Detectable viral load associated with unmet mental health and substance use needs among trans women living with HIV in San Francisco, California.

BACKGROUND: Substance use and mental distress are known barriers to HIV care engagement among trans women. Less is known about access and utilization of mental health and substance use care among trans women and the relationship between unmet behavioral health needs and HIV viral suppression. We examined the relationship between mental health and substance use on HIV viral load among trans women living with HIV. We also examined the relationship between mental health and substance use services needs with HIV care engagement and having a detectable viral load by comparing engagement in care cascades. METHODS: Data are from a 2022 baseline assessment for an intervention with trans women living with HIV (n = 42) in San Francisco. Chi-Squared or Fisher's exact tests were conducted to determine associations between HIV viral load, mental health, and substance use. We also examine characteristics associated with each step in the HIV, mental health, and substance use care cascades. RESULTS: Most participants were trans women of color (85.7%), 40 years of age or older (80.9%), with low income (88.1%), and almost half were unstably housed (47.6%). Of the 32 participants who screened positive for depression, anxiety and/or psychological distress, 56.3% were referred for mental health services in the past 12 months. Of those who were referred, 44.4% received mental health services. Of the 26 participants who screened positive for a substance use disorder, 34.6% were referred to substance use services in the past 12 months. Of those referred, 33.3% received substance use services in the past 3 months. Latina trans women had a low referral rate to meet their mental health needs (50%) and only 16.7% of African American/Black trans women who screened positive for a substance use disorder were referred for services, while trans women of other race/ethnicities had high referral and services utilization. No significant results were found between HIV viral load and screening positive for a mental health disorder. Methamphetamine use was statistically associated with having a detectable HIV viral load (p = 0.049). CONCLUSIONS: We identified significant unmet mental health and substance use services needs and noted racial/ethnic disparities in the context of high HIV care engagement among trans women living with HIV. We also found that methamphetamine use was a barrier to having an undetectable viral load for trans women living with HIV. To finally end the HIV epidemic, integration of behavioral health screening, linkage, and support are needed in HIV care services for populations most impacted by HIV, especially trans women. TRIAL REGISTRATION: NCT, NCT 21-34,978. Registered January 19, 2022.

"Lost trust in the system": system barriers to publicly available mental health and substance use services for transgender women in San Francisco.

BACKGROUND: Little is known about the barriers to mental health and substance use services for trans women living with HIV. We conducted a qualitative study with trans women living with HIV and providers to explore barriers to mental health and substance use services in San Francisco. METHODS: We conducted focus group discussions and key informant interviews with a total of 15 medical, mental health, substance use, and social service providers and trans women living with HIV. We identified, analyzed, and reported themes using thematic analysis and derived themes directly from the data. RESULTS: Our study participants identified two main themes and three subthemes. One main theme is that trans women and providers have lost trust in the system due to (a) lack of a linkage system between referrals and services, (b) structural barriers such as service location, language capacity, clinic hours, and (c) constant changes in services available. Another main theme is anti-trans and mental health stigma. CONCLUSIONS: Interventions to coordinate linkage from medical to mental health and substance use (MHSU) services are urgently needed to facilitate the utilization of MHSU services. Other interventions to improve quality monitoring and system improvement, and to address multiple stigmas broadly in society are needed to improve unmet MHSU service needs among trans women living with HIV in San Francisco.