Informing interventions: the importance of contextual factors in the prediction of sexual risk behaviors among transgender women

Decreased Anogenital Gonorrhea and Chlamydia in Transgender and Gender Diverse Primary Care Patients Receiving Gender-Affirming Hormone Therapy

BACKGROUND

Transgender and gender diverse (TGD) adults in the U.S. experience health disparities, including in anogenital sexually transmitted infections (STI). Gender-affirming hormone therapy (GAHT) is known to be medically necessary and improve health. Few studies have assessed the effect of GAHT on STI diagnoses.

OBJECTIVE

To evaluate the effect of GAHT delivered in primary care as an intervention to improve STI outcomes for TGD adults.

DESIGN

LEGACY is a longitudinal, multisite cohort study of adult TGD primary care patients from two federally qualified community health centers in Boston, MA, and New York, NY.

PARTICIPANTS

Electronic health record data for eligible adult TGD patients contributed to the LEGACY research data warehouse (RDW). A total of 6330 LEGACY RDW patients were followed from 2016 to 2019, with 2555 patients providing STI testing data.

MAIN MEASURES

GAHT exposure was being prescribed hormones, and the clinical outcome was anogenital gonorrhea or chlamydia diagnoses. Log-Poisson generalized estimating equations assessed the effect of prescription GAHT on primary outcomes, adjusting for age, race, ethnicity, gender identity, poverty level, health insurance, clinical site, and cohort years.

KEY RESULTS

The median age was 28 years (IQR = 13); the racial breakdown was 20.4% Black, 8.1% Multiracial, 6.9% Asian/Pacific Islander, 1.8% Other; 62.8% White; 21.3% Hispanic/Latinx; 47.0% were assigned female at birth, and 16.0% identified as nonbinary. 86.3% were prescribed hormones. Among those tested, the percentage of patients with a positive anogenital STI diagnosis ranged annually from 10.0 to 12.5% between 2016 and 2019. GAHT prescription was associated with a significant reduction in the risk of anogenital STI diagnosis (aRR = 0.75; 95% CI = 0.59-0.96) over follow-up.

CONCLUSIONS

GAHT delivered in primary care was associated with less STI morbidity in this TGD cohort over follow-up. Patients may benefit from individualized and tailored clinical care alongside GAHT to optimize STI outcomes.

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.

Health Service Utilization and Its Associations with Depression and Sexual Risk Behaviors Among Transgender Women in Shanghai, China

Purpose

Given the limited research on health care utilization among transgender women in China, we described the use of primary health care and gender-affirming health care, and the associations between utilization of gender-affirming health care and depression and sexual risk behaviors.

Methods

We conducted a cross-sectional survey in 2017 among a purposive sample of transgender women in Shanghai, China (N=199). We examined correlates of health care utilization and its association with depression and sexual risk behaviors with Chi-square (χ2), Fisher's exact tests, and analysis of variance.

Results

The majority of the sample (78.5%) only had physician appointments when having an illness, while about one-fifth of the sample had physician appointments for yearly checkups. Nineteen out of 199 participants (9.5%) received gender-affirming surgery, among which only five used hormone therapy prescribed by a doctor (26.3%). Receiving some form of gender-affirming surgery was associated with higher depression scores [Welch's F(2, 12.22)=4.16, p=0.04], engagement in sex work (p=0.001), having 7 or more male sexual partners in the last 30 days (p=0.003), lifetime unprotected sex with a man (p=0.050), and unprotected sex with a main partner (p=0.043). Compared with transgender women who received both breast augmentation and vulvo-vaginoplasty (mean=5.86), those who received breast augmentation only (mean=12.33) scored higher on depression (p=0.04).

Conclusions

Access to gender-affirming health care is low among transgender women in this study. The utilization of gender-affirming surgery is associated with depression and sexual risk behaviors. Findings suggest China should establish national guidelines on transgender-related health care and set up more clinics to provide consultation and services for the transgender population in China.

Sex and Sexual Agreement Negotiation among Trans Women and Trans Men Partnered with Cis Men

Though trans individuals have some of the highest rates of HIV in the U.S., little is known about how trans couples navigate these risks within committed relationships. Thirty-nine couples, composed of one trans partner and one cis male partner, were asked about their relationship agreements, including sexual negotiations, in semi-structured, qualitative interviews. Couples reported definitions of monogamy and non-monogamy that were inconsistent with previous literature, each ranging as if on a continuum. While agreements varied, most non-monogamous couples reported a focus on safe sex practices and HIV risk mitigation, specifically highlighting negotiations around fluid exchange or fluid bonding. Changes in sexual desire arose for many couples, often due to hormonal changes during gender-affirming measures. Most couples navigated these shifts successfully, by changing their relationship agreement or sexual practices. Changing sexual behavior included addressing motivations for sex that were unrelated to one's own sexual pleasure; this motivation is called "maintenance sex." Alarmingly, nearly half of the couples interviewed reported discrepant agreements, which is associated with higher sexual risk. With an apparent ambiguity in defining agreements, it is imperative to trans communities' sexual health that relationship agreements are explicitly communicated to partners and healthcare providers.

Validation of the Patient Health Questionnaire-9 for Suicide Screening in Transgender Women

Purpose

High prevalence of depression in transgender women highlights the importance of validating the measure to assess depression. Moreover, depression is significantly associated with suicide across research studies. The aims of the current study were to validate a Chinese-language version of the Patient Health Questionnaire-9 (PHQ-9) and to assess operating characteristics of the PHQ-9 for suicide screening in transgender women.

Methods

With the approval of an Institutional Review Board (IRB), a total of 198 transgender women living in Shenyang, China, were recruited, and asked to complete the PHQ-9, including measures of their suicidal ideation, planning and attempt.

Results

A one-factor model of the PHQ-9 was supported in the current sample, showing good reliability and validity. The best cutoff point for the PHQ-9 in suicidal ideation was 17, with a sensitivity/specificity of 77.78%; the best cutoff point for PHQ-9 in suicidal planning was 17, with a sensitivity of 81.82% and a specificity of 73.26%; and the best cutoff point for PHQ-9 in suicidal attempt was 20, with a sensitivity of 75% and a specificity of 90.21%.

Conclusion

Findings supported the validity of the PHQ-9. With potential clinical or research application, the PHQ-9 can be an efficient instrument for suicide screening in transgender women.

A life course health development model of HIV vulnerabilities and resiliencies in young transgender women in Peru

BACKGROUND

Globally transgender women (TW) are at heightened vulnerability for HIV infection. In Lima Peru, sharp increases in HIV prevalence are seen among TW ages 25 years and older highlighting the need for early HIV prevention efforts for young TW. This study conducted in-depth qualitative interviews to elucidate the social and developmental contexts of HIV vulnerability for young TW in Lima Peru.

METHODS

Between November 2019 and February 2020, young TW ages 16-24 years (n = 21) in Lima Peru were purposively sampled using in-person (e.g., face-to-face outreach) and online (e.g., social media, networking websites) social network-based methods. Interviews were conducted in Spanish and a rapid qualitative analysis was conducted using a modified immersion crystallization methodology to identify themes.

RESULTS

Five themes emerged, informing the conceptualization of a Life Course Health Development Model of HIV Vulnerabilities and Resiliencies: (1) interpersonal contexts (family, school, partners, sexual debut, trans mothers); (2) structural vulnerabilities (poverty, educational constraints, migration, hostile environments, sex work, police violence); (3) concomitant mental health and psychosocial factors (discrimination, violence, depression, suicidality, substance use, life hopes/dreams/future expectations); (4) gender affirmation processes (gender identity development, hormones, surgery, legal name/gender marker change); (5) HIV prevention and treatment barriers (PrEP uptake, HIV care, condom use, risk reduction).

CONCLUSIONS

Young TW experience formidable developmental challenges associated with transphobia, violence, and pre-maturely facing accelerated milestones. Developmentally and culturally appropriate interventions to mitigate HIV vulnerability in Peru are needed, including those that consider co-occurring stigma-related conditions in adolescence and young adulthood.

The prevalence of childhood sexual experiences and intimate partner violence among transgender women in China: Risk factors for lifetime suicidal ideation

Objective

Several studies highlighted childhood sexual experiences (CSEs) and intimate partner violence (IPV) as risk factors that affected lifetime suicidal ideation. TW had higher rates of CSEs and IPV than cisgender people. The aim of this study was to comprehensively assess the prevalence of CSEs and IPV among TW and their association with lifetime suicidal ideation.

Methods

A cross-sectional survey was conducted among 247 TW in Shenyang and Kunming, China, from April to September 2018. CSEs, IPV, and lifetime suicidal ideation were assessed. Logistic regression models were used to examine the association between self-reported CSEs under 18 years of age, IPV in adulthood, and lifetime suicidal ideation.

Results

In the study, 14.2% (35/247) of the sample participants reported CSEs under 18 years of age; 44.9% (111/247) reported experiencing IPV in adulthood, including 18.6% (44/247) of physical IPV, 27.1% (67/247) of trans-specific identity IPV, 31.6% (78/247) of verbal IPV, and 19.4% (48/247) of sexual IPV; and 26.3% (65/247) had thought about attempting suicide at least one time. CSEs and any form of IPV were significantly associated with suicidal ideation in this sample population. A final stepwise multivariate logistic regression model found that both physical and verbal IPVs were significantly associated with suicidal ideation when controlling for other factors (ORm₁ = 2.58, 95% confidence interval (CI) = 1.163-5.724; ORm₂ = 2.72, 95% CI = 1.334-5.547).

Conclusions

The findings highlight the effects of CSEs and IPV among TW and suggest the need for research on suicide in the future. Suicide prevention efforts for this invisible and vulnerable population should focus on those with physical and verbal IPV.

Prevalence and correlates of substance use and associations with HIV-related outcomes among trans women in the San Francisco Bay Area

BACKGROUND

Trans women face tremendous social inequities as well as disproportionate rates of HIV and substance use, yet disaggregated substance use data specific to trans women remain limited.

METHODS

We conducted a secondary analysis of baseline data from the Trans*National Study (2016-2017) surveying trans women in the San Francisco Bay Area (n = 629). Multivariable logistic regression was used to analyze socio-demographic and environmental correlates of substance use, and bivariate associations between substance use and HIV-associated outcomes are presented alongside prevalence data.

RESULTS

Over half (52.9%) reported using substances in the prior year, most frequently marijuana, methamphetamine, and crack/cocaine. Those with unmet gender-affirming health care needs, lack of insurance, or a history of experiencing racial violence, transphobic violence, adult housing instability, or extreme poverty had higher odds of substance use. Sex work and condomless anal sex were also independently associated with substance use.

CONCLUSIONS

Among this sample of trans women, substance use and substance use concurrent with sex were highly prevalent, and associated with a number of socioeconomic and health care needs. These findings corroborate the need for holistic and intersectional efforts to reduce substance use and HIV risk.

Ethical HIV research with transgender and non-binary communities in the United States

INTRODUCTION

Because transgender individuals experience disproportionately high rates of HIV infection, this population is an increasing focus of epidemiological and implementation science research to combat the epidemic. However, study participants, providers and other advocates have become increasingly concerned about research practices that may alienate, objectify, exploit or even re-traumatize the communities they are designed to benefit. This commentary explores the common pitfalls of HIV research with transgender communities and provides a potential framework for ethical, community-engaged research practice.

DISCUSSION

We review some of the critical challenges to HIV research with transgender and non-binary communities that limit the potential for such studies to improve practice. For example, scales that measure stigma perceptions/experiences often include activating language, while the consistent focus in research on risk and trauma can often feel judgemental and redundant. Because of limited employment opportunities, some participants may feel undue influence by research stipends; others may perceive their participation as fuelling the larger research economy without providing research jobs to community members. Questions remain regarding optimal strategies for authentic research partnership beyond community advisory boards or focus groups. Transgender and non-binary researchers are under-represented and may be tokenized. Many demonstration projects provide much-needed services that disappear when the research funding is over, and community-based dissemination efforts are often perceived as "too little, too late" to effect change.

CONCLUSIONS

Based on this review and input from study participants across the United States, we detail six recommendations for ethical HIV research with transgender and non-binary communities, including (1) equitable budgeting with community-based programme partners; (2) representation in the development of both research agenda and methods; (3) integration of research activities into the ongoing work of any clinical or service site, so that individuals' needs as "clients" can continue to be prioritized over their role as "participants;" (4) mindfully considered compensation that values the contributions of community members, but avoids undue influence; (5) transparent, community-focused and timely communication at every stage of the study, including research purpose, data usage, preliminary findings and full-scale results; and (6) planning for sustainability of any programme or services beyond the life of the research project.

Engagement in Care and Housing Instability Influence HIV Screening Among Transgender Individuals in South Florida

Purpose: HIV screening is a critical step in the HIV care continuum to lowering incidence and achieving viral load suppression among at-risk populations. Few studies assess factors associated with HIV screening among transgender individuals living in the southeast region of the United States. This study was conducted to determine factors that influence HIV screening among transgender individuals in South Florida. Methods: During Fall 2016, 68 participants were recruited to complete a questionnaire as part of a pilot pre-exposure prophylaxis study. Correlations were examined between sociodemographic factors, HIV risk, and access to and engagement in care. Significant correlations were entered into one logistic regression model to estimate predictors of HIV screening and knowledge of HIV status. Results: Almost half (48.5%) of the respondents were Latinx, 38.2% Black, 10.3% non-Latinx White, and 3% other. Seventy-eight percent reported access and routine engagement in care within the past year, 25% had not screened for HIV in the past year, and of those who knew their status, 16.7% reported living with HIV. Regression analysis revealed that participants with routine engagement in care were twice as likely to screen for HIV (p=0.02). Unstable housing was associated with no HIV screening in the past year (p=0.05). Conclusion: Stable housing is linked to engagement in routine care that can increase the likelihood of an at-risk transgender individual screening for HIV. Further research is needed to develop interventions to improve engagement in care among transgender individuals who do not have adequate housing or access to care.

Transgender Women's Internet Survey and Testing: Protocol and Key Indicators Report

Purpose: There is a need for ongoing behavioral surveillance of human immunodeficiency virus (HIV)/sexually transmitted infection (STI) risk among transgender women, using assessments adapted to this population. We therefore developed and piloted the Transgender Women's Internet Survey and Testing (TWIST) study, a cross-sectional behavioral survey of transgender women in the United States coupled with remote biospecimen collection and testing. Methods: Participants age 15+ were recruited by using social media advertisements. Participants were eligible to take the survey if they reported male sex at birth, identified as female or as a transgender woman, resided in the United States, and reported ever having oral, vaginal, or anal sex. We examined a number of behavioral indicators by age, county population density, and medical gender affirmation treatment, using multivariable regression modeling. A sample of respondents was invited to receive a home biospecimen collection kit for HIV/STI testing. Results: The 401 participants were mainly non-Hispanic white and younger than 25 years. Self-reported HIV prevalence was 1.3% (5/401), and almost half (47.1%, 189/401) did not know their HIV status. Receiving medical gender affirmation was strongly associated with past-year HIV and STI testing, independent of general health care engagement. Of the 155 participants invited to receive home biospecimen collection kits, 48 (31.0%) consented and of those, 21 (43.8%) returned specimens for testing. Conclusion: This pilot study successfully reached its recruitment target and generated useful behavioral measures from an online sample of transgender women. We anticipate that online recruitment combined with self-collection of biospecimens will serve as an innovative and scalable strategy for ongoing monitoring of HIV/STI behavioral trends among U.S. transgender women.

Evaluating Locally Developed Interventions to Promote PrEP Among Racially/Ethnically Diverse Transgender Women in the United States: A Unique CDC Initiative

In the United States, transgender women are disproportionately affected by HIV. However, few evidence-based prevention interventions exist for this key population. We describe two promising, locally developed interventions that are currently being implemented and evaluated through the Centers for Disease Control and Prevention Combination HIV Prevention for Transgender Women Project: (a) ChiCAS, designed to promote the uptake of pre-exposure prophylaxis (PrEP), condom use, and medically supervised hormone therapy among Spanish-speaking transgender Latinas, and (b) TransLife Care, designed to address the structural drivers of HIV risk through access to housing, employment, legal services, and medical services, including HIV preventive care (e.g., PrEP use) among racially/ethnically diverse urban transgender women. If the evaluation trials determine that these interventions are effective, they will be among the first such interventions for use with transgender women incorporating PrEP, thereby contributing to the evidence-based resources that may be used to reduce HIV risk among this population.

Evaluating Locally Developed Interventions to Promote PrEP Among Racially/Ethnically Diverse Transgender Women in the United States: A Unique CDC Initiative

In the United States, transgender women are disproportionately affected by HIV. However, few evidence-based prevention interventions exist for this key population. We describe two promising, locally developed interventions that are currently being implemented and evaluated through the Centers for Disease Control and Prevention Combination HIV Prevention for Transgender Women Project: (a) ChiCAS, designed to promote the uptake of pre-exposure prophylaxis (PrEP), condom use, and medically supervised hormone therapy among Spanish-speaking transgender Latinas, and (b) TransLife Care, designed to address the structural drivers of HIV risk through access to housing, employment, legal services, and medical services, including HIV preventive care (e.g., PrEP use) among racially/ethnically diverse urban transgender women. If the evaluation trials determine that these interventions are effective, they will be among the first such interventions for use with transgender women incorporating PrEP, thereby contributing to the evidence-based resources that may be used to reduce HIV risk among this population.

Sociocultural Contexts of Access to HIV Primary Care and Participant Experience with an Intervention Project: African American Transgender Women Living with HIV in Alameda County, California

The baseline data of the intervention project for African American transgender women living with HIV showed that more than one-third of the participants having ever enrolled in HIV care had not received ART and that among those in ART, more than half reported their adherence to ART was poor. Those who had engaged in sex work, sold drugs, or experienced higher levels of transphobia were less likely to have enrolled in care. The qualitative interviews with participants who had completed the intervention or dropped out revealed barriers to enroll in care, such as community stigma and transphobia.

Young Transgender Women of Color: Homelessness, Poverty, Childhood Sexual Abuse and Implications for HIV Care

This study describes a sample of HIV+ young transgender women of color aged 18-24 and their experience with homelessness as part of a demonstration project of engagement and retention in HIV medical care funded by Health Resources and Services Administration. The study engaged transgender women of color in HIV care in nine sites across the US between 2012 and 2017. This analysis describes and compares transwomen who had been homeless in the last 6 months to those not homeless. We hypothesized that homelessness would compete with HIV care, food, shelter, and be associated with poverty. Variable domains included sociodemographic, mental health and substance use, HIV care, sexual risk behavior, social support from transgender and other friends, and childhood sexual abuse. There were 102 youth enrolled, 77 (75.5%) who had been homeless, and 25 (24.5%) who had not been homeless. Bivariate analyses showed that low income, sex work as source of income, inability to afford food, lack of viral load (VL) suppression, childhood sexual abuse, lower levels of social support, and higher levels of depression were associated with homelessness. A logistic regression model showed that being unable to afford food (AOR = 9.24, 95% CI 2.13-40.16), lack of VL suppression in last 6 months (AOR = 0.10, 95% CI .02-.57), and lack of transgender friend support (AOR = 0.09, 95% CI .02-.53) was associated with homelessness. Programs that place basic needs first-food and shelter-may be able to engage and assist young transgender women of color with HIV to survive and live healthier lives.

Engagement in HIV Care Among New York City Transgender Women of Color: Findings from the Peer-Led, TWEET Intervention, a SPNS Trans Women of Color Initiative

Transgender women (TW) have higher HIV prevalence rates than cisgender (i.e., non-transgender) women. However, utilization of healthcare for transgender people in the U.S. is low. As part of a multisite initiative to facilitate entry and retention in HIV care for TW of color, we compared health outcomes between participants who became Peer Leaders and those who did not. From 2013 to 2016, 163 New York City, mostly Latina, TW enrolled in the Transgender Women Engagement and Entry to Care Project (TWEET). The TWEET intervention included peer-led, group-based educational sessions called Transgender Leader-Teach Back; 39% completed Peer Leadership requirements. Comparing pre-post change by Peer Leader status, Peer Leaders had a significant decrease in viral load and significant increase in CD4 at the last HIV care visit compared to the first. In multivariable logistic regression, predictors associated with Peer Leadership included having at least some college education, being in a relationship, stable housing, receiving legal assistance for political asylum, and having two or more HIV care visits during the intervention. Findings suggest that, for trans women who have completed at least secondary school education, participating in a peer-led intervention can lead to improved HIV care engagement. Understanding which program components lead to becoming a Peer Leader, and how to better engage non-Peer Leaders, are important next steps.

Longitudinal Cohort Study of Gender Affirmation and HIV-Related Health in Transgender and Gender Diverse Adults: The LEGACY Project Protocol

Background

Transgender and gender diverse (TGD) adults in the United States experience health disparities, especially in HIV infection. Medical gender affirmation (eg, hormone therapy and gender-affirming surgeries) is known to be medically necessary and to improve some health conditions. To our knowledge, however, no studies have assessed the effects of gender-affirming medical care on HIV-related outcomes.

Objective

This study aims to evaluate the effects of medical gender affirmation on HIV-related outcomes among TGD primary care patients. Secondary objectives include characterizing mental health, quality of life, and unmet medical gender affirmation needs.

Methods

LEGACY is a longitudinal, multisite, clinic-based cohort of adult TGD primary care patients from two federally qualified community health centers in the United States: Fenway Health in Boston, and Callen-Lorde Community Health Center in New York. Eligible adult TGD patients contribute electronic health record data to the LEGACY research data warehouse (RDW). Patients are also offered the option to participate in patient-reported surveys for 1 year of follow-up (baseline, 6-month, and 12-month assessments) with optional HIV and sexually transmitted infection (STI) testing. Biobehavioral data from the RDW, surveys, and biospecimen collection are linked. HIV-related clinical outcomes include pre-exposure prophylaxis uptake (patients without HIV), viral suppression (patients with HIV), and anogenital STI diagnoses (all patients). Medical gender affirmation includes hormones, surgeries, and nonhormonal and nonsurgical interventions (eg, voice therapy).

Results

The contract began in April 2018. The cohort design was informed by focus groups with TGD patients (n=28) conducted between August-October 2018 and in collaboration with a community advisory board, scientific advisory board, and site-specific research support coalitions. Prospective cohort enrollment began in February 2019, with enrollment expected to continue through August 2020. As of April 2020, 7821 patients are enrolled in the LEGACY RDW and 1756 have completed a baseline survey. Participants have a median age of 29 years (IQR 11; range 18-82). More than one-third (39.7%) are racial or ethnic minorities (1070/7821, 13.68% Black; 475/7821, 6.07% multiracial; 439/7821, 5.61% Asian or Pacific Islander; 1120/7821, 14.32% other or missing) and 14.73% (1152/7821) are Hispanic or Latinx. By gender identity, participants identify as 33.79% (2643/7821) male, 37.07% (2900/7821) female, 21.74% (1700/7821) nonbinary, and 7.39% (578/7821) are unsure or have missing data. Approximately half (52.0%) of the cohort was assigned female sex at birth, and 5.4% (421/7821) are living with HIV infection.

Conclusions

LEGACY is an unprecedented opportunity to evaluate the impact of medical gender affirmation on HIV-related health. The study uses a comprehensive research methodology linking TGD patient biobehavioral longitudinal data from multiple sources. Patient-centeredness and scientific rigor are assured through the ongoing engagement of TGD communities, clinicians, scientists, and site clinical staff undergirded by epidemiological methodology. Findings will inform evidence-based clinical care for TGD patients, including optimal interventions to improve HIV-related outcomes.

International Registered Report Identifier (IRRID)

DERR1-10.2196/24198

Perceived acceptability and feasibility of HIV self-testing and app-based data collection for HIV prevention research with transgender women in the United States

In the United States, transgender women are disproportionately burdened by HIV infection. Research aimed at curbing the HIV epidemic for this population may benefit from innovative technology to engage participants in research. Adult transgender women (n = 41) from six cities in the southern and eastern United States participated in seven online focus groups between August 2017 and January 2018. Analyses focused on perceived acceptability of novel technologies for research purposes, particularly HIV self-testing (HIVST) and remote data collection through a mobile app. While participants noted a number of benefits to HIVST and remote study participation, including increased participant engagement and sentiments of agency, they also expressed concerns that may impact HIVST and remote participation including housing instability, inconsistent access to technology, and confidentiality. Study findings provide insight into gaps that must be addressed when using technology-enhanced methods to support HIV testing and research participation among transgender women in the US. Substantial effort is required on the part of investigators to ensure equitable access across subgroups and, thus, minimize bias to avoid reproducing health disparities in research.

Health and Health Care Access Barriers Among Transgender Women Engaged in Sex Work: A Synthesis of U.S.-Based Studies Published 2005-2019

Purpose: Transgender women (TW) are likely to experience job discrimination and engage in commercial sex transactions. As a group, they have the highest risk for HIV/AIDS. However, little is known about the health needs of transgender women sex workers (TWSW) in the United States and the structural and psychosocial barriers to their health care access. The objective of this systematic review was to systematically document these needs and barriers by using a framework approach. Methods: We searched PubMed, JSTOR, and Google Scholar for primary and secondary studies published in 2005-2019 that addressed the health of TWSW in the United States. We used a standardized data extraction form to gather data from eligible articles. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used to assess study quality. Results: Fifty-three articles met the inclusion criteria, including mentioning health-related topics among TWSW. More articles appeared in recent years. Most studies collected data with convenience samples in urban areas. Structural barriers reported included transphobia, lack of pre-exposure prophylaxis targeted at TW, and lack of health insurance coverage. Psychosocial barriers included distrust of the health care system, self-esteem, alcohol and substance use, and mental health. Conclusions: TWSW have unique health care needs that are not being addressed due to barriers to health care access. More research is required to identify non-HIV-related health burdens and details about psychosocial barriers to health care access.

Assessing Sexually Transmitted Infections and HIV Risk Among Transgender Women in Lima, Peru: Beyond Behavior

Purpose: The purpose of this study was to explore risk factors for HIV and sexually transmitted infections (STIs) among transgender women (TW) in Lima, Peru. Methods: HIV-negative or serostatus unknown TW reporting recent condomless receptive anal intercourse underwent testing for STIs and HIV and completed a sociobehavioral survey. Results: Among 120 TW, 29.6% had rectal Neisseria gonorrhoeae (GC) or Chlamydia trachomatis (CT) and 12.6% had HIV. Age and migrant status were associated with rectal GC/CT, and rectal GC/CT predicted HIV infection. Conclusions: Further study is needed to understand individual and social factors that contribute to HIV/STI vulnerability among TW.

A Gap Between Willingness and Uptake: Findings From Mixed Methods Research on HIV Prevention Among Black and Latina Transgender Women

BACKGROUND

Black and Latina transgender women (BLTW) face significant HIV disparities with estimated HIV prevalence up to 50% and annual incidence rates as high as 2.8 per 100 person-years. However, few studies have evaluated the acceptability and uptake of high-impact HIV prevention interventions among BLTW.

SETTING

Data collection took place in Baltimore, MD and Washington, DC from May 2015 to May 2017.

METHODS

This mixed methods study included quantitative interviewer-administered surveys, key informant interviews, and focus group discussions. Rapid HIV testing followed each survey. Logistic regression models tested associations between legal gender affirmation (ie, desired name and gender marker on identity documents), transgender pride, history of exchange sex, HIV risk perception, and willingness to take pre-exposure prophylaxis (PrEP). Transcripts of qualitative data were coded to identify common themes related to engagement in HIV prevention.

RESULTS

Among 201 BLTW, 56% tested HIV-positive and 87% had heard of PrEP. Only 18% who had heard of PrEP had ever taken it. Of the 72 self-reported HIV-negative or status-unknown BLTW who had never taken PrEP, 75% were willing to take it. In multivariable analyses, history of exchange sex was associated with willingness to take PrEP, whereas greater HIV knowledge and transgender pride were associated with lower likelihood of willingness to take PrEP. Concern about drug interactions with hormone therapy was the most frequently reported barrier to PrEP uptake.

CONCLUSIONS

Noting the disconnect between PrEP willingness and uptake among BLTW, HIV prevention programs could bridge this gap by responding to identified access barriers and incorporating community-derived strategies.

Barriers and facilitators to uptake of condoms among Filipinx transgender women and cisgender men who have sex with men: A situated socio-ecological perspective

Transgender women (TW) and cisgender men who have sex with men (cis-MSM) are disproportionately impacted by the national HIV crisis in the Philippines, where the HIV incidence has, in large part, been attributed to condomless sex. This study sought to qualitatively examine the socio-ecological factors that contribute to low condom uptake among Filipinx TW and cis-MSM communities in Manila. Between July and August 2017, we conducted semi-structured qualitative interviews with 30 TW and cis-MSM participants (n = 23 and 7, respectively). We identified structural factors described by TW and cis-MSM, and noted that they varied per situation and context of: (a) friends (e.g. as condom promoters and educators), (b) schools (e.g. lack of sex education and HIV curriculum), (c) health care facilities (e.g. availability, educational programmes, and HIV testing requirement), (d) stores (e.g. placement of condoms, distance to store, and cost), and (e) church (e.g. prohibition of condom distribution programmes, and unsupportiveness). Condom-related stigma as a social factor was pervasively present across all situation or context. Our findings support the need for multilevel condom promotion interventions that are tailored per situation or context. Future research is needed to identify factors that can be leveraged for condom promotion strategies within diverse situations.

Psychosocial and sexual factors associated with recent sexual health clinic attendance and HIV testing among trans people in the UK

OBJECTIVES

Trans people remain an understudied population in the UK, with unmet sexual health needs. The aim of this research was to identify possible barriers and facilitators for sexual health clinic attendance and HIV testing among trans people.

METHODS

Lesbian, gay, bisexual and transgender (LGBT) participants from across the UK were invited to take part in a cross-sectional online survey through Facebook advertising (April-June 2018). Psychosocial and sexual factors associated with recent sexual health clinic attendance, and ever having an HIV test were examined using multivariate logistic regression.

RESULTS

A total of 3007 cisgender and 500 trans participants completed the survey. Trans participants were less likely to attend a sexual health clinic than cisgender participants (27% vs 36%, p<0.001) and report ever having an HIV test (49% vs 64%, p<0.001). One trans participant reported living with HIV and three reported currently taking pre-exposure prophylaxis. Factors associated with trans sexual health clinic attendance were: living in London, having a relationship with multiple partners, engaging in condomless anal intercourse, greater life satisfaction, and having alcohol and/or drugs before sex. Being a person of colour, aged 25-49 years, in a relationship with multiple partners, condomless anal intercourse, lower body dissatisfaction, and having drugs before sex were associated with ever having an HIV test among trans participants.

CONCLUSIONS

Trans people were less likely to attend sexual health services than cisgender people, and half of trans participants who reported condomless anal intercourse had never had an HIV test. Further research is needed to understand and improve uptake of sexual health services among trans people.

Measuring Experiences of Minority Stress for Transgender Women: Adaptation and Evaluation of Internalized and Anticipated Transgender Stigma Scales

Purpose: Transgender women (TGW) experience high rates of stigma based on their gender identity. Research has documented how transgender stigma and other discrimination negatively contribute to health inequities, including higher rates of depression compared with the general population. However, few scales measuring transgender stigma exist, even fewer that specifically assess anticipated or internalized transgender stigma. We sought to validate an adapted transgender stigma scale in a diverse sample of TGW. Methods: We adapted an existing stigma measure to capture experiences of anticipated and internalized transgender stigma for TGW. Adapted measures were completed by 213 diverse TGW. Factor analysis was completed to reduce the number of items in each scale and sociodemographic differences in each construct were explored. Results: The final nine items comprising anticipated transgender stigma and the five items for internalized transgender stigma both showed evidence of adequate model fit, unidimensionality, and internal consistency. The two constructs were moderately correlated with one another (r=0.36, p<0.001). We identified educational and HIV status differences in anticipated transgender stigma but no sociodemographic differences in internalized transgender stigma. Conclusion: We developed brief measures of internalized and anticipated transgender stigma through initial adaptation by TGW themselves and subsequent psychometric evaluation, demonstrating evidence of unidimensionality and internal consistency. These subscales were only moderately associated with one another and may provide unique insights in future research on minority stress among TGW.

Partnership-level correlates of sexual risk taking within the sexual partnerships of young transwomen in San Francisco, California

OBJECTIVES

Little is known about the sexual networks of young transwomen, leaving a major gap in what we know about transmission dynamics and the elevated rates of HIV in this population. The objective of this study was to understand partnership-level factors associated with condomless anal sex among young transwomen.

METHODS

A secondary data analysis of the sexual partnerships of young transwomen was conducted using baseline data from the SHINE study. Generalised estimating equation logistic regressions were used to assess for partnership-level associations between partnership type, age, injection drug use and racial concordance, HIV seroconcordance, sexual role and condomless receptive (CRAI) and insertive anal intercourse (CIAI).

RESULTS

Our analysis included 187 young transwomen that reported a total of 464 sexual partnerships where they had at least one episode of anal sex in the past 6 months. We found casual (n=232 or 50%) and commercial partnerships (n=106 or 22.8%) to be significantly associated with a lower odds of CIAI (OR=0.53, 95% CI 0.32 to 0.86 and OR=0.39, 95% CI 0.18 to 0.82) and CRAI (OR=0.30, 95% CI 0.19 to 0.47 and OR=0.35, 95% CI 0.2 to 0.62) compared with main partnerships (n=126 or 27.2%). Additionally, HIV-positive seroconcordant (n=25 or 5.4%, OR=4.05, 95% CI 1.44 to 11.40) and injection-drug using partnerships (n=25 or 5.4%, OR=3.66, 95% CI 1.34 to 9.95) were found to be significantly associated with an increased odds of CIAI among participants compared with HIV-negative seroconcordant (n=330 or 71.1%) and non-using partnerships (n=338 or 72.8%), respectively.

CONCLUSION

Young transwomen, like other populations, engage in condomless sex more often with main than casual and commercial partners, suggesting a need for interventions that address sexual practices with steady main partners.

High HIV prevalence and associated risk factors among transgender women in China: a cross-sectional survey

INTRODUCTION

Transgender women may face the highest prevalence of HIV of any population, experiencing a disproportionate burden of disease frequently confirmed in surveys throughout the developing and developed world. However, few studies have been conducted specifically for transgender women in China. This study aimed to measure HIV prevalence and explore risk factors for infection in a diverse sample of Chinese transgender women to help advocate for prevention and care interventions for this population.

METHODS

From July 2018 to May 2019, we adapted a respondent-driven sampling (RDS) approach to recruit a diverse sample of 250 transgender women through chains of peer referrals in two cities of eastern China, Nanjing and Suzhou. Eligible participants (i.e. 18 years of age or older, living in Jiangsu province and assigned male sex at birth but currently self-identified as a gender different from male) completed a self-administered questionnaire on a mobile phone to collect demographic characteristics and risk behaviours and underwent HIV testing.

RESULTS AND DISCUSSION

The survey sample was young (82% under age 35 years), with 28.8% having a university degree, 39.2% reporting work at entertainment venues, 47.6% ever having taken hormones and 6.4% being diagnosed with an STI in the last year. One in five (20.8%) reported having engaged in sex work. HIV prevalence was 14.8% (95% CI 10.6 to 19.8), with 75.6% of those testing HIV positive reporting they were already aware of their serostatus. In multivariate analysis, HIV prevalence was significantly higher among transgender women above the age of 24 years, those who work at entertainment venues, who never have taken hormones, and who had been diagnosed with an STI in the last year.

CONCLUSIONS

The prevalence of HIV among transgender women in our study, at 14.8%, is among the highest detected in any population in eastern China. Chinese transgender women may therefore follow the disparity in the burden of HIV noted worldwide. Data support policies to prioritize transgender women for HIV testing outreach, for in-depth research to better understand the specific drivers of infection in this population, and for trans-friendly HIV care and prevention programmes to address their specific needs.

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

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

Women in Sex Work and the Risk Environment: Agency, Risk Perception, and Management in the Sex Work Environments of Two Mexico-U.S. Border Cities

Sex work around the world takes place under conditions of structural violence and vulnerability. The México-U.S. border region is characterized by the presence of factors that increase the risk for health harms among female sex workers (FSW); located in this context, the risk environments of Tijuana and Ciudad Juárez have similar yet distinct characteristics that influence how risk is produced and experienced among FSWs. Exploring the ways in which FSWs enact agency in risk environments can illustrate how environmental characteristics shape perceived risks and the strategies that FSWs develop to manage them. This approach also identifies the limits that are placed by environmental characteristics over the capacity for harm reduction and prevention practices among FSWs. We analyzed the role of agency in the work environments of female sex workers and its relationship with risk perception and management in the cities of Tijuana and Cd. Juárez.

Text Messaging to Improve Linkage, Retention, and Health Outcomes Among HIV-Positive Young Transgender Women: Protocol for a Randomized Controlled Trial (Text Me, Girl!)

Background

Transgender women in the United States experience numerous risk factors for HIV acquisition and transmission, including increased rates of homelessness, alcohol and drug use, sex work, and nonprescribed hormone and soft tissue–filler injections. In addition, transgender women face discrimination and social/economic marginalization more intense and deleterious than that experienced by lesbian, gay, or bisexual individuals, further worsening health outcomes. Although little research has been done specifically with young transgender women aged 35 years and younger, existing evidence suggests even further elevated rates of homelessness, substance use, and engagement in HIV transmission risk behaviors relative to their older transgender women and nontransgender young adult counterparts. Young transgender women living with HIV experience a range of barriers that challenge their ability to be successfully linked and retained in HIV care.

Objective

The aim of this randomized controlled trial, Text Me, Girl!, is to assess the impact of a 90-day, theory-based, transgender-specific, text-messaging intervention designed to improve HIV-related health outcomes along the HIV care continuum among young (aged 18-34 years) transgender women (N=130) living with HIV/AIDS.

Methods

Participants were randomized into either Group A (immediate text message intervention delivery; n=61) or Group B (delayed text message intervention delivery whereby participants were delivered the text-messaging intervention after a 90-day delay period; n=69). Over the course of the 90-day intervention, participants received 270 theory-based text messages that were targeted, tailored, and personalized specifically for young transgender women living with HIV. Participants received 3 messages per day in real time within a 10-hour gradual and automated delivery system. The text-message content was scripted along the HIV care continuum and based on social support theory, social cognitive theory, and health belief model. The desired outcome of Text Me, Girl! was virological suppression.

Results

Recruitment began on November 18, 2016, and the first participant was enrolled on December 16, 2016; enrollment closed on May 31, 2018. Intervention delivery ended on November 30, 2018, and follow-up evaluations will conclude on August 31, 2019. Primary outcome analyses will begin immediately following the conclusion of the follow-up evaluations.

Conclusions

Text messaging is a communication platform well suited for engaging young transgender women in HIV care because it is easily accessible and widely used, as well as private, portable, and inexpensive. Text Me, Girl! aimed to improve HIV care continuum outcomes among young transgender women by providing culturally responsive text messages to promote linkage, retention, and adherence, with the ultimate goal of achieving viral suppression. The Text Me, Girl! text message library is readily scalable and can be adapted for other hard-to-reach populations.

International Registered Report Identifier (IRRID)

DERR1-10.2196/12837

Longitudinal Analysis of Syndemic Psychosocial Problems Predicting HIV Risk Behavior Among a Multicity Prospective Cohort of Sexually Active Young Transgender Women in the United States

BACKGROUND

Worldwide, young transgender women (YTW) contend with exceptionally high risks of HIV infection. Cross-sectional studies have suggested that co-occurring epidemics or "syndemics" of psychosocial problems may accelerate HIV acquisition and transmission through elevated sexual risk behavior among transgender women. We aimed to examine how a syndemic of 7 psychosocial problems potentiates HIV sexual risk behavior among a multicity, longitudinal cohort of sexually active YTW in the United States.

METHODS

Between 2012 and 2015, 233 YTW from Boston, MA, and Chicago, IL, completed behavioral surveys at baseline, 4, 8, and 12 months. We used generalized estimating equations to examine the prospective relationship of overlapping psychosocial problems and HIV sexual risk behavior (ie, condomless anal or vaginal sex) among YTW.

RESULTS

The prevalence of 7 psychosocial syndemic problems was substantial at baseline and remained high at each time point: 6.4% reported polydrug use in the past 4 months (excluding stimulants); 7.7% reported heavy alcohol use in the past 4 months; 10% reported a history of childhood sexual abuse; 15.9% reported stimulant use in the past 4 months; 41.7% reported experiencing lifetime intimate partner violence; 42.1% reported clinically significant depressive symptoms; and 68.6% reported lifetime transgender-specific victimization. We identified a statistically significant positive "dose-response" relationship between the number of psychosocial syndemic problems and condomless anal or vaginal sex over time.

CONCLUSIONS

The accumulation of "syndemic" psychosocial problems predicted HIV sexual risk behavior in a prospective cohort of YTW. Given the high prevalence of psychosocial problems and HIV sexual risk behavior, as well as having the highest HIV incidence among any risk group, the HIV prevention agenda requires a shift toward improved assessment of psychosocial comorbidities and stronger integration with gender-affirming and supportive mental health, violence recovery, and addiction treatment services for this population.

Increasing Access to Pre-Exposure Prophylaxis Among Transgender Women and Transfeminine Nonbinary Individuals

In the United States, transgender women and transfeminine nonbinary individuals (TGWNBI) are a highly vulnerable and marginalized population at high risk for HIV. Despite disproportionate rates of HIV, a striking lack of research exists on pre-exposure prophylaxis (PrEP) use among TGWNBI. We conducted 30 semi-structured interviews with TGWNBI both on PrEP and those not on PrEP. Questions explored PrEP access, initiation, and factors to increase broad interest and participation in PrEP. Qualitative data were coded and analyzed using thematic analysis. Participants identified five components to increase PrEP use among TGWNBI: (1) eliminating the practice of conflating TGWNBI with cisgender men who have sex with men, (2) recognition of and support for the contextual factors associated with HIV risk among TGWNBI, (3) ensuring the design and development of transgender-inclusive and gender-affirming sexual health programs that include PrEP, (4) active provider engagement and assistance around PrEP, and (5) identification and implementation of strategies to bolster existing community mobilization/activism around PrEP.

Feasibility and Acceptability of a Behavioral Group Support Intervention Among Transgender Women: A Sexual and Mental Health Mixed-Methods Pilot Study in Beirut, Lebanon

Transgender women are among the most at risk of populations for HIV infection and transmission globally. Feasible and acceptable intervention strategies that are culturally and contextually appropriate are urgently needed to address the burden of disease worldwide. The first study to address the unique health needs of transgender women in the Middle East and North Africa, this mixed-methods pilot (N = 16) demonstrated high levels of feasibility and acceptability among adult transgender women in Lebanon as measured quantitatively and qualitatively in the domains of: time allotment, venue, group dynamics, facilitation, content, and retention. The intervention, adapted from an existing trans-facilitated group support intervention, addresses the sexual and mental health of transgender women with mixed HIV status. Next steps should include scale-up, randomization, and testing to determine larger-scale feasibility, acceptability, and efficacy for mitigating sexual and mental health risk and promoting community connectedness and social cohesion.

A Multilevel Analysis of Social Network Characteristics and Technology Use on HIV Risk and Protective Behaviors Among Transgender Women

This study examined the empirical structure (i.e., size, density, duration) of transgender women's social networks and estimated how network alters' perceived HIV risk/protective behaviors influenced transgender women's own HIV risk/protective behaviors. From July 2015 to September 2016, 271 transgender women completed surveys on sociodemographic characteristics, HIV risk/protective behaviors, and social networks. Hierarchical generalized linear models examined the associations of social network alter member data 'nested' within participant data. Analyses revealed that social network factors were associated with HIV risk/protective behaviors, and that the gender identity of the alters (cisgender vs. transgender), and social network sites and technology use patterns ("SNS/tech") moderated these associations. Among network alters with whom the participant communicated via SNS/tech, participants' HIV risk behavior was positively associated with alters' HIV risk behavior (cisgender alters aOR 4.10; transgender alters aOR 5.87). Among cisgender alters (but not transgender alters) with whom the participant communicated via SNS/tech, participants' HIV protective behavior was positively associated with alters' HIV protective behavior (aOR 8.94).

Transhealth Information Project: A Peer-Led HIV Prevention Intervention to Promote HIV Protection for Individuals of Transgender Experience

Individuals of transgender experience (ITE) in the United States face an elevated risk of HIV infection. Several conditions have been attributed to the high HIV incidence and prevalence within this group, including experiences of discrimination, unemployment, incarceration, stigma, and elevated rates of sexual risk and substance use. In response to these needs, the Gay and Lesbian Latino AIDS Education Initiative and Prevention Point Philadelphia, two local community-based organizations in Philadelphia, developed the Transhealth Information Project (TIP). TIP is a peer-led six-session hybrid individual- and group-based intervention emphasizing leadership, social and structural interventions, and HIV risk reduction that incorporates other evidence-based practices for HIV prevention and care. Since 2003, TIP has served over 1,500 ITE and linked them to HIV prevention and care services. TIP has an established record of reaching ITE and linking them to HIV prevention services and HIV primary care. TIP’s utilization speaks to the need for interventions to respond to the complex, interacting syndemic factors that cumulatively determine HIV vulnerability among ITE.

Medical Mistrust and PrEP Perceptions Among Transgender Women: A Cluster Analysis

Transgender (trans) women experience unique barriers in accessing preventative health services such as HIV preexposure prophylaxis (PrEP). These barriers may be exacerbated by past real or anticipated mistreatment in health care settings, but little is known about the relationship between medical mistrust and poor PrEP uptake and knowledge. Using a multistep approach, this study used a novel survey instrument administered to a pilot sample of 78 trans women. Item responses on a 0-10 scale were subjected to a TwoStep cluster analysis to explore how perceptions of PrEP and experiences with health care vary among trans women. Two distinct clusters (C1,C2) were defined on the basis of race (C1: 82% White, C2: 69% Black) and highest level of education completed (C1: 53% college or above, C2: 42% high school diploma or GED). Analyses suggest that varying levels of medical mistrust exist between clusters. Higher mean scores on medical mistrust items were reported in C1. A similar relationship was found on attitudes toward PrEP. Differences in intention to use PrEP and differences in past PrEP use were not significant; however, C2 members were more likely to have heard of PrEP from a doctor. Results suggest that levels of medical mistrust and PrEP perceptions vary among distinct subpopulations in this community, which may affect willingness to use PrEP. Interventions aimed at addressing unique perceptions in subpopulations could move trans women from intention to PrEP use.

Mental Health and Proximal Stressors in Transgender Men and Women

This paper explores the subjective perception of some personal and interpersonal aspects of the lives of transgender people and the relationship they have with their mental health. One hundred and twenty transgender people (60 men and 60 women) participated in semi-structured interviews. Following quantitative methodology, analysis highlighted that social loneliness is the main predictor of lower levels of mental health (anxiety and depression) for both genders and recognized romantic loneliness as the strongest factor among transgender men. In both cases, higher levels of loneliness were associated with lower levels of mental health. The results have guided us to improve institutional and social responses and have provided an opportunity to promote the mental health of transgender people.

Alternative kinship structures, resilience and social support among immigrant trans Latinas in the USA

Latinas comprise the largest racial/ethnic group of trans women (male-to-female transgender people) in New York City, where HIV seroprevalence among trans Latinas has been found to be as high as 49%. Despite this population's high risk of HIV, little is known about resilience among trans Latinas that may provide protective health factors. Six focus groups and one in-depth interview were conducted with 34 low-income trans/gender-variant people of colour who attended transgender support groups at harm reduction programmes in New York City. This paper reports on data from 13 participants who identified as immigrant trans Latinas. Focus groups were coded and analysed using thematic qualitative methods. The majority of immigrants were undocumented but reported having robust social support. Unique characteristics of immigrant trans Latinas included alternative kinship structures and sources of income. Social creativity was used to develop achievable ways in which to improve their health outcomes. Resilience was evident in informal kinship dynamics, formal support groups, gender-transition, educational access and skills training and substance use reduction. Individual-level resilience increased as a result of strong community-level resilience.

Transgender Identities, Pressures, and Social Policy: A Study Carried Out in Spain

This article draws on a qualitative research project concerning the relationship between trans people's mental health and wellbeing, pressures, social policy, and heteronormative gender norms in Spain. Drawing on interviews carried out with trans people from all regions and generations, we use an ecological framework to illustrate how a socially entrenched heteronormativity pressures trans people to comply with gender norms that impact negatively their mental health and wellbeing. The article argues that the legal changes in Spain are not enough in themselves to bring about social change, but, rather, Spanish social policy makers also need to challenge gender categorization and work toward transforming public discourses on gender issues if trans people are to gain full social recognition and equal social rights.

Correlates of HIV infection among transgender women in two Chinese cities

Background

In an era when HIV transmission has been on the rise among men who have sex with men (MSM), transgender women may play a considerable role in China’s current HIV epidemic as a potential “bridge” of HIV transmission between homosexual and heterosexual populations. We sought to understand the risk behaviours and factors associated with HIV infection among transgender women in two cities in China.

Methods

From January to December 2016, we recruited transgender women with the help of community-based organizations (CBOs) through a wide range of methods, including snowball sampling. After recruitment, we asked participants to fill out a structured questionnaire including questions about socio-demographics, sexual behaviours, condom use, substance use and uptake of health care services. HIV infection status was determined by using two different rapid testing reagents.

Results

Among 498 subjects enrolled in this study, 233 were from Shanghai and 265 were from Tianjin. The median age was 30 years (range: 18–68; IQR: 24–33). Of them, 337 (67.7%) preferred feminine dress, 13 (2.6%) had undergone transsexual operation and 68 (13.7%) had used hormones for transition purposes. Nearly half (45.6%) reported having regular partners, and 351 (70.5%) had casual partners. Regarding condom use, 81.5% reported not always using condoms with stable partners, and 70.9% reported not using condoms with casual partners. Twenty-five (5.0%) had a history of buying sex and fifty-one (10.2%) had a history of selling sex in the past three months. A total of 200 (40.2%) participants had used at least one kind of controlled substance in the past six months. The most commonly used substances were amyl nitrates (rush popper) (99.5%) and 5-MeO-DiPT (20.0%). Among rush popper users, 170 (85.4%) reported always having sex while on the drug, and 177 (88.9%) reported increased sexual pleasure after using the drug. The HIV infection risk factors identified in our study were being located in Shanghai (aOR = 9.35, 95% CI = 3.89–22.49), selling sex in the past three months (aOR = 3.44, 95% CI = 1.31–9.01), and substance use in the past six months (aOR = 5.71, 95% CI = 2.63–12.41).

Conclusions

Transgender women bear a high HIV burden in the two Chinese cities. Those involved in commercial sex tended to have inconsistent condom use, leading to high risk of HIV infection. Substance use was an independent risk factor of HIV infection by increasing sexual activities and unprotected sex, which indicated an aggravated and complex situation with possible interacting syndemic factors that could cumulatively facilitate sexual risk behaviours and HIV infection in transgender women. There is an urgent need for innovative and appropriate HIV prevention programmes targeting this unique population. Efforts should be made to provide them with tailored services including persuasive communication on consistent condom use, substance use counselling and related referral services, all with the goal of reducing HIV epidemic among transgender women.

Electronic supplementary material

The online version of this article (10.1186/s40249-018-0508-2) contains supplementary material, which is available to authorized users.

Structural Inequities and Social Networks Impact Hormone Use and Misuse Among Transgender Women in Los Angeles County

In order to reduce gender dysphoria and combat stigma, transgender women often affirm their gender through social and medical transition, which may include cross-sex hormone therapy. This study examined associations between medically monitored hormone use and hormone misuse (non-prescribed hormone use including "fillers"), structural inequities (access to housing, health insurance, and income), and social network dynamics among 271 transgender women in Los Angeles. Hormone use status was coded trichotomously (hormone use, hormone misuse, no hormone use), and robust multinomial logistic regression as well as novel social network analysis was conducted to examine associations. Results demonstrated that younger, African-American/Black transgender women were most likely to engage in hormone misuse compared to transgender women who were older or non-African-American/Black. One-third of the sample reported sex work as a main source of income, and this group was more likely to misuse hormones than those with another primary source of income. Transgender women with access to stable housing and health insurance were most likely to engage in medically monitored hormone use. Social network analysis revealed that transgender women with a greater number of hormone-using network alters were most likely to misuse hormones, but that using the Internet to find transgender friends mitigated this association. Results demonstrate the multifaceted risk profile of transgender women who use and misuse hormones, including that social networks play an important role in hormone usage among transgender women.

Voices from the frontline: barriers and strategies to improve tuberculosis infection control in primary health care facilities in South Africa

Background

Tuberculosis (TB) infection control at primary healthcare (PHC) level remains problematic, especially in South Africa. Improvements are significantly dependent on healthcare workers’ (HCWs) behaviours, underwriting an urgent need for behaviour change. This study sought to 1) identify factors influencing TB infection control behaviour at PHC level within a high TB burden district and 2) in a participatory manner elicit recommendations from HCWs for improved TB infection control.

Method

A qualitative case study was employed. TB nurses and facility managers in the Mangaung Metropolitan District, South Africa, participated in five focus group and nominal group discussions. Data was thematically analysed.

Results

Utilising the Information Motivation and Behaviour (IMB) Model, major barriers to TB infection control information included poor training and conflicting policy guidelines. Low levels of motivation were observed among participants, linked to feelings of powerlessness, negative attitudes of HCWs, poor district health support, and general health system challenges. With a few exceptions, most behaviours necessary to achieve TB risk-reduction, were generally regarded as easy to accomplish.

Conclusions

Strategies for improved TB infection control included: training for comprehensive TB infection control for all HCWs; clarity on TB infection control policy guidelines; improved patient education and awareness of TB infection control measures; emphasis on the active role HCWs can play in infection control as change agents; improved social support; practical, hands-on training or role playing to improve behavioural skills; and the destigmatisation of TB/HIV among HCWs and patients.

Bibliometric analysis of peer-reviewed literature in transgender health (1900 - 2017)

BACKGROUND

Transgender community is marginalized and under-researched. Analysis of peer-reviewed literature in transgender health is needed to better understand health needs and human rights of transgender people. Therefore, the aim of this study was to analyze global research activity in transgender health published in peer-reviewed journals.

METHODS

Peer-reviewed documents in transgender health were retrieved using Scopus database. VOSviewer was used to map frequently encountered author keywords while ArcGIS 10.1 was used to map the geographical distribution of the retrieved documents. Most active countries, institutions, and authors were presented. The study period was set from 1900 to 2017.

RESULTS

In total, 5772 peer-reviewed documents were obtained. English (5008; 86.8%) was the most frequently encountered language. A dramatic increase in the number of publications was seen in the last decade. The retrieved documents had an average of 12.1 citations per document and h-index of 92. Most frequently encountered author keywords were Human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS), mental health, and discrimination. Authors from 80 different countries contributed to publishing the retrieved documents. Publications originated mainly from Northern America, certain European countries, Australia, and Brazil. Professor Gooren, L.J.G. was the most active author in this field with 104 (1.88%) publications. Top active authors were in the fields of endocrinology, plastic surgery, psychiatry/psychology, public health, and sexology. Five of the top ten active authors were from the USA, three were from the Netherlands, and two were from Belgium. The most active institution was the VU University Medical Center (Netherlands) (184; 3.2%) followed by the University of California, San Francisco (USA) (157; 2.7%). The International Journal of Transgenderism was most active (284; 4.9%) in publishing articles in transgender health. However, documents published in the American Journal of Public Health had the highest impact with 53.5 citations per article.

CONCLUSION

There was a noticeable growth of research in transgender health in the last decade. Researchers from different world regions need to get involved in health and human rights research of transgender community.

A comparison of HIV-risk behaviors between young black cisgender men who have sex with men and young black transgender women who have sex with men

This study compared sexually transmitted infection (STI)-associated risks between young Black cisgender men who have sex with men (YBMSM) and young Black transwomen who have sex with men (YBTWSM). Comparisons pertained to: (1) prevalence of infections; (2) sexual risk; (3) partner-related risks; and (4) socioeconomic marginalization. YBMSM (n = 577) and YBTWSM (n = 32) were recruited from an STI clinic in the USA. Volunteers completed a computer-assisted self-interview and medical records were abstracted for STI/HIV information. Significantly greater prevalence of pharyngeal Chlamydia ( P < .001) and pharyngeal gonorrhea ( P = .04) occurred among YBTWSM; however, both associations were moderated and only significant for HIV-uninfected volunteers. YBTWSM had more oral sex partners and more frequent engagement in oral sex. The number of new sex partners for anal receptive sex was greater in YBTWSM. YBTWSM were more likely to exchange sex for money/drugs ( P < .001), have sex with men recently in prison ( P < .001), who were "anonymous" ( P = .004), or who were "one night stands" ( P < .001). YBTWSM were more likely to depend on sex partners for money food, etc. ( P < .001), to miss meals due to lack of money ( P = .01), and to report having ever being incarcerated ( P = .009). Compared to cisgender YBMSM, YBTWSM experience multiple risk factors relative to the acquisition/transmission of STIs and HIV.

Victimization and Human Immunodeficiency Virus-Related Risk Among Transgender Women in India: A Latent Profile Analysis

Globally, transgender women (TGW) experience multiple forms of victimization such as violence and discrimination that can place them at risk for poor sexual health. To date, research overlooks the heterogeneity in experiences of victimization among TGW. Furthermore, few studies have examined the association between victimization and sexual risk among TGW in India, despite the high burden of HIV and victimization in this community. Latent profile analysis was performed to identify patterns of victimization in a convenience sample of 299 TGW recruited from nongovernmental organizations across four states in India. Analysis of covariance was performed to examine differences in sexual risk (i.e., alcohol use before sex; inconsistent condom use with a male regular partner, a male causal partner, and a male paying partner; and having multiple sexual partners) between latent profiles. Five distinct profiles of Indian TGW were identified based on the type and severity of victimization: (1) Low victimization, (2) High verbal police victimization, (3) High verbal and physical police victimization, (4) Moderate victimization, and (5) High victimization. While controlling for age, education, income, HIV status, and marital status, results revealed that TGW in the moderate victimization and high victimization profiles had higher sexual risk than TGW in the low victimization and high verbal police victimization profiles. In addition, TGW in high verbal and physical police victimization profile had higher sexual risk than TGW in low victimization profile. These findings underscore the importance of tailoring sexual risk reduction interventions to the specific needs of TGW based on patterns of victimization.

Perceived Barriers and Facilitators to Integrating HIV Prevention and Treatment with Cross-Sex Hormone Therapy for Transgender Women in Lima, Peru

Transgender women (TW) represent a vulnerable population at increased risk for HIV infection in Peru. A mixed-methods study with 48 TW and 19 healthcare professionals was conducted between January and February 2015 to explore barriers and facilitators to implementing a model of care that integrates HIV services with gender-affirmative medical care (i.e., hormone therapy) in Lima, Peru. Perceived acceptability of the integrated care model was high among TW and healthcare professionals alike. Barriers included stigma, lack of provider training or Peruvian guidelines regarding optimal TW care, and service delivery obstacles (e.g., legal documents, spatial placement of clinics, hours of operation). The hiring of TW staff was identified as a key facilitator for engagement in health care. Working in partnership with local TW and healthcare provider organizations is critical to overcoming existing barriers to successful implementation of an integrated HIV services and gender-affirmative medical care model for this key population in Peru.

Behavioral Interventions to Prevent HIV Transmission and Acquisition for Transgender Women: A Critical Review

Worldwide, transgender women are at disproportionately higher risk of HIV infection, with the primary mode of infection being condomless anal intercourse. Although very few HIV prevention interventions have been developed and tested specifically for transgender women, growing evidence suggests that behavioral HIV risk reduction interventions for other marginalized groups are efficacious. We outline the current state of knowledge and areas in need of further development in this area.

Integrated and Gender-Affirming Transgender Clinical Care and Research

Transgender (trans) communities worldwide, particularly those on the trans feminine spectrum, are disproportionately burdened by HIV infection and at risk for HIV acquisition/transmission. Trans individuals represent an underserved, highly stigmatized, and under-resourced population not only in HIV prevention efforts but also in delivery of general primary medical and clinical care that is gender affirming. We offer a model of gender-affirmative integrated clinical care and community research to address and intervene on disparities in HIV infection for transgender people. We define trans terminology, briefly review the social epidemiology of HIV infection among trans individuals, highlight gender affirmation as a key social determinant of health, describe exemplar models of gender-affirmative clinical care in Boston MA, New York, NY, and San Francisco, CA, and offer suggested “best practices” for how to integrate clinical care and research for the field of HIV prevention. Holistic and culturally responsive HIV prevention interventions must be grounded in the lived realities the trans community faces to reduce disparities in HIV infection. HIV prevention interventions will be most effective if they use a structural approach and integrate primary concerns of transgender people (eg, gender-affirmative care and management of gender transition) alongside delivery of HIV-related services (eg, biobehavioral prevention, HIV testing, linkage to care, and treatment).

Health Care Use and HIV-Related Behaviors of Black and Latina Transgender Women in 3 US Metropolitan Areas: Results From the Transgender HIV Behavioral Survey

PURPOSE

HIV prevalence estimates among transgender women in the United States are high, particularly among racial/ethnic minorities. Despite increased HIV risk and evidence of racial disparities in HIV prevalence among transgender women, few data are available to inform HIV prevention efforts.

METHODS

A transgender HIV-related behavioral survey conducted in 2009 in 3 US metropolitan areas (Chicago, Houston, and Los Angeles County), used respondent-driven sampling to recruit 227 black (n = 139) and Latina (n = 88) transgender women. We present descriptive statistics on sociodemographic, health care, and HIV-risk behaviors.

RESULTS

Of 227 transgender women enrolled, most were economically and socially disadvantaged: 73% had an annual income of less than $15,000; 62% lacked health insurance; 61% were unemployed; and 46% reported being homeless in the past 12 months. Most (80%) had visited a health care provider and over half (58%) had tested for HIV in the past 12 months. Twenty-nine percent of those who reported having an HIV test in the past 24 months self-reported being HIV positive. Most of the sample reported hormone use (67%) in the past 12 months and most hormone use was under clinical supervision (70%). Forty-nine percent reported condomless anal sex in the past 12 months and 16% reported ever injecting drugs.

CONCLUSION

These findings reveal the socioeconomic challenges and behavioral risks often associated with high HIV risk reported by black and Latina transgender women. Despite low health insurance coverage, the results suggest opportunities to engage transgender women in HIV prevention and care given their high reported frequency of accessing health care providers.

Access to Medical and Mental Health Services Across the HIV Care Continuum Among Young Transgender Women: A Qualitative Study

Purpose: (1) To describe psychosocial, medical, and mental health outcomes of young transgender women (YTW) living with or at risk for HIV infection and (2) to explore barriers and facilitators to medical and mental health services across the HIV care continuum.

Methods: We conducted a cross-sectional observational study of YTW aged 16–24 years who were at risk for contracting or living with HIV. Participants were recruited from an adolescent HIV clinic and local community-based organizations that serve YTW. The single study visit included: a computer-assisted self-interview of demographics, medical and mental health measures, a qualitative semi-structured interview, optional rapid HIV testing for HIV-negative/status-unknown participants, and a chart review to determine rates of antiretroviral therapy (ART) prescription and viral suppression among HIV+ participants. Descriptive statistics were used for quantitative data, and a modified-grounded theory approach was used for qualitative analysis.

Results: Participants (n=25) had a mean age of 21.2 years; the majority were non-white (76%), had less than a college education (76%), were unemployed (52%), and had an income <$12,000/year (80%). More than one-third were unstably housed (36%) and uninsured (36%), and 28% reported having transactional sex. A majority had taken gender-affirming hormones (72%), but 17% obtained them from a source other than their doctor. Among HIV+ participants (n=8), 50% were prescribed ART and all four participants achieved viral suppression. Qualitative themes included lack of respect for or misunderstanding of gender identity, mismatch of mental health needs with available provider skills, challenges in finding HIV prevention services during adolescence or when transitioning to adult care, and importance of workforce diversity, including representation of transgender women in care teams.

Conclusion: This study identified significant unmet mental health needs and several barriers and facilitators to engaging in healthcare for YTW across the HIV care continuum. Our data suggest an urgent need for provider competency training in gender-affirming care and integration of appropriate mental health and gender-affirming treatment with HIV prevention and treatment services for this population.