Site-based and Digital Cohort Participation Among Transgender Women in the Eastern and Southern USA: Findings from the LITE Study.

BACKGROUND: Transgender women (TW) are highly burdened by HIV. There is increasing interest in digital (i.e., through internet-based interfaces) HIV research; yet few studies have assessed potential biases of digital compared to site-based data collection. This study examined differences in characteristics between TW participating via site-based versus digital-only modes in an HIV incidence cohort. METHODS: Between March 2018-Aug 2020, a multisite cohort of 1,312 adult TW in the eastern and southern USA was enrolled in site-based and exclusively digital modes. We evaluated differences in baseline demographics, socio-structural vulnerabilities, healthcare access, gender affirmation, mental health, stigma, social support, and HIV acquisition risk comparing site-based vs digital modes using chi square tests and Poisson regression modeling with robust standard errors. RESULTS: The overall median age was 28 (interquartile range=23-35) years and over half identified as people of color (15% Black, 13% Multiracial, 12% Another Race, 18% Latina/e/x). A higher proportion of site-based (vs. digital mode) participants resided in the Northeast, were younger, identified as people of color, experienced socio-structural vulnerabilities, had a regular healthcare provider, received medical gender affirmation, endorsed mental health symptoms and stigma, reported HIV acquisition risk but also greater experience with biomedical HIV prevention (pre-exposure and post-exposure prophylaxis), and had larger social networks (all p<0.05). CONCLUSION: Site-based and digital approaches enrolled TW with different demographics, life experiences, and HIV acquisition risks. A hybrid cohort model may achieve a more diverse and potentially representative sample of TW than either site-based or online cohorts alone for HIV research.

Enhanced Cohort Methods for HIV Research and Epidemiology (ENCORE): Protocol for a Nationwide Hybrid Cohort for Transgender Women in the United States.

BACKGROUND: In the United States, transgender women are disproportionately impacted by HIV and prioritized in the national strategy to end the epidemic. Individual, interpersonal, and structural vulnerabilities underlie HIV acquisition among transgender women and fuel syndemic conditions, yet no nationwide cohort monitors their HIV and other health outcomes. OBJECTIVE: Our objective is to develop a nationwide cohort to estimate HIV incidence, identify risk factors, and investigate syndemic conditions co-occurring with HIV vulnerability or acquisition among US transgender women. The study is informed by the Syndemics Framework and the Social Ecological Model, positing that stigma-related conditions are synergistically driven by shared multilevel vulnerabilities. METHODS: To address logistical and cost challenges while minimizing technology barriers and research distrust, we aim to establish a novel, hybrid community hub-supported digital cohort (N=3000). The digital cohort is the backbone of the study and is enhanced by hubs strategically located across the United States for increased engagement and in-person support. Study participants are English or Spanish speakers, are aged ≥18 years, identify as transgender women or along the transfeminine spectrum, reside in 1 of the 50 states or Puerto Rico, and do not have HIV (laboratory confirmed). Participants are followed for 24 months, with semiannual assessments. These include a questionnaire and laboratory-based HIV testing using self-collected specimens. Using residential zip codes, person-level data will be merged with contextual geolocated data, including population health measures and economic, housing, and other social and structural factors. Analyses will (1) evaluate the contribution of hub support to the digital cohort using descriptive statistics; (2) estimate and characterize syndemic patterns among transgender women using latent class analysis; (3) examine the role of contextual factors in driving syndemics and HIV prevention over time using multilevel regression models; (4) estimate HIV incidence in transgender women and examine the effect of syndemics and contextual factors on HIV incidence using Poisson regression models; and (5) develop dynamic, compartmental models of multilevel combination HIV prevention interventions among transgender women to simulate their impact on HIV incidence through 2030. RESULTS: Enrollment launched on March 15, 2023, with data collection phases occurring in spring and fall. As of February 24, 2024, a total of 3084 individuals were screened, and 996 (32.3%) met the inclusion criteria and enrolled into the cohort: 2.3% (23/996) enrolled at a hub, and 53.6% (534/996) enrolled through a community hub-supported strategy. Recruitment through purely digital methods contributed 61.5% (1895/3084) of those screened and 42.7% (425/996) of those enrolled in the cohort. CONCLUSIONS: Study findings will inform the development of evidence-based interventions to reduce HIV acquisition and syndemic conditions among US transgender women and advance efforts to end the US HIV epidemic. Methodological findings will also have critical implications for the design of future innovative approaches to HIV research. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/59846.

Transgender health research needed.

Ever since the Cass Review was released in April-an evaluation by the United Kingdom's National Health Service that has led to a ban on pubertysuppressing medication for transgender and gender diverse (TGD) youth-there has been criticism of the assessment and its recommendations, and concern about how it could be leveraged to more broadly affect public health care. In response, physicians, researchers, and major medical organizations worldwide have emphasized that scientific studies point to the benefits of medical interventions supporting gender affirmation. Indeed, more care innovation is needed, driven by community-led research, to improve the well-being of TGD people in ways that can benefit all of society.

Missed Opportunity or Cause for Concern? Methamphetamine Use Is Associated With Greater Interest in Event-Driven PrEP Among Sexual Minority Men.

Our study assessed the association between methamphetamine (i.e., crystal meth, CM) use and awareness and interest in event-driven (ED) PrEP among HIV-negative and those with unknown serostatus cisgender males and transgender people. We performed log-binomial regression analysis to predict awareness (i.e., having heard of ED PrEP) and being interested in ED PrEP. We found that participants who recently used CM were less likely to know of ED PrEP (aPR = 0.83, 95% CI [0.69, 0.99]) but more interested in ED PrEP (aPR = 1.12, 95% CI [1.01, 1.30]), after accounting for demographic and HIV-related behaviors. Opportunities to expand PrEP uptake and improve adherence among individuals who report CM use are essential to impact the HIV epidemic significantly. Continued research on the needs and best practices to work with this community is needed to ensure a successful rollout and implementation of ED PrEP.

To Improve Motivational Barriers to Retention in High Resolution Anoscopy, Patients and Providers Recommend Social and Environmental Changes: A Sequential Explanatory Mixed-Methods Pilot Study in a Federally Qualified Health Center.

Loss to follow-up (LTFU) in high-resolution anoscopy (HRA) programs jeopardizes the procedure's potential to help prevent anal cancer. We explored quality improvement factors to understand how to address this LTFU. Using the transtheoretical COM-B Model (Capability, Opportunity, Motivation, and Behavior) and a sequential explanatory mixed-methods design, we surveyed and interviewed 13 patients who remained engaged in HIV care but who delayed their HRA monitoring or treatment visits in the same community clinic, and 6 HRA clinicians and medical assistants. Analyses involved descriptive statistics and rapid qualitative analysis. Patients were racially, ethnically, and economically representative of the LTFU population, and were generally experienced with HRA (Mean HRA visits = 4.6, SD = 2.8, mdn = 3). Providers were experienced clinicians and medical assistants (Mean years providing HRA = 6.0, SD = 2.2). Analyses revealed two primary, related barriers: (A) motivational barriers such as physical pain, discomfort, embarrassment, and anxiety; which were largely borne from (B) opportunity barriers such as difficulties with scheduling, inconsistent after-care (particularly for pain and discomfort), anxiety-inducing exam rooms and equipment, and internalized and anticipated stigma. Capability barriers, such as limited health literacy about HRA, were less common and, like motivational barriers, linked to opportunity barriers. Participants recommended potential facilitators, including easier scheduling, standardization of pain management and after-care services, and examination room modifications to reduce anxiety. To retain HRA patients in community settings, interventions should address social and physical opportunity barriers that strongly determine motivational and capability barriers. Improving convenience, standardizing pain management, and introducing stigma interventions specific to HRA, could alleviate both motivational and capability barriers.

RESUMEN: La pérdida de seguimiento (LTFU) en los programas de anoscopia de alta resolución (HRA) pone en peligro el potencial del procedimiento para ayudar a prevenir el cáncer anal. Exploramos factores de mejora de la calidad para comprender cómo abordar este LTFU. Utilizando el modelo COM-B transteórico (Capacidad, Oportunidad, Motivación y Comportamiento) y un diseño de métodos mixtos explicativos secuenciales, encuestamos y entrevistamos a 13 pacientes que permanecieron involucrados en la atención del VIH pero que retrasaron sus visitas de seguimiento o tratamiento de la HRA en la misma clínica comunitaria y 6 médicos y asistentes médicos de la HRA. Los análisis involucraron estadísticas descriptivas y análisis cualitativo rápido. Los pacientes eran representativos de la población LTFU en cuanto a raza, etnia, y estatus económico. En general, tenían experiencia con HRA (visitas HRA media = 4,6, DE = 2,8, mdn = 3). Los proveedores eran médicos y asistentes médicos con experiencia (promedio de años proporcionando HRA = 6,0, DE = 2,2). Los análisis revelaron dos barreras principales relacionadas: (A) barreras motivacionales como el dolor físico, la incomodidad, la vergüenza y la ansiedad; que se debieron en gran medida a (B) barreras de oportunidad, como dificultades con la programación, cuidados posteriores inconsistentes (particularmente para el dolor y el malestar), salas de examen y equipos que inducen ansiedad, y estigma internalizado y anticipado. Las barreras a la capacidad, como la limitada alfabetización sanitaria sobre la HRA, fueron menos comunes y, al igual que las barreras motivacionales, estaban vinculadas a las barreras de oportunidades. Los participantes recomendaron posibles facilitadores, incluida una programación más sencilla, la estandarización del manejo del dolor y los servicios de cuidados posteriores, y modificaciones en la sala de examen para reducir la ansiedad. Para retener a los pacientes de HRA en entornos comunitarios, las intervenciones deben abordar las barreras de oportunidades sociales y físicas que determinan fuertemente las barreras motivacionales y de capacidad. Mejorar la conveniencia, estandarizar el manejo del dolor e introducir intervenciones de estigma específicas para la HRA podría aliviar las barreras tanto motivacionales como de capacidad.

Hepatitis C Virus Reinfection Among Men Who Have Sex With Men With HIV in New York City.

BACKGROUND: Hepatitis C virus (HCV) reinfection rates are substantially higher than primary infection rates among men who have sex with men (MSM) with human immunodeficiency virus (HIV) in European cohorts. The behaviors mediating this high rate of transmission among MSM are poorly characterized. METHODS: We performed a prospective cohort study in New York City (NYC) of MSM with HIV who cleared HCV to determine the incidence of and risk factors for HCV reinfection. We assessed the risk behaviors for primary HCV in NYC: receipt of semen in the rectum, and sexualized methamphetamine use, along with route of use. Multivariable analysis was performed with Andersen-Gill extension of the Cox proportional hazards model. RESULTS: From 2000 through 2018, among 304 MSM with HIV who cleared HCV, 42 reinfections occurred over 898 person-years, for an incidence rate of 4.7 per 100 person-years. Assessing 1245 postclearance visits, only receipt of semen into the rectum was associated with reinfection (hazard ratio, 9.7 [95% confidence interval: 3.3-28.3], P < .001); methamphetamine use was not. CONCLUSIONS: The high HCV reinfection rate over almost 2 decades demonstrates that sexual transmission of HCV is not inefficient or unusual and that direct-acting antiviral treatment is not sufficient for HCV elimination among MSM in NYC. The contrasts between both the rates of and risk factors for primary and HCV reinfection suggest that HCV prevalence is highly heterogenous among sexual networks and that sexualized methamphetamine use, rather than mediating transmission, is instead a surrogate marker for the highest HCV prevalence networks. As neither condoms nor treatment have been successful strategies for HCV prevention in NYC, novel interventions are needed to stem this sexually transmitted HCV epidemic.

Neighborhood Safety and Neighborhood Police Violence Are Associated with Psychological Distress among English- and Spanish-Speaking Transgender Women of Color in New York City: Finding from the TURNNT Cohort Study.

Transgender women of color (TWOC) experience high rates of police violence and victimization compared to other sexual and gender minority groups, as well as compared to other White transgender and cisgender women. While past studies have demonstrated how frequent police harassment is associated with higher psychological distress, the effect of neighborhood safety and neighborhood police violence on TWOC's mental health is rarely studied. In this study, we examine the association between neighborhood safety and neighborhood police violence with psychological distress among TWOC. Baseline self-reported data are from the TURNNT ("Trying to Understand Relationships, Networks and Neighborhoods among Transgender Woman of Color") Cohort Study (analytic n = 303). Recruitment for the study began September 2020 and ended November 2022. Eligibility criteria included being a TWOC, age 18-55, English- or Spanish-speaking, and planning to reside in the New York City metropolitan area for at least 1 year. In multivariable analyses, neighborhood safety and neighborhood police violence were associated with psychological distress. For example, individuals who reported medium levels of neighborhood police violence had 1.15 [1.03, 1.28] times the odds of experiencing psychological distress compared to those who experienced low levels of neighborhood police violence. Our data suggest that neighborhood safety and neighborhood police violence were associated with increased psychological distress among TWOC. Policies and programs to address neighborhood police violence (such as body cameras and legal consequences for abusive officers) may improve mental health among TWOC.

Neighborhood-level characteristics as effect modifiers on the efficacy of the MyPEEPS mobile intervention in same-sex attracted adolescent men.

To estimate the effect of neighborhood-level modification on the efficacy of the MyPEEPS Mobile intervention on the reduction of condomless anal sex acts among same-sex attracted adolescent men. A series of generalized linear mixed model was used to examine if the effect of the MyPEEPS Mobile intervention on condomless anal sex acts was moderated by neighborhood-level factors using data from the 2019 American Community Survey US Census Bureau. "The magnitudes of intervention were significantly smaller at both 6- and 9-month follow-up among adolescents living in neighborhood with high proportions of Hispanic or Latino residents (IRR6M = 1.02, 95 % CI: 1.01, 1.02; IRR9M = 1.03, 95 % CI: 1.01, 1.05) and high proportions of families with income below the poverty level (IRR6M = 1.07, 95 % CI: 1.01, 1.12; IRR9M = 1.05, 95 % CI: 1.01, 1.10), which indicated that living in communities with a higher concentration of residents living under poverty or of Hispanic/and Latino ethnicity significantly modified the effective of program intervention on condomless sex among adolescent MSM. Understanding how neighborhood characteristics modify the effect of HIV prevention interventions may be useful in better targeting delivery and tailoring content of interventions based on neighborhood level characteristics such as the ones identified in this study.

MyPEEPS Mobile App for HIV Prevention Among Transmasculine Youth: Adaptation Through Community-Based Feedback and Usability Evaluation.

BACKGROUND: Transgender men and transmasculine youth are at high risk for acquiring HIV. Growing research on transgender men demonstrates increased HIV risk and burden compared with the general US population. Despite biomedical advancements in HIV prevention, there remains a dearth of evidence-based, sexual health HIV prevention interventions for young transgender men. MyPEEPS (Male Youth Pursuing Empowerment, Education, and Prevention around Sexuality) Mobile is a web-based app that builds on extensive formative community-informed work to develop an evidence-based HIV prevention intervention. Our study team developed and tested the MyPEEPS Mobile intervention for 13- to 18-year-old cisgender young men in a national randomized controlled trial, which demonstrated efficacy to reduce sexual risk in the short term-at 3-month follow-up. Trans men and transmasculine youth resonated with basic HIV educational information and sexual scenarios of the original MyPEEPS app for cisgender men, but recognized the app's lack of transmasculine specificity. OBJECTIVE: The purpose of this study is to detail the user-centered design methods to adapt, improve the user interface, and enhance the usability of the MyPEEPS Mobile app for young transgender men and transmasculine youth. METHODS: The MyPEEPS Mobile app for young transgender men was adapted through a user-centered design approach, which included an iterative review of the adapted prototype by expert advisors and a youth advisory board. The app was then evaluated through a rigorous usability evaluation. RESULTS: MyPEEPS Mobile is among the first mobile health interventions developed to meet the specific needs of young transgender men and transmasculine youth to reduce HIV risk behaviors. While many of the activities in the original MyPEEPS Mobile were rigorously developed and tested, there was a need to adapt our intervention to meet the specific needs and risk factors among young transgender men and transmasculine youth. The findings from this study describe the adaptation of these activities through feedback from a youth advisory board and expert advisors. Following adaptation of the content, the app underwent a rigorous usability assessment through an evaluation with experts in human-computer interaction (n=5) and targeted end users (n=20). CONCLUSIONS: Usability and adaptation findings demonstrate that the MyPEEPS Mobile app is highly usable and perceived as potentially useful for targeting HIV risk behaviors in young transgender men and transmasculine youth.

Gender-Affirming Care for Older Transgender and Gender Diverse Adults.

In the United States, it is estimated that 0.3% of Americans aged 65 and older, or almost 172,000 individuals, identify as transgender. Aging comes with a unique set of challenges and experiences for this population, including health care disparities, mental health concerns, and social isolation. It is crucial for clinicians to use a patient-centered and trauma-informed care approach to address their specific needs and provide evidence-based quality health care, including preventive screenings, mental health support, and advocating for legal protections.

Primary Care and Health Care of Transgender and Gender-Diverse Older Adults.

Clinicians working with older transgender and gender-diverse (TGD) individuals need to acquire the necessary knowledge and skills to provide care that is high quality and culturally appropriate. This includes supporting patients in their exploration of gender and attainment of gender-affirming medical interventions. Clinicians should strive to create environments that are inclusive and safe, and that will facilitate health care access and build constructive provider-patient relationships. Clinicians should be aware of best practices, including that age-appropriate health screenings should be anatomy based, and ensure that TGD older adults on gender-affirming hormone therapy (GAHT) receive ongoing laboratory monitoring and physical assessments, including serum hormone levels and biomarkers. Older TGD adults underutilize advance care planning, and need individualized assessments that consider their unique family structures, social support, and financial situation. End-of-life care services should ensure that TGD individuals are treated with dignity and respect.

Racial/ethnic differences in the association between transgender-related U.S. state policies and self-rated health of transgender women.

BACKGROUND: Policy protections for transgender adults in the United States are consistently associated with positive health outcomes. However, studies over-represent non-Latinx White transgender people and obscure variation in policies' intended goals. This study examined racial differences in the relationship between transgender-related policies and transgender women's self-rated health. Guided by Critical Race Theory, we hypothesized that policies conferring access to resources (e.g., healthcare) would be associated with better self-rated health among all participants while policies signifying equality (e.g., nondiscrimination laws) would be associated with better self-rated health only for White participants. METHODS: Using cross-sectional data collected between March 2018-December 2020 from 1566 transgender women, we analyzed 7 state-level 'access policies,' 5 'equality policies,' and sum indices of each. Participants represented 29 states, and 54.7% were categorized as people of color. We fit a series of multilevel ordinal regression models predicting self-rated health by each policy. Multivariate models were adjusted for relevant covariates at the individual- and state-level. We then tested moderation by race/ethnicity using interaction terms and generated stratified predicted probability plots. RESULTS: In bivariate models, 4 access policies, 2 equality policies, and both indices were associated with better self-rated health, but associations did not persist in adjusted models. Results from the multivariable models including interaction terms indicated that policies concerning private insurance coverage of gender-affirming care, private insurance nondiscrimination, credit nondiscrimination, and both indices were statistically significantly associated with better self-rated health for White participants and worse self-rated health for participants of color. CONCLUSIONS: The policies included in this analysis do not mitigate racism's effects on access to resources, indicating they may be less impactful for transgender women of color than White transgender women. Future research and policy advocacy efforts promoting transgender women's health must center racial equity as well as transgender people of color's priorities.

Food Insecurity Is High in a Multi-Site Cohort of Transgender Women Vulnerable to or Living with HIV in the Eastern and Southern United States: Baseline Findings from the LITE Cohort.

The prevalence and correlates of food insecurity-the unavailability of food and limited access to it-have not been adequately considered among transgender women (TW), particularly alongside other health-related conditions burdening this population, such as HIV infection. This study examined the prevalence and correlates of food insecurity among TW. Between 2018 and 2020, 1590 TW in the Eastern and Southern U.S. completed a multi-site baseline assessment (socio-behavioral survey and HIV testing). Descriptive statistics were calculated and multivariable Poisson models with robust error variance were used to estimate prevalence ratios and 95% confidence intervals for correlates of food insecurity (dichotomized as sometimes-to-always vs. seldom-to-never running out of food). Eighteen percent of TW were living with HIV and nearly half of participants (44%) reported food insecurity. Correlates of food insecurity included being Black, multiracial, or another race/ethnicity; having < college education, low income, unstable housing, and high anticipated discrimination; and a history of sex work and sexual violence (all p < 0.05). Food insecurity was highly prevalent among TW. Current programs to provide food support do not adequately meet the needs of TW. HIV pr evention and care programs may benefit from addressing food insecurity.

Incidence, Complications, and Long-term Outcomes of Gender-affirming Phalloplasty: Analysis of a Large Statewide Population-based Dataset.

OBJECTIVE: To evaluate the incidence of gender-affirming phalloplasty and postoperative complications in a large population-based dataset. METHODS: Retrospective cohort study was done using the California Department of Health Care Access and Information datasets which include patient-level data from all licensed hospitals, emergency departments, and ambulatory surgery facilities in California. Adult patients 18 years or older undergoing gender-affirming phalloplasty in California from January 1, 2009 to December 31, 2019 were included. We examined phalloplasty-related complications using International Classification of Disease diagnosis and procedure codes and Current Procedural Terminology codes. Unique record linkage number identifiers were used to follow patients longitudinally. Statistical analysis included Kaplan-Meier survival analysis and Cox proportional hazards analysis. RESULTS: We identified 766 patients who underwent gender-affirming phalloplasty in 23 facilities. Of 475 patients with record linkage numbers, 253 (55.3%) had subsequent re-presentations to the inpatient, emergency department, and ambulatory surgery settings related to phalloplasty complications. Survival analysis indicated that 50% of patients re-presented by 1year post-phalloplasty. Asian/Pacific Islander patients had lower risk of complications, and California residents had higher risk of complications. CONCLUSION: This population-based study confirms that gender-affirming phalloplasty has a high complication rate, and demonstrates for the first time an association with high rates of return to hospitals, emergency departments, and ambulatory surgery centers. These findings provide additional higher-level evidence that may aid patient counseling, shared surgical decision-making, and institutional and government policy.

Identifying Key Factors to PrEP Initiation and Persistence Among YMSM Through Focus Groups and Surveys in Two High-Priority Settings.

Cisgender men are diagnosed with HIV at a rate four times greater than cisgender women, with 71% of infections attributed to male-male sexual contact. Despite expanding accessibility, pre-exposure prophylaxis (PrEP) for HIV prevention is initiated by only 30% of people with PrEP indications. Five focus groups with 42 young men who have sex with men from New York and Alabama were conducted to identify key factors to PrEP initiation and persistence. Thirty focus group participants completed a survey on demographics, PrEP choices and health care attitudes. Findings suggest provider competency significantly influences PrEP use due to stigmatization in medical settings. Participants noted benefits of PrEP including HIV protection and sexual empowerment, yet barriers like cost and side effects were prevalent. Our findings outline barriers and facilitators to PrEP use among young men who have sex with men in two high priority settings that will inform PrEP care updates in participating clinics.

Sexual Health and Well-Being: A Framework to Guide Care.

Although the acceptance of sex positivity centering pleasure and justice has grown, clinical and public health strategies for sexually transmitted infection management have remained focused on risk and adverse outcomes. To promote sex-positive health care practice in clinical settings and beyond, health care practitioners should use an integrated, patient-centered approach to sexual health. These strategies include initiating discussions, continued sexual health education, providing informative material for patients, and knowledge of different communication strategies. Patient-provider interactions might be enhanced by using such methods.