The Risks for HIV and Sexually Transmitted Infections Among Men Who Have Sex with Men Who Engage in Chemsex in Low- and Middle-Income Countries: A Mixed Methods Systematic Review and Meta-Analysis.

Chemsex, the use of drugs during and/or prior to sex, has been found to increase the risk of HIV and sexually transmitted infections (STI) among men who have sex with men (MSM). Many studies and reviews on chemsex were focused among MSM in high-income countries (HIC), with less attention given to understanding chemsex in low- and middle-income countries (LMIC). We estimated the prevalence of chemsex and its association with sexual risk behaviors, HIV, and STI among MSM in LMIC. We searched MEDLINE, Embase, GlobalHealth, PsychINFO, and CINAHL for quantitative, qualitative, and mixed-methods studies describing chemsex and its association with sexual risk behaviors, HIV, and STI among MSM in LMIC, published January 1, 2000-October 15, 2023. We used the Mixed Methods Appraisal Tool to assess study quality. We developed a narrative review and performed meta-analysis using a random effects model and the DerSimonian and Laird approach (PROSPERO #CRD42022339663). Thirty-two studies from LMIC, particularly from Asia, Africa, Latin America, and the Middle East, were included. MSM who engaged in chemsex had higher prevalence of condomless anal intercourse, group sex, having multiple sexual partners, and of HIV and STI compared to MSM who did not. We estimated a pooled prevalence for recent chemsex (≤ 12 months) of 16% (95% CI 11%-22%, τ = 0.01, I2 = 99.07%, p < 0.01). Chemsex and its associated behaviors are associated with HIV and STI among MSM in LMIC. Integration of harm reduction and sexual health services and structural changes could prevent HIV and STI prevention among MSM who engage in chemsex in LMIC.

Epidemiologic and Clinical Features of Mpox in Adults Aged >50 Years - United States, May 2022-May 2023.

During May 2022-May 2023, approximately 30,000 mpox cases were reported in the United States, predominantly among young adult men. Persons aged >50 years might experience more severe mpox disease because of a higher prevalence of comorbidities. Conversely, they could have residual protection from childhood smallpox vaccination against monkeypox virus infection and severe mpox, as has been suggested by investigation of some previous mpox outbreaks. To examine the characteristics of mpox cases among adults aged >50 years, analysts compared mpox epidemiology and clinical outcomes among all adults aged ≥18 years, by age group. Further, outcomes were compared among adults aged >50 years by JYNNEOS vaccination status. During May 10, 2022-May 17, 2023, among 29,984 adults with probable or confirmed mpox reported to CDC, 2,909 (9.7%) were aged >50 years, 96.3% of whom were cisgender men. Compared with adults aged 18-50 years, adults aged >50 years had higher prevalences of immunocompromising conditions (p<0.001) and HIV infection (p<0.001). Among adults with mpox aged >50 years, 27.6% had received JYNNEOS vaccination; this group had lower prevalences of constitutional symptoms (p<0.001), pruritus (p<0.001), and hospitalization (p = 0.002) compared with those who had not received JYNNEOS vaccine. Currently recommended JYNNEOS vaccination among all adults at risk for mpox should be encouraged, irrespective of childhood smallpox vaccination status.

Outcomes of a community-led online-based HIV self-testing demonstration among cisgender men who have sex with men and transgender women in the Philippines during the COVID-19 pandemic: a retrospective cohort study.

INTRODUCTION: The Philippines, which has the fastest rising HIV epidemic globally, has limited options for HIV testing and its uptake remains low among cisgender men who have sex with men (cis-MSM) and transgender women (TGW), especially amid the COVID-19 pandemic. As HIV self-testing (HIVST) and technology-based approaches could synergize to expand uptake of HIV testing, we aimed to evaluate the outcomes of a community-led online-based HIVST demonstration and to explore factors associated with HIVST-related behaviours and outcomes. METHODS: We did a secondary data analysis among cis-MSM and TGW who participated in the HIVST demonstration, who were recruited online and tested out-of-facility, in Western Visayas, Philippines, from March to November 2020. We reviewed data on demographics, sexuality-, and context-related variables. Using multivariable logistic regression, we tested for associations between the aforementioned covariates and two primary outcomes, opting for directly-assisted HIVST (DAH) and willingness to secondarily distribute kits. RESULTS: HIVST kits were distributed to 647 individuals (590 cis-MSM, 57 TGW), 54.6% were first-time testers, 10.4% opted DAH, and 46.1% were willing to distribute to peers. Reporting rate was high (99.3%) with 7.6% reactivity rate. While linkage to prevention (100%) and care (85.7%) were high, pre-exposure prophylaxis (PrEP) (0.3%) and antiretroviral therapy (ART) (51.0%) initiation were limited. There were no reports of adverse events. Those who were employed, had recent anal intercourse, opted for DAH, not willing to secondarily distribute, and accessed HIVST during minimal to no quarantine restriction had significantly higher reactivity rates. Likelihood of opting for DAH was higher among those who had three or more partners in the past year (aOR = 2.01 [CI = 1.01-4.35]) and those who accessed during maximal quarantine restrictions (aOR = 4.25 [CI = 2.46-7.43]). Odds of willingness to share were higher among those in urban areas (aOR = 1.64 [CI = 1.15-2.36]) but lower among first-time testers (aOR = 0.45 [CI = 0.32-0.62]). CONCLUSIONS: HIVST could effectively reach hard-to-reach populations. While there was demand in accessing online-based unassisted approaches, DAH should still be offered. Uptake of PrEP and same-day ART should be upscaled by decentralizing these services to community-based organizations. Differentiated service delivery is key to respond to preferences and values of key populations amid the dynamic geographical and sociocultural contexts they are in.

Non-uptake of HIV testing among trans men and trans women: cross-sectional study of client records from 2017 to 2019 in a community-based transgender health center in Metro Manila, Philippines.

BACKGROUND: Transgender individuals are considered at high risk of contracting HIV infection. Integrating HIV testing and counseling (HTC) services into current transgender health programs is necessary to increase its uptake. Our study aimed to describe the characteristics of trans men (TM) and trans women (TW) who accessed HTC services in a community-based transgender health center in Metro Manila, Philippines, and to examine the relationship between gender identity and their non-uptake of HIV testing.  METHODS: We conducted a cross-sectional study of TM and TW seeking care from 2017 to 2019. Medical records of clients were reviewed to ascertain their age, gender identity, year and frequency of clinic visits, lifestyle factors, and non-uptake of HIV testing. The effect of gender identity on the non-uptake of HIV testing was estimated using a generalized linear model with Poisson distribution, log link function, and a robust variance, adjusted for confounding variables.  RESULTS: Five hundred twenty-five clients were included in the study, of which about 82.3% (432/525) of the clients declined the HTC services being offered. In addition, the prevalence of non-uptake of HIV testing was 48% higher (Adjusted Prevalence Ratio: 1.48; 95% Confidence Interval: 1.31-1.67) among TM compared to TW. Approximately 3.7% (1/27) and 10.6% (7/66) of the TM and TW, respectively, who accessed the HTC services were reactive. Moreover, most reactive clients were on treatment 87.5% (7/8); three were already virally suppressed, four were on ART but not yet virally suppressed, and one TW client was lost to follow up. CONCLUSION: The non-uptake of HTC service of TM and TW is high. HIV program implementers should strategize solutions to reach this vulnerable population for increased and better HTC service uptake and linkage to care.

Social Support and the Association Between Certain Forms of Violence and Harassment and Suicidal Ideation Among Transgender Women - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020.

Violence and harassment toward transgender women are associated with suicidal thoughts and behaviors, and social support might moderate such association. This analysis explored the association between certain forms of violence and harassment and suicidal ideation and moderation by social support. Better understanding of these associations could guide mental health services and structural interventions appropriate to lived experiences of transgender women. This cross-sectional analysis used data from CDC's National HIV Behavioral Surveillance Among Transgender Women. During 2019-2020, transgender women were recruited via respondent-driven sampling from seven urban areas in the United States for an HIV biobehavioral survey. The association between experiencing certain forms of violence and harassment (i.e., gender-based verbal and physical abuse or harassment, physical intimate partner abuse or harassment, and sexual violence) and suicidal ideation was measured using adjusted prevalence ratios and 95% CIs generated from log-linked Poisson regression models controlling for respondent-driven sampling design and confounders. To examine moderation, the extents of social support from family, friends, and significant others were assessed for interaction with certain forms of violence and harassment; if p interaction was <0.05, stratified adjusted prevalence ratios were presented. Among 1,608 transgender women, 59.7% experienced certain forms of violence and harassment and 17.7% reported suicidal ideation during the past 12 months; 75.2% reported high social support from significant others, 69.4% from friends, and 46.8% from family. Experiencing certain forms of violence and harassment and having low-moderate social support from any source was associated with higher prevalence of suicidal ideation. Social support from family moderated the association between experiencing certain forms of violence and harassment and suicidal ideation (p interaction = 0.01); however, even in the presence of high family social support, experiencing certain forms of violence and harassment was associated with higher prevalence of suicidal ideation. Social support did not completely moderate the positive association between experiencing violence and harassment and suicidal ideation. Further understanding of the social support dynamics of transgender women might improve the quality and use of social support. Policymakers and health care workers should work closely with transgender women communities to reduce the prevalence of violence, harassment, and suicide by implementing integrated, holistic, and transinclusive approaches.

The Association Between Sexual Violence and Suicidal Ideation Among Transgender Women and the Role of Gender-Affirming Healthcare Providers in Seven Urban Areas in the United States, 2019 to 2020.

Transgender women are disproportionately affected by sexual violence and corresponding mental health sequelae; however, many do not access healthcare due to experiences with transphobia. This analysis evaluated the association between sexual violence and suicidal ideation and the moderating effect of having a healthcare provider (HCP) with whom transgender women were comfortable discussing gender-related issues ("gender-affirming HCP"). We analyzed cross-sectional data from the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance among Transgender Women (NHBS-Trans). Transgender women were recruited using respondent-driven sampling from seven urban areas from 2019 to 2020 and participated in an HIV biobehavioral survey. This analysis was restricted to transgender women who visited a HCP in the past 12 months ("healthcare-seeking transgender women" [HSTW]) (N = 1,489). Log-linked Poisson regression models provided adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) to estimate the association between sexual violence and suicidal ideation in the past 12 months. The interaction between sexual violence and having a gender-affirming HCP was statistically significant (p-value = .034). Among 1,489 HSTW, 225 (15.1%) experienced sexual violence and 261 (17.5%) reported suicidal ideation; 1,203 (80.8%) reported having a gender-affirming HCP. Sexual violence was associated with suicidal ideation (aPR = 2.65, 95% CI [2.08, 3.38]); the association was notably higher among those who did not have a gender-affirming HCP (aPR = 3.61, [2.17, 6.02]) than among those who did (aPR = 1.87, [1.48, 2.37]). Eliminating transphobia and promoting trauma- and violence-informed approaches in healthcare are necessary for sexual violence and suicide prevention among HSTW.

The State of the HIV Epidemic in the Philippines: Progress and Challenges in 2023.

In the past decade, the Philippines has gained notoriety as the country with the fastest-growing human immunodeficiency virus (HIV) epidemic in the Western Pacific region. While the overall trends of HIV incidence and acquired immunodeficiency syndrome (AIDS)-related deaths are declining globally, an increase in new cases was reported to the HIV/AIDS and ART Registry of the Philippines. From 2012 to 2023, there was a 411% increase in daily incidence. Late presentation in care remains a concern, with 29% of new confirmed HIV cases in January 2023 having clinical manifestations of advanced HIV disease at the time of diagnosis. Men having sex with men (MSM) are disproportionately affected. Various steps have been taken to address the HIV epidemic in the country. The Philippine HIV and AIDS Policy Act of 2018 (Republic Act 11166) expanded access to HIV testing and treatment. HIV testing now allows for the screening of minors 15-17 years old without parental consent. Community-based organizations have been instrumental in expanding HIV screening to include self-testing and community-based screening. The Philippines moved from centralized HIV diagnosis confirmation by Western blot to a decentralized rapid HIV diagnostic algorithm (rHIVda). Dolutegravir-based antiretroviral therapy is now the first line. Pre-exposure prophylaxis in the form of emtricitabine-tenofovir disoproxil fumarate has been rolled out. The number of treatment hubs and primary HIV care facilities continues to increase. Despite these efforts, barriers to ending the HIV epidemic remain, including continued stigma, limited harm reduction services for people who inject drugs, sociocultural factors, and political deterrents. HIV RNA quantification and drug resistance testing are not routinely performed due to associated costs. The high burden of tuberculosis and hepatitis B virus co-infection complicate HIV management. CRF_01AE is now the predominant subtype, which has been associated with poorer clinical outcomes and faster CD4 T-cell decline. The HIV epidemic in the Philippines requires a multisectoral approach and calls for sustained political commitment, community involvement, and continued collaboration among various stakeholders. In this article, we outline the current progress and challenges in curbing the HIV epidemic in the Philippines.

Prevalence of and factors associated with the use of gender-affirming hormonal therapy outside the reference regimen among transgender people in a community-led clinic in Metro Manila, Philippines: a retrospective cross-sectional study.

OBJECTIVES: We aimed to describe the gender-affirming hormonal therapy (GAHT) intake behaviour and regimen and the factors associated with the use of hormones inconsistent with reference GAHT regimen among transgender people in the Philippines. DESIGN: Cross-sectional study. SETTING: Transgender community clinic in Metro Manila, Philippines from March 2017 to December 2019. PARTICIPANTS: Gender-affirming care-seeking individuals of at least 18 years old, who self-identified as transgender or non-binary, and who self-reported current or previous use of GAHT at baseline consult. PRIMARY OUTCOME MEASURES: Reported drugs and/or administration routes not congruent with the World Professional Association for Transgender Health Standard of Care eighth edition were classified as hormone use outside the reference regimen. RESULTS: 253 transgender people reported current or previous intake of GAHT. Many trans women and transfeminine people (TWTFP; 58.9%, 86/146) reported using oral contraceptive pills (OCPs), whereas most trans men (TM; 73.8%, 79/107) reported injecting testosterone esters. Furthermore, 59.7% (151/253) used hormones outside the reference regimen, widely using OCP and anabolic steroids among TWTFP and TM, respectively. TWTFP (crude prevalence ratio, PR, 3.52; 95% CI 2.35 to 5.49) and those who take unprescribed GAHT (crude PR 2.37; 95% CI 1.08 to 6.68) were more likely to use hormones outside the reference regimen than TM and taking healthcare provider-prescribed GAHT, respectively. On adjusting for covariates, the prevalence of using hormones outside the reference regimen was approximately three times higher (adjusted PR 3.22; 95% CI 2.09 to 5.12) among TWTFP than TM. CONCLUSION: Trans people act on their high unmet gender-affirming care needs by taking unprescribed GAHT, many outside the reference regimen. Structural changes in the health system are warranted, including strengthened community-based self-administration practices.

Prevalence and Factors Associated With Gender-Affirming Surgery Among Transgender Women & Transgender Men in a Community-Based Clinic in Metro Manila, Philippines: A Retrospective Study.

BACKGROUND: More information is needed about gender-affirming surgery (GAS) in the Philippines because of many self- or peer-prescribed gender-affirming procedures among transgender people. AIM: To assess the desire of transgender adults for GAS, determined the prevalence, and evaluated factors associated with the desire. METHODS: We did a retrospective study of medical charts of 339 transgender men (TGM) and 186 transgender women (TGW) who attended clinical services at Victoria by LoveYourself, a transgender-led community-based clinic in Metro Manila, from March 2017 to December 2019. The medical charts were reviewed to ascertain data on gender dysphoria (GD), clinical and sociodemographic characteristics, health-seeking behaviors, and gender-affirmation-related practices, including the use of gender-affirming hormone therapy (GAHT). We also estimated the prevalence and explored factors associated with the desire for GAS using generalized linear models with a Poisson distribution, log link function, and a robust variance. MAIN OUTCOME MEASURES: Our primary outcome was the self-reported desire for GAS. RESULTS: Almost half were already on GAHT, of whom 93% were self-medicating. Our study's prevalence of GD is 95% and nearly 3 in 4 desire GAS. The prevalence of desiring GAS was related to the specific surgical procedure chosen. Transgender adults opting for breast surgery and genital surgeries have 8.06 [adjusted prevalence ratio, (aPR): 8.06; 95% Confidence Interval, (CI): 5.22-12.45; P value < .001] and 1.19 (aPR: 1.19; 95% CI: 1.11-1.28; P value < .001) times higher prevalence of GAS desire, respectively, compared with otherwise not opting for those procedures. Moreover, the prevalence of GAS desire was higher among patients with GD (aPR 1.09; 95% CI: 1.01-1.18; P value = .03) than individuals without GD. CLINICAL TRANSLATION: Providers' awareness of patients' desires, values, and health-seeking preferences could facilitate differentiated guidance on their gender affirmation. STRENGTHS AND LIMITATIONS: This quantitative study is the first to explore gender-affirming practices among transgender adults in the Philippines and provide significant insights into their healthcare needs. Our study focused only on TGM and TGW and did not reflect the other issues of transgender people outside of Metro Manila, Philippines. Furthermore, our retrospective study design may have missed essential predictors or factors not captured in the medical charts; hence, our study could never dismiss confounding factor bias due to unmeasured or residual confounding factors. CONCLUSIONS: There is a high prevalence of self- and peer-led attempts from TGM and TGW to facilitate the gender transition, with the desire for GAS being significantly associated with GD and by which specific surgical procedure is chosen. Eustaquio PC, Castelo AV, Araña YS et al. Prevalence and Factors Associated With Gender-Affirming Surgery Among Transgender Women & Transgender Men in a Community-Based Clinic in Metro Manila, Philippines: A Retrospective Study. Sex Med 2022;10:100497.

HIV care cascade among cisgender men who have sex with men in a key population-led community center in the Philippines.

The HIV epidemic in the Philippines is the fastest growing globally, and disproportionately affects cisgender men who have sex with men (cis-MSM) demanding effective strategies for this key population (KP) group. KP-specific and community-based (CB) interventions have improved the HIV response elsewhere, but these have yet to be evaluated locally. We analyzed the HIV care cascade outcomes in a KP-led, CB HIV test-and-treat center and determined factors that affect these by performing a retrospective study of medical records of 3137 patients diagnosed from January 2016 to March 2019 in LoveYourself in Manila, Philippines. Multivariate logistic regression was performed to determine predictors affecting the likelihood of antiretroviral therapy (ART) initiation and viral load (VL) suppression. As to UNAIDS 90-90-90 targets, LoveYourself had higher rates than national outcomes with 78% initiated ART and 84% achieved VL suppression. Such satisfactory performance is consistent with other studies exploring CB, KP-led approaches among cis-MSM. Patients who presented with WHO Stages 2-4 and those with sexually transmitted infections were less likely to initiate ART. Patients who presented with WHO Stages 2-4 and those whose ART was started late were less likely to be virally suppressed. These findings suggest the need to develop responsive interventions to reach the UNAIDS targets.