Inequities in Conversion Practice Exposure at the Intersection of Ethnoracial and Gender Identities.

Objectives. To examine inequities in conversion practice exposure across intersections of ethnoracial groups and gender identity in the United States. Methods. Data were obtained from The Population Research in Identity and Disparities for Equality Study of sexual and gender minority people from 2019 to 2021 (n = 9274). We considered 3 outcomes: lifetime exposure, age of first exposure, and period between first and last exposure among those exposed to conversion practices. We used log-binomial, Cox proportional hazards, and negative binomial models to examine inequities by ethnoracial groups and gender identity adjusting for confounders. We considered additive interaction. Results. Conversion practice prevalence was highest among minoritized ethnoracial transgender and nonbinary participants (TNB; 8.6%). Compared with White cisgender participants, minoritized ethnoracial TNB participants had twice the prevalence (prevalence ratio = 2.16; 95% confidence interval [CI] = 1.62, 2.86) and risk (hazard ratio = 2.04; 95% CI = 1.51, 2.69) of conversion practice exposure. Furthermore, there was evidence of a positive additive interaction for age of first exposure. Conclusions. Minoritized ethnoracial TNB participants were most likely to recall experiencing conversion practices. Public Health Implications. Policies banning conversion practices may reduce the disproportionate burden experienced by minoritized ethnoracial TNB participants. (Am J Public Health. 2024;114(4):424-434. https://doi.org/10.2105/AJPH.2024.307580).

Family connectedness and sexual minority Asian Americans' eating behavior regulation.

To date, psychosocial and interpersonal protective factors such as family connectedness have received little attention in studies of eating behaviors among sexual minority Asian Americans. Therefore, we investigated associations of family connectedness and two types of eating behavior regulation motives and the moderating role of individualism in these associations among 134 sexual minority Asian American young adults. Linear regression models assessed the main and interaction effects of family connectedness and individualism on introjected and identified eating behavior regulation motives. We observed a significant interaction effect between family connectedness and individualism only on introjected regulation. For participants with low levels of individualism, those who reported high levels of family connectedness had lower scores for introjected regulation of eating behavior. The findings of this study highlight the importance of examining strengths related to sexual minority Asian Americans by demonstrating the important role family connectedness plays in eating behavior regulation motives, particularly for those with lower individualism.

Prevalence of 12 Common Health Conditions in Sexual and Gender Minority Participants in the All of Us Research Program.

Importance: Limited data describe the health status of sexual or gender minority (SGM) people due to inaccurate and inconsistent ascertainment of gender identity, sex assigned at birth, and sexual orientation. Objective: To evaluate whether the prevalence of 12 health conditions is higher among SGM adults in the All of Us Research Program data compared with cisgender heterosexual (non-SGM) people. Design, Setting, and Participants: This cross-sectional study used data from a multidisciplinary research consortium, the All of Us Research Program, that links participant-reported survey information to electronic health records (EHR) and physical measurements. In total, 372 082 US adults recruited and enrolled at an All of Us health care provider organization or by directly visiting the enrollment website from May 31, 2017, to January 1, 2022, and were assessed for study eligibility. Exposures: Self-identified gender identity and sexual orientation group. Main Outcomes and Measures: Twelve health conditions were evaluated: 11 using EHR data and 1, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), using participants' physical measurements. Logistic regression (adjusting for age, income, and employment, enrollment year, and US Census division) was used to obtain adjusted odds ratios (AORs) for the associations between each SGM group and health condition compared with a non-SGM reference group. Results: The analytic sample included 346 868 participants (median [IQR] age, 55 [39-68] years; 30 763 [8.9%] self-identified as SGM). Among participants with available BMI (80.2%) and EHR data (69.4%), SGM groups had higher odds of anxiety, depression, HIV diagnosis, and tobacco use disorder but lower odds of cardiovascular disease, kidney disease, diabetes, and hypertension. Estimated associations for asthma (AOR, 0.39 [95% CI, 0.24-0.63] for gender diverse people assigned male at birth; AOR, 0.51 [95% CI, 0.38-0.69] for transgender women), a BMI of 25 or higher (AOR, 1.65 [95% CI, 1.38-1.96] for transgender men), cancer (AOR, 1.15 [95% CI, 1.07-1.23] for cisgender sexual minority men; AOR, 0.88 [95% CI, 0.81-0.95] for cisgender sexual minority women), and substance use disorder (AOR, 0.35 [95% CI, 0.24-0.52] for gender diverse people assigned female at birth; AOR, 0.65 [95% CI, 0.49-0.87] for transgender men) varied substantially across SGM groups compared with non-SGM groups. Conclusions and Relevance: In this cross-sectional analysis of data from the All of Us Research Program, SGM participants experienced health inequities that varied by group and condition. The All of Us Research Program can be a valuable resource for conducting health research focused on SGM people.

Geolocation to Identify Online Study-Eligible Gay, Bisexual, and Men who have Sex with Men in Philadelphia, Pennsylvania.

BACKGROUND: Data collection and cleaning procedures to exclude bot-generated responses are used to maintain the data integrity of samples from online surveys. However, these procedures may be time-consuming and difficult to implement. Thus, we aim to evaluate the validity of a single-step geolocation algorithm for recruiting eligible gay, bisexual, and men who have sex with men in Philadelphia for an online study. METHODS: We used a 4-step approach, based on common practices for evaluating bot-generated and fraudulent responses, to assess the validity of participants' Qualtrics survey data as our referent standard. We then compared it to Qualtrics' single-step geolocation algorithm that used the MaxMind commercial database to map participants' Internet protocol address to their approximate location. We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the single-step geolocation approach relative to the 4-step approach. RESULTS: There were 826 respondents who completed the survey and 440 (53%) were eligible for enrollment based on the 4-step approach. The single-step geolocation approach yielded a sensitivity of 91% (95% CI = 88%, 93%), specificity of 79% (95% CI = 74%, 83%), PPV of 83% (95% CI = 80%, 86%), and NPV of 88% (95% CI = 85%, 91%). CONCLUSIONS: Geolocation alone provided a moderately high level of agreement with the 4-step approach for identifying geographically eligible participants in the online sample, but both approaches may be subject to additional misclassification. Researchers may want to consider multiple procedures to ensure data integrity in online samples.

A Note on Preexposure Prophylaxis Preferences Among Women Who Inject Drugs.

ABSTRACT: We informed women who inject drugs about different preexposure prophylaxis (PrEP) formulations; they then ranked their preferences. Daily oral PrEP was most preferred, followed by injectable PrEP and vaginal rings/gels, especially among women of color. Multiple PrEP options should be discussed with women who inject drugs to increase uptake.

State-level heterogeneity in associations between structural stigma and individual health care access: A multilevel analysis of transgender adults in the United States.

OBJECTIVE: State-level variation in how restrictive policies affect health care access for transgender populations has not been widely studied. Therefore, we assessed the association between structural stigma and four measures of individual health care access among transgender people in the United States, and the extent to which structural stigma explains state-level variability. METHODS: Data were drawn from the 2015-2019 Behavioral Risk Factor Surveillance System and the Human Rights Campaign's State Equality Index. We calculated weighted proportions and conducted multilevel logistic regression of individual heterogeneity and discriminatory accuracy. RESULTS: An increase in the structural stigma score by one standard deviation was associated with lower odds of health care coverage (OR = 0.80; 95% CI: 0.66, 0.96) after adjusting for individual-level confounders. Approximately 11% of the total variance for insurance coverage was attributable to the state level; however, only 18% of state-level variability was explained by structural stigma. Adding Medicaid expansion attenuated the structural stigma-insurance association and explained 22% of state-level variation in health insurance. For the remaining outcomes (usual source of care, routine medical check-up, and cost-related barriers), we found neither meaningful associations nor considerable between-state variability. CONCLUSIONS: Our findings support the importance of Medicaid expansion and transgender-inclusive antidiscrimination protections to enhance health care insurance coverage. From a measurement perspective, however, additional research is needed to develop and validate measures of transgender-specific structural stigma to guide future policy interventions.

An Exploration of Racial Differences of Psychosocial Stressors and Their Association With Mental Health Between Asian and White Sexual Minority Men: The P18 Cohort Study.

There is growing concern that Asian sexual minority men (SMM), including gay, bisexual, and other men who have sex with men, may be at elevated risk of psychological distress and suicidal ideation, yet limited attention has focused on how psychosocial stressors may affect them. This study seeks to (a) explore differences in psychosocial stressors, anxiety, depression, and suicidal ideation between Asian and White SMM and (b) evaluate the potential moderation of associations between psychosocial stressors and mental health by race. Data were obtained from the P18 Cohort Study. We restricted the sample to only those who identified as non-Hispanic Asian or White and used regression analysis to assess the associations of psychosocial stressors and mental health outcomes in the overall sample by race. Of the 217 participants in our analytic sample, 23% self-identified as Asian. Compared with White SMM, Asian SMM had a higher prevalence of loneliness, internalized homophobia, and public gay-related stigma. In regression analyses, most psychosocial stressors were significantly associated with anxiety, depression, and suicidal ideation in the overall sample. Associations between each stressor and mental health outcome primarily did not differ between Asian and White SMM. However, White SMM experiencing higher levels of public gay-related stigma had greater odds of suicidal ideation, although this was not observed for Asian SMM. Overall, Asian SMM may be experiencing similar effects of psychosocial stressors on mental health to White SMM. Health professionals may want to consider how these stressors impact the mental health and well-being of their Asian SMM clients.

Perceived Barriers to and Facilitators of Long-Acting Injectable HIV PrEP Use Among Black, Hispanic/Latino, and White Gay, Bisexual, and Other Men Who Have Sex With Men.

Long-acting injectable pre-exposure prophylaxis (LAI-PrEP) was recently approved for HIV prevention as an alternative to daily oral PrEP. We explored preferences and attitudes toward LAI-PrEP among Black, Hispanic/Latino, and White gay, bisexual, and other men who have sex with men (GBM) using focus groups (n = 13) and in-depth interviews (n = 17). Participants expressed differing levels of interest in LAI-PrEP. While important benefits of LAI-PrEP included convenience, provider-facilitated PrEP discussion, and expansion of PrEP options, participants raised concerns about treatment efficacy and side effects, discomfort with needles/injections, cost, and frequency of clinic visits. Our findings highlight ongoing challenges with accessing HIV-prevention tools and provide guidance for developing strategies to enhance LAI-PrEP uptake among GBM.

Countering the rise of syphilis: A role for doxycycline post-exposure prophylaxis?

Doxycycline post-exposure prophylaxis (PEP) holds the potential to mitigate increasing rates of syphilis among sexual minority men (SMM) in the US yet has received limited attention. Since evaluation of this intervention in actual populations is not currently feasible, we used agent-based models (ABM) to assess the population-level impact of this strategy. We adapted ABM of HIV and HPV transmission, representing a population of 10,230 SMM in Philadelphia, Pennsylvania, US. Parameter inputs were derived from the literature, and ABM outputs during the pre-intervention period were calibrated to local surveillance data. Intervention scenarios varied doxycycline uptake by 20, 40, 60, 80 and 100%, while assuming continued condom use and syphilis screening and treatment. Under each intervention scenario, we incorporated treatment adherence at the following levels: 0, 20, 40, 60, 80 and 100%. Long-term population impact of prophylactic doxycycline was measured using the cumulative incidence over the 10-year period and the percentage of infections prevented attributable to doxycycline at year 10. An uptake scenario of 20% with an adherence level of 80% would reduce the cumulative incidence of infections by 10% over the next decade, translating to 57 fewer cases per 1000 SMM. At year 10, under the same uptake and adherence level, 22% of infections would be prevented due to doxycycline PEP in the instances where condoms were not used or failed. Findings suggest that doxycycline PEP will have a modest impact on syphilis incidence when assuming a reasonable level of uptake and adherence. Doxycycline PEP may be most appropriate as a secondary prevention measure to condoms and enhanced syphilis screening for reducing infections among SMM.

Limited Risk Compensation Among Women Who Inject Drugs: Results From the Project Sexual Health Equity Preexposure Prophylaxis Demonstration Study in Philadelphia.

ABSTRACT: The impact of preexposure prophylaxis uptake on sexual and injection-related behaviors among women who inject drugs is poorly understood. Over 24 weeks, preexposure prophylaxis uptake among women who inject drugs was associated with increased sharing of injection equipment but not syringes and no changes in condomless sex, providing limited evidence of risk compensation in this vulnerable population.

Wearable biosensors have the potential to monitor physiological changes associated with opioid overdose among people who use drugs: A proof-of-concept study in a real-world setting.

INTRODUCTION: Wearable biosensors have the potential to monitor physiological change associated with opioid overdose among people who use drugs. METHODS: We enrolled 16 individuals who reported ≥ 4 daily opioid use events within the previous 30 day. Each was assigned a wearable biosensor that measured respiratory rate (RR) and actigraphy every 15 s for 5 days and also completed a daily interview assessing drug use. We describe the volume of RR data collected, how it varied by participant characteristics and drug use over time using repeated measures one-way ANOVA, episodes of acute respiratory depression (≤5 breaths/minute), and self-reported overdose experiences. RESULTS: We captured 1626.4 h of RR data, an average of 21.7 daily hours/participant over follow-up. Individuals with longer injection careers and those engaging in polydrug use captured significantly fewer total hours of respiratory data over follow-up compared to those with shorter injections careers (94.7 vs. 119.9 h, p = 0.04) and injecting fentanyl exclusively (98.7 vs. 119.5 h, p = 0.008), respectively. There were 385 drug use events reported over follow-up. There were no episodes of acute respiratory depression which corresponded with participant reports of overdose experiences. DISCUSSION: Our preliminary findings suggest that using a wearable biosensor to monitor physiological changes associated with opioid use was feasible. However, more sensitive biosensors that facilitate triangulation of multiple physiological data points and larger studies of longer duration are needed.

Intention to initiate and uptake of PrEP among women who injects drugs in a demonstration project: an application of the theory of planned behavior.

Some women who inject drugs (WWID) would benefit from pre-exposure prophylaxis (PrEP), yet there are few studies of issues related to uptake in real-world settings. In this study, participants (n = 95) were offered PrEP and responded to items measuring PrEP-related attitudes, norms, and perceived behavioral control based on the Theory of Planned Behavior. We tested associations with intention to initiate PrEP and uptake. Most WWID (88%) intended to initiate PrEP and 78% accepted a prescription. Compared to WWID who did not express PrEP intentions, those who did were less concerned about attitudinal and perceived behavioral control constructs such as temporary (75% vs. 36%, p = 0.01) and long-term (63% vs. 27%, p = 0.05) side effects, negative interactions with their birth control (93% vs. 38%, p < 0.01), their ability to take a daily pill (80% vs. 36%, p < 0.01), and the cost of PrEP (87% vs. 36%, p < 0.01). WWID who went on to take PrEP had fewer concerns with subjective norms constructs such as talking to health care providers about sex (91% vs. 65%, p < 0.01) and drug use (88% vs. 55%, p < 0.01) compared to those who did not. Attitudes and perceived behavioral control influenced intention while subjective norms had a greater impact on actual uptake.

Practical data considerations for the modern epidemiology student.

As an inherent part of epidemiologic research, practical decisions made during data collection and analysis have the potential to impact the measurement of disease occurrence as well as statistical and causal inference from the results. However, the computational skills needed to collect, manipulate, and evaluate data have not always been a focus of educational programs, and the increasing interest in "data science" suggest that data literacy has become paramount to ensure valid estimation. In this article, we first motivate such practical concerns for the modern epidemiology student, particularly as it relates to challenges in causal inference; second, we discuss how such concerns may be manifested in typical epidemiological analyses and identify the potential for bias; third, we present a case study that exemplifies the entire process; and finally, we draw attention to resources that can help epidemiology students connect the theoretical underpinning of the science to the practical considerations as described herein.

Integrating HIV Preexposure Prophylaxis With Community-Based Syringe Services for Women Who Inject Drugs: Results From the Project SHE Demonstration Study.

INTRODUCTION: To guide future preexposure prophylaxis (PrEP) implementation for women who inject drugs (WWID), a population increasingly represented in new HIV cases in the United States, we present results from a demonstration project integrated within a syringe services program (SSP) in Philadelphia, PA. METHODS: WWID ≥18 years were educated about and offered 24 weeks of daily PrEP. Participants completed surveys and clinical assessments at baseline and at weeks 1, 3, 12, and 24. We used descriptive statistics to estimate feasibility/acceptability, engagement in the care cascade, HIV/sexually transmitted diseases (STI) and pregnancy, issues of safety/tolerability, and preferences/satisfaction with PrEP services. Multivariable logistic regression with generalized estimating equations was used to identify factors associated with PrEP uptake and retention. RESULTS: We recruited 136 WWID. Of those, 95 were included in the final sample, and 63 accepted a PrEP prescription at week 1. Uptake was associated with greater baseline frequency of SSP access [adjusted odds ratio (aOR) = 1.85; 95% confidence interval (CI): 1.24 to 2.77], inconsistent condom use (aOR = 3.38; 95% CI: 1.07 to 10.7), and experiencing sexual assault (aOR = 5.89; 95% CI: 1.02, 33.9). Of these 95, 42 (44.2%) were retained at week 24. Retention was higher among women who reported more frequent baseline SSP access (aOR = 1.46; 95% CI: 1.04 to 2.24). Self-reported adherence was high but discordant with urine-based quantification of tenofovir. Baseline STI prevalence was 17.9%; there were 2 HIV seroconversions and 1 pregnancy. Safety/tolerability issues were uncommon, and acceptability/satisfaction was high. CONCLUSIONS: Integrating PrEP with SSP services is feasible and acceptable for WWID. This suggests that daily PrEP is a viable prevention tool for this vulnerable population.

The heterogeneous effect of marijuana decriminalization policy on arrest rates in Philadelphia, Pennsylvania, 2009-2018.

BACKGROUND: Marijuana decriminalization holds potential to reduce health inequities. However, limited attention has focused on assessing the impact of decriminalization policies across different populations. This study aims to determine the differential effect of a marijuana decriminalization policy change in Philadelphia, PA on marijuana arrests by demographic characteristics. METHODS: Using a comparative interrupted time series design, we assessed whether the onset of marijuana decriminalization in Philadelphia County was associated with reduction in arrests rates from 2009 to 2018 compared to Dauphin County. Stratified models were used to describe the differential impact of decriminalization across different demographic populations. RESULTS: Compared to Dauphin, the mean arrest rate for all marijuana-related crimes in Philadelphia declined by 19.9 per 100,000 residents (34.9% reduction), 17.1 per 100,000 residents (43.1% reduction) for possession, and 2.8 per 100,000 resident (15.9% reduction) for sales/manufacturing. Arrest rates also differed by demographic characteristics post-decriminalization. Notably, African Americans had a greater absolute/relative reduction in possession-based arrests than Whites. However, relative reductions for sales/manufacturing-based arrests was nearly 3 times lower for African Americans. Males had greater absolute/relative reduction for possession-based arrests, but lower relative reduction for sales/manufacturing-based arrests compared to females. There were no substantial absolute differences by age; however, youths (vs. adults) experienced higher relative reduction in arrest rates. CONCLUSIONS: Findings suggest an absolute/relative reduction for possession-based arrests post-decriminalization; however, relative disparities in sales/manufacturing-based arrests, specifically for African Americans, increased. More consideration towards the heterogeneous effect of marijuana decriminalization are needed given the unintended harmful effects of arrest on already vulnerable populations.

Prevalence and correlates of carrying naloxone among a community-based sample of opioid-using people who inject drugs.

BACKGROUND: Overdose prevention programs are effective at reducing opioid overdose deaths through training people who inject drugs (PWID) how to respond to witnessed overdoses and use naloxone. This report examines prevalence and correlates of carrying naloxone among a community-based sample of PWID. METHODS: Using respondent driven sampling, PWID (n = 571) in Philadelphia, PA were recruited for the 2015 National HIV Behavioral Surveillance project. The impact of socio-demographics, social services, and law enforcement interaction on naloxone carrying were analyzed using multivariable logistic regression. RESULTS: Odds of carrying naloxone were higher among PWID who were: homeless (adjusted odds ratio [aOR] = 1.65, 95% confidence interval [CI]: 1.01, 2.83), reported a syringe exchange program as their primary source of syringes (aOR = 2.92, CI: 1.68, 5.09), and had been stopped by police ≥6 times (aOR = 2.16, CI: 1.12, 4.16) or arrested (aOR = 1.84, CI: 1.02, 3.30) in the past year. CONCLUSIONS: Syringe exchange access was associated with naloxone carrying and is likely a primary source for naloxone and overdose reversal training for PWID. Homelessness and law enforcement encounters are known barriers to harm reducing behaviors; however, both were positively associated with carrying naloxone in this sample. Larger studies are needed to explore these relationships in greater depth.

Modeling HPV vaccination scale-up among urban young men who have sex with men in the context of HIV.

INTRODUCTION: Young men who have sex with men (YMSM) are at high risk to contract human papillomavirus (HPV). While an effective vaccination exists, its use among YMSM is markedly lower compared to non-MSM and women. This study compares scaling up HPV vaccination in conjunction with other prevention strategies. METHODS: An agent-based model of urban YMSM (≤26 years of age) reflective of the demography of Philadelphia, PA, simulated for up to ten years of follow-up to examine anal and oral transmission of the HPV genotypes covered in the nonavalent (9v) vaccine: 6, 11, 16, 18, 31, 33, 45, 52, 58. Starting HPV prevalences ranged from a high of 18% (type 6) to a low of 6% (type 31); overall 65% of individuals carried any HPV genotype. Simulated levels of vaccination were ranged from 0% to 13% (present-day level), 25%, 50%, 80% (Healthy People 2020 target), and 100% in conjunction with condom use and HIV seroadaptive practices. The primary outcome was the relative reduction in HPV infection. RESULTS: Compared to present-day vaccination levels (13%), scaling-up vaccination led to expected declines in 10-year post-simulation HPV prevalence. Anal HPV (any 9v types) declined by 9%, 27%, 46%, and 58% at vaccination levels of 25%, 50%, 80%, and 100%, respectively. Similarly, oral HPV (any 9v types) declined by 11%, 33%, 57%, and 71% across the same levels of vaccine uptake. Comparing the prevention strategies, condoms blocked the greatest number of anal transmissions when vaccination was at or below present-day levels. For oral transmission, vaccination was superior to condom use at all levels of coverage. CONCLUSIONS: Public health HPV preventions strategies should continue to emphasize the complementary roles of condoms and vaccination, especially for preventing oral infection. Improving vaccination coverage will ultimately have the greatest impact on reducing HPV infection among YMSM.