Detectable viral load associated with unmet mental health and substance use needs among trans women living with HIV in San Francisco, California.

BACKGROUND: Substance use and mental distress are known barriers to HIV care engagement among trans women. Less is known about access and utilization of mental health and substance use care among trans women and the relationship between unmet behavioral health needs and HIV viral suppression. We examined the relationship between mental health and substance use on HIV viral load among trans women living with HIV. We also examined the relationship between mental health and substance use services needs with HIV care engagement and having a detectable viral load by comparing engagement in care cascades. METHODS: Data are from a 2022 baseline assessment for an intervention with trans women living with HIV (n = 42) in San Francisco. Chi-Squared or Fisher's exact tests were conducted to determine associations between HIV viral load, mental health, and substance use. We also examine characteristics associated with each step in the HIV, mental health, and substance use care cascades. RESULTS: Most participants were trans women of color (85.7%), 40 years of age or older (80.9%), with low income (88.1%), and almost half were unstably housed (47.6%). Of the 32 participants who screened positive for depression, anxiety and/or psychological distress, 56.3% were referred for mental health services in the past 12 months. Of those who were referred, 44.4% received mental health services. Of the 26 participants who screened positive for a substance use disorder, 34.6% were referred to substance use services in the past 12 months. Of those referred, 33.3% received substance use services in the past 3 months. Latina trans women had a low referral rate to meet their mental health needs (50%) and only 16.7% of African American/Black trans women who screened positive for a substance use disorder were referred for services, while trans women of other race/ethnicities had high referral and services utilization. No significant results were found between HIV viral load and screening positive for a mental health disorder. Methamphetamine use was statistically associated with having a detectable HIV viral load (p = 0.049). CONCLUSIONS: We identified significant unmet mental health and substance use services needs and noted racial/ethnic disparities in the context of high HIV care engagement among trans women living with HIV. We also found that methamphetamine use was a barrier to having an undetectable viral load for trans women living with HIV. To finally end the HIV epidemic, integration of behavioral health screening, linkage, and support are needed in HIV care services for populations most impacted by HIV, especially trans women. TRIAL REGISTRATION: NCT, NCT 21-34,978. Registered January 19, 2022.

The association between religiosity and resilience among young trans women.

INTRODUCTION: Young transgender women (trans women) experience poor health in part due to discrimination. Factors that promote resilience may help young trans women positively adapt to discrimination, resulting in attenuation of poor health outcomes. While religion is sometimes a source of stigma and transphobia, qualitative studies have identified religiosity as an important resilience resource for young trans women. The goals of this study were to quantitatively measure religiosity and resilience among young trans women and to assess whether they are associated. METHODS: From 2012-2013, 300 young trans women between the ages of 16-24 years were enrolled in a longitudinal study; we examined the cross-sectional baseline data on demographics, religiosity, and resilience. Bivariate and multivariable logistic regression analysis examined the correlation between demographics (age, gender, race/ethnicity, education, income) and religiosity among young trans women. Additionally, bivariate and multivariable logistic regression analysis examined the association between religiosity and resilience among young trans women, controlling for age, gender, race/ethnicity, education, and income. RESULTS: Participants who reported high religiosity had significantly greater odds (aOR 1.78, 95% CI 1.05-3.01, p = .03) of reporting high resilience compared to those reporting low religiosity. Black/African American participants had significantly higher odds (aOR 6.16, 95% CI 2.34-16.20, p = < .001) of reporting high religiosity compared to those who identified as White. CONCLUSION: Religiosity may be an important resilience resource for young trans women. Gender affirming religious and spiritual interventions may promote resilience among some young trans women.

Through a Different Lens: Occupational Health of Sex-Working Young Trans Women.

Purpose: Sex work is a common form of work among young trans women (YTW). Methods: Using an occupational health frame, we measured associations between demographics, sex work, and vocational outcomes in 18-month visit data from the SHINE study (n=263, San Francisco). Results: Overall, 41.8% reported lifetime sex work, primarily escorting/paid sex. Motivations included "better pay" and "can't get a job due to gender discrimination." Occupational injuries included anxiety (53.6%) and depression (50%), with significantly higher relative risk for YTW doing multiple types of sex work. Criminalization experiences (i.e., incarceration, arrests, and police interaction) were common. Conclusion: Results echo calls for sex worker-affirming mental health care for YTW.

Stigma as a barrier and sex work as a protective factor for HIV testing among trans women in Nepal.

Stigma towards trans women in Nepal creates individual and system-level risks for HIV. A critical protective factor is access to HIV prevention. Research is needed to determine the impact of stigma on HIV testing among trans women in Nepal. We conducted a secondary analysis of data collected using respondent driven sampling in 2019 on HIV risk among trans women in Nepal. Data analysis was restricted to trans women who were HIV negative at testing through the parent study. Descriptive statistics, tests for bivariable associations between HIV testing and stigma variables, and binomial Poisson regression were conducted to examine HIV testing outcomes. There were 173 participants who tested negative for HIV in our sample. The majority were under age 35 (59%) and most had a grade school education or less (64.7%). No trans women were homeless and most rented a room (70.5%) or owned their home (19.7%). The majority were currently sex workers (57.8%). Almost all HIV-negative trans women had ever been tested for HIV (90.8%), but only 53.5% in the last 3 months. The most frequently cited reason for not having been tested was thinking they were at low risk for HIV (40.9%) and being afraid of receiving a positive test result (22.7%). HIV and anti-trans stigma were high across most measures, including that almost all (94.2%) believed that most people in Nepal would discriminate against people with HIV. And most participants thought trans women were not accepted in Nepali Society (65.9%). Most participants also reported high social support (70.5%). Social cohesion among participants varied, with most experiencing medium (41.6%) or high (33.5%) social cohesion. Just over half had high social participation (55.5%). Participants who reported current sex work had lower prevalence of not testing for HIV in the last 3 months (prevalence ratio, PR = 0.54, 95% confidence interval, 95%CI = 0.32-0.92, p = 0.02). Every one-unit increase in social cohesion was associated with 1.05 times the prevalence of not testing for HIV in the last 3 months (95%CI = 1.01-1.09, p-value = 0.02). Trans women who did sex work were more likely to be HIV tested while those who were more socially connected to peers were less likely to have recently been tested for HIV. HIV stigma may result in fear of social rejection from peers if one tests positive. Interventions that focus on addressing stigma within trans women's social networks and strategies to mitigate HIV stigma in society may result in increased frequency of HIV testing among trans women in Nepal.

Transphobic Adverse Childhood Experiences as a Determinant of Mental and Sexual Health for Young Trans Women in the San Francisco Bay Area.

This study characterized the prevalence of transphobic adverse childhood experiences (ACEs) among young trans women (YTW) and assessed its relationship with poor mental health and sexual risk. A survey was administered between 2012 and 2014 to 300 YTW aged 16-24 living in the San Francisco Bay Area. Transphobic childhood verbal abuse, physical abuse, and high transphobic childhood adversity were endemic, and we found strong associations with depression, posttraumatic stress disorder, and any and receptive anal intercourse. ACEs may be critical social determinants of mental and sexual health for YTW and validated measures to screen for ACEs are needed, along with interventions that provide gender-affirmative support for parents.

COVID-19 Symptoms, Testing, and Test Positivity Among Trans Women in the San Francisco Bay Area in 2020-2021.

Background: The novel coronavirus (COVID-19) is negatively impacting vulnerable and marginalized communities. Growing research among sexual and gender minority communities shows increased COVID-19 risk and burden due to underlying social structure factors, however, not as much is known about the impact on trans women. Our team gathered data on COVID-19 risk, self-reported prevalence, and testing behaviors as part of an ongoing study of trans women's HIV risk and partnerships to fill this gap in data. Methods: This is a secondary analysis of data from The Partners Study, a study of HIV risk and transmission among trans women and their sexual partners in the San Francisco Bay Area. We collected COVID-19-related data from 87 trans women from July 2020 to January 2021. Participants were asked whether they were tested for COVID-19, had symptoms, or tested positive for the virus between March 2020 to the time they were screened to participate for a survey interview. Results: The majority of trans women did not report experiencing COVID-19 symptoms (85.05%, n=74/87) since March 2020. More than half had been tested for COVID-19 (68.9%, n=60/87). Overall, we found a COVID-19 prevalence of 8.33% (n=5/60) among those who received a COVID-19 test. Public Health Implications: The COVID-19 prevalence among trans women in our sample was higher than in other gender groups in San Francisco, suggesting that trans women may be disproportionately impacted by this disease. More research is needed to determine the impact of COVID-19 on trans women, and to develop strategies to increase testing and vaccinations among vulnerable communities preventing onward spread.

HIV prevalence, engagement in care, and risk behavior among trans women, San Francisco: Evidence of recent successes and remaining challenges.

BACKGROUND: Trans women have high HIV prevalence and lag behind 90-90-90 targets for HIV care. In San Francisco in 2017, 96% of trans women were aware of their status, 75% were on antiretroviral therapy, 88% had viral suppression. Initiatives to address gaps include peer navigators, free gender-affirming surgery, and housing. Our study updates HIV prevalence and engagement in care among trans women. METHODS: Cross-sectional community-based survey of trans women living in San Francisco sampled by respondent-driven sampling, 7/2019-2/2020 (N = 201). Eligibility was: self-identified trans women or other gender and assigned male at birth; living in San Francisco; English/Spanish-speaking; and 18 years or older. RESULTS: HIV prevalence was 42.3% (95%CI 35.4.-49.4) and associated with having a partner who injected drugs (adjusted odds ratio [AOR] 3.30, 95%CI 1.58-6.90), ever injected drugs (AOR 2.28, 95%CI 1.06-4.89), cost not a barrier to healthcare (AOR 2.63, 95%CI 1.02-6.67), emotional support from family (AOR 2.85, 95%CI 1.43-5.65), and Black/African-American (AOR 2.59, 95%CI 1.16-5.79). Of trans women with HIV, 92.9% were previously diagnosed, 89.9% were on ART, 91.5% reported viral suppression. CONCLUSIONS: Trans women met 90-90-90 targets in 2020, at 93-90-92. Interventions need to reach Black/African-American trans women, trans women who inject drugs, and partners of trans women.

The Dose Response Effects of Digital HIV Care Navigation on Mental Health and Viral Suppression Among Young People Living With HIV: Single-Arm, Prospective Study With a Pre-Post Design.

BACKGROUND: The HIV epidemic has revealed considerable disparities in health among sexual and gender minorities of color within the Unites States, disproportionately affecting cisgender men who have sex with men (MSM) and trans women. Social inequities further disadvantage those with intersectional identities through homophobia, antitrans discrimination, and racism, shaping not only those at risk for HIV infection but also HIV prevention and care outcomes. Digital interventions have great potential to address barriers and improve HIV care among cisgender MSM and trans women; however, efficacy of digital HIV care interventions vary and need further examination. OBJECTIVE: This study assessed the 12-month efficacy of a 6-month digital HIV care navigation intervention among young people living with HIV in San Francisco, California. We examined dose-response relationships among intervention exposure (eg, text messaging), viral suppression, and mental health. Health electronic navigation (eNav) is a 6-month, text message-based, digital HIV care navigation intervention, in which young people living with HIV are connected to their own HIV care navigator through text messaging to improve engagement in HIV primary care. METHODS: This study had a single-arm, prospective, pre-post design. Eligibility criteria for the study included the following: identifying as cisgender MSM or trans women, being between the ages of 18 and 34 years, being newly diagnosed with HIV, or not being engaged or retained in HIV care or having a detectable viral load. We assessed and analyzed sociodemographics, intervention exposure, and HIV care and mental health outcome data for participants who completed the 6-month Health eNav intervention. We assessed all outcomes using generalized estimating equations to account for within-subjects correlation, and marginal effects of texting engagement on all outcomes were calculated over the entire 12-month study period. Finally, we specified an interaction between texting engagement and time to evaluate the effects of texting engagement on outcomes. RESULTS: Over the entire 12-month period, this study shows that every one-text increase in engagement was associated with an increased odds of undetectable viral load (adjusted odds ratio 1.01, 95% CI 1.00-1.02; P=.03). Mean negative mental health experiences decreased significantly at 12 months compared to baseline for every one-text increase in engagement (coefficient on interaction term 0.97, 95% CI 0.96-0.99; P<.01). CONCLUSIONS: Digital care navigation interventions including Health eNav may be a critical component in the health delivery service system as the digital safety net for those whose social vulnerability is exacerbated in times of crisis, disasters, or global pandemics owing to multiple social inequities. We found that increased engagement in a digital HIV care navigation intervention helped improve viral suppression and mental health-intersecting comorbid conditions-6 months after the intervention concluded. Digital care navigation may be a promising, effective, sustainable, and scalable intervention. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/16406.

Prevalence and Correlates of Violence Experienced by Trans Women.

Objectives: To measure the prevalence and correlates of intimate partner, physical, and sexual violence experienced by trans women. Materials and Methods: A National HIV Behavioral Surveillance (NHBS) Study of 201 trans women was conducted in San Francisco from July 2019 to February 2020 using respondent-driven sampling. Prevalence ratio tests were used to test differences in the prevalence of violence by demographic characteristics including housing status. Results: Among 201 trans women interviewed, 26.9% were currently homeless. In the past year, 59.7% had been homeless, 34.3% changed housing, 60.7% had a housing situation other than renting or owning. Experiences of violence were common: 36.8% experienced any form of violence, including sexual (16.9%), intimate partner (14.9%), and other physical (25.4%) in the past year. Experiences of violence were significantly associated with multiple measures of housing insecurity. Younger age, being misgendered, and substance use were also associated with experiences of violence. Conclusions: Trans women face dual crises in housing and violence. Affordable, subsidized, and safe housing has the potential to reduce the exposure and vulnerability to violence faced by trans women.

A global cautionary tale: discrimination and violence against trans women worsen despite investments in public resources and improvements in health insurance access and utilization of health care.

BACKGROUND: To determine if improvements in social determinants of health for trans women and decreases in transphobic discrimination and violence occurred over three study periods during which extensive local programs were implemented to specifically address longstanding inequities suffered by the transgender community. METHODS: Interviewer-administered surveys from repeated cross-sectional Transwomen Empowered to Advance Community Health (TEACH) studies in 2010, 2013 and 2016-2017 in San Francisco collected experiences with transphobia violence and discrimination. Respondent-driven sampling was used to obtain a sample of participants who identified as a trans woman. RESULTS: Violence due to gender identity was prevalent; in each study period, verbal abuse or harassment was reported by over 83% of participants, and physical abuse or harassment was reported by over 56%. Adverse social determinants of health including homelessness, living below the poverty limit, methamphetamine use, depression, PTSD, and anxiety all significantly increased from 2010 to 2016. When testing for trends, housing discrimination and physical violence were both more likely in 2016-2017 compared to the two earlier study periods. Housing discrimination (aOR 1.41, 95% CI 1.00-1.98) and physical violence due to gender identity/presentation (aOR 1.39, 95% CI 1.00-1.92) both significantly increased from 2010 to 2016. CONCLUSION: Our findings are particularly alarming during a period when significant public health resources and community-based initiatives specifically for trans women were implemented and could have reasonably led us to expect improvements. Despite these efforts, physical violence and housing discrimination among trans women worsened during the study periods. To ensure future improvements, research and interventions need to shift the focus and burden from trans people to cisgender people who are the perpetuators of anti-trans sentiment, stigma, discrimination and victimization.

In Their Own Words: How Trans Women Acquired HIV Infection.

Despite high HIV prevalence, the reasons trans women acquire HIV are not well understood. Trans women are often mis-classified or aggregated with men who have sex with men (MSM) in epidemiologic studies and HIV surveillance data. Trans women enrolled in the 2019/2020 National HIV Behavioral Surveillance Study in San Francisco were asked an open-ended question about how they were infected with HIV. The most common responses were "Sex with a straight cisgender man partner when the respondent identified as a trans woman" (43.0%); "Sexual assault" (13.9%); "Injection drug use (IDU)" (10.1%); "IDU or sexual contact" (7.6%) and "Sex with a partner who injected drugs" (7.6%). Sex with a cisgender man partner prior to identifying as a trans women (MSM contact) was not mentioned by any respondent. HIV prevention strategies targeting MSM will fail to reach trans women and many of their cisgender men partners.

RESUMEN: A pesar de la alta prevalencia del VIH, las razones por las que las mujeres trans adquieren el VIH no se comprenden bien. Las mujeres trans a menudo se clasifican erróneamente o se agregan a los hombres que tienen sexo con hombres (HSH) en los estudios epidemiológicos y en los datos de vigilancia del VIH. A las mujeres trans inscritas en el Estudio Nacional de Vigilancia del Comportamiento del VIH 2019/2020 en San Francisco se les hizo una pregunta abierta sobre cómo se infectaron con el VIH. Las respuestas más comunes fueron "Sexo con una pareja heterosexual de hombre cisgénero cuando el encuestado se identificó como una mujer trans" (43,0%); "Agresión sexual" (13,9%); "Uso de drogas inyectables (UDI)" (10,1%); "UDI o contacto sexual" (7,6%) y "Sexo con pareja que se inyecta drogas" (7,6%). Ningún encuestado mencionó el sexo con una pareja hombre cisgénero antes de identificarse como mujer trans (contacto HSH). Las estrategias de prevención del VIH dirigidas a los HSH no llegarán a las mujeres trans ni a muchas de sus parejas masculinas.

A Technology-Based Intervention Among Young Men Who Have Sex With Men and Nonbinary People (The Conectad@s Project): Protocol for A Vanguard Mixed Methods Study.

BACKGROUND: In many parts of the world, including Brazil, uptake for biomedical interventions has been insufficient to reverse the HIV epidemic among key populations at high risk for HIV, including men who have sex with men. Young MSM (YMSM), particularly Black YMSM, have high HIV incidence, low viral suppression, and low preexposure prophylaxis (PrEP) uptake and adherence. Therefore, novel approaches to increase the HIV biomedical interventions uptake by YMSM are urgently needed. OBJECTIVE: We describe the Conectad@s Project, which aims to: (1) estimate the prevalence and incidence of HIV and other sexually transmitted infections, the onset of sexual risk behavior, and barriers to biomedical interventions among YMSM aged 18 to 24 years in Rio de Janeiro, Brazil; and (2) conduct a technology-based adherence intervention study to promote a rapid linkage of YMSM to HIV care or prevention, and support and sustain adherence. METHODS: A cross-sectional survey will be conducted with 400 YMSM recruited using respondent-driven sampling (RDS) adapted for social media-based sampling, preceded by a formative phase. HIV and sexually transmitted infections testing will be conducted, including early HIV infection biomarker detection. Behavioral, partnership, network, and structural measures will be collected through structured questionnaires. All individuals recruited for the survey will have access to HIV risk assessment, antiretroviral therapy (ART), PrEP, prevention counseling, and a technology-based adherence intervention. Those who accept the adherence intervention will receive weekly text messages via a social networking app (WhatsApp) for 24 weeks, with follow-up data collected over 48 weeks. RESULTS: The Conectad@s project has been approved by our local institutional review board (#CAAE 26086719.0.0000.4262) in accordance with all applicable regulations. Questionnaires for the RDS survey and intervention were developed and tested in 2020, formative interviews were conducted in January and February 2021 to guide the development of the RDS, and enrollment is planned to begin in early 2022. CONCLUSIONS: The Conectad@s Project is a vanguard study that, for the first time, will apply digital RDS to sample and recruit YMSM in Brazil and rapidly connect them to ART, PrEP, or prevention counseling through a technology-based adherence intervention. RDS will allow us to estimate HIV prevalence among YMSM and measure HIV infection biomarkers in the context of the onset of risky behavior. The data will lay the groundwork to adapt and implement HIV prevention strategies, identify barriers to the earliest HIV infection diagnosis, immediate ART or PrEP initiation, and detect new clusters of HIV transmission. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34885.

Improved PrEP Awareness and Use among Trans Women in San Francisco, California.

Transgender women face a serious risk of HIV infection. Despite this, there is limited knowledge and use of Pre-exposure prophylaxis (PrEP). We measured the continuity of prevention across services in the PrEP cascade and correlates of PrEP use among trans women in San Francisco enrolled in the 2019/20 National HIV Behavioral Surveillance Study. Knowledge and use of PrEP among trans women in San Francisco increased in recent years; almost all (94.0%) had heard about PrEP, 64.7% had discussed PrEP with a healthcare provider, and 44.8% had taken PrEP in the past 12 months. PrEP use was associated with participation in a PrEP demonstration project (aOR = 31.44, p = 0.001) and condomless receptive anal intercourse (aOR = 3.63, p = 0.024). Injection drug use was negatively associated (aOR = 0.19, p = 0.014). Efforts are needed to combat the gender-based stigma and discrimination faced by trans women, which can result in avoidance and mistrust of the medical system.

RESUMEN: Las mujeres trans enfrentan un grave riesgo de infección por el VIH. A pesar de ello, hay conocimiento y utilización limitada de la profilaxis previa a la exposición (PrEP). Medimos la continuidad de prevención a través de los servicios en la cascada de PrEP y los correlatos del uso de PrEP entre mujeres trans en San Francisco inscritas en el Estudio Nacional de Vigilancia del Comportamiento del VIH en 2019/20. El conocimiento y el uso de PrEP entre las mujeres trans en San Francisco aumentó en los últimos años; casi todas (94.0%) habían escuchado sobre PrEP, el 64.7% habían hablado de PrEP con un proveedor de atención médica y el 44.8% había tomado PrEP en los últimos 12 meses. El uso de PrEP se asoció con el uso actual con participación en un proyecto de demostración de PrEP (ORa = 31.44, p = 0.001) y el coito anal receptivo sin condón (ORa = 3.63, p = 0.024). El uso de drogas inyectables se asoció negativamente (ORa = 0.19, p = 0.014). Se necesitan esfuerzos para combatir el estigma y la discriminación basados en el género que enfrentan las mujeres trans, que pueden resultar en la evitación y desconfianza en el sistema medico.".

Disparities in Sexually Transmitted Infection Testing and the Need to Strengthen Comprehensive Sexual Health Services for Trans Women.

Purpose: Few studies have examined the importance of improving the sexual health delivery system beyond HIV among trans women. We assessed survey data from the National HIV Behavioral Surveillance Transgender Woman (NHBS-Trans) Study in San Francisco to characterize the utilization of sexual health services among HIV-negative trans women and to explore opportunities to improve sexual health services for trans women. Methods: Trans women were recruited through respondent-driven sampling from July 2019 to February 2020. The analytic sample was restricted to 116 HIV-negative trans women. We identified trends in data using chi-squared tests to assess significance between sexual risk behavior and the use of preventative sexual health services and built logistic regression models to assess the relationships between sexual risk behaviors and sexually transmitted infection (STI) testing. Results: The majority of sample was trans women of color with most identifying as Latinx (42.2%). Over half were low income (56%), and majority had been homeless in past 12 months (62.9%). The prevalence of condomless receptive anal sex was 52.6% with about two-thirds (62.1%) recently having an STI test. Participants who engaged in recent condomless receptive anal sex had more than fivefold greater odds of having a recent STI test compared to their counterparts who did not (adjusted odds ratio [aOR] 5.60, 95% confidence interval [CI] 1.83-17.11; p=0.003). We also found age- and education-related disparities in STI testing. Conclusion: This study characterized the utilization of sexual health services among HIV-negative trans women and identified important disparities in STI testing. We discuss opportunities to strengthen sexual health care delivery systems.

Expanding the Pie-Differentiated PrEP Delivery Models to Improve PrEP Uptake in the San Francisco Bay Area.

BACKGROUND: Pre-exposure prophylaxis (PrEP) uptake among trans people to date has been low. Recommendations implemented in San Francisco to offer PrEP with feminizing hormones have not led to improvement of PrEP uptake in trans communities. New delivery models may be needed. The aim of this study was to examine whether a PrEP-only clinic was more likely to serve trans people at highest risk of HIV than trans-affirming primary care clinics. METHODS: Participants were recruited between 2017 and 2019 as part of a PrEP demonstration project in the San Francisco Bay Area. Survey data including sociodemographics, HIV-related risk behavior, barriers to PrEP, and self-reported PrEP adherence were collected at baseline, 3 months, and 6 months for all participants. Bivariable Poisson regression models were used to examine differences between participants in the primary care clinics and PrEP-only clinic delivered to participants. RESULTS: Baseline survey data were collected from 153 participants. Those with a higher number of sexual partners were significantly more likely to use the PrEP-only clinic rather than the primary care clinics. Participants with higher perceived HIV risk and those who engaged in sex work were also more likely to use the PrEP-only clinic compared with the primary care clinic. Medical mistrust was higher at baseline among participants of the PrEP-only clinic. PrEP adherence was not significantly different by delivery model. Few participants identified PrEP barriers, such as interactions with feminizing hormones, to be determinants of PrEP uptake. CONCLUSIONS: A PrEP-only delivery model could improve PrEP uptake and may better meet the needs of trans people who could most benefit from PrEP.

Experiences and factors associated with transphobic hate crimes among transgender women in the San Francisco Bay Area: comparisons across race.

BACKGROUND: Trans women experience high rates of gender-based violence (GBV)-a risk factor for adverse health outcomes. Transphobic hate crimes are one such form of GBV that affect trans women. However, little is understood about factors that shape transphobic hate crimes and racial/ethnic variation in these experiences. To contextualize GBV risk and police reporting, we examined self-reported types and correlates of transphobic hate crimes by racial/ethnic group of trans women in the San Francisco Bay Area. METHODS: From 2016 to 2018, trans women participated in a longitudinal cohort study of HIV. Secondary data analyses (N = 629) examined self-reported experiences of transphobic hate crimes (i.e., robbery, physical assault, sexual assault, and battery with weapon) by race/ethnicity, and whether hate crimes were reported to the police. Chi-square tests and simple logistic regression examined demographic, sociocultural, and gender identity factors associated with transphobic violence experiences and police reporting. RESULTS: About half (45.8%) of participants reported ever experiencing a transphobic hate crime; only 51.1% of these were reported to the police. Among those who reported a hate crime experience, Black (47.9%) and Latina (49.0%) trans women reported a higher prevalence of battery with a weapon; White (26.7%) and trans women of "other" race/ethnicities (25.0%) reported a higher prevalence of sexual assault (p = 0.001). Having one's gender questioned, history of sex work, homelessness as a child and adult, and a history incarceration were associated with higher odds of experiencing a transphobic hate crime. Trans women who felt their gender identity questioned had lower odds of reporting a hate crime to the police compared to those did not feel questioned. CONCLUSIONS: A high proportion of trans women experienced a transphobic hate crime, with significant socio-structural risk factors and racial differences by crime type. However, crimes were underreported to the police. Interventions that address structural factors, especially among trans women of color, can yield violence prevention benefits.

Prevalence and Correlates of Nonprescription Hormone Use Among Trans Women in São Paulo, Brazil.

Purpose: The purpose of this study was to determine the prevalence and correlates of nonprescription hormone use among Brazilian trans women. Methods: This study is a cross-sectional survey of trans women in São Paulo, Brazil, recruited by respondent-driven sampling in 2017-2019. Results: Of 790 trans women, 36.8% were taking nonprescribed hormones. Nonprescribed hormone use was higher with younger age, lower education, homelessness, and using estrogen plus progesterone. Lower use was associated with accessing health care and having trans-specific health needs met. Conclusion: Marginalized Brazilian trans women exhibit high use of nonprescription hormones, which may have health consequences and requires further examination and research.

Population-based HIV prevalence, stigma and HIV risk among trans women in Nepal.

BACKGROUND: Transgender women (trans women) in Nepal are underserved in the HIV response. Data are needed to determine the HIV prevalence disaggregated from other key populations and to identify the particular risks faced by this community. Trans women are marginalized around the world and research is also needed to determine the impact of stigma on HIV risk to inform trans-specific interventions. METHODS: In 2019, we conducted the first population-based HIV behavioral surveillance study of trans women disaggregated from other key populations using respondent driven sampling (RDS). We estimated the HIV prevalence for trans women, and bivariate and multivariate Poisson binomial regression models were constructed to examine the relationship between HIV risk and stigma. RESULTS: Trans women participants (N = 200) had a mean age of 33 years old (SD = 10.96). We found a weighted HIV prevalence of 11.3% (95% CI 6·82% - 18·13). We found that depression and anxiety (aPR 0.81; 95% CI 0.67-0.97; p = 0·02) and current engagement in sex work (aPR 1.31; 95% CI 1.01-1.71; p = 0·046) were significantly associated with greater prevalence of condomless receptive anal intercourse. We found that experienced stigma of ever being verbally abused due to gender identity was significantly associated with lower prevalence of depression and anxiety (aPR 0.42; 95% CI 0.20-0.87; p = 0·002). Feeling unaccepted in Nepali society and believing people thought they were a criminal because of their trans identity was significantly associated greater prevalence of current sex work (aPR 1.36; 95% CI 1.03-1.78; p = 0·03; aPR 1.45; 95% CI 1.03-2.07; p = 0.04). Every measure of experienced stigma assessed was significantly associated with greater prevalence of current engagement in sex work. CONCLUSIONS: Trans women are highly stigmatized in Nepal, leading to individual and systems factors that impact their risk for HIV. Interventions are needed that support the economic and mental wellbeing of trans women to prevent their heighted risk of HIV from stigma.

Disparities in HIV-related risk and socio-economic outcomes among trans women in the sex trade and effects of a targeted, anti-sex-trafficking policy.

INTRODUCTION: Marginalization of sex work presents numerous risks for trans women (TW) engaged in the sex trade, including criminalization, traumatization, and contracting HIV. We identified socio-economic and HIV risk disparities among trans women sex workers and others who do sex work (TWSW/OWSW), and evaluated these disparities for TWSW/OWSW compared to TW not engaged in sex work from pre- and post-implementation of the US 2018 "Allow States and Victims to Fight Online Sex Trafficking Act" and "Stop Enabling Sex Traffickers Act" (FOSTA-SESTA). METHODS: We analyzed 429 trans women (TW) from the Trans*National cohort study (2016-2019). Generalized estimating equations (GEE) characterized differences in socio-economic and HIV risk outcomes for TWSW/OWSW compared to TW not engaged in sex work over the study period. Adjusted, pre-to-post law changes in these outcomes for TWSW/OWSW versus TW not engaged in sex work were compared using difference-in-differences GEE regression analyses. RESULTS: Over 18 months, TWSW/OWSW had higher adjusted odds of being unstably housed, having income from criminalized sources, experiencing transphobic hate crimes, experiencing discrimination from police/courts, being incarcerated, meeting sex partners in the street/public settings, meeting sex partners on Craigslist or other online forums (except dating apps), or engaging in condomless anal intercourse, (p < 0.01 for all comparisons); TWSW/OWSW also had a higher mean number of income sources (p = 0.03). One difference-in-differences analysis showed additive interaction: the adjusted mean number of income sources reported by TWSW/OWSW compared to those not engaged in sex work decreased from pre-to post-FOSTA-SESTA (from 1.79 to 1.48 for TWSW/OWSW and from 1.52 to 1.47 for TW not engaged in sex work; p = 0.01). CONCLUSIONS: Disparities in socio-economic and HIV-related risk outcomes exist for TWSW/OWSW in San Francisco. There is an urgent need for comprehensive, long-term follow-up data of TW to accurately analyze policy effects, especially given the recent enactment of a number of other policies targeting TW.

Intercategorical and Intracategorical Experiences of Discrimination and HIV Prevalence Among Transgender Women in San Francisco, CA: A Quantitative Intersectionality Analysis.

Objectives. To examine differences in HIV prevalence and experiences of discrimination within the trans women community in California's San Francisco Bay Area.Methods. Intersectional positions were constructed on the basis of race/ethnicity (non-Hispanic White, non-Hispanic Black, Latina) and gender identity (female identifying, transgender identifying). We used baseline data from the Trans*National study (2016-2017) to construct regression models that estimated racial/ethnic differences in the attribution of discrimination experienced and, along with surrogate measures for intersectionality, estimated risk among those who were dually marginalized (racial/ethnic minority and transgender identifying). Margins plots were used to visually compare absolute risk across all intersectional positions.Results. Black and Latina trans women were more likely to be HIV positive than non-Hispanic White trans women. In several of the study domains, we estimated a lower risk of reporting discrimination among dually marginalized trans women than among White female-identifying trans women.Conclusions. Quantitative intersectionality methods highlight the diversity of experiences within the trans women community and reveal potential measurement challenges. Despite facing multiple forms of systemic marginalization, racial/ethnic minority trans women report less discrimination than White trans women. Subjective reporting of discrimination likely undercounts risks among racial/ethnic minorities.