A Peer-to-Peer Collaborative Learning Approach for the Implementation of Evidence-Informed Interventions to Improve HIV-Related Health Outcomes.

The nationwide scale-up of evidence-based and evidence-informed interventions has been widely recognized as a crucial step in ending the HIV epidemic. Although the successful delivery of interventions may involve intensive expert training, technical assistance (TA), and dedicated funding, most organizations attempt to replicate interventions without access to focused expert guidance. Thus, there is a grave need for initiatives that meaningfully address HIV health disparities while addressing these inherent limitations. Here, the Health Resources and Services Administration HIV/AIDS Bureau (HRSA HAB) initiative Using Evidence-Informed Interventions to Improve HIV Health Outcomes among People Living with HIV (E2i) piloted an alternative approach to implementation that de-emphasized expert training to naturalistically simulate the experience of future HIV service organizations with limited access to TA. The E2i approach combined the HAB-adapted Institute for Healthcare Improvement's Breakthrough Series Collaborative Learning Model with HRSA HAB's Implementation Science Framework, to create an innovative multi-tiered system of peer-to-peer learning that was piloted across 11 evidence-informed interventions at 25 Ryan White HIV/AIDS Program sites. Four key types of peer-to-peer learning exchanges (i.e., intervention, site, staff role, and organization specific) took place at biannual peer learning sessions, while quarterly intervention cohort calls and E2i monthly calls with site staff occurred during the action periods between learning sessions. Peer-to-peer learning fostered both experiential learning and community building and allowed site staff to formulate robust site-specific action plans for rapid cycle testing between learning sessions. Strategies that increase the effectiveness of interventions while decreasing TA could provide a blueprint for the rapid uptake and integration of HIV interventions nationwide.

Interventions for addressing trauma among people with HIV: a narrative review.

Traumatic experiences are disproportionately prevalent among people with HIV and adversely affect HIV-related health outcomes. As part of a national cooperative agreement funded by the Health Resources and Services Administration's HIV/AIDS Bureau, we searched the literature for interventions designed to address trauma among people with HIV in the U.S. Our search yielded 22 articles on 14 studies that fell into five intervention categories: expressive writing, prolonged exposure therapy, coping skills, cognitive-behavioral approaches integrated with other methods, and trauma-informed care. Thematic elements among the interventions included adaptating existing interventions for subpopulations with a high burden of trauma and HIV, such as transgender women and racial/ethnic minorities; addressing comorbid substance use disorders; and implementing organization-wide trauma-informed care approaches. Few studies measured the effect of the interventions on HIV-related health outcomes. To address the intersecting epidemics of HIV and trauma, it is critical to continue developing, piloting, and evaluating trauma interventions for people with HIV, with the goal of wide-scale replication of effective interventions in HIV settings.

A Blueprint for Planning and Implementing a Transgender Health Program.

Transgender and gender-diverse people face multiple barriers to accessing appropriate health care, including denial of service, harassment, and lack of clinician knowledge. This article presents a blueprint for planning and implementing a transgender health program within a primary care practice in order to enhance the capacity of the health care system to meet the medical and mental health needs of this underserved population. The steps described, with emphasis on elements specific to transgender care, include conducting a community needs assessment, gaining commitment from leadership and staff, choosing a service model and treatment protocols, defining staff roles, and creating a welcoming environment.

Transforming Primary Care for Lesbian, Gay, Bisexual, and Transgender People: A Collaborative Quality Improvement Initiative.

PURPOSE: Lesbian, gay, bisexual, and transgender (LGBT) people experience multiple disparities in access to care and health outcomes. We developed a quality improvement initiative, Transforming Primary Care for LGBT People, to enhance the capacity of federally qualified health centers (FQHCs) to provide culturally affirming care for this population. METHODS: The 1-year intervention blended the models of Practice Improvement Collaboratives and Project ECHO (Extension for Community Health Outcomes) to facilitate learning and translate knowledge into action. FQHC teams received coaching in creating LGBT-inclusive environments, collecting sexual orientation and gender identity (SOGI) data, taking risk-based sexual histories, and screening LGBT people for syphilis, chlamydia and gonorrhea, and HIV. We used a preintervention-postintervention evaluation design. RESULTS: We selected 10 FQHCs serving 441,387 patients in 123 clinical sites in 9 states. The intervention spread from 10 clinicians in 10 clinical sites to 431 clinicians in 79 clinical sites. FQHCs reported increases in culturally affirming practices, including collecting patient pronoun information (42.9% increase) and identifying LGBT patient liaisons (300.0% increase). Postintervention, among 9 FQHCs reporting SOGI data from electronic health records, SOGI documentation increased from 13.5% to 50.8% of patients (276.3% increase). Among 8 FQHCs reporting number of LGBT patients, screening of LGBT patients increased from 22.3% (95% CI, 4.9%-40.0%) to 34.6% (95% CI, 19.4%-48.6%) for syphilis (86.5% increase); from 25.3% (95% CI, 7.6%-43.1%) to 44.1% (95% CI, 30.2%-58.1%) for chlamydia and gonorrhea (109.0% increase); and from 14.8% (95% CI, 3.2%-26.5%) to 30.5% (95% CI, 26.7%-34.3%) for HIV (132.4% increase). CONCLUSIONS: FQHCs participating in this initiative reported improved capacity to provide culturally affirming care and targeted screening for LGBT patients.

Strategies to Mitigate Clinician Implicit Bias Against Sexual and Gender Minority Patients.

BACKGROUND: Implicit bias is an ingrained, unconscious cultural stereotype that can negatively affect a person's interactions with members of stigmatized groups, including sexual and gender minorities. Clinician implicit biases may negatively impact the quality of patient care. METHODS: This article uses 4 case scenarios to illustrate how implicit bias among psychiatrists and other clinicians can affect patient-clinician communication and diminish the quality of health care provided to sexual and gender minority people. We offer strategies for clinicians to recognize, challenge, and address implicit bias. DISCUSSION: Through continuing education, self-reflection, and practice, psychiatrists and other clinicians can improve communication and foster more affirming care experiences for their sexual and gender minority patients, with the goal of addressing and ultimately eliminating sexual and gender minority health disparities.

Required Sexual Orientation and Gender Identity Reporting by US Health Centers: First-Year Data.

Objectives. To assess the performance of US health centers during the first year of required sexual orientation and gender identity (SOGI) data reporting and to estimate the baseline proportion of lesbian, gay, bisexual, and transgender patients accessing health centers. Methods. We conducted a secondary analysis of SOGI data from 2016. These data were reported by 1367 US health centers caring for 25 860 296 patients in the United States and territories. Results. SOGI data were missing for 77.1% and 62.8% of patients, respectively. Among patients with data, 3.7% identified as lesbian, gay, bisexual, or something else; 0.4% identified as transgender male or female; 27.5% did not disclose their sexual orientation; and 9.3% did not disclose their gender identity. Conclusions. Although health centers had a high percentage of missing SOGI data in the first year of reporting, among those with data, the percentages of lesbian, gay, bisexual, and transgender people were similar to national estimates, and disclosure was more than 70%. Future data collection efforts would benefit from increased training for health centers and improved messaging on the clinical benefits of SOGI data collection and reporting.

Understanding and treating opioid use disorders in lesbian, gay, bisexual, transgender, and queer populations.

Although little is known about the specific burden of the opioid epidemic on lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations, there is evidence to suggest that opioid use disorders are disproportionately prevalent in the LGBTQ community. In this commentary, we present an overview of the current state of evidence on opioid use and misuse among LGBTQ-identified people in the United States and suggest ways to adapt behavioral health interventions to the specific needs of this population. Programs that integrate behavioral health with primary care, address minority stress, and use a trauma-informed approach have the most potential to produce effective, long-term benefits for LGBTQ-identified people with opioid use disorders.

Barriers to insurance coverage for transgender patients.

Transgender people report discrimination in access to health care that is associated with numerous poor health outcomes, including higher prevalence of HIV infection, substance use disorders, and suicide attempts. The field of obstetrics and gynecology is uniquely positioned to meet a wide range of health care needs for transgender people, and obstetrician-gynecologists can and ought to provide gender-affirming care for these patients. Despite growing evidence that gender-affirming care is both necessary and cost-effective, transgender patients continue to face barriers to securing insurance coverage, which prevents clinicians from practicing standards of care. The purpose of this article is to delineate the major barriers transgender patients face when seeking insurance reimbursement for services routinely available to cisgender (nontransgender) women.

Communicating With Patients Who Have Nonbinary Gender Identities.

The increasing visibility of transgender people and others who do not conform to traditional gender norms challenges us to think about gender in new ways, and to use new terminology when communicating with patients. People who describe themselves as nonbinary have a gender identity that is not exclusively girl/woman or boy/man. A small but growing body of research indicates they experience high levels of societal victimization and discrimination, and are misunderstood by health care clinicians. Using language that is inclusive of all gender identities can reduce these burdens and barriers. In this essay, we use a case scenario that illustrates ways to interact respectfully and affirmatively with nonbinary people throughout the patient care experience.

Taking a Sexual History and Creating Affirming Environments for Lesbian, Gay, Bisexual, and Transgender People.

MISSISSIPPI RANKS AMONG THE TOP STATES IN THE COUNTRY FOR RATES OF HIV AND STDs. Among those at highest risk are gay and bisexual men and transgender women; yet these groups often delay or avoid care because they fear being misunderstood or stigmatized. This article focuses on how providers in Mississippi can minimize these barriers by taking sexual histories that are inclusive and affirming of all sexual orientations and gender identities. The article also offers strategies for improving the environment of care within health care organizations in order to create welcoming and safe spaces for lesbian, gay, bisexual, and transgender people.

Resilience as a research framework and as a cornerstone of prevention research for gay and bisexual men: theory and evidence.

This commentary presents the content and results of a recent symposium held to discuss how resiliencies among gay and bisexual men, and other men who have sex with men, could inform HIV prevention interventions. We outline the argument for including resiliencies in prevention work and present a critique of the deficit-based approached to public health research as it applies to this line of inquiry. The commentary makes the case that HIV prevention work would be more efficacious if it were designed to incorporate naturally occurring resiliencies that manifest among gay male communities rather than primarily using interventions that address vulnerabilities among men who continue to reside in high risk contexts. The commentary concludes by listing a set of resiliency variables and constructs proposed at the meeting that could be tested in theoretically-based investigations to raise resiliencies among gay and bisexual men thereby lowering HIV risks in this population.

Addressing Gaps in Access to LGBTQIA + Health Education Resources: A Novel E-Learning Platform.

OBJECTIVES: To reduce health inequities for lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexually and gender diverse (LGBTQIA+) people, healthcare professionals need increased access to education and training resources on LGBTQIA + health. Web-based, asynchronous, electronic learning (e-learning) resources are critical for expanding the availability of LGBTQIA + health programs. This article presents the design and utilization outcomes of a novel e-learning platform for engaging healthcare professionals in LGBTQIA + health online continuing education. METHODS: As of December 2022, the e-learning platform consisted of 293 resources within 17 topic domains. Modalities included: learning modules, recorded webinars, publications, videos, and toolkits. We conducted a descriptive analysis of the e-learning platform's website traffic and user engagement data. Google Universal Analytics and event tracking were used to measure website traffic, user locations, and publication downloads. Learning module and webinar completions were exported from the learning management system and run as frequencies. RESULTS: Between January 1, 2020, and December 31, 2022, over 650,000 people from all U.S. states, 182 countries, and 31 territories visited the website. Platform users downloaded publications 66,225 times, and completed 29,351 learning modules and 24,654 webinars. CONCLUSION: The broad reach and high user engagement of the e-learning platform indicate acceptability of web-based, asynchronous online continuing education in LGBTQIA + health, and suggest that this platform is filling a need in health professional education. Remote, online learning opportunities may be especially important in jurisdictions with bans on medical care for transgender and gender diverse youth. Future growth of the platform, paired with in-person and other online learning opportunities, has the potential to reduce gaps in LGBTQIA + health training, and mitigate LGBTQIA + health inequities.

A Novel Medical Student Elective Course in Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, and Sexually and Gender Diverse Health: Training Tomorrow's Physician-Leaders.

Purpose: Inadequate medical training in lesbian, gay, bisexual, transgender, queer, intersex, asexual, and sexually and gender diverse (LGBTQIA+) health care contributes to health disparities. This article reports on a novel 4-week elective course at Harvard Medical School that prepares students to become physician-leaders in LGBTQIA+ health care. Methods: The course engages students in multidisciplinary clinical placements, self-directed learning, and mentored scholarly projects, all specifically relevant to LGBTQIA+ health. The authors qualitatively reviewed student experiences, and quantitatively analyzed course evaluations. Results: Between 2016 and 2022, 30 students completed the course, and 12 scholarly projects resulted in a published peer-reviewed article authored by the student. Students who completed evaluations rated the course as excellent and reported increased interest and core knowledge in LGBTQIA+ health care. Conclusion: This novel program has demonstrated feasibility and may serve as a model for establishing other advanced medical student clinical and scholarly electives on LGBTQIA+ health care.

TransECHO: A National Tele-Education Program for Expanding Transgender and Gender Diverse Health Care.

Purpose: Few clinicians have received training to provide comprehensive primary care for transgender and gender diverse (TGD) people. This article describes the program design and evaluation outcomes of TransECHO, a national professional development program for training primary care teams on the provision of affirming integrated medical and behavioral health care for TGD people. TransECHO is based on Project ECHO (Extension for Community Healthcare Outcomes), a tele-education model that aims to reduce health disparities and increase access to specialty care in underserved areas. Methods: Between 2016 and 2020, TransECHO conducted 7 year-long cycles of monthly training sessions facilitated by expert faculty through videoconference technology. Primary care teams of medical and behavioral health providers from federally qualified health centers (HCs) and other community HCs across the United States engaged in didactic, case-based, and peer-to-peer learning. Participants completed monthly postsession satisfaction surveys and pre-post TransECHO surveys. Results: TransECHO trained 464 providers from 129 HCs in 35 U.S. states, Washington DC, and Puerto Rico. On satisfaction surveys, participants provided high scores for all items, including those related to enhanced knowledge, effectiveness of teaching methods, and intentions to apply knowledge and change practice. Compared with pre-ECHO survey responses, post-ECHO responses averaged higher self-efficacy and lower perceived barriers to providing TGD care. Conclusions: As the first Project ECHO on TGD care for U.S. HCs, TransECHO has helped to fill the gap in training on comprehensive primary care for TGD people.

Advancing Excellence in Transgender Health: An International Professional Development Conference on Affirming Care for Transgender and Gender Diverse People.

OBJECTIVE: Increasing workforce capacity to provide knowledgeable, skilled, and affirming care for transgender and gender diverse people is critical to reduce health inequities; however, few clinicians receive sufficient training on this topic. This article describes Advancing Excellence in Transgender Health (AETH), an annual international conference that offers continuing professional development on evidence-based medical and behavioral healthcare for transgender and gender diverse people across the lifespan. METHODS: Registration data and post-conference evaluation data were descriptively analyzed to assess conference reach, participant satisfaction, and participant intentions to change practice. RESULTS: Between 2015 and 2022, AETH trained 2677 participants from all US states and 24 countries. Based on post-conference evaluations, 2017-2022, participant satisfaction was high (mean ≥4.4 on a 5-point scale) on all measures, including meeting learning objectives, quality of presentations, and relevance to practice. Participants reported intentions to: implement new information or skills (86.7%); create or revise protocols, policies, and/or procedures (63.2%); and seek additional information (64.2%). To increase equity, the conference waives fees for transgender and gender diverse participants and offers free online sessions. The conference also holds sessions specifically for transgender and gender diverse participants to promote opportunities for community-building, self-care, and professional networking. CONCLUSION: The broad reach of AETH demonstrates a large demand for more continuing professional development on transgender and gender diverse healthcare. This conference has expanded the availability of training designed to increase and enhance clinical workforce capacity to meet the health needs of transgender and gender diverse communities in the US and across the world.

HIV Care Continuum Interventions for Transgender Women: A Topical Review.

Transgender women experience a disproportionate prevalence of HIV and barriers to linkage to care, retention in care, medication adherence, and viral suppression. As part of a national cooperative agreement funded by the Health Resources and Services Administration's HIV/AIDS Bureau, we searched the literature from January 1, 2010, through June 1, 2020, for English-language articles on interventions designed to improve at least 1 HIV care continuum outcome or address 1 barrier to achieving HIV care continuum outcomes among transgender women diagnosed with HIV in the United States. To be included, articles needed to identify transgender women as a priority population for the intervention. We found 22 interventions, of which 15 reported quantitative or qualitative outcomes and 7 reported study protocols. Recent interventions have incorporated a range of strategies that show promise for addressing pervasive structural and individual barriers rooted in societal and cultural stigma and discrimination against transgender people. Cross-cutting themes found among the interventions included meaningful community participation in the design and implementation of the interventions; culturally affirming programs that serve as a gateway to HIV care and combine gender-affirming care and social services with HIV care; interventions to improve behavioral health outcomes; peer-led counseling, education, and navigation; and technology-based interventions to increase access to care management and online social support. Ongoing studies will further elucidate the efficacy and effectiveness of these interventions, with the goal of reducing disparities in the HIV care continuum and bringing us closer to ending the HIV epidemic among transgender women in the United States.

Pediatric sexual orientation and gender identity data collection in the electronic health record.

The systematic documentation of sexual orientation and gender identity data in electronic health records can improve patient-centered care and help to identify and address health disparities affecting sexual and gender minority populations. Although there are existing guidelines for sexual orientation and gender identity data among adult patients, there are not yet standard recommendations for pediatric patients. In this article, we discuss methods that pediatric primary care organizations can use to collect and document sexual orientation and gender identity information with children and adolescents in electronic health records. These recommendations take into consideration children's developmental stages, the role of caregivers, and the need to protect the privacy of this information. We also focus on the current limitations of electronic health records in capturing the nuances of sexual and gender minority identities and make suggestions for addressing these limitations.

A Pilot Sexual and Gender Minority Health Curriculum for the Largest Public Health Care System in the United States.

PROBLEM: Sexual and gender minority (SGM) people face multiple health disparities. Clinicians often lack adequate training to address health needs of SGM people. In this setting, some health care organizations have sought to develop system-wide curricula to build clinician knowledge and capacity around SGM health. APPROACH: NYC Health + Hospitals partnered with the National LGBTQIA+ [lesbian, gay, bisexual, transgender, queer, intersex, asexual] Health Education Center at The Fenway Institute to design and implement a novel SGM health care curriculum, offered from 2017 to 2020. The pilot program featured a 90-minute live introductory session, a pretest, a post-test, and six 45-minute online modules focusing on a range of topics in SGM health care. OUTCOMES: Of approximately 35,000 employees from a range of settings and professional roles across NYC Health + Hospitals, 792 participated in the pilot program; most were clinicians at acute care hospitals, with the single largest group being attending clinicians. The proportion of eligible employees completing each component of the curriculum varied: 544 of 792 (68.7%) completed the online pretest, while 373 of 792 (47.1%) completed the module on behavioral health. Of 373 participants who completed both the pre- and post-tests, mean scores rose significantly from 60.9 on the pretest to 81.9 on the post-test ( P < .001). NEXT STEPS: Future efforts should focus on increasing staff participation in the curriculum through scale-up efforts across the health care system, as well as measuring patient outcomes to assess the clinical impact of the initiative.

Interventions for Integrating Behavioral Health Services Into HIV Clinical Care: A Narrative Review.

The integration of behavioral health services within human immunodeficiency virus (HIV) care settings holds promise for improving substance use, mental health, and HIV-related health outcomes for people with HIV. As part of an initiative funded by the Health Resources and Services Administration's HIV/AIDS Bureau, we conducted a narrative review of interventions focused on behavioral health integration (BHI) in HIV care in the United States (US). Our literature search yielded 19 intervention studies published between 2010 and 2021. We categorized the interventions under 6 approaches: collaborative care; screening, brief intervention, and referral to treatment (SBIRT); patient-reported outcomes (PROs); onsite psychological consultation; integration of addiction specialists; and integration of buprenorphine/naloxone (BUP/NX) treatment. All intervention approaches appeared feasible to implement in diverse HIV care settings and most showed improvements in behavioral health outcomes; however, measurement of HIV outcomes was limited. Future research studies of BHI interventions should evaluate HIV outcomes and assess facilitators and barriers to intervention uptake.