U.S. transgender women's preferences for microeconomic interventions to address structural determinants of HIV vulnerability: a qualitative assessment

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.

Unmet Needs for Ancillary Services and Associations with Clinical Outcomes Among Transgender Women with Diagnosed HIV: Medical Monitoring Project, United States, 2015-2020

Purpose: Access to ancillary services-including HIV support services, non-HIV clinical services, and subsistence services-can support care engagement and viral suppression and reduce disparities among people with HIV (PWH). We used representative U.S. data to assess differences in unmet needs for ancillary services between transgender women with HIV and other PWH. In addition, we examined associations between unmet needs and clinical outcomes among transgender women. Methods: We analyzed 2015-2020 Medical Monitoring Project data among transgender women (N = 362), cisgender men (N = 17,319), and cisgender women (N = 6016) with HIV. We reported weighted percentages for characteristics, and reported adjusted prevalence ratios (aPRs) controlling for race/ethnicity and age, and 95% confidence intervals (CI) using logistic regression with predicted marginal means to assess differences between groups. Results: Among transgender women, unmet needs were highest for dental care (24.9%), shelter or housing (13.9%), and transportation assistance (12.6%). Transgender women were more likely than cisgender men to have unmet subsistence needs. Among transgender women, unmet needs for ancillary services were negatively associated with many clinical outcomes after adjusting for age and race/ethnicity. Unmet needs for subsistence services were associated with higher levels of antiretroviral therapy nonadherence (aPR: 1.39; 95% CI: 1.13-1.70) and detectable viral loads (aPR: 1.47; 1.09-1.98), emergency room visits (aPR: 1.42; 1.06-1.90), and depression (aPR: 2.74; 1.83-4.10) or anxiety (aPR: 3.20; 2.05-5.00) symptoms. Conclusions: Transgender women with HIV were more likely than cisgender men with HIV to experience unmet needs for subsistence services-likely a reflection of substantial socioeconomic disadvantage. Addressing unmet needs is an essential step for improving care outcomes among transgender women with HIV.

Hard-to-Reach or Hardly Reached? The "Difficulty" of Engaging Cisgender Black Females in Sexual Health Research

Rather than placing the onus on stigmatized and disenfranchised communities as hard-to-reach in sexual health research, we challenge researchers to recognize and provide outreach to populations who are hardly reached, such as cisgender Black women. We posit that the disparate human immunodeficiency virus (HIV) and sexually transmitted infection (STI) rates experienced by Black women in the USA are due in part to social and structural inequities and lack of researcher outreach within these communities. Social inequities give rise to racial and gender discrimination, which often results in structural barriers that researchers may not acknowledge. Structural barriers include medical mistrust and lack of access to preventative sexual health services, health care, education, and other resources. To achieve health equity, researchers must engage with Black women to understand the unique struggles they face and intervene with non-stigmatizing, culturally appropriate interventions. Interventions must utilize gatekeepers, influencers, community organizations, community advisory boards, and peer support. It is critical that sexual health researchers reach out to those who do not fall under the traditional hard-to-reach category but are hardly reached to counteract the current projection that 1 in 32 Black women will be diagnosed with HIV in their lifetime.

Preferences for pre-exposure prophylaxis (PrEP) among sexual and gender minorities: a discrete choice experiment in Brazil

Background

Men who have sex with men (MSM) and transgender women (TGW) are disproportionally affected by HIV infection in Latin America. This study aims to assess pre-exposure prophylaxis (PrEP) preferences among sexual and gender minorities (SGM) and identify attributes and levels that are related to PrEP uptake and adherence, both crucial for PrEP success.

Methods

We conducted a discrete choice experiment (DCE) among SGM from all Brazilian regions (September-December/2020). The survey was administered face-to-face (five Brazilian capitals) and online (entire country). We used a D-efficient zero-prior blocked experimental design to select 60 paired-profile DCE choice tasks.

Findings

The total sample size was 3924 (90.5% MSM; 7.2% TGW and 2.3% non-binary or gender diverse persons). In random-effects logit models, highest levels of protection and "no side effects" were the most important attribute levels. For "presentation", injectable and implant were preferred over oral. Participants were willing to accept a 4.1% protection reduction to receive injectable PrEP or a 4.2% reduction if PrEP were taken monthly. The largest class in the latent class models was defined predominantly by the preference for the highest HIV protection level (p < 0.005). Respondents in this class also preferred no side effects, injectable and implant presentations.

Interpretation

Higher HIV protection, no side effects, and presentation, whether injectable or implant, were the most important attributes in PrEP preferences. Protection against HIV was the most important attribute. PrEP programs should make available technologies such as long-acting presentations that could reunite the most desired attributes, thus maximizing acceptability and user-appropriateness.

Funding

Unitaid.

The ethical imperative to reduce HIV stigma through community-engaged, status-neutral interventions designed with and for transgender women of colour in the United States

INTRODUCTION

In the era of biomedical HIV prevention and treatment technologies, such as treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP), there is momentum to develop and rigorously evaluate interventions focused on PrEP among those at risk for HIV acquisition and antiretroviral therapy (ART) adherence among people living with HIV. While HIV status-specific interventions focused on PrEP or ART provide valuable information, status-segregated interventions can create, perpetuate, and even increase HIV stigma among transgender women of colour and other marginalized communities in the United States (US).

DISCUSSION

Due largely to community advocacy, discourses that support status-neutral approaches have emerged in the scientific literature. Although US-based funding mechanisms have typically designated awards focused on a specific HIV status, intervention developers and implementing agencies find creative ways to design and implement status-neutral programmes despite such restrictions. We present our experience with intervention research in New York, Detroit, New Orleans, Puerto Rico and the San Francisco Bay Area, all Ending the HIV Epidemic (EHE) priority jurisdictions. Kickin it with the Gurlz' was developed to be status-neutral through two grants due to community demands for a unifying approach. The Transgender Women Engagement and Entry to (TWEET) Care Project was designed to improve HIV care engagement for transgender women living with HIV, but developers realized the importance of including participants of any HIV status. Healthy Divas was designed for transgender women living with HIV but subsequent implementing agencies prioritized adapting it to be status-neutral. These examples support the urgency of designing, implementing and evaluating status-neutral interventions.

CONCLUSIONS

Community-based organizations strive for inclusivity in their programming and are rightly often reluctant to segregate services based on the HIV status of their clients. As researchers, we have an ethical imperative to work to reduce HIV stigma and respond to the needs of those most impacted by HIV, including transgender women of colour. As such, we call upon funders to develop mechanisms that support the development and testing of HIV status-neutral interventions to reduce HIV stigma and support community building, thereby increasing the possibility of fully realizing the benefits of biomedical HIV prevention and treatment technologies for all.