The forecasted prevalence of comorbidities and multimorbidity in people with HIV in the United States through the year 2030: A modeling study.

BACKGROUND: Estimating the medical complexity of people aging with HIV can inform clinical programs and policy to meet future healthcare needs. The objective of our study was to forecast the prevalence of comorbidities and multimorbidity among people with HIV (PWH) using antiretroviral therapy (ART) in the United States (US) through 2030. METHODS AND FINDINGS: Using the PEARL model-an agent-based simulation of PWH who have initiated ART in the US-the prevalence of anxiety, depression, stage ≥3 chronic kidney disease (CKD), dyslipidemia, diabetes, hypertension, cancer, end-stage liver disease (ESLD), myocardial infarction (MI), and multimorbidity (≥2 mental or physical comorbidities, other than HIV) were forecasted through 2030. Simulations were informed by the US CDC HIV surveillance data of new HIV diagnosis and the longitudinal North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) data on risk of comorbidities from 2009 to 2017. The simulated population represented 15 subgroups of PWH including Hispanic, non-Hispanic White (White), and non-Hispanic Black/African American (Black/AA) men who have sex with men (MSM), men and women with history of injection drug use and heterosexual men and women. Simulations were replicated for 200 runs and forecasted outcomes are presented as median values (95% uncertainty ranges are presented in the Supporting information). In 2020, PEARL forecasted a median population of 670,000 individuals receiving ART in the US, of whom 9% men and 4% women with history of injection drug use, 60% MSM, 8% heterosexual men, and 19% heterosexual women. Additionally, 44% were Black/AA, 32% White, and 23% Hispanic. Along with a gradual rise in population size of PWH receiving ART-reaching 908,000 individuals by 2030-PEARL forecasted a surge in prevalence of most comorbidities to 2030. Depression and/or anxiety was high and increased from 60% in 2020 to 64% in 2030. Hypertension decreased while dyslipidemia, diabetes, CKD, and MI increased. There was little change in prevalence of cancer and ESLD. The forecasted multimorbidity among PWH receiving ART increased from 63% in 2020 to 70% in 2030. There was heterogeneity in trends across subgroups. Among Black women with history of injection drug use in 2030 (oldest demographic subgroup with median age of 66 year), dyslipidemia, CKD, hypertension, diabetes, anxiety, and depression were most prevalent, with 92% experiencing multimorbidity. Among Black MSM in 2030 (youngest demographic subgroup with median age of 42 year), depression and CKD were highly prevalent, with 57% experiencing multimorbidity. These results are limited by the assumption that trends in new HIV diagnoses, mortality, and comorbidity risk observed in 2009 to 2017 will persist through 2030; influences occurring outside this period are not accounted for in the forecasts. CONCLUSIONS: The PEARL forecasts suggest a continued rise in comorbidity and multimorbidity prevalence to 2030, marked by heterogeneities across race/ethnicity, gender, and HIV acquisition risk subgroups. HIV clinicians must stay current on the ever-changing comorbidities-specific guidelines to provide guideline-recommended care. HIV clinical directors should ensure linkages to subspecialty care within the clinic or by referral. HIV policy decision-makers must allocate resources and support extended clinical capacity to meet the healthcare needs of people aging with HIV.

Health of two-spirit, lesbian, gay, bisexual and transgender people experiencing poverty in Canada: a review.

Two-spirit, lesbian, gay, bisexual and transgender (2SLGBTQ+) people are disproportionately represented among those experiencing poverty. Both 2SLGBTQ+ people and people experiencing poverty face poorer health outcomes and greater difficulty accessing healthcare. Evidence of intersectional impacts of 2SLGBTQ+ status and poverty on health can help to inform economic and health policy. The objective of this review is to determine what is known about the health of 2SLGBTQ+ people in Canada experiencing poverty. Following the PRISMA framework, we searched and summarized Canadian literature on 2SLGBTQ+ poverty indexed in Medline, Sociological Abstracts, PsycInfo and EconList (N = 33). 2SLGBTQ+ poverty-related literature remains sparse but is expanding as illustrated by the fact that most (31/33) studies were published in the past decade. Half the studies analysed poverty as a focal variable and half as a covariate. Intersectionality theory assists in understanding the three health-related themes identified-healthcare access, physical health and mental health and substance use-as these outcomes are shaped by intersecting social structures that result in unique forms of discrimination. Those at the intersection of poverty and 2SLGBTQ+ status face poorer health outcomes than other 2SLGBTQ+ people in Canada. Discrimination was an overarching finding that explained persistent associations between 2SLGBTQ+ status, poverty and health. Research that directly interrogated the experiences of 2SLGBTQ+ populations experiencing poverty was sparse. In particular, there is a need to conduct research on underrepresented 2SLGBTQ+ sub-groups who are disproportionately impacted by poverty, including transgender, bisexual and two-spirit populations.

Two-spirit, lesbian, gay, bisexual and transgender (2SLGBTQ+) people experience poverty much more than the general population. 2SLGBTQ+ people and people experiencing poverty face poorer health and greater difficulty accessing healthcare. Studies focussing on the impacts of 2SLGBTQ+ status and poverty on health can help inform policy. We sought to find out what is known about the health of 2SLGBTQ+ people in Canada experiencing poverty. Following systematic guidelines, we searched and summarized literature on 2SLGBTQ+ poverty from a variety of online databases. 2SLGBTQ+ poverty research remains sparse but is growing, demonstrated by most studies being published in the past decade. Half the studies explicitly focussed on poverty and the other half did not. Intersectionality helped to understand the health-related themes identified­healthcare access, physical health and mental health and substance use­as these outcomes are shaped by unique forms of oppression. 2SLGBTQ+ people experiencing poverty face poorer health than other 2SLGBTQ+ people in Canada. Discrimination was an overarching finding that explained consistent connections between 2SLGBTQ+ status, poverty and health. Research that directly questioned the experiences of 2SLGBTQ+ people experiencing poverty was limited. Research is needed on underrepresented 2SLGBTQ+ sub-groups who face higher rates of poverty, including transgender, bisexual and two-spirit populations.

Age, period, and cohort patterns in the epidemiology of suicide attempts among sexual minorities in the United States and Canada: detection of a second peak in middle adulthood.

PURPOSE: Sexual minority adults experience fivefold greater risk of suicide attempt, as compared with heterosexuals. Establishing age-specific epidemiological patterns of suicide is a prerequisite to planning interventions to redress the sexual orientation suicide inequity, and such patterns must be carefully interpreted in light of correlated period and cohort effects. We, therefore, combined US and Canadian data (1985-2017) from primary (two pooled multi-year national surveys, N = 15,477 and N = 126,463) and secondary (published, meta-analytic, N = 122,966) sources to separately estimate age, period, and cohort trends in self-reported suicide attempts among sexual minorities. METHODS: Age- and gender-stratified cross-sectional data were used to infer age and cohort effects. Age-collapsed meta-analyzed data were used to infer period effects among sexual minorities of all genders. RESULTS: We identified a bimodal age distribution in recent suicide attempts for sexual minorities across genders, though more pronounced among sexual minority men: one peak in adolescence (18-20 years of age for both genders) and one peak nearing mid-life (30-35 years of age for men; 35-40 years of age for women). This pattern was also apparent using recall data within birth cohorts of sexual minority men, suggesting it is not an artifact of birth cohort effects. Finally, we observed decreasing trends in lifetime suicide attempt prevalence estimates for both sexual minorities and heterosexuals, though these decreases did not affect the magnitude of the sexual orientation disparity. CONCLUSION: In the context of exclusively adolescent-focused suicide prevention interventions for sexual minorities, tailored suicide prevention for sexual minority adults should be pursued throughout the life course.

Longitudinal Analysis of HIV Risk and Substance Use Patterns for Men Who Have Sex with Men and Women and Men Who Have Sex with Men Only.

Men Who Have Sex with Men and Women (MSMW) experience discrimination from same-sex and heterosexual communities partially because of perceptions they feature high-risk sexual behavior, elevated polysubstance use levels, and constitute an HIV bridge population. We used a longitudinal multivariate generalized linear mixed model comparing sexual risk and substance use patterns for Men Who Have Sex with Men Only (MSMO) with MSMW in the same cohort study. Data consisted of 771 men reporting 3,705 sexual partnerships from 2012-2017. For high-risk sexual behavior multivariate results showed non-significant (p>0.05) differences for partner number and commercial sex work, and significantly less (p<0.05) HIV prevalence and condomless anal sex. However, MSMW had significantly higher levels of hallucinogen and prescription opioid use, and substance treatment histories. Only one HIV-positive MSMW had a transmittable viral load, negating the concept of an HIV bridge population. Results indicate the need for additional longitudinal studies comparing MSMO and MSMW.

Characterizing the Human Immunodeficiency Virus Care Continuum Among Transgender Women and Cisgender Women and Men in Clinical Care: A Retrospective Time-series Analysis.

BACKGROUND: Prior studies suggest that transgender women (TW) with human immunodeficiency virus (HIV) are less likely to be virally suppressed than cisgender women (CW) and cisgender men (CM). However, prior data are limited by small sample sizes and cross-sectional designs. We sought to characterize the HIV care continuum comparing TW to CW and CM in the United States and Canada. METHODS: We analyzed annual HIV care continuum outcomes by gender status from January 2001 through December 2015 among adults (aged ≥18 years) in 15 clinical cohorts. Outcomes were retention in care and viral suppression. RESULTS: The study population included TW (n = 396), CW (n = 14 094), and CM (n = 101 667). TW had lower proportions retained in care than CW and CM (P < .01). Estimates of retention in care were consistently lower in TW, with little change over time within each group. TW and CW had similar proportions virally suppressed over time (TW, 36% in 2001 and 80% in 2015; CW, 35% in 2001 and 83% in 2015) and were lower than CM (41% in 2001 and 87% in 2015). These differences did not reach statistical significance after adjusting for age, race, HIV risk group, and cohort. CONCLUSIONS: TW experience challenges with retention in HIV care. However, TW who are engaged in care achieve viral suppression that is comparable to that of CW and CM of similar age, race, and HIV risk group. Further research is needed to understand care engagement disparities.

Substance Use as a Mechanism for Social Inclusion among Gay, Bisexual, and Other Men Who Have Sex with Men in Vancouver, Canada.

Background: Previous research demonstrates that substance use preferences and social-sexual environments are highly interrelated for gay, bisexual, and other men who have sex with men (gbMSM). Objective: We conducted a qualitative study to explore the socio-cultural context of substance use among local gbMSM communities in Metro Vancouver, Canada. Methods: Twenty gbMSM were purposively sampled from the larger Momentum Health Study cohort, a sexual health study of gbMSM in Greater Vancouver. Participants were demographically diverse in terms of HIV serostatus, age, income, ethnicity, and area of residence within the city and neighboring suburbs. Community maps generated by participants during formative research served as prompts for semi-structured interviews which were audio recorded and transcribed verbatim. Thematic analysis identified three themes of common experience. Results: First, participants indicated that substance use is intrinsically social in Vancouver gbMSM communities and that it functions as both a means of social inclusion and exclusion. Second, a distinction was made between types of substances and the location and context of their use, with specific substances having particular uses and meanings. Third, analysis suggested that gbMSM change their substance use over the life course and that this is affected by shifting priorities as people age. Discussion: For Vancouver gbMSM communities, substance use serves several social-cultural functions and can simultaneously serve as both a potential facilitator and barrier for community connection. Future research and health programing should consider venue and context specific messaging and recognize the heterogeneity of substance use within the larger gbMSM population.

Perceived Barriers to Mental Health Services Among Canadian Sexual and Gender Minorities with Depression and at Risk of Suicide.

This study examines barriers to mental health services among sexual and gender minorities (SGM) who screened positive for depression and risk of suicide. Data from an online survey of SGM (N = 2778) are analyzed. 37.5% met criteria for depression and 73.6% screened for being at risk of suicide. The most frequently cited barriers to mental health services access were inability to pay (62.3%), insufficient insurance (52.2%), a preference for 'waiting' for the problems to go away (51.5%), discomfort discussing emotions (45.7%), and feeling embarrassed and ashamed about mental health challenges (42.5%). Policy and practices implications of these findings are discussed.

The Need and Desire for Mental Health and Substance Use-Related Services Among Clients of Publicly Funded Sexually Transmitted Infection Clinics in Vancouver, Canada.

CONTEXT: Sexually transmitted infections (STI) and mental health and substance use (MHSU) disorders all occur at elevated rates in sexual and gender minorities. These overlapping epidemics, or syndemics, are exacerbated by challenges these same populations face in accessing sexual/gender minority-affirming services. Many publicly funded STI clinics are a low barrier and provide sexual minority-competent care. These sites therefore may be uniquely situated to address clients' MHSU-related needs. OBJECTIVE: We characterize the need and desire for MHSU services among STI clinic clients. DESIGN, SETTING, PARTICIPANTS: We conducted a waiting room survey at 6 STI clinics in Metro Vancouver, Canada. MAIN OUTCOME MEASURES: We calculated the proportion of clients with self-reported unmet MHSU needs in the previous 12 months and, among these clients, barriers to accessing MHSU services and desire for MHSU services within the STI clinic. We also examined social disparities in barriers to accessing MHSU services. RESULTS: Among 1115 respondents-65% of whom were sexual minorities-39% reported a recent need for MHSU-related care, most frequently in relation to anxiety (29%), depression (26%), substance use (10%), or suicide ideation (7%). Seventy-two percent of this group had not yet talked to a provider about their concern. Common barriers included shame (26%) and inability to afford the service (24%). Eighty-three percent of clients with unmet MHSU needs indicated that they were comfortable discussing MHSU concerns with an STI clinic provider, and 94% expressed desire to receive MHSU assessments, referrals, or counseling in the STI clinic. Sexual and gender minorities and those attending a suburban clinic were more likely to report barriers to accessing MHSU services. CONCLUSIONS: More than a quarter of STI clinic clients report unmet MHSU health care needs; moreover, these clients report high levels of comfort with and desire to discuss MHSU concerns with STI clinic providers. Sexually transmitted infections clinics are thus opportune sites for syndemic service integration.

Estimating the Size of the MSM Population in Metro Vancouver, Canada, Using Multiple Methods and Diverse Data Sources.

Men who have sex with men (MSM) are disproportionately affected by HIV globally, regionally in Canada, and locally in Vancouver. Lack of reliable population size estimates of MSM impedes effective implementation of health care services and limits our understanding of the HIV epidemic. We estimated the population size of MSM residing in Metro Vancouver drawing on four data sources: the Canadian Community Health Survey (CCHS), a cross-sectional bio-behavioural MSM survey, HIV testing services data from sexually transmitted infection (STI) clinics serving MSM, and online social networking site Facebook. Estimates were calculated using (1) direct estimates from the CCHS, (2) "Wisdom of the Crowds" (WOTC), and (3) the multiplier method using data from a bio-behavioural MSM survey, clinic-based HIV testing, and online social media network site Facebook. Data sources requiring greater public disclosure of sexual orientation resulted in our mid-range population estimates (Facebook 23,760, CCHS 30,605). The WOTC method produced the lowest estimate, 10,000. The multiplier method using STI clinic HIV testing data produced the largest estimate, 41,777. The median of all estimates was 27,183, representing 2.9% of the Metro Vancouver census male adult population, with an interquartile range of 1.1-4.5%. Using multiple data sources, our estimates of the MSM population in Metro Vancouver are similar to population prevalence estimates based on population data from other industrialized nations. These findings will support understanding of the HIV burden among MSM and corresponding public health and health services planning for this key population.

Sexual orientation measurement, bisexuality, and mental health in a sample of men who have sex with men in Vancouver, Canada.

This cross-sectional study used a validated index (i.e., Hospital Anxiety and Depression Scale) to measure anxiety and depression (caseness score: ≥8) among men who have sex with men recruited via respondent-driven sampling in Vancouver, Canada (n=774), and investigated whether differences in mental health outcomes varied by sexual orientation measure (i.e., identity, attraction, behavior). Of the sample, 15.5% identified as bisexual, 33.4% reported any bisexual attraction, and 22.7% reported any bisexual sexual activity. More bisexual than gay men met the case definition for anxiety and depression, across all sexual orientation measures. In adjusted multivariable models, bisexual men had higher odds of anxiety by attraction and identity and higher odds of depression by identity. Findings highlight the value of measuring multiple sexual orientation dimensions in surveys and routine surveillance, and the need to ensure sexual minority groups and sexual orientation dimensions are not considered commensurate for mental health prevention and treatment.

Event-Level Analysis of Anal Sex Roles and Sex Drug Use Among Gay and Bisexual Men in Vancouver, British Columbia, Canada.

This study analyzed event-level partnership data from a computer-assisted survey of 719 gay and bisexual men (GBM) enrolled in the Momentum Health Study to delineate potential linkages between anal sex roles and the so-called "sex drugs," i.e., erectile dysfunction drugs (EDD), poppers, and crystal methamphetamine. Univariable and multivariable analyses using generalized linear mixed models with logit link function with sexual encounters (n = 2514) as the unit of analysis tested four hypotheses: (1) EDD are significantly associated with insertive anal sex roles, (2) poppers are significantly associated with receptive anal sex, (3) both poppers and EDD are significantly associated with anal sexual versatility, and (4) crystal methamphetamine is significantly associated with all anal sex roles. Data for survey respondents and their sexual partners allowed testing these hypotheses for both anal sex partners in the same encounter. Multivariable results supported the first three hypotheses. Crystal methamphetamine was significantly associated with all anal sex roles in the univariable models, but not significant in any multivariable ones. Other multivariable significant variables included attending group sex events, venue where first met, and self-described sexual orientation. Results indicate that GBM sex-drug use behavior features rational decision-making strategies linked to anal sex roles. They also suggest that more research on anal sex roles, particularly versatility, is needed, and that sexual behavior research can benefit from partnership analysis.

Substance use, sexual behaviour and prevention strategies of Vancouver gay and bisexual men who recently attended group sex events.

Group sex events are an epidemiologically important part of some gay and bisexual men's sexual culture in Canada. Associated with condomless anal intercourse and polysubstance use, such events have been cited as disproportionally contributing to HIV infection rates. We analysed questionnaire data from the Momentum Health Study in Vancouver, Canada, to understand substance use, sexual behaviour, psychosocial variables (Sexual Sensation Seeking, Sexual Escape Motivation, Treatment Optimism) and HIV prevention strategies (sero-sorting, strategic positioning, avoiding anal sex, disclosure, treatment as prevention) of men attending such events, which were defined as group (n ≥ 4 partners) sex parties, blackout events and darkrooms. Analysis by multivariable logistic regression compared men attending group sex events within the past six months (n = 180) with non-attendees (n = 539). Results showed that attendees reported: (1) significantly higher use of sex drugs and alcohol consumption, (2) higher scores on the Sexual Sensation Scale, more anal sex partners, greater odds of any condomless anal sex with sero-discordant partners and greater odds of reporting fisting and sex toy use and (3) different prevention practices that varied by HIV-serostatus. Findings are interpreted in light of the importance of pleasure, sociality and HIV/STI prevention strategies associated with group sex events. Findings contribute to the development of appropriate education and intervention for attendees.

Health status of transgender people globally: A systematic review of research on disease burden and correlates.

BACKGROUND AND OBJECTIVES: Transgender and gender diverse (trans) health research has grown rapidly, highlighting the need to characterize the scientific evidence base. We conducted a systematic review of peer-reviewed research on disease burden and correlates in trans adolescents and adults over a 20-month period to identify knowledge gaps and assess methodological characteristics including measurement of gender identity, community engagement, and study quality. DATA SOURCES, ELIGIBILITY CRITERIA, AND SYNTHESIS METHODS: We searched seven databases using terms related to (a) transgender populations and (b) health or disease. Eligible studies were in English, French, or Spanish and reported original quantitative data on mental health or substance use conditions, infectious diseases, or non-communicable conditions in at least 25 trans individuals aged 15+. Quality assessment was performed in duplicate on a 10% sample of articles and findings were summarized using narrative synthesis. RESULTS: The 328 included studies were conducted in 45 countries, with most from North America (54%) and limited research from South Asia (3%), Sub-Saharan Africa (3%), and the Middle East and North Africa (2%). Most studies used cross-sectional designs (73%) and convenience sampling (65%). Only 30% of studies reported any form of community engagement. Mental health and substance use disorders were the most studied area (77% of studies) and non-communicable conditions the least (16%). Available data indicated that trans populations experience high disease burden with considerable heterogeneity within and across settings. Of 39 articles assessed for quality, 80% were rated as fair, 18% as poor, and 3% as good quality. CONCLUSIONS AND IMPLICATIONS: Geographic, gender-specific, and topical gaps remain in trans health, but we found more research from African countries, with transmasculine people, and on non-communicable conditions than previous syntheses. Areas for growth in trans health research include community engagement, non-binary health, chronic and age-related conditions, and health determinants. REGISTRATION: PROSPERO CRD42021234043.

Brief Report: Interruptions in HIV Prevention and Treatment During the COVID-19 Pandemic: A Cross-Sectional Study of Transgender and Gender Nonbinary Adults in the United States.

BACKGROUND: Transgender and gender nonbinary (TNB) people have been disproportionately affected by HIV and the COVID-19 pandemic. This study explored the prevalence of HIV prevention and treatment (HPT) interruptions during the pandemic and identified factors associated with these interruptions. SETTING: Data were drawn from LITE Connect, a US-based, nationwide, online, self-administered survey designed to examine the experiences of TNB adults during the COVID-19 pandemic. A convenience sample of 2134 participants were recruited between June 14, 2021, and May 1, 2022. METHODS: The analytic sample was restricted to participants taking antiretroviral medications to prevent or treat HIV before the onset of the pandemic (n = 153). We calculated descriptive statistics as well as Pearson χ 2 bivariate tests and multivariable models to identify factors associated with HPT interruptions during the pandemic. RESULTS: Thirty-nine percent of participants experienced an HPT interruption. We found a lower odds of HPT interruptions among participants living with HIV [adjusted odds ratios (aOR) 0.45; 95% Confidence Intervals (CI): 0.22, 0.92; P = 0.02] and essential workers [aOR 0.49; 95% CI: 0.23, 1.0; P = 0.06] and higher odds among people with chronic mental health conditions [aOR 2.6; 95% CI: 1.1, 6.2; P = 0.03]. When sex and education were included, we found a lower odds of interruptions among people with higher education. CI widened, but the magnitude and direction of effects did not change for the other variables. CONCLUSIONS: Focused strategies to address longstanding psychosocial and structural inequities are needed to mitigate HPT treatment interruptions in TNB people and prevent similar challenges during future pandemics.

Effects of Race and Gender Classifications on Atherosclerotic Cardiovascular Disease Risk Estimates for Clinical Decision-Making in a Cohort of Black Transgender Women.

Introduction: Despite their dynamic, socially constructed, and imprecise nature, both race and gender are included in common risk calculators used for clinical decision-making about statin therapy for atherosclerotic cardiovascular disease (ASCVD) prevention. Methods and Materials: We assessed the effect of manipulating six different race-gender categories on ASCVD risk scores among 90 Black transgender women. Results: Risk scores varied by operationalization of race and gender and affected the proportion for whom statins were recommended. Discussion: Race and gender are social constructs underpinning racialized and gendered health inequities. Their rote use in ASCVD risk calculators may reinforce and perpetuate existing inequities.

Cardiovascular Disease Risk Estimation for Transgender and Gender-Diverse Patients: Cross-Sectional Analysis of Baseline Data From the LITE Plus Cohort Study.

Introduction: Approximately 2% of the U.S. population identifies as transgender, and transgender people experience disproportionate rates of cardiovascular disease mortality. However, widely used cardiovascular disease risk estimators have not been validated in this population. This study sought to determine the impact on statin therapy recommendations using 3 different approaches to operationalizing sex in the American Health Association/American College of Cardiology Pooled Cohort Equation Risk Estimator. Methods: This is a cross-sectional analysis of baseline clinical data from LITE Plus, a prospective cohort study of Black and/or Latina transgender women with HIV. Data were collected from October 2020 to June 2022 and used to calculate Pooled Cohort Equation scores. Results: The 102 participants had a mean age of 43 years. A total of 88% were Black, and 18% were Latina. A total of 79% were taking gender-affirming hormones. The average Pooled Cohort Equation risk score was 6% when sex assigned at birth was used and statins would be recommended for the 31% with Pooled Cohort Equation >7.5%. The average risk score was 4%, and 18% met the criteria for statin initiation when current gender was used; the mean risk score was 5%, and 22% met the criteria for statin initiation when current hormone therapy was used. Conclusions: Average Pooled Cohort Equation risk scores vary substantially depending on the approach to operationalizing the sex variable, suggesting that widely used cardiovascular risk estimators may be unreliable predictors of cardiovascular disease risk in transgender populations. Collection of sex, gender, and hormone use in longitudinal studies of cardiovascular health is needed to address this important limitation of current risk estimators.

Impact of subgroup-specific heterogeneities and dynamic changes in mortality rates on forecasted population size, deaths, and age distribution of persons receiving antiretroviral treatment in the United States: a computer simulation study.

PURPOSE: Model-based forecasts of population size, deaths, and age distribution of people with HIV (PWH) are helpful for public health and clinical services planning but are influenced by subgroup-specific heterogeneities and changes in mortality rates. METHODS: Using an agent-based simulation of PWH in the United States, we examined the impact of distinct approaches to parametrizing mortality rates on forecasted epidemiology of PWH on antiretroviral treatment (ART). We first estimated mortality rates among (1) all PWH, (2) sex-specific, (3) sex-and-race/ethnicity-specific, and (4) sex-race/ethnicity-and-HIV-acquisition-risk-specific subgroups. We then assessed each scenario by (1) allowing unrestricted reductions in age-specific mortality rates over time and (2) restricting the mortality rates among PWH to subgroup-specific mortality thresholds from the general population. RESULTS: Among the eight scenarios examined, those lacking subgroup-specific heterogeneities and those allowing unrestricted reductions in future mortality rates forecasted the lowest number of deaths among all PWH and 9 of the 15 subgroups through 2030. The forecasted overall number and age distribution of people with a history of injection drug use were sensitive to inclusion of subgroup-specific mortality rates. CONCLUSIONS: Our results underscore the potential risk of underestimating future deaths by models lacking subgroup-specific heterogeneities in mortality rates, and those allowing unrestricted reductions in future mortality rates.

Preventable mortality among sexual minority Canadians.

Background: Epidemiologic studies point to multiple health inequities among sexual minority people, but few studies have examined mortality. Some causes of death are more preventable than others, and access to prevention is theorized to follow patterns of access to social and material resources. The objective of this study is to compare estimates of preventable mortality between sexual minority (SM)-i.e., bisexual, lesbian, gay-and heterosexual adults in Canada. Methods: A population-based retrospective cohort with 442,260 (unweighted N) Canadian adults, ages 18-59 years, was drawn from the Canadian Community Health Survey/Canadian Mortality Database linked database (2003-2017). The Rutstein preventability rating index was used to classify cause-specific mortality (low/high). Longitudinal analyses were conducted using Cox proportional hazards models. Results: SM respondents had higher hazard of all-cause mortality (unadjusted hazard ratio [uHR] 1.28, 95% CI 1.06, 1.55). The uHR increased when the outcome was limited to highly-preventable causes of mortality (uHR 1.43, 95% CI 1.14, 1.80). The uHR further increased in sensitivity analyses using higher thresholds of the Rutstein index. SM respondents had higher hazard of cause-specific mortality for heart disease (uHR 1.53, 95% CI 1.03, 2.29), accidents (uHR 1.97, 95% CI 1.01, 3.86), HIV (uHR 75.69, 95% CI 18.77, 305.20), and suicide (uHR 2.22, 95% CI 0.93, 5.30) but not for cancer (uHR 0.86, 95% CI 0.60, 1.25). The adjusted HR (aHR) for highly-preventable mortality was not attenuated by adjustment for confounders (aHR 1.57, 95% CI 1.20, 2.05) but was reduced by adjustment for hypothesized mediators relating to access to social and material resources (marital status, children, income, education; aHR 1.11, 95% CI 0.78, 1.58). Conclusions: Preventable mortality was elevated for SM Canadians compared to heterosexuals. Early and broad access to sexual minority-affirming primary and preventive healthcare should be expanded.

Hosts as Gatekeepers for North American Gay and Bisexual Men's Private Group Sex Parties.

Gay and bisexual men's (GBM) group sex parties are considered HIV risk environments due to their association with concurrent sexual partners, condomless anal sex, and polysubstance use. The possibility of group sex party hosts acting as gatekeepers to minimize risks has been suggested, but remains understudied. We analyzed qualitative data from 20 in-depth interviews with North American GBM who recently attended private group sex parties to determine if hosts' actions constitute harm reduction strategies. Results showed hosts acting as gatekeepers before parties by establishing and disseminating themes and rules, screening applicants, and selecting guests. During parties hosts enforced rules and rejected uninvited guests. By their actions, hosts established a more controlled environment compared to public sex-on-premises bathhouses, and facilitated boundary play, the paradoxical behavior of simultaneously desiring risk and safety, previously noted for GBM circuit parties. Results suggest initiating education programs focusing on private group sex party hosts as gatekeepers.

Longitudinal HIV care outcomes by gender identity in the United States.

OBJECTIVE: Describe engagement in HIV care over time after initial engagement in HIV care, by gender identity. DESIGN: Observational, clinical cohort study of people with HIV engaged in routine HIV care across the United States. METHODS: We followed people with HIV who linked to and engaged in clinical care (attending ≥2 visits in 12 months) in cohorts in the North American Transgender Cohort Collaboration, 2000-2018. Within strata of gender identity, we estimated the 7-year (84-month) restricted mean time spent: lost-to-clinic (stratified by pre/postantiretroviral therapy (ART) initiation); in care prior to ART initiation; on ART but not virally suppressed; virally suppressed (≤200 copies/ml); or dead (pre/post-ART initiation). RESULTS: Transgender women ( N  = 482/101 841) spent an average of 35.5 out of 84 months virally suppressed (this was 30.5 months for cisgender women and 34.4 months for cisgender men). After adjustment for age, race, ethnicity, history of injection drug use, cohort, and calendar year, transgender women were significantly less likely to die than cisgender people. Cisgender women spent more time in care not yet on ART, and less time on ART and virally suppressed, but were less likely to die compared with cisgender men. Other differences were not clinically meaningful. CONCLUSIONS: In this sample, transgender women and cisgender people spent similar amounts of time in care and virally suppressed. Additional efforts to improve retention in care and viral suppression are needed for all people with HIV, regardless of gender identity.