Depression, injecting drug use, and risky sexual behavior syndemic among women who inject drugs in Kenya: a cross-sectional survey

Patterns of Health-related Quality of Life in Men Who Inject Drugs: A Survey in Southeast Iran

OBJECTIVES

Understanding patterns of quality of life in people who inject drugs (PWID) can help healthcare providers plan and manage their health problems in a more focused manner. Therefore, the current study aimed to identify patterns of health-related quality of life in PWID in southeast Iran.

METHODS

This cross-sectional study was conducted in southeast Iran on men who had injected drugs at least once during the last year. We used convenience sampling in 2 drop-in centers and venue-based sampling at 85 venues. Demographic characteristics, high-risk behaviors, and health-related quality of life were evaluated using the 5-level EQ-5D version (EQ-5D-5L) questionnaire. Latent profile analysis was used to identify patterns of quality of life.

RESULTS

This study enrolled 398 PWID, who had a mean age of 34.1±11.4 years. About 47.9% reported a prison history in the last 10 years, 59.2% had injected drugs in the last month, and 31.6% had a history of sharing syringes. About 46.3% reported having 2 or more sexual partners in the last 6 months, and 14.7% had a history of sex with men. Out of the 5 EQ-5D-5L profiles, the fifth profile had the most people (36.6%). Most variations in quality of life were related to pain and discomfort.

CONCLUSIONS

We showed that the pain and discomfort dimension of EQ-5D-5L had more variation in PWID. This finding will be useful for allocating appropriate interventions and resources to promote health-related quality of life in this population.

Effectiveness of trauma-focused cognitive behavioral therapy compared to psychosocial counseling in reducing HIV risk behaviors, substance use, and mental health problems among orphans and vulnerable children in Zambia: a community-based randomized controlled trial

Orphans and vulnerable children (OVC) in sub-Saharan Africa are at high risk for HIV infection and transmission. HIV prevention and treatment efforts with OVC are hindered by mental health and substance use problems. This randomized controlled trial compared a mental health intervention, Trauma Focused Cognitive Behavioral Therapy (TF-CBT), to an enhanced version of an existing HIV Psychosocial Counseling (PC+) program among 610 adolescents who met PEPFAR criteria for OVC and had HIV risk behaviors in Lusaka, Zambia. Outcomes included HIV risk behaviors (e.g., risky sexual behaviors), mental health (internalizing symptoms, externalizing behaviors, PTSD) and substance use. At 12-month follow-up, there were significant within group reductions in both groups for all outcomes, with the only significant between group difference being for substance use, in which OVC who received TF-CBT had significantly greater reductions than OVC who received PC+. In a subgroup analysis of OVC with high levels of PTSD symptoms, TF-CBT was superior to PC + in reducing internalizing symptoms, functional impairment, and substance use. Findings support TF-CBT for reducing substance use among OVC. Subgroup analysis results suggest that a robust intervention such as TF-CBT is warranted for OVC with significant mental and behavioral health comorbidities. The similar performance of TF-CBT and PC + in the overall sample for risky sexual behavior and mild mental health problems indicates that enhancing existing psychosocial programs, such as PC, with standard implementation factors like having a defined training and supervision schedule (as was done to create PC+) may improve the efficacy of HIV risk reduction efforts.Clinical Trials Number: NCT02054780.

Psychosocial Syndemic Classes and Longitudinal Transition Patterns Among Sexual Minority men Living with or Without HIV in the Multicenter AIDS Cohort Study (MACS)

Mental health and substance use epidemics interact to create psychosocial syndemics, accelerating poor health outcomes. Using latent class and latent transition analyses, we identified psychosocial syndemic phenotypes and their longitudinal transition pathways among sexual minority men (SMM) in the Multicenter AIDS Cohort Study (MACS, n = 3,384, mean age 44, 29% non-Hispanic Black, 51% with HIV). Self-reported depressive symptoms and substance use indices (i.e., smoking, hazardous drinking, marijuana, stimulant, and popper use) at the index visit, 3-year and 6-year follow-up were used to model psychosocial syndemics. Four latent classes were identified: "poly-behavioral" (19.4%), "smoking and depression" (21.7%), "illicit drug use" (13.8%), and "no conditions" (45.1%). Across all classes, over 80% of SMM remained in that same class over the follow-ups. SMM who experienced certain psychosocial clusters (e.g., illicit drug use) were less likely to transition to a less complex class. These people could benefit from targeted public health intervention and greater access to treatment resources.

The Association between Perceived Family Financial Stress and Adolescent Suicide Ideation: A Moderated Mediation Model

Nowadays, suicide (especially adolescents' suicide) has been an increasingly prominent social problem worldwide; suicide ideation, as an important predictor, has been the focus of relevant studies and practices. Against this background, the present study aimed to examine the association between perceived family financial stress and adolescents' suicidal ideation, as well as the potential roles of depression and parent-child attachment. A sample of 526 junior middle school students was recruited voluntarily to participate in this cross-sectional study, and the results indicated that the prevalence of suicidal ideation among junior high school students was 15.45%; perceived family financial stress was positively associated with suicidal ideation, and depression could significantly mediate this relation; parent-child attachment significantly moderated the mediating effect of depression (in particular, the relation between depression and suicidal ideation); specifically, this relation was stronger among adolescents with lower values of parent-child attachment. These findings could deepen our understanding of the influences of perceived family financial condition and the risky factors of adolescents' suicidal ideation, which could provide guidance for the prevention and intervention of adolescents' depression and suicidal ideation.

A multicomponent holistic care pathway for people who use drugs in Tayside, Scotland

BACKGROUND

People Who Use Drugs (PWUD) are at high risk of non-fatal overdose and other drug-related harms. The United Kingdom drugs policy landscape makes it challenging to support those at risk. Tayside, in East Scotland, has a sizeable population at risk of drug-related harms. In 2021, the National Health Service implemented a care pathway for PWUD to provide multidimensional healthcare interventions. We aimed to quantify drug-related harms; assess wider health and well-being; and understand substance use trends and behaviours, among those engaged in the pathway.

METHODS

Existing community-embedded blood-borne virus pathways were adapted to provide multiple healthcare assessments over three visits. We undertook an observational cohort study to analyse uptake and outcomes for the initial cohort of PWUD engaged at appointment one.

RESULTS

From August 2021-September 2022, 150 PWUD engaged with the pathway. Median age was 39 (34-42) years, 108 (72%) were male, and 124 (83%) lived in deprived areas. Seventy (47%) had been disengaged from healthcare for over a year. Polysubstance use was reported by 124 (83%), 42 (28%) disclosed injecting daily, and 54 (36%) shared equipment. Fifty-four (36%) experienced recent non-fatal overdose, and there were six overdose fatalities (4.1 [1.5-9.0] per 100PY). The offer of take-home naloxone was accepted by 108 (72%). Fourteen (9%) were diagnosed with Hepatitis C and two (1%) with HIV. Renal, hepatological, and endocrine impairment were observed among 30 (20%), 23 (15%), and 11 (7%), people respectively. Ninety-six (65%) had high risk of clinical depression. Forty-eight (32%) declined Covid-19 vaccination.

CONCLUSION

The pathway engaged PWUD with high exposure to recent non-fatal overdose and other drug-related harms, alongside co-morbid health issues. Our results suggest multi-dimensional health assessments coupled with harm reduction in community settings, with appropriate linkage to care, are warranted for PWUD. Service commissioners should seek to integrate these assessments where possible.

Prevalence and predictors of depressive and anxiety symptoms in a sample of women who use drugs in Tanzania: the key role of drug use stigma

BACKGROUND

Globally, women who use drugs face multiple health vulnerabilities, including poor mental health. Little is known about the mental health burden among women who use drugs in sub-Saharan Africa. This cross-sectional study examined the prevalence and predictors of depressive and anxiety symptoms among a sample of women who use drugs in Dar es Salaam, Tanzania.

METHODS

We administered a cross-sectional survey to a non-random sample of 200 women who use drugs in Dar es Salaam between November 2018 and March 2019. We used descriptive statistics to characterize the study sample and fitted separate logistic regression models to assess depressive and anxiety symptoms and their predictors.

RESULTS

The percentages of women reporting depressive and anxiety symptoms were 67.5% and 43.7%, respectively. Internalized drug use stigma (AOR = 1.34, 95% CI: 1.03-1.75) and prior attempts to stop heroin use (AOR = 2.99, 95% CI: 1.28-7.00) were associated with depressive symptoms. Enacted drug use stigma from health workers (AOR = 2.02, 95% CI: 1.34-3.04) and anticipated drug use stigma from family (AOR = 1.49, 95% CI: 1.02-2.16) were associated with anxiety symptoms.

CONCLUSIONS

Depressive and anxiety symptoms were high among our study sample, with higher reports of symptoms of depression than anxiety. Drug use stigma was a key factor that contributed to elevated symptoms of depression and anxiety.

High prevalence of risky sexual behaviour among key populations receiving antiretroviral therapy at a large HIV clinic in northern Uganda

Background

Risky sexual behaviour (RSB) among key populations pose a significant risk of human immunodeficiency virus (HIV) infection but remains understudied.

Objectives

We assessed the prevalence and factors associated with RSB among key populations living with HIV (KPLHIV) in the post-conflict region of northern Uganda.

Methods

We designed a cross-sectional study using secondary data, with the outcome as RSB defined as having multiple sexual partners, or condomless sex in the past 3 months, or sexual intercourse with a commercial sex worker in the past 3 months, or sexual intercourse under the influence of substance use in the past 3 months. We used modified Poisson regression to determine factors associated with RSB, reported as adjusted risk ratio (aRR) with 95% confidence interval (CI).

Results

We studied 165 participants and 122 (73.9%) reported RSB and this was more likely among heterosexual females (aRR, 2.39; 95% CI, 1.54-3.71), the married (aRR, 1.92; 95% CI, 1.42-2.49) or separated participants (aRR, 1.47; 95% CI, 1.21-1.79), and transgender persons (aRR, 3.71; 95% CI, 2.05-6.71).

Conclusions

RSB is highly prevalent among KPLHIV in northern Uganda so they should be targeted with HIV prevention and behavioural interventions to prevent potential HIV transmission to the general population.

The Relationship Between Sexual Behavior Stigma and Depression Among Men Who have Sex with Men and Transgender Women in Kigali, Rwanda: a Cross-sectional Study

To evaluate the role of sexual behavior stigma as a determinant of depressive symptoms among men who have sex with men (MSM) and transgender women (TGW) in Kigali, Rwanda. MSM/TGW aged ≥18 years were recruited using respondent-driven sampling (RDS) between March-August, 2018. Mental health was assessed using the Patient Health Questionnaire (PHQ-9). Sexual behavior stigma from friends and family, healthcare workers, and community members was assessed using a validated instrument. Multinomial logistic regression models were used to determine the association between sexual behavior stigma and depressive symptoms and depression. Secondary analyses further compared depression and depressive symptoms among MSM and TGW. Among the 736 participants included, 14% (106/736) identified as TGW. Depression 8.9% (RDS-adjusted, 7.6%; 95% CI, 4.6-10.6) and mild/moderate symptoms of depression 26.4% (RDS-adjusted, 24.1%; 95% CI, 19.4-28.7) were common and higher among TGW compared to MSM (p < 0.001). Anticipated (41%), perceived (36%), and enacted (45%) stigmas were highly prevalent, and were also significantly higher among TGW (p < 0.001). In multivariable RDS-adjusted analysis, anticipated (relative risk ratio (RRR), 1.88; 95% CI, 1.11-3.19) and perceived (RRR, 2.06; 95% CI, 1.12-3.79) stigmas were associated with a higher prevalence of depressive symptoms. Anticipated (RRR, 4.78; 95% CI, 1.74-13.13) and enacted (RRR, 3.09; 95% CI, 1.61-5.93) stigmas were also associated with a higher prevalence of depression. In secondary analyses, the significant differences between MSM and TGW were lost after adjusting for stigma. These data demonstrate a high burden of depressive symptoms and depression among MSM/TGW in Kigali. Conceptually, stigma is a likely antecedent of mental health stress among MSM and TGW suggesting the potential utility of scaling up stigma mitigation interventions to improve the quality of life and mental health outcomes among sexual and gender minority communities in Rwanda.

Factors Associated with the Involvement of Women Drug Users in Risky Sexual Behaviors: A Narrative Review

BACKGROUND

Drug use is known as an important underlying factor in the occurrence of risky sexual behaviors. The present study was conducted to identify the factors associated with the involvement of women drug users in risky sexual behaviors.

MATERIALS AND METHODS

This review was conducted by searching databases of ISI Web of Science, Scopus, Science Direct, Cochrane, PubMed, Scientific Information Database (SID), the Iranian Magazine Database (Magiran), the Iranian Research Institute for Information Science and Technology (IranDoc), and the Iranian Medical Articles Database (IranMedex) and searching through the Google Scholar engine. All the articles published in English and Persian using the keywords including substance use, drug users, addiction, substance use disorders, substance-related disorders, sexual risks, high-risk sexual behavior, HIV risk behavior, unsafe sex, unprotected sex, and risky sex were searched from January 2000 to December 2020. After reviewing the articles, out of 110 articles, 21 articles were selected for final evaluation.

RESULTS

Factors related to the involvement of women drug users in risky sexual behaviors were divided into five categories: individual factors, factors related to drug use, inter-personal relationships, gender discrimination, and socio-economic factors.

CONCLUSIONS

The results can be used in the field of women's social harms in finding strategies and designing the necessary interventions to prevent risky sexual behaviors in women drug users in different societies and cultural contexts. Also, the results can be used by all researchers who want to study the relationship between these factors and the involvement of women drug users in risky sexual behaviors.

Housing instability and violence among women who use drugs in Dar es Salaam, Tanzania

BACKGROUND

Women who use heroin and other drugs (WWUD) are a key population with elevated risk of physical and sexual violence perpetrated by intimate partners and non-partners. While housing instability has been shown to be associated with violence in high-income settings, this is an underexplored topic in sub-Saharan Africa. In this research, we aimed to assess the relationship between housing instability and various forms of violence within a sample of WWUD in Dar es Salaam.

METHODS

This analysis uses data from a parent study from 2018. A total of 200 WWUD were recruited through respondent-driven sampling methods and administered a survey. Two multivariable logistic regression models were built to assess the relationship between housing instability and physical violence (Model 1) and housing instability and sexual violence (Model 2) while controlling for a number of sociodemographic characteristics.

RESULTS

Approximately 35% of participants were classified as housing unstable. More than half of participants (62%) reported experiencing physical violence in the past 12 months, and more than a third (36%) reported sexual violence in the same time period. Housing instability was found to be independently associated with both physical and sexual violence victimization in the past year when adjusting for covariates (Model 1 adjusted odds ratio [AOR]: 2.40, 95% CI 1.22-4.46; Model 2 AOR: 1.93. 95% CI 1.02-3.67).

CONCLUSION

To our knowledge, this is the first study to document a significant association between housing instability and violence among WWUD communities in sub-Saharan Africa. This analysis adds to the growing body of literature on the relationship between stable housing and livelihood and health outcomes across differing populations. The cyclical nature of housing instability and violence may be disrupted through housing programming that provides safety, security, and stability for WWUD.

A systematic review of substance use and substance use disorder research in Kenya

Objectives

The burden of substance use in Kenya is significant. The objective of this study was to systematically summarize existing literature on substance use in Kenya, identify research gaps, and provide directions for future research.

Methods

This systematic review was conducted in line with the PRISMA guidelines. We conducted a search of 5 bibliographic databases (PubMed, PsychINFO, Web of Science, Cumulative Index of Nursing and Allied Professionals (CINAHL) and Cochrane Library) from inception until 20 August 2020. In addition, we searched all the volumes of the official journal of the National Authority for the Campaign Against Alcohol & Drug Abuse (the African Journal of Alcohol and Drug Abuse). The results of eligible studies have been summarized descriptively and organized by three broad categories including: studies evaluating the epidemiology of substance use, studies evaluating interventions and programs, and qualitative studies exploring various themes on substance use other than interventions. The quality of the included studies was assessed with the Quality Assessment Tool for Studies with Diverse Designs.

Results

Of the 185 studies that were eligible for inclusion, 144 investigated the epidemiology of substance use, 23 qualitatively explored various substance use related themes, and 18 evaluated substance use interventions and programs. Key evidence gaps emerged. Few studies had explored the epidemiology of hallucinogen, prescription medication, ecstasy, injecting drug use, and emerging substance use. Vulnerable populations such as pregnant women, and persons with physical disability had been under-represented within the epidemiological and qualitative work. No intervention study had been conducted among children and adolescents. Most interventions had focused on alcohol to the exclusion of other prevalent substances such as tobacco and cannabis. Little had been done to evaluate digital and population-level interventions.

Conclusion

The results of this systematic review provide important directions for future substance use research in Kenya.

Systematic review registration

PROSPERO: CRD42020203717.

Socioeconomic Status, Individual Behaviors and Risk for Mental Disorders: A Mendelian Randomization Study

Background

There is increasing attention on the association of socioeconomic status and individual behaviors (SES/IB) with mental health. However, the impacts of SES/IB on mental disorders are still unclear. To provide evidence for establishing feasible strategies on disease screening and prevention, we implemented Mendelian randomization (MR) design to appraise causality between SES/IB and mental disorders.

Methods

We conducted a two-sample MR study to assess the causal effects of SES and IB (dietary habits, habitual physical activity, smoking behaviors, drinking behaviors, sleeping behaviors, leisure sedentary behaviors, risky behaviors, and reproductive behaviors) on three mental disorders, including bipolar disorder, major depressive disorder and schizophrenia. A series of filtering steps were taken to select eligible genetic instruments robustly associated with each of the traits. Inverse variance weighted was used for primary analysis, with alternative MR methods including MR-Egger, weighted median, and weighted mode estimate. Complementary methods were further used to detect pleiotropic bias.

Results

After Bonferroni correction and rigorous quality control, we identified that SES (educational attainment), smoking behaviors (smoking initiation, number of cigarettes per day), risky behaviors (adventurousness, number of sexual partners, automobile speeding propensity) and reproductive behavior (age at first birth) were causally associated with at least one of the mental disorders.

Conclusions

MR study provides robust evidence that SES/IB play broad impacts on mental disorders.

Challenges of sexually transmitted infections and sexual health among people who inject drugs

PURPOSE OF REVIEW

This review provides a summary of recently published research on sexually transmitted infections (STI) and related behaviors among people who inject drugs (PWID), covering three major areas: sexual behavior and its role in STI transmission among PWID, multilevel factors associated with STI risk, and strategies addressing sexual health of PWID. This review is timely given the growing priority of combination prevention approaches and integrated care for PWID.

RECENT FINDINGS

Modern research improves the understanding that PWID have an increased risk of STI, which varies by gender, setting, type of substance used, and presence of mental disorders. Major socioeconomic and structural factors, specific and nonspecific to PWID, facilitate inequality and sexual risk behavior. Sexual transmission continues to contribute substantially to the spread of bloodborne infections among PWID, accounting for at least 10% of new HIV cases according to epidemiological modeling. Despite the substantial evidence that behavioral interventions can improve sexual health and reduce sex-related risks among PWID, there is a research-practice gap, reflected in the scarcity of implementation studies published recently.

SUMMARY

Integration of sexual health into prevention programs for PWID is essential to curb transmission of STI, including HIV, among PWID and their sexual partners.

Cumulative Burden of Mental Health Factors and Engagement in HIV Care in Argentina

BACKGROUND

Cumulative burden of multiple mental health conditions may worsen physical health outcomes in vulnerable populations. Accordingly, identifying cumulative burdens of mental health conditions that may affect HIV treatment and care can guide public health strategies to reduce their impact on HIV-related health outcomes. This study examined the relationship between the cumulative burden of mental health conditions and factors associated with engagement in HIV care in Argentina.

METHOD

Data for this study was obtained at baseline from Conexiones y Opciones Positivas en la Argentina 2 (COPA2). Participants (N = 360) were cisgender patients living with HIV who were lost to care, recruited from seven clinics serving people living with HIV in four Argentine urban centers. Cumulative burden of mental health conditions (i.e., depressive symptoms, problematic substance use, unhealthy alcohol use, and psychotic symptoms) was assessed.

RESULTS

Every one-point increase in the number of mental health conditions present was associated with a decrement in patient-provider communication (b = - 0.22, p < .001), self-efficacy (b = - 0.13, p = .012), and motivation for adherence (b = - 0.11, p = .039).

CONCLUSION

This study found cumulative burden of depression, problematic substance use, unhealthy alcohol use, and psychotic symptoms to be negatively associated with factors related to engagement in HIV care. Results highlight the importance of identification and treatment of challenges to mental health, in order to ameliorate their influence on engagement in HIV care.

A prospective cohort study of risk behaviours, retention and loss to follow-up over 5 years among women and men in a needle exchange program in Stockholm, Sweden

BACKGROUND

Needle exchange programs (NEP) are important in reducing risk behaviours among people who inject drugs (PWID), also exposed to HIV and hepatitis C (HCV) through injecting drug use (IDU). Women (WWID) compared to men who inject drugs (MWID), are particularly vulnerable with complex needs, however less is known about their risk determinants and NEP outcomes.

METHODS

In an open prospective NEP cohort, 697 WWID and 2122 MWID were followed, 2013-2018. Self-reported socio/drug-related determinants for receptive injection (needle/syringe and paraphernalia) and sexual risk behaviours at enrolment, lost to follow-up (LTFU) and probability of retention, were assessed for both groups. Multivariable logistic regression (adjusted odds ratios, aOR) for enrolment and Poisson regression (adjusted incidence rate ratios, aIRR) for LTFU, were used. Cumulative NEP-retention probability was analysed using a six- and 12-month scenario.

RESULTS

At NEP enrolment, injection risk behaviours among WWID were associated with: younger age; homelessness; amphetamine-IDU; non-participation in opioid substitution therapy (OST); history of custody and among MWID: lower education level; cohabitation; homelessness, being a tenant; amphetamine-IDU; non-participation in OST; history of being sectioned, HIV-negative and HCV-positive. Condomless sex among WWID was associated with: younger age; lower education-level; cohabitation; having a partner; amphetamine-IDU; non-participation in OST; being HIV-negative and HCV-positive and among MWID: younger age; married; cohabitation; having a partner; amphetamine-IDU; non-participation in OST; history of custody, prison and being HIV-negative. WWID had higher NEP-retention levels compared to MWID over time. Being LTFU among WWID was associated with being HIV-negative and reporting injection risk behaviours and among MWID, younger age, non-participation in OST, being HIV-negative and having protected sex.

CONCLUSIONS

Despite better NEP compliance among WWID, high injection and sexual risk behaviours in both gender-subgroups, especially in intimate relationships, suggests ongoing HCV and HIV-infection risks. Subgroup-variation in the NEP continuum of care warrants more gender-disaggregated research and tailoring gender-sensitive services may improve prevention, health and retention outcomes.

Undiagnosed HIV, hepatitis B, and hepatitis C infections in people with severe psychiatric disorders in Ethiopia

Background

Worldwide, there is limited epidemiologic evidence on the seroprevalence of undiagnosed chronic viral infections including HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections among patients with severe psychiatric disorders. To our knowledge, this is the first study to explore and compare undiagnosed seroprevalence rates of HIV, HBV, and HCV infections among patients with severe psychiatric disorders.

Method

In this study, we included a random sample of 309 patients with severe psychiatric disorders selected by systematic sampling technique. We used a structured clinical interview for DSM-IV (SCID) to confirm the diagnosis of severe psychiatric disorders among the participants. Binary and multivariable logistic regression models, adjusting for the potential confounding factors was used to explore the potential determinants of chronic viral infections.

Result

The prevalence estimates of HIV infection among patients with severe psychiatric disorders in this study (3.24%) was roughly 3 times the estimated population prevalence of HIV infection in Ethiopia (1.1%). This study showed that the prevalence rates of HBV and HCV infections among patients with severe psychiatric disorders were 4.85 and 1.29%, respectively. Our results also showed that among patients with chronic viral infections, HIV, HBV and HCV, 76.92, 60, 80, and 75% respectively were undiagnosed. Regarding associated factors, the presence of chronic viral infection was found to be significantly associated with the age of the participants (ranging between 30 and 40 years) after adjusting for the possible confounding factors [AOR = 3.95 (95%CI.18–13.17)].

Conclusion

Even though the prevalence estimates of HIV (3.24%), HBV (4.85%), and HCV (1.29%) infections were high among patients with severe psychiatric disorders, the majority of them remained undiagnosed. HBV was found to be the commonly undiagnosed infection (4 out of 5) followed by HCV (3 out of 4) and HIV (6 out of 10). The present study provided evidence of a significant association between the age of the participant (between 30 and 40 years) and chronic viral infections in patients with severe psychiatric disorders. Increasing the awareness of psychiatry professionals and early screening, as well as interventions of chronic viral infections among patients with severe psychiatric disorders are imperative.

Understanding HIV risk and vulnerability among cisgender men with transgender partners

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