Drivers of Active Amphetamine-Type Stimulant Use among Transgender Women in Malaysia: A Cross-Sectional Study

While ample evidence exists regarding the use of active amphetamine-type stimulants (ATS) among sex workers, the impact of ATS use has yet to be characterized among the transgender population in Malaysia. Our aim is to highlight and assess health-related factors associated with ATS use among transgender women in Malaysia. A total of 361 transgender women completed a cross-sectional survey regarding their attitude towards PrEP knowledge and use for HIV prevention. The original study explored a myriad of health-related topics including active ATS use. Data was analyzed using logistic regression analyses to determine factors associated with active ATS use. Most of the participants were between 25-40 years old (57.3%), ethnically identified as Malay (75%), and single (67.6%). We found that 10.2% of the participants were actively using ATS. On a multivariate level, hormone therapy use was associated with reduced odds of active ATS use (aOR = 0.364; 95% CI = 0.169, 0.784) and was positively associated with a history of drug related arrest (aOR = 4.604; 95%CI = 1.813, 11.691). Our findings show a high prevalence of active ATS use among transgender women in Malaysia, in addition to its correlation to other health-related factors. Interestingly, we found that trans women who were actively using hormone therapy, were less likely to engage in active ATS use. This relationship should be explored further along with the relationship between incarceration history. In addition, further prevention strategies and efforts are needed to decrease ATS use among transgender women in Malaysia.

Mapping Community-Engaged Implementation Strategies with Transgender Scientists, Stakeholders, and Trans-Led Community Organizations

PURPOSE OF REVIEW

Pre-exposure prophylaxis (PrEP) represents one of the most effective methods of prevention for HIV, but remains inequitable, leaving many transgender and nonbinary (trans) individuals unable to benefit from this resource. Deploying community-engaged PrEP implementation strategies for trans populations will be crucial for ending the HIV epidemic.

RECENT FINDINGS

While most PrEP studies have progressed in addressing pertinent research questions about gender-affirming care and PrEP at the biomedical and clinical levels, research on how to best implement gender-affirming PrEP systems at the social, community, and structural levels remains outstanding. The science of community-engaged implementation to build gender-affirming PrEP systems must be more fully developed. Most published PrEP studies with trans people report on outcomes rather than processes, leaving out important lessons learned about how to design, integrate, and implement PrEP in tandem with gender-affirming care. The expertise of trans scientists, stakeholders, and trans-led community organizations is essential to building gender-affirming PrEP systems.

Gender affirming hormone therapy dosing behaviors among transgender and nonbinary adults

Gender-affirming hormones have been shown to improve psychological functioning and quality of life among transgender and nonbinary (trans) people, yet, scant research exists regarding whether and why individuals take more or less hormones than prescribed. Drawing on survey data from 379 trans people who were prescribed hormones, we utilized multivariable logistic regression models to identify factors associated with hormone-dosing behaviors and content analysis to examine the reasons for dose modifications. Overall, 24% of trans individuals took more hormones than prescribed and 57% took less. Taking more hormones than prescribed was significantly associated with having the same provider for primary and gender-affirming care and gender-based discrimination. Income and insurance coverage barriers were significantly associated with taking less hormones than prescribed. Differences by gender identity were also observed. Addressing barriers to hormone access and cost could help to ensure safe hormone-dosing behaviors and the achievement trans people's gender-affirmation goals.

Experiences of violence and discrimination among LGBTQ+ individuals during the COVID-19 pandemic: a global cross-sectional analysis

Objectives

To characterise the extent to which the levels of violence and discrimination against lesbian, gay, bisexual, transgender and queer (LGBTQ+) people have changed amid COVID-19.

Design

Cross-sectional, secondary analysis.

Setting

79 countries.

Participants

All adults (aged ≥18 years) who used the Hornet social networking application and provided consent to participate.

Main outcome measure

The main outcome was whether individuals have experienced less, or the same or more levels of discrimination and violence from specific groups (eg, police and/or military, government representatives, healthcare providers).

Results

7758 LGBTQ+ individuals provided responses regarding levels of discrimination and violence. A majority identified as gay (78.95%) and cisgender (94.8%). Identifying as gay or queer was associated with increased odds of experiencing the same or more discrimination from government representatives (OR=1.89, 95% CI 1.04 to 3.45, p=0.045) and healthcare providers (OR=2.51, 95% CI 0.86 to 7.36, p=0.002) due to COVID-19. Being a member of an ethnic minority was associated with increased odds of discrimination and violence from police and/or military (OR=1.32, 95% CI 1.13 to 1.54, p=0.0) and government representatives (OR=1.47, 95% CI 1.29 to 1.69, p=0.0) since COVID-19. Having a disability was significantly associated with increased odds of violence and discrimination from police and/or military (OR=1.38, 95% CI 1.15 to 1.71, p=0.0) and healthcare providers (OR=1.35, 95% CI 1.07 to 1.71, p=0.009).

Conclusions

Our results suggest that despite the upending nature of the COVID-19 pandemic, around the world, government representatives, policymakers and healthcare providers continue to perpetuate systemic discrimination and fail to prevent violence against members of the LGBTQ+ community.

Gender-Inclusive and Gender-Specific Approaches in Trans Health Research

The recent proliferation of trans health literature for the past 20 years has prompted a need to examine two contested approaches used in designing study protocols and analyses in trans health research, as either specific to only one gender group (gender-specific approach) or across gender groups (i.e., gender-inclusive approach). In this critique, we aim to explicate and provide guidance for when the application of each approach is methodologically appropriate.

Characterizing Awareness of Pre-Exposure Prophylaxis for HIV Prevention in Manila and Cebu, Philippines: Web-Based Survey of Filipino Cisgender Men Who Have Sex With Men

Background

The Philippines is experiencing an HIV crisis and is considering implementing pre-exposure prophylaxis (PrEP) as a national public health strategy for HIV prevention for cisgender men who have sex with men (cis-MSM). However, critical information on the awareness of PrEP among cis-MSM is needed to roll out this public health initiative.

Objective

This study aims to assess PrEP awareness and related correlates (ie, sociodemographic variables, social factors, and health care access and use) among Filipino cis-MSM.

Methods

We conducted a web-based survey with Filipino cis-MSM (n=179) residing in the cities of Manila and Cebu, Philippines. Multivariable analysis procedures were performed to examine the factors associated with PrEP awareness.

Results

Our sample demonstrated high awareness (134/179, 74.9%) and interest (159/179, 88.8%) in taking PrEP. The adjusted model showed that greater odds of PrEP awareness were associated with having a college education or higher versus a high school education or lower (adjusted odds ratio [aOR] 7.30, 95% CI 1.01-52.47), earning between PHP 10,000 (US $198.6) and PHP 20,000 (US $397.2) versus <PHP 10,000 (US $198.60; aOR 9.32, 95% CI 1.41-6.22), having had a prior HIV test (aOR 6.06, 95% CI 1.20-13.55), having high HIV knowledge (aOR 3.50, 95% CI 1.11-10.98), and having friends who discussed PrEP (aOR 11.17, 95% CI 2.73-14.5).

Conclusions

Our findings demonstrate that Filipino cis-MSM are aware of and interested in taking PrEP, but there is currently an unmet need for such biomedical HIV prevention technologies among this population. Incorporating PrEP education into routine HIV screening and leveraging cis-MSM social networks may be useful in optimizing potential PrEP implementation in the Philippines.

Utilization and Costs of Gender-Affirming Care in a Commercially Insured Transgender Population

Many transgender people need specific medical services to affirm their gender. Gender-affirming health care services may include mental health support, hormone therapy, and reconstructive surgeries. Scant information is available about the utilization or costs of these services among transgender people, which hinders the ability of insurance regulators, health plans, and other health care organizations to plan and budget for the health care needs of this population and to ensure that transgender people can access medically necessary gender-affirming care. This study used almost three decades of commercial insurance claims from a proprietary database containing data on more than 200 million people to identify temporal trends in the provision of gender-affirming hormone therapy and surgeries and to quantify the costs of these services.

Transgender Individuals and Digital Health

PURPOSE OF REVIEW

The goal of this review is to assess the use of digital technologies to promote the health and well-being of transgender and gender diverse (TGD) people.

RECENT FINDINGS

TGD individuals experience numerous health disparities, including low uptake of HIV prevention strategies, such as pre-exposure prophylaxis, increased HIV incidence, and suboptimal HIV-related outcomes. These health disparities are the result of widespread intersectional stigma on the basis of gender identity, gender expression, socioeconomic class, race, and ethnicity, which negatively impact access to general medical and transgender-specific health care. TGD individuals often delay or avoid essential medical services due to fear of discrimination. Clinicians frequently lack training, competence, and skills in transgender medicine, further exacerbating the health disparities faced by TGD people. Digital technologies have been used to improve research and clinical care for TGD populations through various modalities; telemedicine, telehealth and mHealth. Digital health technologies, including HIT-enabled clinical decision support, telehealth, telemedicine, and mHealth, offer innovative ways to improve health care access, improve quality of care, and reduce health disparities for TGD populations, including and beyond HIV outcomes, through enhanced care delivery, clinician education, and enhancing social support networks.

Responsive Medical Providers and Recent HIV Medical Services Engagement Among Transgender Women and Cisgender Men Who Have Sex With Men in the Philippines

Transgender women and cisgender men who have sex with men (trans-WSM and cis-MSM) comprise the majority of new HIV infections in the Philippines. There is limited research in the Philippines on the relationship between having a provider responsive to the needs of these populations and recent engagement in HIV medical services such as HIV testing and treatment. We used multivariate logistic regression to examine the relationship between having a responsive medical provider and engagement in HIV medical services in the past 12 months among an online sample of 318 trans-WSM and cis-MSM in the Philippines. Participants without a responsive medical provider had lower adjusted odds of recent HIV medical service engagement than those who did (aOR = 0.32, 95% CI [0.16, 0.62], p = .00). In stratified analyses, this relationship was significant for trans-WSM but not cis-MSM. Increasing access to responsive providers in the Philippines could bolster recent engagement with HIV medical services.

Assessing inclusion of trans people in HIV national strategic plans: a review of 60 high HIV prevalence countries

INTRODUCTION

Trans people are disproportionately impacted by HIV yet have not been adequately prioritized in national HIV responses or policy documents. This review aims to understand the extent of meaningful inclusion of trans people in national strategic plans (NSPs) for HIV/AIDS as an essential step in ensuring that HIV policy aligns with epidemiologic data, and trans-specific programming is funded, implemented and sustained.

METHODS

HIV NSPs from 60 countries, across five global regions, were assessed for the level of inclusion of trans populations between January and March 2021. The most recently available NSP for each country, published after 2011, was obtained through publicly accessible online sources or through researcher networks. Data were manually extracted from NSPs using a framework of indicators focusing on trans inclusion in these five major sections of NSPs: (1) narratives; (2) epidemiological data; (3) monitoring and evaluation (M&E) indicators and targets; (4) activities; and (5) budgets.

RESULTS AND DISCUSSION

Within all reviewed NSPs, 65.0% (39/60) mentioned trans people in at least one of the five key sections but only 8.3% (5/60) included trans people in all five key sections. Trans people were more commonly mentioned in the background/narratives of NSPs (61.7%, 37/60) but less commonly included NSP activities (38.3%, 23/60), in M&E indicators and targets (23.7%, 14/60), in epidemiological data (20.0% 12/60), and in NSP budgets (13.3%, 8/60). Countries in the Asia and Pacific region most frequently included trans people in all five key sections (38%, 5/13), while no countries in Eastern and Southern Africa included trans people in all NSP sections.

CONCLUSIONS

This analysis finds substantial gaps in the inclusion of trans populations in NSPs globally. Results highlight the pressing need for states, technical partners, and international funders to engage with trans communities to improve trans-inclusion in all key sections of NSPs. Trans inclusion in NSPs is an essential step towards reaching the populations most at risk of HIV and ultimately achieving country-level epidemic control.

Exploring Multiple Forms of Intimate Partner Violence in a Gender and Racially/Ethnically Diverse Sample of Transgender Adults

Intimate partner violence (IPV) is highly prevalent in transgender (trans) populations in the United States; however, details about its manifestations and correlates have not been well captured. Using data from the 2015 U.S. Transgender Survey, we analyzed weighted data from 23,999 adult transgender participants to estimate the prevalence and explore correlates of five IPV subtypes: psychological IPV, physical IPV, trans-related IPV, stalking, and forced sex committed by an intimate partner. Regression models examined race/ethnicity, gender identity, past-year incarceration, past-year sex work, and lifetime homelessness, and adjusted for annual household income, highest level of education, age, birthplace, Census region, and relationship status. The sample was racially/ethnically diverse (62.6% White, 0.7% Alaskan Native/American Indian, 4.7% Asian/Native Hawaiian/Pacific Islander, 12.7% Black/African American, 16.5% Latinx/Hispanic, 0.4% Middle Eastern/North African, 2.5% Multiracial/Not Listed), and comprised of 31.2% transgender men, 34.2% transgender women, 27.5% assigned-female-at-birth nonbinary participants, and 7.1% assigned-male-at-birth nonbinary participants. Rates of IPV were high, with variability by IPV subtype: 42.0% endorsed psychological IPV, 39.9% endorsed physical IPV, 30.4% endorsed trans-related IPV, 18.0% endorsed stalking, and 21.5% endorsed forced sex by an intimate partner. We observed disparities in IPV subtypes by race/ethnicity, gender identity, and experiences of social marginalization. Results highlight the need for targeted, trans-inclusive IPV screening practices and interventions. Future studies should examine the syndemic effects of IPV, social marginalization, and health outcomes related to HIV, substance use, and mental health in trans populations.

Prevalence and associations of COVID-19 testing in an online sample of transgender and non-binary individuals

BACKGROUND

Testing for COVID-19 and linkage to services is fundamental to successful containment and control of transmission. Yet, knowledge on COVID-19 testing among transgender and non-binary communities remains limited.

METHODS

Between October 2020 and November 2020, we examined the prevalence and associations of COVID-19 testing in an online sample of transgender and non-binary people (n=536). Multivariable hierarchical logistic regression analyses examined associations between COVID-19 testing and participants' sociodemographic, mental health, substance use, gender affirmation, economic changes and healthcare experiences.

RESULTS

Prevalence of COVID-19 testing in this sample was 35.5% (n=190/536). In the final model, transgender and non-binary participants from upper socioeconomic income background and Europe, who reported having active alcohol use disorder, limited access to gender-affirming surgery, had more than 20% reduction in income, and experienced mistreatment in a health facility due to gender identity had significantly increased odds of COVID-19 testing (all p<0.05); those who reported recent tobacco use had significantly lower odds of COVID-19 testing (p=0.007).

CONCLUSIONS

These findings highlight structural disparities in COVID-19 testing and reinforce the importance of increasing testing strategies for transgender and non-binary populations.

HIV Prevention Among Cisgender Men Who have Sex with Transgender Women

Cisgender men who have sex with transgender women face elevated risk for HIV, yet are understudied in prevention research. We conducted in-depth interviews with 19 men who have sex with transgender women in Baltimore, Maryland and Atlanta, Georgia to explore perspectives on HIV prevention. Participants used several strategies to reduce HIV risk: condoms, frequent HIV testing, communication about HIV status with partners, and limiting the types of sex acts performed. While condom use was inconsistent, it was preferred over pre-exposure prophylaxis, in part due to medical distrust. HIV self-testing was generally viewed unfavorably. Although most participants were referred to the study by their transgender women partners, they recommended reaching other men who have sex with transgender women in bars, nightclubs, online, and through social media. HIV prevention interventions should be inclusive of the needs and experiences of men who have sex with transgender women.

Gender-affirming care, mental health, and economic stability in the time of COVID-19: A multi-national, cross-sectional study of transgender and nonbinary people

BACKGROUND

Transgender and nonbinary people are disproportionately affected by structural barriers to quality healthcare, mental health challenges, and economic hardship. This study examined the impact of the novel coronavirus disease (COVID-19) crisis and subsequent control measures on gender-affirming care, mental health, and economic stability among transgender and nonbinary people in multiple countries.

METHODS

We collected multi-national, cross-sectional data from 964 transgender and nonbinary adult users of the Hornet and Her apps from April to August 2020 to characterize changes in gender-affirming care, mental health, and economic stability as a result of COVID-19. We conducted Poisson regression models to assess if access to gender-affirming care and ability to live according to one's gender were related to depressive symptoms, anxiety, and changes in suicidal ideation.

RESULTS

Individuals resided in 76 countries, including Turkey (27.4%, n = 264) and Thailand (20.6%, n = 205). A majority were nonbinary (66.8%, n = 644) or transfeminine (29.4%, n = 283). Due to COVID-19, 55.0% (n = 320/582) reported reduced access to gender-affirming resources, and 38.0% (n = 327/860) reported reduced time lived according to their gender. About half screened positive for depression (50.4%,442/877) and anxiety (45.8%, n = 392/856). One in six (17.0%, n = 112/659) expected losses of health insurance, and 77.0% (n = 724/940) expected income reductions. The prevalence of depressive symptoms, anxiety, and increased suicidal ideation were 1.63 (95% CI: 1.36-1.97), 1.61 (95% CI: 1.31-1.97), and 1.74 (95% CI: 1.07-2.82) times higher for individuals whose access to gender-affirming resources was reduced versus not.

DISCUSSION

The COVID-19 crisis is associated with reduced access to gender-affirming resources and the ability of transgender and nonbinary people to live according to their gender worldwide. These reductions may drive the increased depressive symptoms, anxiety, and suicidal ideation reported in this sample. To improve health of transgender and nonbinary communities, increased access to gender-affirming resources should be prioritized through policies (e.g., digital prescriptions), flexible interventions (e.g., telehealth), and support for existing transgender health initiatives.

Overview of the epidemiological conditions of HIV among key populations in Africa

INTRODUCTION

Despite extraordinary progress in HIV treatment coverage and expanding access to HIV prevention services and that multiple African countries are on track in their efforts to reach 90-90-90 goals, the epidemic continues to persist, with prevalence and incidence rates too high in some parts of the continent to achieve epidemic control. While data sources are improving, and research studies on key populations in specific contexts have improved, work on understanding the HIV burdens and barriers to services for these populations remains sparse, uneven and absent altogether in multiple settings. More data have become available in the last several years, and data published in 2010 or more recently are reviewed here for each key population. This scoping review assesses the current epidemiology of HIV among key populations in Africa and the social and political environments that contribute to the epidemic, both of which suggest that without significant policy reform, these epidemics will likely continue.

RESULTS AND DISCUSSION

Across Africa, the HIV epidemic is most severe among key populations including women and men who sell or trade sex, men who have sex with men, people who inject drugs, transgender women who have sex with men and prisoners and detainees. These groups account for the majority of new infections in West and Central Africa, and an estimated 25% of new infections in East and Southern Africa, despite representing relatively small proportions of those populations. The HIV literature in Africa emphasizes that despite significant health needs, key populations experience barriers to accessing services within the healthcare and legal justice systems. Current shortcomings of surveillance systems in enumerating key populations impact the way funding mechanisms and resources are allocated and distributed. Adapting more equitable and epidemiologically sound frameworks will be necessary for current and future HIV programming investments.

CONCLUSIONS

Through this review, the available literature on HIV epidemiology among key populations in Africa brings to light a number of surveillance, programmatic and research gaps. For many communities, interventions targeting the health and security conditions continue to be minimal. Compelling evidence suggests that sweeping policy and programmatic changes are needed to effectively tackle the persistent HIV epidemic in Africa.

From imperialism to inpatient care: Work differences of Filipino and White registered nurses in the United States and implications for COVID-19 through an intersectional lens

In the United States, nursing is the largest healthcare profession, with over 3.2 million registered nurses (RNs) nationwide and comprised of mostly women. Foreign‐trained RNs make up 15 percent of the RN workforce. For over half a century, the U.S. healthcare industry has recruited these RNs in response to nurse shortages in hospitals and nursing homes. Philippines‐trained RNs make up 1 out of 20 RNs in this country and continue to be the largest group of foreign‐trained nurses today. Recently, the news media has publicized the many deaths of Filipino RNs as a result of the COVID‐19 pandemic in the United States. Given the imperial historical ties between these two countries in the context of the nursing profession and the enduring labor inequities that persist, this nationally representative study is one of the few to our knowledge to not only quantitatively examine the current work differences in characteristics and experiences of Philippines‐trained RNs and U.S.‐trained white RNs practicing in the United States today, but to also do so from an intersectionality lens. The overall aim of this paper is to illuminate how these differences may serve as potential factors contributing to the disproportionate number of Filipino nurses' COVID‐19 related vulnerability and deaths in the workplace.

Gender-affirming care, mental health, and economic stability in the time of COVID-19: a global cross-sectional study of transgender and non-binary people

BACKGROUND

Transgender and non-binary people are disproportionately burdened by barriers to quality healthcare, mental health challenges, and economic hardship. This study examined the impact of the novel coronavirus disease (COVID-19) pandemic and subsequent control measures on gender-affirming care, mental health, and economic stability among transgender and non-binary people globally.

METHODS

We collected global cross-sectional data from 964 transgender and non-binary adult users of the Hornet and Her apps from April to August 2020 to characterize changes in gender-affirming care, mental health, and economic stability as a result of the COVID-19 pandemic. We conducted Poisson regression models to assess if access to gender-affirming care and ability to live according to one's gender were related to depressive symptoms, anxiety, and changes in suicidal ideation.

RESULTS

Individuals resided in 76 countries, including Turkey (27.4%,n=264/964) and Thailand (20.6%,n=205). A majority were non-binary (66.8%,n=644) or transfeminine (29.4%,n=283). Due to the COVID-19 pandemic, 55.0% (n=320/582) reported reduced access to gender- affirming resources, and 38.0% (n=327/860) reported reduced time lived according to their gender. About half screened positive for depression (50.4%,442/877) and anxiety (45.8%,n=392/856). One in six (17.0%,n=112/659) expected losses of health insurance, and 77.0% (n=724/940) expected income reductions. The prevalence of depressive symptoms, anxiety, and increased suicidal ideation were 1.63 (95% CI: 1.36-1.97), 1.61 (95% CI: 1.31-1.97), and 1.74 (95% CI: 1.07-2.82) times higher for individuals whose access to gender- affirming resources was reduced versus not.

DISCUSSION

The COVID-19 pandemic has reduced access to gender-affirming resources and the ability of transgender and non-binary people to live according to their gender worldwide. These reductions may drive the increased depressive symptoms, anxiety, and suicidal ideation reported in this sample. To improve transgender and non-binary health globally, increased access to gender-affirming resources should be achieved through policies (e.g., digital prescriptions), flexible interventions (e.g., telehealth), and support for existing transgender health initiatives.

Poor sleep health is associated with increased mental health problems, substance use, and HIV sexual risk behavior in a large, multistate sample of gay, bisexual and other men who have sex with men (GBMSM) in Nigeria, Africa

BACKGROUND

Poor sleep health has been linked to mental health problems, substance use, and sexual risk-taking among gay, bisexual, and other men who have sex with men (GBMSM). No known published study has examined these relationships among African GBMSM. Consequently, we investigated poor sleep health and associated health-related factors among a large multistate sample of Nigerian GBMSM.

METHODS

Between March and June 2019, 406 GBMSM were recruited from Abuja, Delta, Lagos, and Plateau and asked to complete an interviewer-administered survey. Bivariate and multivariable logistic regression models were constructed to examine the relationship between poor sleep health and other health-related factors.

RESULTS

In the past month, 45.5% of participants reported sleeping an average of 6 hours or less every night, and 30.7% reported experiencing a sleep problem. Factors associated with increased odds of reporting short sleep included: residing in Delta [adjusted odds ratio (aOR) 2.16; 95% confidence interval (CI): 1.15 to 4.04] and Lagos (aOR 2.40; 95% CI: 1.29 to 4.45), depressive symptoms (aOR 1.94; 95% CI: 1.13 to 3.32), and reporting lifetime history of using four or more drugs (aOR 2.52; 95% CI: 1.06 to 6.01). Reporting condom use at last anal sex was associated with decreased odds of reporting short sleep in the last month (aOR 0.54; 95% CI: 0.31 to 0.92). Factors associated with increased odds of reporting sleep problems included: reporting an STI diagnosis in the last year (aOR 1.79; 95% CI: 1.05 to 3.05) and reporting monthly or higher polydrug use in the last 3 months (aOR 2.19; 95% CI: 1.14 to 4.24).

DISCUSSION

Sleep health interventions should be developed for Nigerian GBMSM, which may improve mental health and reduce substance use and sexual risk-taking.

Maternal Support Is Protective Against Suicidal Ideation Among a Diverse Cohort of Young Transgender Women

Purpose: We assessed if young transgender women (YTW) with parents who are supportive of their transgender identity had lower odds of having suicidal ideation compared with YTW with unsupportive parents. Methods: This study analyzed baseline findings from a diverse sample of 297 sexually active, YTW 16-29 years of age who were enrolled in Project LifeSkills, a randomized controlled HIV prevention intervention efficacy trial in Chicago and Boston, between 2012 and 2015. Bivariate and multivariable logistic regression were used to assess if parental support was associated with a decreased odds of suicidal ideation. Results: Nearly one-fifth (18.9%) of YTW reported suicidal ideation at baseline. In our adjusted multivariable model, YTW with supportive mothers had 0.37 (95% confidence interval = 0.15-0.90) times the odds of having suicidal ideation compared with YTW with unsupportive mothers. Conclusion: This study found that the odds of suicidal ideation were lower among YTW who had mothers who were supportive of their transgender identity. Our results suggest that parent-focused interventions to improve the relationships between YTW and their parents may lower the odds of YTW having suicidal ideation. Clinical Trial Registration Identifier: NCT01575938.

Fatalism in the context of COVID-19: Perceiving coronavirus as a death sentence predicts reluctance to perform recommended preventive behaviors

To manage the spread of coronavirus, health entities have urged the public to take preventive measures such as social distancing and handwashing. Yet, many appear reluctant to take these measures. Research is needed to understand factors underlying such reluctance, with the aim of developing targeted health interventions. We identify associating coronavirus with death as one such factor. 590 participants completed surveys in mid-March 2020, which included attitudes toward coronavirus, preventive behavioral intentions, and sociodemographic factors. Associating coronavirus with death negatively predicted intentions to perform preventive behaviors. Further, associating coronavirus with death was not evenly distributed throughout the sample and was related with a number of sociodemographic factors including age, race, and availability of sick leave. Following recommended preventive measures to slow the spread of coronavirus appears to relate to the degree to which people associate coronavirus with death. These findings can be used by public health researchers and practitioners to identify those for whom targeted health communication and interventions would be most beneficial, as well as to frame health messaging in ways that combat fatalism.

Using structural equation modelling to characterise multilevel socioecological predictors and mediators of condom use among transgender women and cisgender men who have sex with men in the Philippines

BACKGROUND

Risks for condomless sex among transgender women and cisgender men who have sex with men (trans-WSM and cis-MSM, respectively) in the Philippines, where HIV recently became a national public health crisis, are shaped and exacerbated by various risk factors across multiple levels.

METHODS

Between June 2018 and August 2019, we conducted a cross-sectional online study with 318 trans-WSM and cis-MSM respondents from Manila and Cebu cities. Structural equational modelling procedures were performed to determine direct, indirect and overall effects between condom use and latent variables across multiple socioecological levels: personal (ie, condom self-efficacy), social (ie, social capital), environmental (ie, barriers to condom and HIV services) and structural (ie, structural violence, antidiscrimination policies).

RESULTS

Adjusted for gender, age, location and income, our model showed that: (1) all latent variables at the structural and environmental levels were significantly positively associated with each other (all ps<0.05); (2) barriers to condom and HIV services were significantly negatively associated with social capital (p<0.001) as well as condom self-efficacy (p<0.001); and (3) there were significantly positive associations between social capital and condom self-efficacy (p<0.001), and between condom self-efficacy and condom use (p<0.001). Moreover, social capital and condom self-efficacy fully mediated and buffered the negative effects between environmental and structural barriers and condom use.

CONCLUSION

This is the first known study pointing to multiple relationships and pathways across multiple socioecological levels that can potentially be leveraged for future interventions aimed at improving condom use among Filipinx trans-WSM and cis-MSM. Such interventions should be multicomponent and build and/or strengthen social capital and condom self-efficacy, as well as intentionally target prominent structural and environmental barriers to condom use.

Legal gender marker and name change is associated with lower negative emotional response to gender-based mistreatment and improve mental health outcomes among trans populations

Background

In recent years, Massachusetts (MA) and Rhode Island (RI) joined a growing list of states allowing residents to easily change the gender marker and name on government-identification (ID) documents. This was an important change for transgender and gender diverse (trans) residents, who face frequent mistreatment and thus for whom legal gender affirmation is critical. Little is known about associations between legal gender affirmation and psychological outcomes.

Methods

We examined associations between legal gender affirmation (i.e., having changed gender marker/name on neither, one, or both a passport and state ID), upsetting responses to gender-based mistreatment, and mental health outcomes in a sample of trans MA and RI residents. Analyses controlled for gender identity, age, race/ethnicity, education, employment, income, and insurance status.

Findings

Legal gender affirmation was significantly associated with lower reports of depression, anxiety, somatization, global psychiatric distress, and upsetting responses to gender-based mistreatment.

Conclusions

These data provide corroborate recent studies suggesting having pursued legal gender affirmation may be protective. Findings bolster calls to increase structural support for trans individuals, including enactment of state policies easing legal gender affirmation.

An initial randomized controlled trial of behavioral activation for treatment of concurrent crystal methamphetamine dependence and sexual risk for HIV acquisition among men who have sex with men

Men who have sex with men (MSM) continue to be the largest risk group for HIV infections in the U.S., where crystal methamphetamine abuse heightens risk for HIV infection through greater engagement in condomless anal sex (CAS). Existing treatments lack attention to replacement activities or the role of depressed mood. Behavioral activation (BA) is an evidence-based approach for depression that involves identifying and participating in pleasurable, goal-directed activities. We hypothesize, for MSM abusing crystal methamphetamine, re-learning how to engage in non-drug-using aspects of life would facilitate their ability to benefit from sexual risk reduction (SRR) counseling. Project IMPACT was a pilot randomized-controlled-trial. Forty-six MSM at sexual risk of acquiring HIV who met DSM-IV criteria for crystal methamphetamine dependence were enrolled. Of those MSM, 41 were randomized: 21 were assigned to the intervention, two sessions of SRR, ten sessions of BA with SRR, and one session of relapse prevention; 20 participants were assigned to a control condition (two sessions of SRR). At the acute post-intervention visit, intervention participants reported an average of 3.2 CAS acts with men who were HIV-infected or whose status they did not know, compared to 4.5 among control participants (β = -0.36; 95% CI: -0.69, -0.02; p = 0.035). At the 6-month post-intervention visit, intervention participants reported 1.1 CAS acts with men who were HIV-infected or whose status they did not know compared to 2.8 among control participants (β = -0.95; 95% CI: -1.44, -0.46; p < 0.0001). Similarly, intervention participants reported 1.0 CAS acts under the influence of crystal methamphetamine with men who were HIV-infected or whose status they did not know compared to 2.5 among control participants (β = -0.87; 95% CI: -1.38, -0.36; p = 0.0005). Lastly, intervention participants reported more continuous days abstaining from crystal methamphetamine compared to control (50.1 vs. 39.0, respectively) (β = 0.25; 95% CI: 0.16, 0.34; p < 0.0001). Findings are encouraging, provide evidence of feasibility and acceptability, and demonstrate initial efficacy for reducing sexual risk for HIV and crystal methamphetamine use.

Developmental Milestones in Young Transgender Women in Two American Cities: Results from a Racially and Ethnically Diverse Sample

To understand developmental milestones among young transgender women (YTW), we mapped age estimates per milestone by race/ethnicity and cohort age using baseline data from Project Lifeskills (n=298). Compared with older and white participants, younger black, Latina, Asian, and other/mixed race transgender (trans) women reported earlier experiences of sexual debut, transfeminine identity disclosure to others, sexual debut as trans, transfeminine identity expression in public, and integration of hormone use. Findings call for increased research and utilization of gender-affirmative interventions among YTW, with incorporation of nuanced, intersecting roles of race/ethnicity and cohort age across milestones.

Relationship Dynamics in the Context of Binge Drinking and Polydrug Use Among Same-Sex Male Couples in Atlanta, Boston, and Chicago

An estimated one- to two-thirds of incident HIV infections among U.S. men who have sex with men (MSM) occur within the context of a primary relationship. The existing, yet limited, literature on sexual risk behavior among same-sex couples suggests that MSM with main partners are more often to report having lower perceived HIV risk, higher unrecognized HIV infection, and increased frequency of condomless anal intercourse with their primary partner. Furthermore, numerous studies document the strong relationship between polydrug use and binge drinking with HIV infection among MSM. However, more research is needed that identifies how individual- and relationship-level factors are related to polydrug use and binge drinking in the context of same-sex male relationships. We used baseline data collected as part of a prospective randomized controlled trial of 160 same-sex male couples (total N = 320 individuals). In 2015, recruitment commenced in three U.S. cities: Atlanta, GA, Boston, MA, and Chicago, IL. Participants completed a self-report assessment using an audio-computer-assisted self-interview system during their baseline enrollment visit. We collected information on participants' sociodemographic characteristics, drug and alcohol use, individual- and relationship-level variables of interest, as well as relationship quality. Multinomial logistic regression models were fit for three different categories of polydrug use and of binge drinking for which (1) both partners exhibited the behavior, (2) only the respondent exhibited the behavior, or (3) only the partner exhibited the behavior. Participants' age ranged from 18 to 69 (M = 35.9). The sample majority (77.5%) was White (248/320), with 12.2% Black (39/320) and 10.3% Multiracial (33/320); 68.4% had completed a college degree; and 9.6% were unemployed. A high proportion (62.2%) reported any drug use, including marijuana; 45% reported using drugs other than marijuana; and 18.1% reported polydrug use. Overall, 22.2% reported current binge drinking. Age discordance and being in a long-term relationship (6 or more years) were associated with a decreased odds of polydrug use among couples; being in an interracial dyad, recent history of arrest, living with HIV, and self-reported clinically significant depressive symptoms were associated with an increased odds of polydrug use. Additionally, being the older partner and reporting higher levels of internalized homophobia decreased odds for binge drinking, while recent history of arrest, living with HIV, and feeling more loved in their relationship were associated with an increased odds of binge drinking. Findings have implications for developing interventions to reduce substance use and promote health among same-sex male couples. Future research would benefit by using longitudinal study designs to understand the individual-, relationship-, and structural-level factors that potentiate polydrug use and binge drinking among same-sex male couples.

Unmet Health Care Needs Among Young Transgender Women at Risk for HIV Transmission and Acquisition in Two Urban U.S. Cities: The LifeSkills Study

Purpose: The physical health care needs of transgender women are not being adequately addressed in the United States. The current study adds to the literature on the state of health care among young transgender women (YTW) by describing the occurrence of unmet health needs among a sample of YTW and providing unique data on psychosocial and demographic factors associated with access to adequate care. Methods: Baseline data were analyzed from Project LifeSkills, an intervention study funded by the National Institutes of Health (NIH). YTW (N=300) between the ages of 16 and 29 were recruited from the Boston and Chicago metropolitan areas between 2012 and 2015. Data were collected on health care experiences, indicators of social marginalization, and sociodemographic information. The final analytic sample (N=273) was restricted to participants with complete data; participants that were removed did not significantly differ demographically from the final analytic sample retained. Bivariate logistic regression models examined the association between having unmet health care needs and sociodemographics, social marginalization, and health care utilization indicators. A final adjusted multivariable logistic regression model was constructed with independent variables that were statistically significant in bivariate models. Results: Overall, nearly a quarter (23%) of YTW indicated that they had unmet health care needs. In the final multivariable model adjusted for enrollment city, avoiding health care due to cost (adjusted odds ratio [aOR]=1.98, 95% confidence interval [CI]=1.05-3.76) and experiencing prior transgender-specific discrimination in a medical setting (aOR=4.54, 95% CI=2.30-8.95]) were associated with a greater odds of having unmet health care needs. Conclusion: YTW face significant barriers to accessing health care in the United States. Among this sample, prior experiences of discrimination and inability to afford health care increased YTW odds of having unmet health care needs. Efforts to improve the unmet health care needs among YTW should promote access to affordable, gender-affirming care.

Trends and emerging directions in HIV risk and prevention research in the Philippines: A systematic review of the literature

BACKGROUND

The Philippines is experiencing one of the fastest growing epidemics globally. Evidence-based public health policies are needed. To describe the public health literature on HIV risk groups and prevention approaches in the Philippines, we reviewed published empirical studies with HIV-related outcomes.

METHODS

Based on an a priori systematic review protocol, we searched PubMed, PsycINFO and CINAHL databases for quantitative studies conducted in the Philippines that reported on HIV risk groups factors and interventions to prevent HIV. The search included studies published as of April 2018.

RESULTS

We identified 755 records, screened 699 unique titles and abstracts, and conducted full text review of 122 full reports of which 51 articles met inclusion criteria. The majority were cross-sectional studies describing HIV and STI prevalence and risk factors in samples recruited from the Philippines. Four HIV prevention programs conducted in the Philippines were identified, all of which reported improvements on HIV knowledge, attitudes, and behaviors. Overall, female sex workers (FSWs) constituted the primary study population, and few studies reported data from men who have sex with men (MSM), people who inject drugs (PWIDs), and youth. No studies reported on transgender populations. Most studies were focused on examining condom use-related outcomes and STI history, few had biomarkers for HIV, and none addressed biomedical HIV prevention strategies.

CONCLUSION

This review identifies an agenda for future HIV research that is needed to address the growing and shifting nature of the HIV epidemic in the Philippines.

Burden of HIV among young transgender women: factors associated with HIV infection and HIV treatment engagement

Young transgender women (YTW) are disproportionately affected by HIV, however, little is known about the factors associated with HIV infection and treatment engagement. We examined correlates of HIV infection and the steps of the HIV treatment cascade, specifically, being aware of their HIV infection, linked to care, on ART, and adherent to ART. We analyzed the baseline data of Project LifeSkills, a randomized control trial of sexually active YTW recruited from Chicago, Illinois and Boston, Massachusetts. We conducted multivariable Poisson regressions to evaluate correlates of HIV infection and the steps of the HIV treatment cascade. Nearly a quarter (24.7%) of YTW were HIV-infected. Among HIV-infected YTW, 86.2% were aware of their HIV status, 72.3% were linked to care, 56.9% were on ART, and 46.2% were adherent to ART. Having avoided healthcare due to cost in the past 12 months and not having a primary care provider were associated with suboptimal engagement in HIV care. Our results suggest that improving linkage and retention in care by addressing financial barriers and improving access to primary care providers could significantly improve health outcomes of YTW as well as reduce forward transmission of HIV.

Intentional and Unintentional Condom Breakage and Slippage in the Sexual Interactions of Female and Male Sex Workers and Clients in Mombasa, Kenya

We examined why male condoms broke or slipped off during commercial sex and the actions taken in response among 75 female and male sex workers and male clients recruited from 18 bars/nightclubs in Mombasa, Kenya. Most participants (61/75, 81%) had experienced at least one breakage or slippage during commercial sex. Many breakages were attributed to the direct actions of clients. Breakages and slippages fell into two main groups: those that were intentionally caused by clients and unintentional ones caused by inebriation, forceful thrusting during sex and incorrect or non-lubricant use. Participant responses included: stopping sex and replacing the damaged condoms, doing nothing, getting tested for HIV, using post-exposure prophylaxis and washing. Some sex workers also employed strategies to prevent the occurrence of condom breakages. Innovative client-oriented HIV prevention and risk-reduction interventions are therefore urgently needed. Additionally, sex workers should be equipped with skills to recognize and manage breakages.

A minority stress--emotion regulation model of sexual compulsivity among highly sexually active gay and bisexual men

OBJECTIVE

Sexual compulsivity represents a significant public health concern among gay and bisexual men, given its co-occurrence with other mental health problems and HIV infection. The purpose of this study was to examine a model of sexual compulsivity based on minority stress theory and emotion regulation models of mental health among gay and bisexual men.

METHOD

Gay and bisexual men in New York City reporting at least nine past-90-day sexual partners (n = 374) completed measures of distal minority stressors (i.e., boyhood gender nonconformity and peer rejection, adulthood perceived discrimination), hypothesized proximal minority stress mediators (i.e., rejection sensitivity, internalized homonegativity), hypothesized universal mediators (i.e., emotion dysregulation, depression, and anxiety), and sexual compulsivity.

RESULTS

The hypothesized model fit the data well (RMSEA = 0.05, CFI = 0.98, TLI = 0.95, SRMR = 0.03). Distal minority stress processes (e.g., adulthood discrimination) were generally found to confer risk for both proximal minority stressors (e.g., internalized homonegativity) and emotion dysregulation. Proximal minority stressors and emotion dysregulation, in turn, generally predicted sexual compulsivity both directly and indirectly through anxiety and depression.

CONCLUSIONS

The final model suggests that gay-specific (e.g., internalized homonegativity) and universal (e.g., emotion dysregulation) processes represent potential treatment targets to attenuate the impact of minority stress on gay and bisexual men's sexual health. Tests of interventions that address these targets to treat sexual compulsivity among gay and bisexual men represent a promising future research endeavor.

Providers' perspectives on the best practices for HIV prevention for men who have sex with men in Berlin, Germany: lessons for policy and prevention

Using qualitative data via providers' perspectives, the goal of this study was to identify strengths and weaknesses in the current approaches being used to prevent onward transmission of HIV among men who have sex with men (MSM) in Berlin, Germany. In 2013, 18 participants from 10 organizations who provide direct outreach or services to MSM were interviewed (30-75 minutes). With regard to strategies and services that individuals believed contributed to the organization's success, we identified five themes: (1) Having staff and volunteers to "match" the target population, (2) Embracing homosexuality and gay identity, (3) Being invested in the cause, (4) Coordination of services to avoid overlap and duplication, and (5) Seeing eye-to-eye with the target population. Finally, with regard to areas in which organizations felt they could use improvement (i.e., continuing challenges), we identified three themes: (1) Insufficient funding and resources, (2) Insufficient services, and (3) HIV stigma, homophobia, and shifting attitudes about HIV. This study informs HIV prevention approaches in Berlin, Germany as well as other urban centers where MSM are disproportionally affected by the HIV epidemic.