COVID-19 Vaccination Uptake, Infection Rates, and Seropositivity Among Youth Experiencing Homelessness in the United States.

BACKGROUND: People experiencing homelessness are at greater risk of exposure and poor health outcomes from COVID-19. Yet, little data exists on the prevalence and correlates of COVID-19 among homeless populations. To mitigate the spread and severity, uptake of the COVID-19 vaccine is needed. This can be challenging among youth experiencing homelessness who are more likely to be unvaccinated when compared to stably housed youth. OBJECTIVE: We conducted this study to determine the prevalence and correlates of COVID-19 among youth experiencing homelessness. METHODS: We examined experiences of COVID-19 symptoms, self-report of infection, rates of COVID-19 antibodies and distinguished between natural and vaccinated immunity among youth experiencing homelessness (N = 265) recruited in one large metropolitan area in the South. RESULTS: Based on self-report, very few participants experienced any symptoms, and 80% had never been diagnosed with COVID-19. Of those with COVID-19 antibodies (68%), the proportion with antibodies resulting from natural infection was 44%. The vaccination rate was 42%. Younger and vaccinated participants and those in shelters were likelier to have COVID-19 antibodies. Black and Hispanic youth were more likely than White youth to have had COVID-19. Those who adopted only one or two prevention behaviors were more likely to acquire a natural infection than those who adopted three or more prevention behaviors. DISCUSSION: Youth experiencing homelessness report low vaccination rates, disrupted access to health care and social supports, and underlying chronic conditions, which may explain why they face poorer outcomes when infected with COVID-19. Vaccination and risk mitigation strategies to combat the high prevalence of COVID-19 are especially needed for sheltered youth who are at high risk yet are often asymptomatic.

What Adolescents Say in Text Messages to Motivate Peer Networks to Access Health Care and Sexually Transmitted Infection Testing: Qualitative Thematic Analysis.

BACKGROUND: While rates of HIV and sexually transmitted infections (STIs) are extremely high among adolescents and young adults in the United States, rates of HIV and STI testing remain low. Given the ubiquity of mobile phones and the saliency of peers for youths, text messaging strategies may successfully promote HIV or STI testing among youths. OBJECTIVE: This study aimed to understand the types of messages youths believe were motivating and persuasive when asked to text friends to encourage them to seek HIV or STI testing services at a neighborhood clinic. METHODS: We implemented an adolescent peer-based text messaging intervention to encourage clinic attendance and increase STI and HIV testing among youths (n=100) at an adolescent clinic in San Francisco, California. Participants were asked to send a text message to 5 friends they believed were sexually active to encourage their friends to visit the clinic and receive STI or HIV screening. Thematic analysis was used to analyze the content of the text messages sent and received during the clinic visit. Member checking and consensus coding were used to ensure interrater reliability and significance of themes. RESULTS: We identified four themes in the messages sent by participants: (1) calls to action to encourage peers to get tested, (2) personalized messages with sender-specific information, (3) clinic information such as location and hours, and (4) self-disclosure of personal clinic experience. We found that nearly all text messages included some combination of 2 or more of these broad themes. We also found that youths were inclined to send messages they created themselves, as opposed to sending the same message to each peer, which they tailored to each individual to whom they were sent. Many (40/100, 40%) received an immediate response to their message, and most participants reported receiving at least 1 positive response, while a few reported that they had received at least 1 negative response. There were some differences in responses depending on the type of message sent. CONCLUSIONS: Given the high rates of STI and HIV and low rates of testing among adolescents, peer-driven text messaging interventions to encourage accessing care may be successful at reaching this population. This study suggests that youths are willing to text message their friends, and there are clear types of messages they develop and use. Future research should use these methods with a large, more diverse sample of youths and young adults for long-term evaluation of care seeking and care retention outcomes to make progress in reducing HIV and STI among adolescents and young adults.

Lessons learned from conducting a community-based, nurse-led HIV prevention trial with youth experiencing homelessness: Pivots and pitfalls.

OBJECTIVE: This article highlights key lessons learned while conducting a nurse-led community-based HIV prevention trial with youth experiencing homelessness (YEH), focusing on sexually transmitted infections testing and treatment, intervention sessions, community partnerships, and participant recruitment and retention. DESIGN: The insights and experiences shared aim to inform future research and the design of interventions targeting populations at high risk, particularly when facing unanticipated challenges. By addressing these areas, the article contributes to the decision-making for the design and delivery of effective strategies to improve the health outcomes among marginalized populations. RESULTS: The findings underscore the importance of flexibility and active participant engagement, cultivating strong relationships with community partners, utilizing technology and social media, and fostering a diverse research team that represents the heterogeneity of youth experiencing homelessness across race/ethnicity, gender identity, sexual orientation, and lived experiences. CONCLUSIONS: These recommendations aim to enhance participant access, engagement, and retention, while promoting rigorous research and meaningful study outcomes for YEH.

Clinician and Staff Perspectives on Implementing Adverse Childhood Experience (ACE) Screening in Los Angeles County Pediatric Clinics.

PURPOSE: To understand clinician and clinical staff perspectives on the implementation of routine Adverse Childhood Experience (ACE) screening in pediatric primary care. METHODS: We conducted a qualitative evaluation in 5 clinics in Los Angeles County, California, using 2 rounds of focus group discussions: during an early phase of the initiative, and 7 months later. In the first round, we conducted 14 focus group discussions with 67 participants. In the second round, we conducted 12 focus group discussions with 58 participants. Participants comprised clinic staff involved in ACE screening, including frontline staff that administer the screening, medical clinicians that use screening to counsel patients and make referrals, and psychosocial support staff who may receive referrals. RESULTS: Themes were grouped into 3 categories: (1) screening acceptability and perceived utility, (2) implementation and quality improvement, and (3) effects of screening on patients and clinicians. Regarding screening acceptability and perceived utility, clinicians generally considered ACE screening to be acceptable and useful. In terms of implementation and quality improvement, significant barriers included: insufficient time for screening and response, insufficient training, and lack of clarity about referral networks and resources that could be offered to patients. Lastly, regarding effects of screening, clinicians expressed that ACE screening helped elicit important patient information and build trust with patients. Further, no adverse events were reported from screening. CONCLUSIONS: Clinic staff felt ACE screening was feasible, acceptable, and beneficial within pediatric care settings to improve trauma-informed care and that ACE screening could be strengthened by addressing time constraints and limited referral resources.

Systematic Review of mHealth Interventions for Adolescent and Young Adult HIV Prevention and the Adolescent HIV Continuum of Care in Low to Middle Income Countries.

Adolescents and young adults (AYA) in low to middle income countries (LMIC) have poorer outcomes along each step in the HIV continuum of prevention and care compared to younger children or older adults. The use of mHealth technology provides a potentially promising implementation strategy for interventions to remedy these disparities. We therefore conducted a systematic review of the English literature and conference proceedings from January 1, 2000 to April 1, 2021 evaluating mHealth interventions targeting AYA along each step of the HIV continuum of care in LMIC. We identified 27 mHealth interventions across the HIV continuum, with no interventions addressing transition from pediatric to adult care. The majority of studies were single arm, uncontrolled or underpowered, with few randomized trials resulting in mixed and inconclusive outcomes. mHealth interventions have potential to remedy disparities along the HIV continuum of care for AYA in LMIC but larger, powered randomized trials are needed.

RESUMEN: Los adolescentes y adultos jóvenes (AYA) en países de ingresos bajos a medianos (LMIC) tienen peores resultados en cada paso del continuo de prevención y atención del VIH en comparación con los niños más pequeños o los adultos mayores. El uso de la tecnología mHealth proporciona una estrategia de implementación potencialmente prometedora para las intervenciones para remediar estas disparidades. Por lo tanto, realizamos una revisión sistemática de los resúmenes y artículos publicados en inglés desde el 1 de enero de 2000 hasta el 1 de abril de 2021 para evaluar las intervenciones de mHealth dirigidas a AYA a lo largo de cada paso del continuo de atención del VIH en LMIC. Identificamos 27 intervenciones de mHealth en todo el continuo del VIH, sin intervenciones que abordaran la transición de la atención pediátrica a la de adultos. La mayoría de los estudios fueron de un solo brazo, no controlados o con bajo poder estadístico, con pocos ensayos aleatorios que dieron resultados mixtos y no concluyentes. Las intervenciones de mHealth tienen el potencial de remediar las disparidades a lo largo de la continuidad de la atención del VIH para AYA en LMIC, pero se necesitan ensayos aleatorios más grandes y potentes.

COVID-19 Testing and Vaccine Acceptability Among Homeless-Experienced Adults: Qualitative Data from Two Samples.

BACKGROUND: Homeless-experienced populations are at increased risk of exposure to SARS-CoV-2 due to their living environments and face an increased risk of severe COVID-19 disease due to underlying health conditions. Little is known about COVID-19 testing and vaccination acceptability among homeless-experienced populations. OBJECTIVE: To understand the facilitators and barriers to COVID-19 testing and vaccine acceptability among homeless-experienced adults. DESIGN: We conducted in-depth interviews with participants from July to October 2020. We purposively recruited participants from (1) a longitudinal cohort of homeless-experienced older adults in Oakland, CA (n=37) and (2) a convenience sample of people (n=57) during a mobile outreach COVID-19 testing event in San Francisco. PARTICIPANTS: Adults with current or past experience of homelessness. APPROACH: We asked participants about their experiences with and attitudes towards COVID-19 testing and their perceptions of COVID-19 vaccinations. We used participant observation techniques to document the interactions between testing teams and those approached for testing. We audio-recorded, transcribed, and content analyzed all interviews and identified major themes and subthemes. KEY RESULTS: Participants found incentivized COVID-19 testing administered in unsheltered settings and supported by community health outreach workers (CHOWs) to be acceptable. The majority of participants expressed a positive inclination toward vaccine acceptability, citing a desire to return to routine life and civic responsibility. Those who expressed hesitancy cited a desire to see trial data, concerns that vaccines included infectious materials, and mistrust of the government. CONCLUSIONS: Participants expressed positive evaluations of the incentivized, mobile COVID-19 testing supported by CHOWs in unsheltered settings. The majority of participants expressed a positive inclination toward vaccination. Vaccine hesitancy concerns must be addressed when designing vaccine delivery strategies that overcome access challenges. Based on the successful implementation of COVID-19 testing, we recommend mobile delivery of vaccines using trusted CHOWs to address concerns and facilitate wider access to and uptake of the COVID vaccine.

Social Change and the Health of Sexual Minority Individuals: Do the Effects of Minority Stress and Community Connectedness Vary by Age Cohort?

This study examined the extent to which social stress stemming from a stigmatized social status (i.e., minority stress) was associated with three domains of health in younger as compared with older age cohorts of sexual minority individuals. Data were analyzed from the Generations Study, a longitudinal study using a probability sample (N = 1518) of age cohorts of sexual minority individuals in the USA. Exposure to a variety of minority stressors was associated with poorer health for all age cohorts. We hypothesized that because of improved social and legal environments in recent years, the associations between minority stress and health would be diminished in the younger cohort. As expected, we found that the associations between some minority stressors and health outcomes were diminished in the younger cohort compared to older cohorts. Positive associations between community connectedness and mental health and social well-being were observed for all participants but were attenuated in the younger cohort. Findings demonstrate the continuing negative association between minority stress and health among sexual minorities, which, despite some attenuation, persists even for young cohorts of sexual minority individuals in a more equal and accepting social climate.

Cigarette Smoking and Minority Stress Across Age Cohorts in a National Sample of Sexual Minorities: Results From the Generations Study.

BACKGROUND: Sexual minority populations in the United States have persistently higher rates of cigarette use than heterosexuals, partially driven by exposure to minority stressors (e.g., discrimination and victimization). Little is known about cigarette use across cohorts of sexual minority adults who came of age in distinctly different sociopolitical environments. PURPOSE: To examine cigarette use and minority stressors across three age cohorts of U.S. sexual minority adults. METHODS: We used data from the Generations Study, a nationally representative sample (N = 1,500) of White, Black, and Latino/a sexual minority adults in three age cohorts (younger: 18-25 years; middle: 34-41 years; and older: 52-59 years). Survey data were collected from March 2016 to March 2017. We used sex-stratified logistic regression models to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between age cohort, minority stressors (discrimination and victimization), and two indicators of cigarette smoking (lifetime use and current use). RESULTS: Prevalence of current cigarette use in each age cohort was high (younger: 20%; middle: 33%; and older: 29%). Relative to the younger cohort, men and women in the middle- and older-age cohorts had significantly higher odds of lifetime and current smoking (e.g., men, current, aOR [95% CI]: middle = 2.47 [1.34, 4.52], older = 2.85 [1.66, 4.93]). Minority stressors were independently associated with higher odds of current smoking; when victimization was included, the magnitude of the association between age cohort and current smoking was diminished but remained significant. CONCLUSIONS: Smoking cessation interventions must consider the role of minority stress and the unique needs of sexual minority people across the life course.

Efficacy of a Just-in-Time Adaptive Intervention to Promote HIV Risk Reduction Behaviors Among Young Adults Experiencing Homelessness: Pilot Randomized Controlled Trial.

BACKGROUND: People experiencing homelessness have higher rates of HIV than those who are stably housed. Mental health needs, substance use problems, and issues unique to homelessness such as lack of shelter and transiency need to be considered with regard to HIV prevention. To date, HIV prevention interventions for young adults experiencing homelessness have not specifically addressed modifiable real-time factors such as stress, sexual or drug use urge, or substance use, or been delivered at the time of heightened risk. Real-time, personalized HIV prevention messages may reduce HIV risk behaviors. OBJECTIVE: This pilot study tested the initial efficacy of an innovative, smartphone-based, just-in-time adaptive intervention that assessed predictors of HIV risk behaviors in real time and automatically provided behavioral feedback and goal attainment information. METHODS: A randomized attention control design was used among young adults experiencing homelessness, aged 18-25 years, recruited from shelters and drop-in centers in May 2019. Participants were randomized to either a control or an intervention group. The intervention (called MY-RID [Motivating Youth to Reduce Infection and Disconnection]) consisted of brief messages delivered via smartphone over 6 weeks in response to preidentified predictors that were assessed using ecological momentary assessments. Bayesian hierarchical regression models were used to assess intervention effects on sexual activity, drug use, alcohol use, and their corresponding urges. RESULTS: Participants (N=97) were predominantly youth (mean age 21.2, SD 2.1 years) who identified as heterosexual (n=51, 52%), male (n=56, 57%), and African American (n=56, 57%). Reports of sexual activity, drug use, alcohol use, stress, and all urges (ie, sexual, drug, alcohol) reduced over time in both groups. Daily drug use reduced by a factor of 13.8 times over 6 weeks in the intervention group relative to the control group (Multimedia Appendix 4). Lower urges for sex were found in the intervention group relative to the control group over the duration of the study. Finally, there was a statistically significant reduction in reports of feeling stressed the day before between the intervention and control conditions (P=.03). CONCLUSIONS: Findings indicate promising intervention effects on drug use, stress, and urges for sex in a hard-to-reach, high-risk population. The MY-RID intervention should be further tested in a larger randomized controlled trial to further investigate its efficacy and impact on sexual risk behaviors. TRIAL REGISTRATION: ClinicalTrials.gov NCT03911024; https://clinicaltrials.gov/ct2/show/NCT03911024.

Findings From a Probability-Based Survey of United States Households About Prevention Measures Based on Race, Ethnicity, and Age in Response to Severe Acute Respiratory Syndrome Coronavirus 2.

We investigated individual behaviors taken by white, African American, and Latino United States (US) households in response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and likelihood of using digital tools for symptom surveillance/reporting. We analyzed cross-sectional week 1 data (April 2020) of the coronavirus disease 2019 (COVID-19) Impact Survey in a large, nationally representative sample of US adults. In general, all groups engaged in the same prevention behaviors, but whites reported being more likely to use digital tools to report/act on symptoms and seek testing, compared with African Americans and Latinos. Individual behaviors may not explain COVID-19 case disparities, and digital tools for tracking should focus on uptake among race/ethnic minorities.

Comparing National Probability and Community-Based Samples of Sexual Minority Adults: Implications and Recommendations for Sampling and Measurement.

Scientific evidence regarding sexual minority populations has generally come from studies based on two types of samples: community-derived samples and probability samples. Probability samples are lauded as the gold standard of population research for their ability to represent the population of interest. However, while studies using community samples lack generalizability, they are often better able to assess population-specific concerns (e.g., minority stress) and are collected more rapidly, allowing them to be more responsive to changing population dynamics. Given these advantages, many sexual minority population studies rely on community samples. To identify how probability and community samples of sexual minorities are similar and different, we compared participant characteristics from two companion samples from the Generations Study, each designed with the same demographic profile of U.S. sexual minority adults in mind. The first sample was recruited for a national probability survey, whereas the second was recruited for a multicommunity sample from four U.S. cities. We examined sociodemographic differences between the samples. Although there were several statistical differences between samples, the effect sizes were small for sociodemographic characteristics that defined the sample inclusion criteria: sex assigned at birth, race/ethnicity, and age cohort. The samples differed across other characteristics: bisexual respondents, respondents with less education, and those living in non-urban areas were underrepresented in the community sample. Our findings offer insights for recruiting community samples of sexual minority populations and for measuring sexual identity on probability surveys. They also bolster confidence in well-designed community samples as sources for data on sexual minority populations.

Strategies to Increase HIV Testing Among MSM: A Synthesis of the Literature.

More than 30 years into the HIV epidemic, men who have sex with men (MSM) continue to be disproportionately impacted. It is estimated that worldwide nearly half of MSM infected with HIV are unaware of their status, making HIV testing along with early linkage to care crucial to HIV prevention efforts. However, there remain significant barriers to HIV testing among MSM, due largely to complex issues of layered stigma that deter MSM from accessing traditional, clinic-based testing. We conducted a review and synthesis of the literature on strategies to increase uptake of HIV testing among MSM. We found that social network-based strategies, community-based testing, HIV self-testing, and modifications to the traditional clinic-based model can effectively reach a subset of MSM, but success was often context-specific and there are significant gaps in evidence. We provide recommendations for increasing HIV testing rates and status awareness among MSM.

Effectiveness of School-Based Teen Pregnancy Prevention Programs in the USA: a Systematic Review and Meta-Analysis.

School-based programs have been a mainstay of youth pregnancy prevention efforts in the USA. We conducted a systematic review and meta-analysis to assess their effectiveness. Eligible studies evaluated the effect on pregnancy rates of programs delivered in elementary, middle, or high schools in the USA and Canada, published between January 1985 and September 2016. The primary outcome was pregnancy; secondary outcomes were delay in sexual initiation, condom use, and oral contraception use. Randomized controlled trials (RCTs) and non-RCTs with comparator groups were eligible. We developed a comprehensive search strategy, applied to major bibliographic databases, article bibliographies, gray literature, and contact with authors. We calculated risk ratios (RR) with 95% confidence intervals (CI) for each outcome and pooled data in random effects meta-analysis. We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess evidence quality. Ten RCTs and 11 non-RCTs conducted from 1984 to 2016 yielded 30 unique pooled comparisons for pregnancy, of which 24 were not statistically significant. Six showed statistically significant changes in pregnancy rates: two with increased risk (RR 1.30, 95% CI 1.02-1.65; and RR 1.39, 95% CI 1.10-1.75) and four with decreased risk ranging from RR 0.56, 95% CI 0.41-0.77, to RR 0.75, 95% CI 0.58-0.96. All studies were at high risk of bias, and the quality of evidence was low or very low. Identified evidence indicated no consistent difference in rates of pregnancies between intervention recipients and controls.

Risk Factors for Substance Use Among Youth Experiencing Homelessness.

BACKGROUND: Youth experiencing homelessness are at high risk for frequent substance use. This study examines individual, interpersonal, and contextual factors associated with substance use among such youth, age 13-24. METHODS: Data were collected through computer-assisted structured interviews with participants (N=474) recruited at service agencies in Los Angeles. RESULTS: Youth had experienced over two years of homelessness on average. Almost a third used substances frequently; significant risk factors included delinquency, sensation seeking, and ongoing homelessness. Time spent in clubs and organizations was protective. CONCLUSIONS: Providing housing and services to curb delinquency may help protect youth from becoming frequent substance users.

Reducing undiagnosed HIV infection among adolescents in sub-Saharan Africa: Provider-initiated and opt-out testing are not enough.

Community efforts and peer support programs are needed in addition to provider-initiated and opt-out HIV testing in adolescents, Sheri Weiser and colleagues discuss.

Contextual influence of Taiwanese adolescents' sexual attitudes and behavioral intent.

This study examined parental, peer, and media influences on Taiwanese adolescents' attitudes toward premarital sex and intent to engage in sexual behavior. Participants included a convenience sample of 186 adolescents aged 13-15 recruited from two middle schools in Taiwan. Parental influence was indicated by perceived parental disapproval toward premarital sex and perceived peer sexual behavior was used to measure peer influence. Media influence was measured by the adolescents' perception of whether the media promotes premarital sex. We conducted structural equation modeling to test a hypothesized model. The findings suggested that the perceived sexual behavior of peers had the strongest effect on Taiwanese adolescents' sexual attitudes and behavioral intent, while parental disapproval and media influence also significantly contributed to adolescents' sexual attitudes and intent to engage in sex. School nurses are in an ideal position to coordinate essential resources and implement evidence-based sexually transmitted infection and HIV/AIDS prevention interventions that address issues associated with the influence of parents, peers, and media.

"I Created Something New with Something that Had Died": Photo-Narratives of Positive Transformation Among Women with HIV.

A dearth of research describes the strengths of women living with HIV (WLH), yet understanding these strengths can promote women's well-being and healthy behavior. This analysis explores positive life transformations among WLH through photo-stories. WLH (N = 30) from three U.S. cities participated in a pilot photovoice project to tell their story of HIV. The project included three group meetings, an individual interview, and a public exhibit. Using qualitative strategies of theme and narrative analysis we identified positive transformations in women's photo-stories. Participants were African American (83 %) and low income (83 %). Women described four major positive transitions in their lives including transformations related to healthfulness, spirituality, self-acceptance, and confidence. Despite challenges, WLH experience positive transformation and growth experiences. Understanding these transformative changes can shed light on women's motivation to make healthy life changes and thus frame strengths-based interventions for WLH. Photovoice itself is a potential strategy to promote WLH's strengths and health.

Compliance to Cell Phone-Based EMA Among Latino Youth in Outpatient Treatment.

Outpatient treatment practices for adolescent substance users utilize retrospective self-report to monitor drug use. Cell phone-based ecological momentary assessment (CEMA) overcomes retrospective self-report biases and can enhance outpatient treatment, particularly among Latino adolescents, who have been understudied with regard to CEMA. This study explores compliance to text message-based CEMA with youth (n = 28; 93% Latino) in outpatient treatment. Participants were rotated through daily, random, and event-based CEMA strategies for 1-month periods. Overall compliance was high (>80%). Compliance decreased slightly over the study period and was less during random versus daily strategies and on days when alcohol use was retrospectively reported. Findings suggest that CEMA is a viable monitoring tool for Latino youth in outpatient treatment, but further study is needed to determine optimal CEMA strategies, monitoring time periods, and the appropriateness of CEMA for differing levels of substance use.

"I am still human and worth a life:" a qualitative study of the impacts of a community based, peer-led, treatment support model for young adults living with HIV in Zimbabwe.

Background: A persistent treatment gap remains between children and adults living with HIV. The Zvandiri program, developed by Africaid, is one of the few models of differentiated service delivery for children, adolescents, and youth that has been shown to improve outcomes along the HIV care continuum, employing Community Adolescent Treatment Supporters (CATS) to offer peer counseling and patient navigation. Our qualitative study provides an in-depth analysis of the feelings and experiences Zimbabwean youth had following an HIV diagnosis, and the ways that CATS facilitated linkage and retention in care. Methods: We conducted in-depth interviews in Shona with adolescents and young adults who were recently diagnosed with HIV in Zimbabwe. Interviews were audio-recorded, transcribed, and then translated to English. Interviews were coded in Dedoose using a structured a priori codebook. We wrote semi-structured summary memos for each interview. We co-conducted thematic analysis, guided by interpretive phenomenology with a team of Zimbabwean and American experienced qualitative researchers and community partners. We co-developed memos to elaborate and understand key themes across interviews. Results: Most of our interview participants recounted an immediate sense of loss upon testing HIV positive and a fear that "there was no hope for the future." CATS played a pivotal role for youth, providing emotional, educational, and logistical support to facilitate treatment initiation, adherence, and persistence in care. The CATS program supported youth through multiple approaches: group sessions, individual meetings, and via text or phone. While CATS offered counseling and comfort to participants, they emphasized the long-term importance of identifying at least one other person in participants' lives who could know their status and support them around HIV. Conclusion: Our findings delineate some of the key concerns that face youth after receiving an HIV diagnosis and the ways that a community-based adherence peer navigation program supported participants to navigate both their feelings and the health care system. Results can inform practice at community-based agencies that are implementing or considering peer youth navigation programs and garner support for policy to fund interventions for youth.

Fluidity in Reporting Gender Identity Labels in a Sample of Transgender and Gender Diverse Adolescents and Young Adults, Los Angeles, California, and New Orleans, Louisiana, 2017-2019.

OBJECTIVES: Treating gender identity as a fixed characteristic may contribute to considerable misclassification and hinder accurate characterization of health inequities and the design of effective preventive interventions for transgender and gender diverse (TGD) adolescents and young adults. We examined changes in how an ethnically and racially diverse sample of TGD adolescents and young adults reported their gender identity over time, the implications of this fluidity on public health, and the potential effects of misclassification of gender identity. METHODS: We recruited 235 TGD adolescents and young adults (aged 15-24 y) in Los Angeles, California, and New Orleans, Louisiana, from May 2017 through August 2019 to participate in an HIV intervention study. We asked participants to self-report their gender identity and sex assigned at birth every 4 months for 24 months. We used a quantitative content analysis framework to catalog changes in responses over time and classified the changes into 3 main patterns: consistent, fluctuating, and moving in 1 direction. We then calculated the distribution of gender identity labels at baseline (initial assessment) and 12 and 24 months and described the overall sample by age, race, ethnicity, and study site. RESULTS: Of 235 TGD participants, 162 (69%) were from Los Angeles, 89 (38%) were Latinx, and 80 (34%) were non-Latinx Black or African American. Changes in self-reported gender identity were common (n = 181; 77%); in fact, 39 (17%) changed gender identities more than twice. More than 50% (n = 131; 56%) showed a fluctuating pattern. CONCLUSIONS: Gender identity labels varied over time, suggesting that misclassification may occur if data from a single time point are used to define gender identity. Our study lays the foundation for launching studies to elucidate the associations between shifting gender identities and health outcomes.