A cross-sectional analysis of psychosocial and structural barriers and facilitators associated with PrEP use among a sample of transgender women in Chicago, IL.

BACKGROUND: Expanding pre-exposure prophylaxis (PrEP) among transgender women in the United States is an important strategy to meet national HIV prevention goals, however self-reported use of PrEP is low in this group. METHODS: This study reports the findings of a cross-sectional analysis of the relationship of barriers as well as facilitators to recent PrEP use among transgender women enrolled in an evaluation of the TransLife Care project (Chicago, Illinois), a structural intervention designed to meet basic needs. We computed multivariable prevalence ratios for barriers, facilitators and recent PrEP use, controlling for demographics. RESULTS: Findings suggest that psychosocial and structural barriers, including moderate/high alcohol use, stimulant use, and history of incarceration were all positively associated with recent PrEP use among urban transgender women. In addition, a psychosocial facilitator, gender affirmation, was positively associated with recent PrEP use, while, while collective self-esteem, a was negatively associated with it. Finally, common indications for PrEP have high sensitivity, but low specificity and predictive value for identifying those on PrEP. CONCLUSION: We conclude that despite a large gap in PrEP use among those with indications, individuals experiencing psychosocial and structural barriers are more likely to use PrEP, and facilitators, such as psychological sense of affirmed gender may support its use. TRIAL REGISTRATION: N/A.

Evaluation of Translife Care: An Intervention to Address Social Determinants of Engagement in HIV Care Among Transgender Women of Color.

The TransLife Care (TLC) project was developed to address the structural factors that act as barriers to HIV care among transgender women of color. The purpose of this study was to evaluate the feasibility and initial efficacy of the TLC project; primary HIV care outcomes included linkage to HIV care, engagement in care, retention in care, use of ART and viral suppression among N = 120 participants. In multivariable analysis, receipt of the intervention (versus none), was associated with any HIV care visit (aOR 2.05; 95% CI 1.25-3.37; p = 0.005), more total HIV care visits (aRR 1.45; 95% CI 1.09-1.94; p = 0.011), being retained in care (aOR 1.58; 95% CI 1.03-2.44; p = 0.038), and having a viral load test done (aOR 1.95; 95% CI 1.23-3.09; p = 0.004). We conclude that a structural intervention, designed and delivered by the focus population, that directly addresses social determinants, is feasible and efficacious to promote HIV care engagement among transgender women of color.

RESUMEN: El proyecto TransLife Care (TLC) se desarrolló para abordar los factores estructurales que actúan como barreras para la atención médica del VIH entre las mujeres transgénero de color. El propósito de este estudio fue evaluar la viabilidad y la eficacia inicial del proyecto TLC; los resultados primarios de la atención médica del VIH incluyeron el vínculo con la atención médica del VIH, la retención en la atención médica, el uso de ART y la supresión viral entre N = 120 participantes. En el análisis multivariable, la recepción de la intervención (versus ninguna) se asoció con la participación en la atención médica (aOR 2.05, IC 95% 1.25­3.37, p = 0.005), más visitas totales al VIH (aRR 1.45, IC 95% 1.09­1.94, p = 0.011), se mantuvo en la atención médica (aOR 1.58; IC 95%: 1.03 - 2.44; p = 0.038) y se realizó una prueba de carga viral (aOR 1.95; IC 95%: 1.23 - 3.09; p = 0.004). Concluimos que una intervención estructural, diseñada y ejecutada por la población de enfoque, que aborda directamente los determinantes sociales, es factible y eficaz para promover el compromiso de la atención del VIH entre las mujeres transgénero de color.

Patterns of Exposure to Socio-structural Stressors and HIV Care Engagement Among Transgender Women of Color.

Transgender women are disproportionately affected by HIV and experiences of social adversity that may interfere with engagement in care and viral suppression. We used latent class analysis to examine patterns of social adversity and their impact on HIV care continuum outcomes in an urban sample of transgender women of color. Participants (n = 224) were median age 29 and 86% non-Hispanic Black. Lack of resources, unemployment, and housing instability were reported by over 50%, and 41% reported history of incarceration. Latent class analysis identified 2 distinct classes representing higher and lower levels of social adversity. In latent class regression, membership in the higher social adversity class was associated with statistically significantly lower odds of viral suppression and HIV care engagement in univariate analysis; when adjusted for age, race, and recruitment site the association remained statistically significant for viral suppression (aOR 0.38, 95% CI 0.18-0.79; chi-square = 6.681, d.f. = 1, p = 0.010), though not for HIV care engagement. Our findings highlight the impact of socio-structural barriers on engagement in the HIV care continuum among transgender women.

RESUMEN: Las mujeres transgénero son desproporcionadamente afectadas por el VIH y las experiencias de adversidad social que pueden interferir con la participación en la atención medica y la supresión viral. Utilizamos un análisis de clase latente para examinar los patrones de adversidad social y su impacto en los resultados continuos de la atención medica del VIH en una muestra urbana de mujeres transgénero de color. Los participantes (n = 224) tenían una mediana de edad de 29 años y 86% negros no hispanos. La falta de recursos, el desempleo y la inestabilidad de la vivienda fueron reportados en más del 50%, y el 41% reportó antecedentes de encarcelamiento. El análisis de clase latente identificó 2 clases distintas que representan niveles más altos y más bajos de adversidad social. En la regresión de clase latente, la pertenencia a la clase de mayor adversidad social se asoció con probabilidades estadísticamente significante más bajas de supresión viral y participación en la atención medica del VIH en el análisis univariante; cuando se ajustó por edad, raza y sitio de reclutamiento, la asociación siguió siendo estadísticamente significativa para la supresión viral (aOR 0.38, IC 95% 0.18­0.79; chi-cuadrado = 6.681, df = 1, p = 0.010), aunque no para la participación en la atención medica del VIH. Nuestros hallazgos destacan el impacto de las barreras socioestructurales en la participación en el continuo de atención medica del VIH entre las mujeres transgénero.

An Evaluation of TransLife Care: A Locally Developed Structural HIV Prevention Intervention for Transgender Women in Chicago, Illinois.

Transgender women are disproportionately impacted by HIV infection. We report herein the findings of a pre-post evaluation of the TransLife Care (TLC) project in Chicago, Illinois, on behaviors associated with HIV transmission among transgender women. Participants who received any TLC component versus those who did not were compared using mixed-effects logistic regression with random intercepts across follow-up time points. Ninety-seven participants aged 18 to 59 (median age 24) enrolled; 76.3% were transgender women of color. There was a decrease in condomless sex without consistent PrEP use at 8 months, which was not significantly different between those who did and did not receive the TLC intervention, controlling for calendar time. Evidence does not indicate that the TLC reduces condomless sex without PrEP protection among urban transgender women. However, given the preponderance of evidence of the influence of structural barriers on condomless sex, future research should continue to test the efficacy of structural interventions.

Evaluating Locally Developed Interventions to Promote PrEP Among Racially/Ethnically Diverse Transgender Women in the United States: A Unique CDC Initiative.

In the United States, transgender women are disproportionately affected by HIV. However, few evidence-based prevention interventions exist for this key population. We describe two promising, locally developed interventions that are currently being implemented and evaluated through the Centers for Disease Control and Prevention Combination HIV Prevention for Transgender Women Project: (a) ChiCAS, designed to promote the uptake of pre-exposure prophylaxis (PrEP), condom use, and medically supervised hormone therapy among Spanish-speaking transgender Latinas, and (b) TransLife Care, designed to address the structural drivers of HIV risk through access to housing, employment, legal services, and medical services, including HIV preventive care (e.g., PrEP use) among racially/ethnically diverse urban transgender women. If the evaluation trials determine that these interventions are effective, they will be among the first such interventions for use with transgender women incorporating PrEP, thereby contributing to the evidence-based resources that may be used to reduce HIV risk among this population.