Development of a telehealth intervention to promote care-seeking among transgender women of color in Washington, DC.

BACKGROUND: Transgender women of color (TWC) are an underserved population who often experience high rates of HIV and barriers to care including stigma, violence, and trauma. Few health information technology interventions are tailored to serve TWC. The purpose of this study was to inform the development of a TWC-specific telehealth intervention to increase access to care. METHODS: Formative qualitative semi-structured interviews and focus groups were conducted to develop a customized telehealth intervention for TWC. Participants were TWC ≥ 18 years living in the Washington, DC metropolitan area, with at least one structural barrier to care and clinicians ≥18 years who provide care to TWC. Transcripts were analyzed using thematic coding and content analysis; barriers for TWC were categorized into Individual, Organizational, and Environmental levels. Several day-long meetings with TWC and stakeholders were convened to develop the intervention. RESULTS: Saturation of theme on barriers to care was reached with 22 interviews. Identified barriers to service receipt included survival, instability, temporal discounting, and prioritizing hormone therapy over care, incongruence between providers and patients, pessimism, and lack of cultural competency. Each was intentionally addressed with the telehealth intervention. CONCLUSIONS: Data informed the development of an innovative and customized telehealth intervention for TWC. Through the integration of technology and peer consultant outreach, we developed a novel approach that can address population-specific challenges to care. Further development of this model may be able to improve health outcomes among TWC.

Navigating Opportunities, Learning and Potential Threats: Mentee Perspectives on Mentoring in HIV Research.

Increasing the diversity of the HIV research workforce remains a priority for research and funding organizations in the US. Mentorship is a vital component for early-career investigators, especially for underrepresented racial/ethnic and sexual minority HIV investigators. These investigators face unique social and structural challenges to developing and fostering mentorship relationships, as well as building a solid foundation for a successful career in HIV research. This article provides a perspective from four Black early-career investigators, supplemented with comments from 15 underrepresented investigators in the US, as they reflect on their needs, challenges, contributions, and successes in finding the right mentor and mentorship environment, balancing the opportunities for, and "threats" to success, as well as providing mentorship to other underrepresented and aspiring HIV investigators. Mentorship programs must address these needs and challenges while building on the strengths of underrepresented HIV investigators in order to improve recruitment, retention and ultimately the pipeline of these researchers.

Receipt of HIV prevention interventions is more common in community-based clinics than in primary care or acute care settings for Black men who have sex with men in the District of Columbia.

Characterization of structural barriers that impede the receipt of HIV prevention and care services is critical to addressing the HIV epidemic among Black men who have sex with men (BMSM). This study investigated the utilization of HIV prevention and general care services among a non-clinic-based sample of BMSM who reported at least one structural barrier to engagement in care. Proportions of participants who had received HIV prevention services and general care services in different settings were compared using Fisher's exact test and correlates of service receipt were assessed using logistic regression. Among 75 BMSM, 60% had accessed a community-based clinic, 21% had accessed a primary care setting, and 36% had accessed an acute care setting in the last 6 months. Greater proportions of participants who had accessed community-based clinics received HIV prevention services during these visits (90%) compared to those who had accessed primary care (53%) and acute care (44%) settings (p = .005). Opportunities for BMSM to receive HIV prevention interventions differed by care setting. Having access to health care did not necessarily facilitate the uptake of HIV prevention interventions. Further investigation of the structurally rooted reasons why BMSM are often unable to access HIV prevention services is warranted.

Development of a Black Caucus within the HIV Prevention Trials Network (HPTN): Representing the Perspectives of Black Men Who Have Sex with Men (MSM).

Black men who have sex with men (MSM) have disproportionate HIV disease burden in the United States. Black MSM have been underrepresented in biomedical research, including HIV clinical trials, due to a myriad of socio-structural, socio-cultural, and psychosocial factors. The HIV Prevention Trials Network (HPTN) 061, a feasibility study of a multi-component HIV prevention intervention for Black MSM in six US cities, incorporated the development and implementation of a Black Caucus as a culturally grounded model for the integration of Black MSM in clinical trials and research in HPTN. Based on a qualitative methodological approach, we describe the formation and implementation of the Black Caucus from the perspective of Black MSM key community stakeholders. Three major themes emerged from the qualitative narratives: (1) the role of the Black Caucus in shaping the HPTN, (2) how the Black Caucus addresses the needs of Black MSM communities pertaining to the influence of race and sexual identity, and (3) socio-cultural needs of Black MSM. These findings have implications for the provision of culturally congruent expertise, community engagement, cultural mistrust, recruitment and retention of Black MSM in HIV clinical trials, culturally-relevant study design and implementation, and the role of developing Black MSM prevention researchers.

Sexual Risk Behaviors Among Black Men Who Have Sex With Men Who Also Report Having Sex With Transgender Partners: Analysis of HIV Prevention Trials Network (HPTN) 061 Study.

HIV Prevention Trials Network (HPTN 061) study data of Black MSM were analyzed to determine characteristics associated with having transgender sexual partners (TGP) and the association of having TGP with sexual risk. Of 1,449 cisgender MSM, 343(24%) reported also having TGP. MSM with TGP were more likely to be older, have a sexual orientation other than homosexual, have a history of incarceration, or have insufficient funds for necessities, but less likely to be HIV positive or report sex with men to health care providers. MSM with TGP were 3.67 times more likely to recently have 5+ new partners and 2.02 times more likely to report 6+ condomless sexual acts. Since MSM with TGP reported not disclosing sex with men to health care providers, these men may need tailored HIV prevention and care. Future studies should examine differing sexual risks MSM take with sexual partners with different gender identities.

Acceptability of a Mobile Smartphone Application Intervention to Improve Access to HIV Prevention and Care Services for Black Men Who Have Sex with Men in the District of Columbia.

Eliminating racial HIV disparities among men who have sex with men (MSM) will require a greater uptake of HIV prevention and care interventions among Black MSM (BMSM), yet such strategies generally require meaningful engagement in a health care system that often does not meet the unique needs of BMSM. This study assessed the acceptability of, and correlates of having favorable perceptions of, a mobile smartphone application (app) intervention for BMSM that aims to remove structural barriers and improve access to culturally relevant HIV prevention and care services. An Internet-based sample of 93 BMSM completed an online survey on their perceptions of the app using 14 items measured on a 100-point visual analogue scale that were validated in exploratory factor analysis (alpha=0.95). Among the sample, perceptions of two sample app modules were generally favorable and most BMSM agreed that they would use the modules (81.2% and 87.1%). Correlates of having favorable perceptions included trusting medical advice from social networks, lacking private health insurance, and not having accessed a primary care physician in the last year. Our findings warrant the further development of this app and point to subgroups of BMSM for which it may have the greatest impact.

Retention strategies and factors associated with missed visits among low income women at increased risk of HIV acquisition in the US (HPTN 064).

Women at high-risk for HIV acquisition often face challenges that hinder their retention in HIV prevention trials. These same challenges may contribute to missed clinical care visits among HIV-infected women. This article, informed by the Gelberg-Andersen Behavioral Model for Vulnerable Populations, identifies factors associated with missed study visits and describes the multifaceted retention strategies used by study sites. HPTN 064 was a multisite, longitudinal HIV seroincidence study in 10 US communities. Eligible women were aged 18-44 years, resided in a census tract/zipcode with high poverty and HIV prevalence, and self-reported ≥1 personal or sex partner behavior related to HIV acquisition. Multivariate analyses of predisposing (e.g., substance use) and enabling (e.g., unmet health care needs) characteristics, and study attributes (i.e., recruitment venue, time of enrollment) identified factors associated with missed study visits. Retention strategies included: community engagement; interpersonal relationship building; reduction of external barriers; staff capacity building; and external tracing. Visit completion was 93% and 94% at 6 and 12 months. Unstable housing and later date of enrollment were associated with increased likelihood of missed study visits. Black race, recruitment from an outdoor venue, and financial responsibility for children were associated with greater likelihood of attendance. Multifaceted retention strategies may reduce missed study visits. Knowledge of factors associated with missed visits may help to focus efforts.