The Association of Depression, Social Determinants and PrEP Uptake Among Black Sexual Minority Men in the Deep South.

Despite its known efficacy in reducing HIV acquisition, pre-exposure prophylaxis (PrEP) uptake and utilization remains alarmingly low among key populations, including Black sexual minority men (SMM). Additionally, research has shown that SMM are at elevated risk of adverse mental health outcomes, including depression, anxiety, illegal drug use, and suicidality. However, there is limited data examining the impact of depression on PrEP uptake among Black SMM. This study analyzes survey data obtained from the ViiV ACCELERATE! Initiative between January 2016 and September 2017 to examine the association between depressive symptoms and uptake of PrEP among a sample of HIV-negative Black SMM ages 18-65 years (N=170) residing in Mississippi, the poorest state in the USA. We found that PrEP-eligible Black SMM reporting depressive symptoms were 60% less likely to take PrEP (aOR = 0.40, CI: 0.18-0.74, p = 0.05). Similarly, PrEP-eligible men lacking health insurance were 63% less likely to start PrEP (aOR = 0.37; CI: 0.17-0.94; p = 0.035). Given the low uptake of PrEP among Black SMM, there is an urgent need for the development and implementation of combination HIV prevention interventions that incorporate access to mental health services among this highly stigmatized and marginalized population.

Sexual Minority Status Disparities in Life's Essential 8 and Life's Simple 7 Cardiovascular Health Scores: A French Nationwide Population-Based Study.

Background A higher burden of cardiovascular disease risk factors has been reported in sexual minority populations. Primordial prevention may therefore be a relevant preventative strategy. The study's objectives are to estimate the associations of Life's Essential 8 (LE8) and Life's Simple 7 (LS7) cardiovascular health scores with sexual minority status. Methods and Results The CONSTANCES is a nationwide French epidemiological cohort study that recruited randomly selected participants older than 18 years in 21 cities. Sexual minority status was based on self-reported lifetime sexual behavior and categorized as lesbian, gay, bisexual, or heterosexual. The LE8 score includes nicotine exposure, diet, physical activity, body mass index, sleep health, blood glucose, blood pressure, and blood lipids. The previous LS7 score included 7 metrics without sleep health. The study included 169 434 cardiovascular disease-free adults (53.64% women; mean age, 45.99 years). Among 90 879 women, 555 were lesbian, 3149 were bisexual, and 84 363 were heterosexual. Among 78 555 men, 2421 were gay, 2748 were bisexual, and 70 994 were heterosexual. Overall, 2812 women and 2392 men declined to answer. In multivariable mixed effects linear regression models, lesbian (ß=-0.95 [95% CI, -1.89 to -0.02]) and bisexual (ß=-0.78 [95% CI, -1.18 to -0.38]) women had a lower LE8 cardiovascular health score compared with heterosexual women. Conversely, gay (ß=2.72 [95% CI, 2.25-3.19]) and bisexual (ß=0.83 [95% CI, 0.39-1.27]) men had a higher LE8 cardiovascular health score compared with heterosexual men. The findings were consistent, although of smaller magnitudes for the LS7 score. Conclusions Cardiovascular health disparities exist in sexual minority adults, particularly lesbian and bisexual women, who may represent a priority population for primordial cardiovascular disease prevention.

A Single Center Review of COVID-19 Testing and Vaccination in the Transgender and Nonbinary Population.

Purpose: The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected transgender and nonbinary (TGNB) persons. We evaluated COVID-19 testing and vaccination rates among TGNB patients at our institution. Methods: We compared COVID-19 testing and vaccination rates between TGNB patients and a cisgender population matched by age, race, and ethnicity. Data were collected through September 22, 2021. Demographic variables, testing rates, and vaccination rates were collected. Descriptive statistics were calculated, and regression was performed on outcomes of interest: any vaccination dose, at least one test, and at least one positive test. Gender modality was the exposure of interest. Results: There were 5050 patients: 1683 cisgender men, 1682 cisgender women, and 1685 TGNB individuals. TGNB patients were more likely to be on Medicaid/Medicare and more likely to be single. The number of patients with at least one test was similar between TGNB (n = 894, 53.1%) and cisgender (n = 1853, 55.1%) groups. The number of patients who had at least one positive test was higher among cisgender patients (n = 238, 7.1%) compared with TGNB patients (n = 73, 4.3%). Vaccination rates were significantly greater among TGNB patients. Compared with cisgender patients, TGNB patients had greater odds of vaccination (adjusted odds ratio [aOR] = 1.25 [95% confidence interval; CI 1.06-1.48]). Compared with cisgender patients, TGNB patients had lower odds of having at least one positive COVID-19 test (aOR = 0.51 [95% CI 0.36-0.72]). Conclusion: Our institutional experience found that vaccination rates for TGNB patients were higher and COVID-19 positivity lower than for cisgender patients.

Instability in Housing and Medical Care Access: The Inequitable Impacts of the COVID-19 Pandemic on U.S. Transgender Populations.

Purpose: To assess whether the COVID-19 pandemic has inequitably impacted key social determinants of health (SDoH), specifically employment, housing, and health care, for U.S. transgender populations. Methods: Between April 13, 2020 and August 3, 2020, we conducted a national, cross-sectional online survey of sexual and gender minority individuals (N=870). We used logistic regression to calculate both unadjusted and adjusted odds of unemployment, homelessness/housing instability, and interruptions in medical care owing to the pandemic by gender and gender modality. Adjusted models controlled for age, race/ethnicity, and region. Results: In adjusted models, transgender and gender diverse people had 2.12 times the odds of reporting homelessness/housing instability and 2.88 times the odds of reporting medical care interruptions compared with cisgender peers. Transgender men, women, and nonbinary people had 4.12, 3.29, and 3.48 times the adjusted odds of interruptions in medical care compared with cisgender men, respectively. We did not observe significant differences in employment. Conclusions: Findings add empirical support to the hypothesis that socioeconomic consequences of COVID-19 are inequitably impacting transgender people. To contextualize our results and support future research in this area, we present a conceptual model of the short- and long-term impacts of COVID-19 on transgender populations using a framework of stigma as a fundamental cause of health inequities. Our findings emphasize that public health professionals must urgently consider-and intervene to address-the pandemic's SDoH-related impacts on transgender populations.

Developing Standards for Cultural Competency Training for Health Care Providers to Care for Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual Persons: Consensus Recommendations from a National Panel.

Purpose: Lesbian, gay, bisexual, transgender, queer, intersex, and/or asexual and other sexual and gender diverse persons (LGBTQIA+ or SGD persons) experience barriers to equitable health care. The purpose of this article is to describe a collaborative process that resulted in core cultural competency recommendations addressing training for those who provide health care and/or social services to LGBTQIA+ patients. Methods: In 2018 and 2019, Whitman-Walker Health, a Federally Qualified Community Health Center in Washington, DC, and the National LGBT Cancer Network purposively selected leaders of community clinics and community-based organizations, cultural competency trainers, and clinicians and researchers with expertise in SGD health with diverse lived experiences to develop consensus-based cultural competency recommendations. Recommendations were developed through a synthesis of peer-reviewed studies, publicly accessible curricula, and evaluations of SGD cultural competency trainings; two in-person convenings; and iterative feedback from diverse stakeholders. Results: Five anchoring recommendations emerged: (1) know your audience; (2) develop and fine-tune the curriculum; (3) employ both adult and transformational learning theories; (4) choose multiple effective trainers; and (5) evaluate impact of training. These recommendations promote an ongoing process of individual and organizational improvement and a stance of humility rather than competence to be mastered. Conclusion: By setting core cultural competency standards for all persons involved in health care and social services, these recommendations complement existing clinical competency recommendations to advance SGD health equity.

African Americans' Hemodialysis Treatment Adherence Data Assessment and Presentation: A Precision-Based Paradigm Shift to Support Quality Improvement Activities.

RATIONALE & OBJECTIVE: Thrice-weekly hemodialysis can result in adequate urea clearance; however, the morbidity and mortality rates of patients treated with maintenance dialysis remain unacceptably high, partly because of nonadherence. African Americans have a higher prevalence of kidney failure treated with dialysis, greater dialysis nonadherence, and higher odds of hospitalization. We hypothesized that more precise ways of assessing dialysis treatment adherence will reflect the severity of nonadherence, distinguish patterns of nonadherence, and inform the design of personalized behavioral interventions. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: African American patients receiving hemodialysis for >90 days. EXPOSURE: Hemodialysis. OUTCOME: Dialysis adherence. ANALYTICAL APPROACH: Dialysis attendance data were displayed using a dot plot, categorized based on missed and shortened treatments, and examined for patterns. Descriptive characteristics were reported. In an exploratory analysis, associations between dialysis treatment adherence and participant characteristics were evaluated using ordinary least squares regression. An analysis was performed using missed minutes of dialysis and current metrics for measuring dialysis treatment adherence (ie, missed and shortened treatments). RESULTS: Among 113 African American patients treated with dialysis, 47% were men; the median age was 57 years (interquartile range, 46-70 years), and the median dialysis vintage was 54 months (interquartile range, 22-90 months). With rows ordered based on the total missed minutes of dialysis, the dot plot displayed a decreasing gradient in the severity of nonadherence, with novel dialysis treatment adherence categories termed as follows: consistent underdialysis, inconsistent dialysis, and consistent dialysis. Distinct patterns of nonadherence and heterogeneity emerged within these categories. Older age was consistently associated with better adherence, as determined by the analyses performed using the total missed minutes of dialysis as well as missed and shortened treatments. LIMITATIONS: The study findings, although replicable and paradigm-shifting, might be limited by the short timeline, focus on adherence data specific to African American patients treated with dialysis, and restriction to dialysis units affiliated with 1 academic center. CONCLUSIONS: This study presents more precise and novel ways of measuring and displaying dialysis treatment adherence. The findings introduce a more personalized approach for evaluating actual dialysis uptake. Identification of unique patterns of adherence behavior is important to inform the design of effective behavioral interventions and improve outcomes for vulnerable African American patients treated with dialysis.

Differential Alcohol Use Disparities by Sexual Identity and Behavior Among High School Students.

AIMS: Sexual minority youth (SMY) use alcohol at disproportionate rates compared to their heterosexual peers. However, sexual orientation is multidimensional. Analyzing alcohol use disparities only by one dimension of sexual orientation may result in critical disparities being obscured. METHODS: Data from state and local versions of the Youth Risk Behavior Survey were pooled (2009-2017), resulting in a large, diverse sample (n = 201,671). Multivariable logistic regression models were used to analyze associations between sexual identity/sexual behavior and three alcohol use outcomes among sexually active youth: age at first drink, binge drinking and current drinking. RESULTS: SMY, when categorized by sexual identity and sexual behavior, reported greater alcohol use than their heterosexual peers, though the magnitude of these disparities varied by subgroup. Both those who identified as bisexual and those who reported sexual behavior with both males and females reported the greatest levels of alcohol use. Decomposition analysis revealed that youth whose reported sexual behavior was not aligned with stereotypical behavioral expectations based on their sexual identity had higher odds of current drinking and drinking before 13 years as compared to other youth. CONCLUSIONS: Results highlight the need to incorporate multiple methods of sexual orientation measurement into substance use research. Interventions based solely on identity, rather than both identity and behavior, may not be sufficient; targeted research into the causes of alcohol use disparities is needed, especially for bisexual youth, youth whose sexual behavior and sexual identity are not stereotypically aligned, and youth who report a sexual identity of 'not sure.'

Differential Decline in Illicit Drug Use by Sexual Identity Among United States High School Students, 2005-2017.

Purpose: Adolescent drug use remains a significant public health concern. Sexual minority youth (SMY) are at elevated risk for illicit drug use compared with their heterosexual peers. We investigated this pattern at the national level, exploring whether trends and disparities in drug use vary over time and by sexual identity. Methods: This study used Youth Risk Behavior Survey (YRBS) data, which were collected at seven time points from 2005 to 2017. Trends and disparities over time in the use of five drugs, as well as any drug use, were analyzed by self-reported sexual identity. Results: The results demonstrated a general decrease in drug use behaviors from 2005 to 2017. The greatest number of significant decreases was among heterosexual and bisexual students; the fewest were among gay and lesbian students. Disparities between heterosexual youth and SMY persisted across years, and were greater for gay and lesbian students in 2017 than for bisexual and not-sure youth. Conclusions: Our results represent the most comprehensive analysis of recent trends in drug use by sexual identity to date. Disparities in drug use remained significant despite overall downward trends within our sample. The significant decreases among bisexual students are not readily explained. We emphasize the need for ongoing research in this area, particularly given the currently volatile social position of sexual minority populations in the United States, and for culturally responsive and trauma-informed responses to SMY drug use.

Addressing the Disproportionate Impacts of the COVID-19 Pandemic on Sexual and Gender Minority Populations in the United States: Actions Toward Equity.

Sexual and gender minority (SGM) populations may be affected disproportionately by health emergencies such as the coronavirus disease 2019 (COVID-19) pandemic. Health professionals must take immediate steps to ensure equitable treatment of SGM populations. These steps are to (1) maintain and increase cultural responsiveness training and preparedness for SGM populations, (2) increase use of sexual orientation and gender identity measures in surveillance, (3) conduct research on the impacts of COVID-19 on SGM populations, and (4) include equity-focused initiatives in disaster preparedness plans. These actions toward equity would begin to allow for our current health system to care more appropriately for SGM populations.

Application of a Multisite Empowerment Evaluation Approach to Increase Evaluation Capacity Among HIV Services Providers: Results From Project Pride in Chicago.

In 2015, the Centers for Disease Control and Prevention (CDC) funded Project PrIDE, a national initiative to implement and evaluate demonstration projects to increase PrEP uptake among HIV-negative individuals and to re-engage HIV-positive individuals in HIV care. Our team served as the Evaluation Center for Project PrIDE organizations in Chicago and used an empowerment evaluation (EE) approach to enhance evaluation capacity at these organizations. To evaluate our approach, we assessed organizations' evaluation capacity and engagement in technical assistance and capacity building activities in 2016 and 2018. Respondents who self-reported higher engagement with the Evaluation Center and who spent a greater number of hours engaged with our evaluators experienced greater increases in evaluation capacity tied to implementation of evaluation activities and technical assistance utilization. These findings demonstrate that multisite EE can be successfully applied to increase the evaluation capacity of organizations providing both HIV prevention and care services.

Lifetime Asthma Prevalence and Correlates Among US Youths by Sexual Identity and Race/Ethnicity, 2009-2017.

Objectives. To comprehensively assess asthma disparities and identify correlates in youths at the intersections of sex, sexual identity, and race/ethnicity in the United States.Methods. We obtained a diverse sample of youths (n = 307 073) from the Centers for Disease Control and Prevention's Youth Risk Behavior Survey. We pooled data across 107 jurisdiction-years (2009-2017). We calculated lifetime asthma prevalence by sexual identity, race/ethnicity, and their intersections-stratified by sex. We developed multivariable weighted logistic regression models to examine the impact of selected correlates on lifetime asthma prevalence.Results. Lesbian, gay, and bisexual youths have significant disparities in asthma prevalence compared with heterosexual peers. Moreover, across sex, higher prevalence of lifetime asthma was seen for most sexual identity and race/ethnicity subpopulations (27 of 30) when compared with White heterosexual sex-matched participants. Selected traditional risk factors (overweight, obese, and smoking) and bullying tended to attenuate odds among groups, especially those with a minority sexual identity.Conclusions. Asthma inequities at the intersection of sexual identity and race/ethnicity are substantive. Future studies should investigate the mechanisms contributing to these disparities to promote health equity among vulnerable youth populations. (Am J Public Health. Published online ahead of print May 21, 2020: e1-e8. doi:10.2105/AJPH.2020.305664).

A Model for Improving Health Care Quality for Transgender and Gender Nonconforming Patients.

PROBLEM DEFINITION: Transgender and gender nonconforming (TGNC) populations are disproportionately affected by limited health care access and poor health outcomes and commonly report discrimination and mistreatment in health care settings. Despite these disparities, comprehensive approaches to improve the quality of health care of TGNC patient populations are currently lacking. INITIAL APPROACH: The Vanderbilt Program for LGBTQ Health has developed a multifaceted, community-engaged approach to improve the quality of health care of TGNC patients, which includes the creation of a transgender patient advocacy program, a community advisory board, and a transgender health clinic. To support the continuous quality improvement of transgender health care, the program is currently piloting a novel multilevel monitoring and evaluation (M&E) system to collect information at the individual patient visit and health systems levels. NEXT STEPS: The next steps for Vanderbilt's community-engaged M&E system are to identify the clinics and health services most used by TGNC patients and assess the level of patient satisfaction in each area. This process will support the identification of high- and low-performing clinics and health services and allow for targeted delivery of trainings to improve the quality of culturally competent health care TGNC patients receive systemwide. CONCLUSION: In collaboration with TGNC patient populations and community stakeholders, Vanderbilt has created a model to improve the quality of both transition- and non-transition-related health care at the systems level that can be adopted by other health care systems nationally.

Bi Us, For Us: Articulating foundational principles for research in partnership with bisexual communities.

Bisexual people comprise over half of all adults who identify as sexual minorities within the United States. Increasingly, population level health research has revealed that bisexual people face striking and broad-ranging health disparities compared not only to heterosexual people, but also often compared to their gay and lesbian peers. Despite the fact that bisexual people comprise an 'invisible majority' of LGBTQ people and are disproportionately impacted by poor health, the vast majority of funding dedicated to LGBTQ community organizing and to sexual and gender minority health research does not address the needs of bisexual people. Within this three-part article, we first describe how manifestations of systematic biphobia have led to the current situation where bisexual community organizations and bisexual health researchers are not granted adequate resources to address the health and health promotion of bisexual populations. In the second section, we articulate foundational ethical guiding principles and propose Bi Us, For Us, a new model to inform the design, evaluation, and implementation of intersectional bisexual community engaged research to inform the development of structural bisexual-specific health equity interventions. In the last section of this paper, we present the Chicago Bisexual Health Task Force as a case study of the model in action to illustrate a real-life approach that community engaged research and advocacy initiatives can take to promote bisexual health equity. We view this article as an invitation for dialogue about how to develop best practices to advance bisexual health equity and hope that it inspires additional bisexual people, organizers, and researchers to join in these pursuits.

Trends in Alcohol Use Behaviors by Sexual Identity and Behavior Among High School Students, 2007-2017.

PURPOSE: Certain groups, particularly sexual minority youth, demonstrate notable disparities in alcohol use risk. Assessing trends in alcohol use behaviors by sexual orientation over time is therefore important to the epidemiologic study of adolescent health equity. METHODS: We analyzed age at first drink, lifetime drinking behavior, current drinking, and binge drinking in a large, national sample of high school youth across six time points, beginning in 2007 and biennially through 2017. We assessed trends by sex, sexual identity, and sexual behavior, controlling for race/ethnicity and age. RESULTS: Our results demonstrated that, although overall alcohol use is decreasing among youth, disparities between heterosexual and sexual minority youth remain significant. The largest decreases were seen in current alcohol use among lesbian youth, which fell from a prevalence of 56.1% in 2007 to 38.9% in 2017, and among bisexual females (64.3% in 2007 to 41.1% in 2017). Despite this, alcohol use behaviors were still elevated among lesbian and bisexual female youth compared with heterosexual sex-matched counterparts. Heterosexual-identified male students saw significant decreases in alcohol use, whereas most alcohol use behaviors among sexual minority males decreased but not to a statistically significant degree, with the exception of binge drinking among those who identified as gay (2007: 36.0% to 2017: 12.6%) and bisexual (2007: 24.7% to 2017: 11.6%). Results by sexual behavior are presented within. CONCLUSIONS: Sexual minority youth continued to demonstrate markedly high prevalence of alcohol use behaviors compared with heterosexual peers across all time points. Downward trends in alcohol use may thus mask serious population health risks if not adequately explored. Research and health promotion efforts must consider sexual minority orientation to avoid incomplete or inaccurate representation of findings.

Evaluation capacity building-Results and reflections across two years of a multisite empowerment evaluation in an HIV prevention context.

As the need for rigorous evidence of program efficacy increases, integrating evaluation activities into program implementation is becoming crucial. As a result, external evaluators are placing increased focus on evaluation capacity building as a practice. However, empirical evidence of how to foster evaluation capacity in different contexts remains limited. This study presents findings from an evaluation capacity survey conducted within a multisite Empowerment Evaluation initiative, in which an external evaluator worked with 20 project teams at diverse community agencies implementing HIV prevention projects. Survey results revealed representatives from project teams (n = 33) reported significantly higher overall evaluation capacity after engaging with the external evaluator on planning and implementing their evaluation. Improvements differed across organization type, intervention type, staff position, and reported engagement on various activities throughout the course of the evaluation. Results indicated empowerment evaluation and other stakeholder-focused evaluation approaches are broadly applicable when evaluation capacity building is a desired outcome, particularly when able to engage project staff in the planning of the evaluation and in delivering technical assistance services. Accordingly, efforts should be made by program funders, staff, and evaluators to encourage active engagement starting in the early stages of program and evaluation planning.

Prevalence of Self-Reported Diabetes by Sexual Orientation: Results from the 2014 Behavioral Risk Factor Surveillance System.

PURPOSE: This study aimed to compare the prevalence of self-reported diabetes and diabetes risk factors among adult sexual minority and heterosexual populations in the United States. METHODS: Data from the 2014 Behavioral Risk Factor Surveillance System for 3776 lesbian, gay, and bisexual (LGB) adults and 142,852 heterosexual adults aged 18 years and older were used to estimate the prevalence of diabetes. Binomial logistic regression models were used to compare the odds of diabetes by sexual orientation. RESULTS: Sexual minorities were younger and more racially diverse than heterosexuals. Gay men less often and lesbian and bisexual women more often reported a body mass index of 30 kg/m2 or higher than heterosexuals. Overall, 14.2% of bisexual men, 11.4% of gay men, and 10.8% of heterosexual men reported a lifetime diabetes diagnosis, as did 8.5% of lesbian women, 5.7% of bisexual women, and 10.2% of heterosexual women. After controlling for multiple factors, gay (odds ratio [OR] = 1.50; confidence interval [95% CI] = 1.09-2.07) and bisexual men [OR = 1.55; 95% CI = 1.00-2.07] were more likely to report a lifetime diabetes diagnosis than heterosexual men. Similar differences were not found for lesbian [OR = 1.22; 95% CI = 0.76-1.95] or bisexual women [OR = 0.88; 95% CI = 0.62-1.26]. CONCLUSION: Sexual minorities may be at increased risk for diabetes than their heterosexual peers. This may be due partly to the chronic stressors associated with being a member of a marginalized population. Future research should explore the underlying causes and consequences of LGB diabetes disparities and elucidate best practices to improve diabetes screening and care for these vulnerable patient populations.