Oestradiol concentrations in trans women with HIV suppressed on unboosted integrase inhibitor regimens versus trans women without HIV taking oral oestradiol: a pilot study.

BACKGROUND: Feminizing hormone therapy (FHT) is essential to many trans women. Concern about negative drug interactions between FHT and ART can be an ART adherence barrier among trans women with HIV. OBJECTIVES: In this single-centre, parallel group, cross-sectional pilot study, we measured serum oestradiol concentrations in trans women with HIV taking FHT and unboosted integrase strand transfer inhibitor (INSTI)-based ART versus trans women without HIV taking FHT. METHODS: We included trans women with and without HIV, aged ≥18 years, taking ≥2 mg/day of oral oestradiol for at least 3 months plus an anti-androgen. Trans women with HIV were on suppressive ART ≥3 months. Serum oestradiol concentrations were measured prior to medication dosing and 2, 4, 6 and 8 h post-dose. Median oestradiol concentrations were compared between groups using Wilcoxon rank-sum tests. RESULTS: Participants (n = 8 with HIV, n = 7 without) had a median age of 32 (IQR: 28, 39) years. Among participants, the median oral oestradiol dose was 4 mg (range 2-6 mg). Participants had been taking FHT for a median of 4 years (IQR: 2, 8). Six trans women with HIV were taking bictegravir/emtricitabine/tenofovir alafenamide and two were taking dolutegravir/abacavir/lamivudine. All oestradiol concentrations were not significantly different between groups. Eleven (73%) participants had target oestradiol concentrations in the range 200-735 pmol/L at C4h (75% among women with HIV, 71% among those without HIV). CONCLUSIONS: Oestradiol concentrations were not statistically different in trans women with HIV compared with those without HIV, suggesting a low probability of clinically relevant drug-drug interactions between FHT and unboosted INSTI-based ART.

Sexually transmitted infection testing among transgender and non-binary persons: results of a community-based cross-sectional survey.

BACKGROUND: Studies show higher rates of sexually transmitted infections (STIs) among transgender (trans) and non-binary (TNB) persons compared with the general population. Scant studies have examined non-HIV STI testing (henceforth referred to as STI testing); fewer inclusive of trans men and non-binary persons. We characterised the prevalence of STI testing and time since last STI test and gender-based differences in these outcomes among TNB persons. METHODS: Data were analysed from a 2018 community-based participatory cross-sectional survey (n =528). Prevalence of lifetime STI testing history and time since last STI test were reported overall and compared across genders (trans men, trans women, non-binary assigned female at-birth, non-binary assigned male at-birth) using Chi-squared, then bivariable and multivariable logistic regression analyses to compare lifetime STI testing history (ever vs never) across sociodemographic and health care characteristics. RESULTS: Most (n =425; 80.5%) participants reported having ever had an STI test; over half (59.8%) ever tested had tested within the past year. Bivariate analyses showed no significant gender differences in lifetime STI testing history (P =0.298) or time since last STI test (P =0.118). In a multivariable model, higher age, reporting multiple committed partners (vs single/divorced), known HIV status, and ever receiving information about pre-exposure prophylaxis (PrEP) were positively associated with ever having had an STI test, whereas Latinx race/ethnicity (vs white) was negatively associated. CONCLUSIONS: Findings showed high rates of lifetime STI testing and recent testing, with no gender-based differences. Never testing rates were concerning considering screening recommendations. Broad based (non-gender specific) TNB-focused interventions may be warranted to increase uptake.

Short report: Characterizing HIV care among a clinical sample of transgender women living with HIV.

INTRODUCTION: This study aimed to characterize and identify factors associated with HIV care among transgender (trans) women living with HIV (TWLWH) in two urban centres in Canada. METHODS: Retrospective data were collected from clinic charts of TWLWH aged 16 years and older across seven family medicine, endocrinology and/or HIV clinics in Montreal and Toronto, Canada, from 2018 to 2019 (n = 86). We assessed the proportion of individuals being ever engaged in HIV care [defined as having any recorded antiretroviral therapy (ART) regimen and/or viral load], current ART use, and most recent viral load (suppressed [<200 copies/ml] vs. unsuppressed) overall and compared across subgroups using χ2 tests. RESULTS: All TWLWH in our sample [100.0%, 95% confidence interval (CI): 95.8-100.0%] were engaged in HIV care; most (93.0%, 95% CI: 85.4-97.4%) were currently using ART and most (93.4%, 95% CI: 85.3-97.8%) with complete data (n = 71/76) were virally suppressed. A higher proportion of trans women of colour (100.0%) reported current ART use compared with white trans women (76.9%, p = 0.017). A higher proportion of those with no documented history of injection drug use (IDU; 96.6%) were virally suppressed compared with those with a history of IDU (66.7%, p = 0.022). Although not statistically significant, 96.2% of those currently reporting feminizing hormone use were virally suppressed, compared with 85.0% of those not reporting use (p = 0.202). CONCLUSIONS: Once engaged in HIV care, TWLWH in Canada appear to have excellent ART use and viral suppression. Findings can be leveraged to identify target populations to enhance HIV care and to further explore the relationship between gender-affirming medical care and HIV care.

Eliciting critical hope in community-based HIV research with transgender women in Toronto, Canada: methodological insights.

Critical hope centres optimism and possibilities for change in the midst of struggles for social justice. It was a central tenet of early participatory pedagogy and HIV research. However, critical hope has been overlooked in contemporary HIV research that largely focuses on risk and biomedical interventions in ways that obscure collective agency and community strengths. We conducted a community-based study with transgender (trans) women of colour in Toronto, Canada to adapt an evidence-based HIV prevention intervention. Participants resisted a focus on HIV, instead calling researchers to centre journeys to self-love in contexts of social exclusion. In response, we piloted three arts-based, participatory methods generated with community collaborators: (i) affirmation cards sharing supportive messages with other trans women, (ii) hand-held mirrors for reflecting and sharing messages of self-acceptance and (iii) anatomical heart images to visualize coping strategies. Participants generated solidarity and community through shared stories of self-acceptance within contexts of pain, exclusion and loss. Narratives revealed locating agency and self-acceptance through community connectedness. Critical hope was a by-product of this participatory process, whereby participants shared personal and collective optimism. Participatory and arts-based methods that centre self-acceptance and solidarity can nurture resistance to pathologizing discourses in HIV research. Centring critical hope and participant-generated methodologies is a promising approach to transformative health promotion and intervention research. These methodological insights can be engaged in future participatory work with other marginalized groups facing dominant biomedical risk discourses. Critical hope holds potential as a participatory health promotion strategy for envisioning possibilities for sustainable change.

Optimism and possibility for change in the midst of social justice struggles are central to critical hope and change-oriented research. The concept of critical hope guided community-based activism and research, including early in the HIV pandemic. Yet current HIV research largely focuses on individual risks and biomedical solutions, which may overlook critical hope and the important role of community connection in promoting wellbeing. Our community-based study with transgender (trans) women of colour in Toronto, Canada aimed to adapt an HIV prevention intervention. Participants challenged the HIV focus and invited the research team to instead focus on pathways to self-acceptance in larger contexts of social exclusion. In response, we developed three arts-based activities to pilot-test at three workshops: affirmation cards to write supportive messages to other trans women, hand-held mirrors to write messages of self-acceptance, and anatomical heart images to visualize coping strategies. Through these activities, participants shared stories of self-acceptance that occurred over time and through community connectedness, often in the face of exclusion and discrimination. Perspectives on personal and collective optimism, reflecting critical hope, were shared in the workshops. Participant-generated methodologies that offer opportunities to discuss critical hope can be promising approach to transformative health promotion and intervention research.

"You Could Tell I Said the Wrong Things": Constructions of Sexual Identity Among Older Gay Men in Healthcare Settings.

Older gay men commonly conceal their sexual identity in healthcare settings due to past experiences and expectations of encountering stigma and discrimination in these contexts. Although insights on how older gay men construct their sexual identity in healthcare may help contextualize this phenomenon, this question remains under-explored. Accordingly, we present the findings of a secondary grounded theory analysis of individual interview data, which we originally collected to examine the healthcare experiences of 27 gay men ages 50 and over, to explore constructions of sexual identity among the group. Our findings broadly reveal that older gay men's varying exposure to intersecting systems of oppression, together with their perceptions of different healthcare settings, may be critical in shaping their constructions of sexual identity in these contexts. Our research supports the need for healthcare policies and practices that address stigma and discrimination as salient barriers to sexual identity disclosure among older gay men.

Mental health among transgender women living with HIV in Canada: findings from a national community-based research study.

Antiretroviral therapy adherence among transgender (trans) women living with HIV (WLWH) is negatively impacted by depression and post-traumatic stress disorder (PTSD). Yet, little is known about factors associated with depression or PTSD among trans WLWH. Using cross-sectional data from a national community-based study of 1422 WLWH (n = 53 trans women), we characterized the prevalence of depressive and PTSD symptoms among trans WLWH and examined associations between factors (e.g., Trans stigma) and depressive and PTSD symptoms. Nearly half of participants reported clinically significant PTSD (45.3%) and depressive symptoms (45.3%) [mean Post-traumatic Stress Disorder Civilian Checklist Version-C score 13.8 (SD = 5.8); mean Center for Epidemiological Studies - Depression score 9.4 (SD = 8.0)]. Univariate linear regression analyses showed that <95% adherence, higher internalized HIV-related stigma, frequency of past-month hazardous alcohol use, and current injection drug use were significantly associated with both higher PTSD and depressive symptom scores, and higher resilience and social support with lower scores. A history of violence in adulthood was associated with higher depressive symptoms scores, whereas sexual relationship power and less difficulty meeting housing costs were associated with lower scores. Findings suggest a need for multi-level interventions to reduce barriers to mental wellbeing while fostering resilience and social support.

Examining TikTok's Potential for Community-Engaged Digital Knowledge Mobilization With Equity-Seeking Groups.

Social media is increasingly being leveraged by researchers to engage in public debates and rapidly disseminate research results to health care providers, health care users, policy makers, educators, and the general public. This paper contributes to the growing literature on the use of social media for digital knowledge mobilization, drawing particular attention to TikTok and its unique potential for collaborative knowledge mobilization with underserved communities who experience barriers to health care and health inequities (eg, equity-seeking groups). Setting the TikTok platform apart from other social media are the unique audiovisual video editing tools, together with an impactful algorithm, that make knowledge dissemination and exchange with large global audiences possible. As an example, we will discuss digital knowledge mobilization with trans and nonbinary (trans) communities, a population that experiences barriers to health care and is engaged in significant peer-to-peer health information sharing on the web. To demonstrate, analytics data from 13 selected TikTok videos on the topic of research on gender-affirming medicine (eg, hormonal therapy and surgeries) are presented to illustrate how knowledge is disseminated within the trans community via TikTok. Considerations for researchers planning to use TikTok for digital knowledge mobilization and other related community engagement with equity-seeking groups are also discussed. These include the limitations of TikTok analytics data for measuring knowledge mobilization, population-specific concerns related to community safety on social media, the spread of disinformation, barriers to internet access, and commercialization and intellectual property issues. This paper concludes that TikTok is an innovative social media platform that presents possibilities for achieving transformative, community-engaged knowledge mobilization among researchers, underserved health care users, and their health care providers, all of whom are necessary to achieve better health care and population health outcomes.

Implementation and evaluation of the 'Transgender Education for Affirmative and Competent HIV and Healthcare (TEACHH)' provider education pilot.

BACKGROUND: Transgender (trans) women face constrained access to gender-affirming HIV prevention and care. This is fueled in part by the convergence of limited trans knowledge and competency with anti-trans and HIV-related stigmas among social and healthcare providers. To advance gender-affirming HIV service delivery we implemented and evaluated 'Transgender Education for Affirmative and Competent HIV and Healthcare (TEACHH)'. This theoretically-informed community-developed intervention aimed to increase providers' gender-affirming HIV prevention and care knowledge and competency and reduce negative attitudes and biases among providers towards trans women living with and/or affected by HIV. METHODS: Healthcare and social service providers and providers in-training (e.g., physicians, nurses, social workers) working with trans women living with and/or affected by HIV (n = 78) participated in a non-randomized multi-site pilot study evaluating TEACHH with a pre-post-test design. Pre- and post-intervention surveys assessed participant characteristics, intervention feasibility (e.g., workshop completion rate) and acceptability (e.g., willingness to attend another training). Paired sample t-tests were conducted to assess pre-post intervention differences in perceived competency, attitudes/biases, and knowledge to provide gender-affirming HIV care to trans women living with HIV and trans persons. RESULTS: The intervention was feasible (100% workshop completion) and acceptable (91.9% indicated interest in future gender-affirming HIV care trainings). Post-intervention scores indicated significant improvement in: 1) knowledge, attitudes/biases and perceived competency in gender-affirming HIV care (score mean difference (MD) 8.49 (95% CI of MD: 6.12-10.86, p < 0.001, possible score range: 16-96), and 2) knowledge, attitudes/biases and perceived competency in gender-affirming healthcare (MD = 3.21; 95% CI of MD: 1.90-4.90, p < 0.001, possible score range: 9-63). Greater change in outcome measures from pre- to post-intervention was experienced by those with fewer trans and transfeminine clients served in the past year, in indirect service roles, and having received less prior training. CONCLUSIONS: This brief healthcare and social service provider intervention showed promise in improving gender-affirming provider knowledge, perceived competency, and attitudes/biases, particularly among those with less trans and HIV experience. Scale-up of TEACHH may increase access to gender-affirming health services and HIV prevention and care, increase healthcare access, and reduce HIV disparities among trans women. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT04096053 ).

Pre-Exposure Prophylaxis (PrEP) Implementation for Gay, Bisexual, and Other Men Who Have Sex with Men: Implications for Social Work Practice.

Social workers have been critical in the response to HIV from its inception, in HIV prevention, support, and advocacy for stigmatized populations including gay, bisexual, and other men who have sex with men (GBM). Recently, social workers have been tasked with working in an era of increasingly biomedicalized HIV prevention, including pre-exposure prophylaxis (PrEP), a safe and highly effective new prevention technology. However, disparities in PrEP access due to structural barriers, including lack of health insurance coverage, and complex decision-making pathways and processes of engagement present substantial challenges for PrEP implementation. Ensuring equitable access to resources and supporting informed decision making are paramount to social work values, yet scant published literature has considered PrEP social work intervention. This article draws on qualitative data from 29 GBM respondents to highlight gaps in PrEP decision-making support and access that may be amenable to social work intervention. Authors describe opportunities for individual, interpersonal, organizational, and structural social work interventions to address multilevel gaps in PrEP implementation. Findings illuminate the complexity of individual experiences and social discourses regarding PrEP and their impact on GBM and raise important issues for social workers to consider in working with GBM clients, service providers, and administrators.

A qualitative study of resilience among transgender women living with HIV in response to stigma in healthcare.

Stigma in healthcare is a pervasive adversity experienced by transgender (trans) women living with HIV (WLWH). Resilience is described as individual and collective processes of navigating and overcoming adversity. This qualitative study sought to explore resilience exhibited by trans WLWH in response to stigma in healthcare. Semi-structured, individual interviews were conducted in 2017-2018 with a purposive sample of trans WLWH (n = 11) participating in a community-based cohort study. Framework analysis was used to identify key themes, patterns within themes between participants, and patterns across themes among participants. Three overarching themes were identified. (1) Resilient responses to stigma in healthcare. Participants exhibited resilient personality traits and processes of resistance and transformation in response to stigma. (2) Motivations, benefits, and consequences of responding. Participants experienced self and altruistic driven motivations. Benefits included increased self-worth, economic resources, and leverage for better healthcare treatment, and reduced internalized stigma and isolation. Negative consequences included defensive provider reactions, being further stereotyped, and decreased physical and mental health. (3) Recommendations for systemic change. Participants recommended trans inclusion in service delivery, development, and management, as well as increased provider education. Providers can leverage trans WLWH's personal and collective strengths while working in solidarity to reduce stigma in healthcare settings.

From surviving to thriving: factors associated with complete mental health among childhood sexual abuse survivors.

BACKGROUND: Despite many negative health and social consequences of childhood sexual abuse (CSA), some of those with a history of adversity manage to thrive in adulthood and achieve complete mental health (CMH). CMH is defined as the absence of mental illness in combination with almost daily happiness and/or life satisfaction, as well as high levels of social and psychological well-being. The objectives of this study were (1) to identify the pathways linking CSA to CMH in adulthood and (2) to estimate the magnitude of risk and protective factors associated with CMH among those exposed to CSA. METHODS: A sample of 17,014 respondents aged 20 years and older from the 2012 Canadian Community Health Survey-Mental Health was selected including 651 with a history of CSA. Path analysis was used to estimate indirect and direct pathways between CSA, a priori hypothesized risk and protective factors, and CMH. Multivariable logistic regression was then used to investigate the magnitude of effects of the same risk and protective factors on CMH among CSA survivors. RESULTS: After controlling for age, sex, race, education, and marital status, the association between CSA and CMH was mediated by lifetime depression, anxiety, substance abuse, chronic pain, and having a confidant. The strongest predictor of past-year CMH among those with a history of CSA was lifetime depression (OR 0.12, 95% CI 0.07-0.20) followed by having a confidant (OR 6.78, 95% CI 1.89-24.38). The odds of CMH was decreased by over three times among those with a history of substance misuse, and halved for those with lifetime anxiety and/or presence of pain. CONCLUSIONS: These findings suggest that CMH among survivors of CSA is related to social and emotional factors such as social support and lifetime history of mental health conditions. Future research should investigate the effectiveness of multilevel interventions for promoting recovery among CSA survivors.

Predicting Retention in HIV Primary Care: Is There a Missed Visits Continuum Based on Patient Characteristics?

Missing 3 + scheduled HIV primary care visits over a 1-year period increases mortality risk for people living with HIV (PLWH). We used electronic health data from PLWH (≥ 18 years old) at a southeastern US HIV clinic in 2016 to examine differences across patient-level characteristics and number of missed visits (1-2 vs. 0, 3 + vs. 0, 3 + vs. 1-2). In multivariable multinomial logistic regression analyses, poverty, lack of Ryan White HIV/AIDS Program support services, being uninsured, not having a high school degree, and being younger were significantly associated with 1-2 or 3 + missed visits (vs. 0 missed). Only poverty remained predictive of missing 3 + versus 1-2 visits (RR = 2.70, 95% CI 1.49-4.88). Patients at risk for missing 3 + visits present similar characteristics to patients who miss 1-2 visits. Interventions aimed at poverty reduction and increased access to education, health insurance, and support services may improve retention and, therefore, decrease mortality risk.

Expanding Knowledge About Implementation of Pre-exposure Prophylaxis (PrEP): A Methodological Review.

Methodological limitations in PrEP implementation studies may explain why PrEP implementation is lagging. This methodological review provides a description and critique of the methods used to identify barriers to PrEP implementation in the United States (2007-18). For each selected article, we provide: (1) research questions; (2) measures; (3) design; (4) sample (size and type); and (5) theoretical orientation. Among 79 articles which identified knowledge, attitudes, and behavioral and social/structural barriers to PrEP implementation, 51 (65%) were quantitative; 25 (32%) qualitative; and 3 (4%) were mixed-methods; overall, just one-half described a conceptual approach. About two-thirds of articles were conducted with patients and one-third with healthcare providers. Our review reveals a paucity of longitudinal, mixed-methods, and ethnographic/observational research and guiding theoretical frameworks; thus, the applicability of results are limited. We recommend that interventions aimed at PrEP implementation address barriers situated at multiple ecological domains, and thus improve PrEP access, uptake, and adherence.

A Latent Class Analysis of the Social Determinants of Health Impacting Heavy Alcohol Consumption Among Women Living with HIV in Canada: The Canadian HIV Women's Sexual and Reproductive Health Cohort Study.

We used longitudinal data from the 2013-2017 Canadian HIV Women's Sexual and Reproductive Health Cohort Study (N = 1422) to assess the clustered impact of social determinants of health (SDoH) on hazardous drinking. Two measures of alcohol use were defined: (i) weekly alcohol use, with > 7 drinks/week as heavy drinking, and (ii) monthly binge drinking (≥ 6 drinks at one sitting), with ≥ 1/month as frequent binging. Twelve SDoH indicators were classified using latent class analysis: no/least adversities, discrimination/stigma, economic hardship, and most SDoH adversities. Inverse-probability weighted multinomial logistic regression was used to report relative-risk ratio (RRR). Women living with HIV (WLWH) in no/least adversity class had a substantially lower likelihood of both heavy weekly alcohol use and frequent binging than those in discrimination/stigma, economic hardship, and most SDoH adversities classes, with RRR estimates ranging from 0.02 to 0.18. Findings indicate the need to address SDoH to reduce hazardous drinking among WLWH.

Gender-affirming healthcare experiences and medical transition among transgender women living with HIV: a mixed-methods study.

Background Transgender (trans) women are overrepresented among people living with HIV, yet trans women living with HIV (WLWH) experience lower access to HIV care. Access to medical transition may facilitate access to HIV care among trans WLWH. This study sought to describe barriers and facilitators to access to medical transition among trans WLWH. METHODS: This convergent parallel mixed-methods study drew on cross-sectional quantitative data from 48 trans WLWH analysed using descriptive and bivariate analyses, as well as qualitative semistructured interview data from a subsample of 11 participants analysed using framework analysis. The primary outcome was self-reported transition experience (completed or in the process of medical transition vs planning to but have not begun medical transition). Quantitative and qualitative results were merged and analysed for convergence, divergence and/or expansion of understanding. RESULTS: Just over half the participants reported being fully completed medical transition or in the process of medical transition (52.1% (25/48); 95% confidence interval (CI) 37.5-67.6%), with one-fifth reporting planning to but not having begun medical transition (18.8% (9/48); 95% CI 8.3-29.2%). Factors significantly associated with not having begun one's medical transition included housing instability, transphobia, HIV-related stigma and barriers in access to care. Qualitative findings revealed varied transition experiences, influenced by community norms, passing and class privilege, HIV and structural barriers. Mixed-methods results showed positive relationships between trans WLWH and HIV care providers in terms of trans and HIV health care. CONCLUSIONS: HIV-related stigma and social determinants of health limit access to medical transition for trans WLWH. Stigma must be addressed in a broad range of healthcare settings, in addition to structural barriers, to increase access to gender-affirming HIV care and medical transition for trans WLWH.

Factors Associated With Syphilis Testing and a History of Syphilis Infection Among a Sample of Transgender Women in Jamaica.

BACKGROUND: Globally, social inequalities contribute to elevated sexually transmitted infections (STIs) rates among transgender women. High syphilis prevalence has been documented among transgender women in Latin America. Little is known, however, of syphilis testing uptake among transgender women in Jamaica, where homosexuality is criminalized. The study objective was to understand factors associated with opting-in for syphilis testing and a syphilis infection history among transgender women in Jamaica. METHODS: We conducted a cross-sectional tablet-based survey of 137 transgender women between March and November 2015 in Jamaica. Bivariate analyses were used to assess differences across sociodemographic, intrapersonal, interpersonal, and structural factors based on syphilis infection history. We conducted univariable and multivariable logistic regression to determine the odds ratio for opting-in for syphilis testing for all factors associated with testing uptake at a P value of less than 0.05 in bivariate analyses, controlling for sociodemographic characteristics. RESULTS: Among 137 participants, 83 (60.6%) opted in for syphilis screening and 8 (9.6%) had positive rapid test results. One quarter of participants (n = 26; 25.2%) reported being HIV positive. Opting-in for syphilis testing was associated with the following: 1 health (HIV-positive serostatus: adjusted odds ratio [AOR], 4.33; 95% confidence interval [CI], 1.31-14.26), 1 intrapersonal (perceived STI risk: AOR, 1.58; 95% CI, 1.04-2.40), 1 interpersonal (childhood sexual abuse: AOR, 2.80; 95% CI, 1.03-7.62), and 1 structural (incarceration: AOR, 0.27; 95% CI, 0.11-0.71) factor. CONCLUSIONS: This study identified factors (HIV-positive serostatus, perceived STI risk, childhood sexual abuse, no incarceration history) associated with syphilis testing uptake among transgender women. Findings can inform multilevel STI testing, prevention, and care strategies tailored for transgender women in Jamaica.

HIV-related stigma, racial discrimination, and gender discrimination: Pathways to physical and mental health-related quality of life among a national cohort of women living with HIV.

Social inequities compromise health-related quality of life (HR-QoL) among women living with HIV (WLWH). Little is known about health impacts of intersecting stigma based on HIV status, race and gender among WLWH or potential mechanisms to promote HR-QoL. We tested pathways from multiple types of stigma (HIV-related, racial, gender) to physical and mental HR-QoL utilizing baseline survey data from a national cohort of WLWH in Canada (2013-2015). Structural equation modeling was conducted using maximum likelihood estimation methods to test the direct effects of HIV-related stigma, racial discrimination, and gender discrimination on HR-QoL and indirect effects via social support and economic insecurity, adjusting for socio-demographic factors. Among 1425 WLWH (median age: 43years [IQR=35-50]), HIV-related stigma and gender discrimination had significant direct effects on mental HR-QoL. Social support mediated the relationship between HIV-related stigma and mental HR-QoL, accounting for 22.7% of the effect. Social support accounted for 41.4% of the effect of gender discrimination on mental HR-QoL. Economic insecurity accounted for 14.3% of the effect of HIV-related stigma, and 42.4% of the effect of racial discrimination, on physical HR-QoL. Fit indices suggest good model fit (χ2[1]=3.319, p=0.069; CFI=0.998; RMSEA=0.042 (90% CI: 0-0.069); SRMR=0.004). Findings reveal complex relationships between intersecting stigma and HR-QoL. Strategies that address intersecting stigma and economic insecurity among WLWH may prevent the harmful impacts of HIV-related stigma and gender discrimination on physical HR-QoL. Increasing social support may mitigate the impacts of stigma on mental health. Findings can inform multi-level interventions to promote health and wellbeing among WLWH.

Sexual Orientation Differences in Health and Wellbeing Among Women Living with HIV in Canada: Findings from a National Cohort Study.

Sexual orientation differences in health and wellbeing among women living with HIV (WLH) are underexplored. Limited research available, however, suggests that sexual minority WLH may experience barriers to HIV care. Cross-sectional baseline data was analyzed from a Canadian cohort study with WLH (sexual minority women [SMW]: n = 180; heterosexual women: n = 1240). SMW (median age 38 years, IQR 13) included bisexual (58.9%), lesbian (17.8%) and other sexualities (23.3%). In multivariable analyses adjusting for age, poverty, education, and ethnicity, SMW identity was associated with increased odds of: clinical (80% vs. 100% antiretroviral adherence), intrapersonal (previous/current injection drug use [IDU] vs. no IDU history, depression, lower resilience), interpersonal (childhood abuse, sex work, adulthood abuse), and structural (HIV support services barriers, unstable housing, racial discrimination, gender discrimination) factors in comparison with heterosexual identity. Sexual minority WLH experience social and health disparities relative to heterosexual WLH, highlighting the need for interventions to promote health equity.

Contextualising sexual health practices among lesbian and bisexual women in Jamaica: a multi-methods study.

Limited research has examined lesbian and bisexual women's sexual health practices in the Caribbean, where lesbian and bisexual women experience sexual stigma that may reduce sexual healthcare utilisation. We conducted a sequential multi-method research study, including semi-structured individual interviews (n = 20) and a focus group (n = 5) followed by a cross-sectional survey (n = 205) with lesbian and bisexual women in Kingston, Montego Bay, and Ocho Rios, Jamaica. Binary logistic analyses and ordinal logistic regression were conducted to estimate the odds ratios for social-ecological factors associated with lifetime STI testing, sex work involvement, and the last time of STI testing. Over half of participants reported a lifetime STI test and of these, 6.1% reported an STI diagnosis. One-fifth of the sample reported ever selling sex. Directed content analysis of women's narratives highlighted that stigma and discrimination from healthcare providers, in combination with low perceived STI risk, limited STI testing access and safer sex practices. Participants described how safer sex self-efficacy increased their safer sex practices. Quantitative results revealed that a longer time since last STI test was positively associated with depression, sexual stigma, and forced sex, and negatively associated with residential location, perceived STI risk, safer sex self-efficacy, and LGBT connectedness. Selling sex was associated with perceived STI risk, relationship status, sexual stigma, food insecurity, and forced sex. Sexual health practices among lesbian and bisexual women in Jamaica are associated with intrapersonal, interpersonal, and structural factors, underscoring the urgent need for multi-level interventions to improve sexual health and advance sexual rights among lesbian and bisexual women in Jamaica.