASRs of syphilis, chlamydia, trichomoniasis, and genital herpes increased by 1.70% (95% confidence interval [CI], 1.62–1.78%), 0.29% (95% CI 0.04–0.54%), 0.27% (95% CI 0.03–0.52%), and 0.40% (95% CI 0.36–0.44%) per year from 2010 to 2019 worldwide, respectively, while that of gonorrhea did not. The American regions had the greatest increase in ASR for syphilis (tropical Latin America: EAPC, 5.72; 95% CI 5.11–6.33), chlamydia (high-income North America: EAPC, 1.23; 95% CI 0.73–1.73), and gonorrhea (high-income North America: EAPC, 0.77; 95% CI 0.12–1.41). Additionally, southern sub-Saharan Africa and East Asia had the greatest increase in ASR for trichomoniasis (EAPC, 0.88; 95% CI 0.57–1.20) and genital herpes (EAPC, 1.44; 95% CI 0.83–2.06), respectively. In the most recent years, the population with the greatest incidence of syphilis tended to be younger globally (25–29 years in 2010 vs. 20–24 years in 2019) but older in North Africa and Middle East (20–24 year vs. 25–29 years); with chlamydia tended to be older in southern sub-Saharan Africa (25–29 years vs. 30–34 years) but younger in Australasia (40–44 years vs. 25–29 years); with genital herpes tended to be older in high-income North America (20–24 years vs. 25–29 years) and South Asia (25–29 years vs. 30–34 years).

Conclusions

Syphilis, chlamydia, trichomoniasis, and genital herpes showed a trend of increasing ASR from 2010 to 2019. The differences in trends by geographical regions and age groups point to the need for more targeted prevention strategies in key regions and populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07544-7.

The EMERALD (Enabling Mobilization, Empowerment, Risk Reduction, and Lasting Dignity) Study: Protocol for the Design, Implementation, and Evaluation of a Community-Based Combination HIV Prevention Intervention for Female Sex Workers in Baltimore, Maryland

Background

Cisgender female sex workers (FSWs) experience high rates of HIV and sexually transmitted infections (STIs), including chlamydia and gonorrhea. Community empowerment–based responses to the risk environment of FSWs have been associated with significant reductions in HIV and STI risk and associated risk behaviors; however, evaluations of US-based interventions targeting FSWs are limited.

Objective

The objective of this study is to describe the design, implementation, and planned evaluation strategy of an ongoing comprehensive community-level intervention in Baltimore City, Maryland, which aims to improve HIV and STI risk and cumulative incidence among FSWs. The two intervention components are the SPARC (Sex Workers Promoting Action, Risk Reduction, and Community Mobilization) drop-in center and the accompanying comprehensive mobile outreach program. The mission of SPARC is to provide low-barrier harm reduction services to FSWs, with a special focus on women who sell sex and use drugs. Services are provided through a harm reduction framework and include reproductive health and sexual health care; medication-assisted treatment; legal aid; counseling; showers, lockers, and laundry; and the distribution of harm reduction tools, including naloxone and sterile drug use supplies (eg, cookers, cotton, syringes, and pipes).

Methods

The SPARC intervention is being evaluated through the EMERALD (Enabling Mobilization, Empowerment, Risk Reduction, and Lasting Dignity) study, which consists of a prospective 2-group comparative nonrandomized trial (n=385), a cross-sectional survey (n=100), and in-depth interviews assessing SPARC implementation (n=45). Participants enrolled in the nonrandomized trial completed a survey and HIV and STI testing at 4 intervals (baseline and 6, 12, and 18 months). Participants recruited from predefined areas closest to SPARC comprised the intervention group, and participants from all other areas of Baltimore were included in the control group.

Results

We hypothesize that addressing structural drivers and more immediate medical needs, in combination with peer outreach, will improve the HIV and STI risk environment, leading to community empowerment, and reduce the HIV and STI cumulative incidence and behavioral risks of FSWs. Data collection is ongoing. A baseline description of the cohort is presented.

Conclusions

In the United States, structural interventions aimed at reducing HIV and STIs among FSWs are scarce; to our knowledge, this is the first intervention of its kind in the United States. The results of the EMERALD study can be used to inform the development of future interventions targeting FSWs and other at-risk populations.

Trial Registration

ClinicalTrials.gov NCT04413591; https://clinicaltrials.gov/ct2/show/NCT04413591.

International Registered Report Identifier (IRRID)

DERR1-10.2196/23412

HEALTH VULNERABILITIES OF TRANSGENDER SEX WORKERS: AN INTEGRATIVE REVIEW

ABSTRACT Objective: to identify the health vulnerabilities of transgender sex workers. Method: an integrative review conducted in July 2020 in the PubMed, Web of Science, SCOPUS, CINAHL, IBECS and LILACS databases, with no language or time restrictions. The following descriptors indexed in DeCS and MESH and their respective synonyms were used: “Transgender persons”, “Sex workers” and “Health vulnerability”. The data were analyzed based on thematic analysis. Results: a total of 547 articles were retrieved and, after the selection and analysis process, 34 were included in this review. Four thematic classes emerged: “Knowledge, prevention and exposure to STIs in sex work”; “Use (and abuse) of illegal substances and alcohol”; “The social and structural dimension of vulnerabilities: from weakened support networks to violence reproduced against dissident bodies”; and “Psychosocial diseases, discrimination and challenges of transgender sex workers”. Conclusion: the health vulnerabilities experienced by transgender sex workers are marked by discrimination, social exclusion, stigma, incarceration contexts, physical, psychological and sexual violence and use of illegal substances and alcohol, in addition to difficulties in accessing essential services such as health, education and leisure.

Prevalence and associated factors of sexualized drug use in sex work among transgender women sex workers in China

Sexualized drug use (SDU) is associated with a higher risk of HIV transmission. There is a dearth of study investigating the association between sex work characteristics and SDU in sex work among transgender women sex workers. To address these gaps, we conducted a secondary analysis of a cross-sectional study among 220 transgender women sex workers in Shenyang, China. The prevalence of SDU in sex work was 20.9% in the past month. After adjustment for age, HIV status, education, monthly income and duration of stay in Shenyang, performing sex work mainly in hotel rooms, charging higher per episode of commercial sex, depressive symptoms and anxiety symptoms were associated with higher likelihood of SDU in sex work. Future SDU prevention programmes SDU targeting transgender women sex workers should focus on those who charged higher and performed sex work in hotel rooms, and integrate mental health promotion as an essential component.

Short-term interruptions to sex work among a prospective cohort of street-based cisgender female sex workers in Baltimore

BACKGROUND

Street-based female sex workers (FSW) often cycle in and out of sex work engagement. For many FSW, substance use plays a critical role in sex work entry, continuation, and interruptions. We examined individual, interpersonal, and structural correlates of short-term interruptions of sex work among street-based FSW in an urban environment.

METHODS

Data were from 205 FSW in Baltimore, MD, USA followed as part of an observational prospective cohort study between April 2016-Februrary 2018. The primary outcome was short-term interruptions of sex work (stopping sex work) over the past 3 months, asked every 3 months over a 12-month follow-up. We assessed the relationship between individual, structural, and interpersonal factors for each woman's prior visit and current visit with short-term sex work interruptions. We employed modified Poisson regression with Generalized Estimating Equations to identify correlates of short-term interruptions of sex work.

RESULTS

Eighty-two women (40%) reported stopping sex work over the past 3 months at least once during follow-up. Past drug treatment (adjusted incidence rate ratio [aIRR] 1.40; 95% CI: 1.06-1.86) and not having used drugs in the past 3 months (aIRR 2.70; 95% CI: 1.96-3.71) were positively associated with short-term interruption to sex work. Past intimate partner violence (IPV) (aIRR 0.52; 95% CI: 0.31-0.86) and current homelessness (aIRR 0.61; 95% CI: 0.41-0.91) were negatively associated with short-term interruption. Results were inconclusive for the association between recent prostitution arrest and short-term interruptions to sex work (IRR 0.86; 95% CI: 0.40-1.86).

CONCLUSION

The study suggests that similar to other professions, women leave sex work for numerous reasons. Substance use cessation and participation in drug treatment programs may contribute to short-term interruptions of sex work by reducing reliance on sex work for income among street-based FSW. Structural vulnerabilities including homelessness and IPV are driving continued street-based sex work, speaking to the need for holistic structural interventions.