Including transgender populations in mathematical models for HIV treatment and prevention: current barriers and policy implications.

INTRODUCTION: Mathematical models of HIV have been uniquely important in directing and evaluating HIV policy. Transgender and nonbinary people are disproportionately impacted by HIV; however, few mathematical models of HIV transmission have been published that are inclusive of transgender and nonbinary populations. This commentary discusses current structural challenges to developing robust and accurate trans-inclusive models and identifies opportunities for future research and policy, with a focus on examples from the United States. DISCUSSION: As of April 2024, only seven published mathematical models of HIV transmission include transgender people. Existing models have several notable limitations and biases that limit their utility for informing public health intervention. Notably, no models include transgender men or nonbinary individuals, despite these populations being disproportionately impacted by HIV relative to cisgender populations. In addition, existing mathematical models of HIV transmission do not accurately represent the sexual network of transgender people. Data availability and quality remain a significant barrier to the development of accurate trans-inclusive mathematical models of HIV. Using a community-engaged approach, we developed a modelling framework that addresses the limitations of existing model and to highlight how data availability and quality limit the utility of mathematical models for transgender populations. CONCLUSIONS: Modelling is an important tool for HIV prevention planning and a key step towards informing public health interventions, programming and policies for transgender populations. Our modelling framework underscores the importance of accurate trans-inclusive data collection methodologies, since the relevance of these analyses for informing public health decision-making is strongly dependent on the validity of the model parameterization and calibration targets. Adopting gender-inclusive and gender-specific approaches starting from the development and data collection stages of research can provide insights into how interventions, programming and policies can distinguish unique health needs across all gender groups. Moreover, in light of the data structure limitations, designing longitudinal surveillance data systems and probability samples will be critical to fill key research gaps, highlight progress and provide additional rigour to the current evidence. Investments and initiatives like Ending the HIV Epidemic in the United States can be further expanded and are highly needed to prioritize and value transgender populations across funding structures, goals and outcome measures.

Getting Precise about Gender and Sex Measurement: A Primer for Epidemiologists.

Accurately measuring gender and sex is crucial in public health and epidemiology. Iteratively reexamining how variables-including gender and sex-are conceptualized and operationalized is necessary to achieve impactful research. Reexamining gender and sex advances epidemiology toward its goals of health promotion and disease elimination. While we cannot reduce the complexities of sex and gender to simply an issue of measurement, striving to capture these concepts and experiences accurately must be an ongoing dialogue and practice-to the benefit of the field and population health. We assert that epidemiology must counteract misconceptions and accurately measure gender and sex in epidemiology. We aim to summarize existing critiques and guiding principles in measuring gender and sex that can be applied in practice.

Combined Motivational Interviewing and Ecological Momentary Intervention to Reduce Hazardous Alcohol Use Among Sexual Minority Cisgender Men and Transgender Individuals: Protocol for a Randomized Controlled Trial.

BACKGROUND: Sexual minority cisgender men and transgender (SMMT) individuals, particularly emerging adults (aged 18-34 years), often report hazardous drinking. Given that alcohol use increases the likelihood of HIV risk behaviors, and HIV disproportionately affects SMMT individuals, there is a need to test interventions that reduce hazardous alcohol use and subsequent HIV risk behaviors among this population. Ecological momentary interventions (EMIs), which use mobile phones to deliver risk reduction messages based on current location and behaviors, can help to address triggers that lead to drinking in real time. OBJECTIVE: This study will test an EMI that uses motivational interviewing (MI), smartphone surveys, mobile breathalyzers, and location tracking to provide real-time messaging that addresses triggers for drinking when SMMT individuals visit locations associated with hazardous alcohol use. In addition, the intervention will deliver harm reduction messaging if individuals report engaging in alcohol use. METHODS: We will conduct a 3-arm randomized controlled trial (N=405 HIV-negative SMMT individuals; n=135, 33% per arm) comparing the following conditions: (1) Tracking and Reducing Alcohol Consumption (a smartphone-delivered 4-session MI intervention), (2) Tracking and Reducing Alcohol Consumption and Environmental Risk (an EMI combining MI with real-time messaging based on geographic locations that are triggers to drinking), and (3) a smartphone-based alcohol monitoring-only control group. Breathalyzer results and daily self-reports will be used to assess the primary and secondary outcomes of drinking days, drinks per drinking day, binge drinking episodes, and HIV risk behaviors. Additional assessments at baseline, 3 months, 6 months, and 9 months will evaluate exploratory long-term outcomes. RESULTS: The study is part of a 5-year research project funded in August 2022 by the National Institute on Alcohol Abuse and Alcoholism. The first 1.5 years of the study will be dedicated to planning and development activities, including formative research, app design and testing, and message design and testing. The subsequent 3.5 years will see the study complete participant recruitment, data collection, analyses, report writing, and dissemination. We expect to complete all study data collection in or before January 2027. CONCLUSIONS: This study will provide novel evidence about the relative efficacy of using a smartphone-delivered MI intervention and real-time messaging to address triggers for hazardous alcohol use and sexual risk behaviors. The EMI approach, which incorporates location-based preventive messaging and behavior surveys, may help to better understand the complexity of daily stressors among SMMT individuals and their impact on hazardous alcohol use and HIV risk behaviors. The tailoring of this intervention toward SMMT individuals helps to address their underrepresentation in existing alcohol use research and will be promising for informing where structural alcohol use prevention and treatment interventions are needed to support SMMT individuals. TRIAL REGISTRATION: ClinicalTrials.gov NCT05576350; https://www.clinicaltrials.gov/study/NCT05576350. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/55166.

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

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

First They Came for Us All: Responding to Anti-Transgender Structural Violence With Collective, Community-Engaged, and Intersectional Health Equity Research and Advocacy.

This article is a call for collective action across health equity researchers and advocates to build a more just world. We attempt to make sense of senseless structural and interpersonal brutality in the context of the current political climate across the United States, whereby the spectrum of gender nonconformity has been and continues to be stigmatized. From drag performance to transgender identities to gender-affirming health care, extremists have instrumentalized primary levers of democracy-the courts, legislatures, and social media-to attempt to outlaw and eradicate gender expansiveness and those who provide forms of support and care, including gender-affirming medical care, to transgender, nonbinary, and gender-expansive (TNBGE) individuals.

Drivers of Active Amphetamine-Type Stimulant Use among Transgender Women in Malaysia: A Cross-Sectional Study.

While ample evidence exists regarding the use of active amphetamine-type stimulants (ATS) among sex workers, the impact of ATS use has yet to be characterized among the transgender population in Malaysia. Our aim is to highlight and assess health-related factors associated with ATS use among transgender women in Malaysia. A total of 361 transgender women completed a cross-sectional survey regarding their attitude towards PrEP knowledge and use for HIV prevention. The original study explored a myriad of health-related topics including active ATS use. Data was analyzed using logistic regression analyses to determine factors associated with active ATS use. Most of the participants were between 25-40 years old (57.3%), ethnically identified as Malay (75%), and single (67.6%). We found that 10.2% of the participants were actively using ATS. On a multivariate level, hormone therapy use was associated with reduced odds of active ATS use (aOR = 0.364; 95% CI = 0.169, 0.784) and was positively associated with a history of drug related arrest (aOR = 4.604; 95%CI = 1.813, 11.691). Our findings show a high prevalence of active ATS use among transgender women in Malaysia, in addition to its correlation to other health- related factors. Interestingly, we found that trans women who were actively using hormone therapy, were less likely to engage in active ATS use. This relationship should be explored further along with the relationship between incarceration history. In addition, further prevention strategies and efforts are needed to decrease ATS use among transgender women in Malaysia.

Adolescent Providers' Experiences of Harassment Related to Delivering Gender-Affirming Care.

PURPOSE: The politicization of adolescent gender-affirming care has occurred alongside targeted harassment (e.g., threats of violence, doxing, bomb threats) of adolescent gender-affirming care providers across the United States. This study sought to explore their experiences of targeted harassment. METHODS: From October to December 2022, mental and physical health gender-affirming care providers from across the United States completed a survey including open-ended questions about the kinds of harassment they experienced (i.e., method and messages of harassment) and its impact on their lives and practices. Thematic analyses were used to analyze their responses. RESULTS: In total, 117 providers completed the survey and 70% shared that either they, their practice, or their institution had received threats specific to delivering gender-affirming care. The most common experiences were threats via social media or mailed letters. Several received death threats. Providers described how targeted harassment impacted their psychological well-being and required them to reassess clinic safety. Additionally, providers expressed the need for a more accurate representation of gender-affirming care in media and stronger advocacy from institutions and organizations emphasizing the importance of this care. DISCUSSION: Adolescent gender-affirming care providers are experiencing targeted harassment, significantly affecting their ability to deliver care to transgender and gender-diverse adolescents and their families. Providers stressed the importance of receiving support from their institutions to ensure their safety. The ongoing sociopolitical climate related to gender-affirming care coupled with targeted harassment of those providing it will further limit access to this care.

Transgender-specific COVID-19-related stressors and their association with depressive symptoms among transgender adults: A nationwide cross-sectional survey in South Korea.

Introduction: COVID-19 has disproportionately impacted marginalized groups, including transgender populations, reproducing and exacerbating inequalities and vulnerabilities that existed in those groups prior to the pandemic. This study aimed to assess the prevalence of transgender-specific COVID-19-related stressors and their association with depressive symptoms among South Korean transgender adults. Methods: We conducted a nationwide cross-sectional study of 564 South Korean transgender adults (trans women, trans men, and nonbinary people) from October 7 to October 31, 2020. We measured four transgender-specific COVID-19-related stressors as follows: (A) had difficulty receiving gender-affirming healthcare due to economic hardship related to COVID-19, (B) had difficulty receiving gender-affirming healthcare due to limited access to hospitals under the COVID-19 situation, (C) had difficulty purchasing a public face mask due to gender information on an identification card, and (D) avoided getting a COVID-19 test in fear of unfair treatment and dirty looks due to gender identity, despite having COVID-19 symptoms. Past-week depressive symptoms were assessed using the Center for Epidemiologic Studies-Depression Scale. Results: Of the total participants, 30.7% experienced any of the four transgender-specific COVID-19-related stressors, and 70.2% were classified as having depressive symptoms during the past week. We found statistically significant associations with depressive symptoms among participants who reported that they had difficulty receiving gender-affirming healthcare due to either economic hardship (adjusted prevalence ratio [aPR] = 1.20, 95% Confidence Interval [CI] = 1.05-1.37) or limited access to hospitals (aPR = 1.15, 95% CI = 1.00-1.32), respectively. Furthermore, those who had two or more of the four transgender-specific COVID-19-related stressors were 1.21 times (95% CI = 1.05-1.40) more likely to report depressive symptoms, compared to those who did not report any stressor. Conclusion: Transgender-specific COVID-19-related stressors may negatively influence depressive symptoms among South Korean transgender adults. Given these findings, transgender-inclusive interventions should be implemented at the policy level during the COVID-19 pandemic in South Korea.

Predictors of PrEP awareness, PrEP discussion and interest in long-acting injectable PrEP among Filipina transfeminine adults.

INTRODUCTION: Transfeminine adults are impacted by the HIV epidemic in the Philippines, and newly approved modalities of pre-exposure prophylaxis (PrEP), including long-acting injectable (LAI-PrEP), could be beneficial for this group. To inform implementation, we analysed PrEP awareness, discussion and interest in taking LAI-PrEP among Filipina transfeminine adults. METHODS: We utilized secondary data from the #ParaSaAtin survey that sampled Filipina transfeminine adults (n = 139) and conducted a series of multivariable logistic regressions with lasso selection to explore factors independently associated with PrEP outcomes, including awareness, discussion with trans friends and interest in LAI-PrEP. RESULTS: Overall, 53% of Filipina transfeminine respondents were aware of PrEP, 39% had discussed PrEP with their trans friends and 73% were interested in LAI-PrEP. PrEP awareness was associated with being non-Catholic (p = 0.017), having previously been HIV tested (p = 0.023), discussing HIV services with a provider (p<0.001) and having high HIV knowledge (p = 0.021). Discussing PrEP with friends was associated with older age (p = 0.040), having experienced healthcare discrimination due to transgender identity (p = 0.044), having HIV tested (p = 0.001) and having discussed HIV services with a provider (p < 0.001). Very interested in LAI-PrEP was associated with living in Central Visayas (p = 0.045), having discussed HIV services with a provider (p = 0.001) and having discussed HIV services with a sexual partner (p = 0.008). CONCLUSIONS: Implementing LAI-PrEP in the Philippines requires addressing systemic improvements across personal, interpersonal, social and structural levels in healthcare access, including efforts to create healthcare settings and environments with providers who are trained and competent in transgender health and can address the social and structural drivers of trans health inequities, including HIV and barriers to LAI-PrEP.

Gender Identity Change Efforts Are Associated with Depression, Panic Disorder, and Suicide Attempts in South Korean Transgender Adults.

Purpose: Gender identity change efforts (GICEs), sometimes referred to as "conversion therapy," are considered pseudoscientific and unethical practices that are not supported by the existing scientific literature. However, a substantial portion of transgender people face such practices during their lives. We assessed lifetime exposure to GICEs and its associations with mental health indicators among transgender adults in South Korea. Methods: We analyzed a nationwide cross-sectional survey of 566 Korean transgender adults conducted in October 2020. Lifetime exposure to GICEs was classified as follows: "never had GICE-related experiences," "received a referral, but did not undergo GICEs," and "undergone GICEs." We assessed mental health indicators, including past-week depressive symptoms; medical diagnosis or treatment of depression and panic disorder; and past 12-month suicidal ideation, suicide attempts, and self-harm. Results: Of the total participants, 12.2% had "received a referral, but did not undergo GICEs," and 11.5% had "undergone GICEs." Compared with those who had "never had GICE-related experiences," participants who had "undergone GICEs" showed significantly higher prevalence of depression (adjusted prevalence ratio [aPR]=1.34, 95% confidence interval [CI]=1.11-1.61), panic disorder (aPR=2.52, 95% CI=1.75-3.64), and suicide attempts (aPR=1.73, 95% CI=1.10-2.72). However, we did not find significant associations between having "received a referral, but did not undergo GICEs" and mental health indicators. Conclusion: Given our findings suggest that lifetime exposure to GICEs may harm transgender adults' mental health, legal restrictions should be imposed to ban GICEs in South Korea.

Health equity necessitates the inclusion of gender identity data in COVID-19 clinical trials.

COVID-19 has highlighted the importance of studying differences by sex and gender. The under-reporting of gender identity in COVID-19 studies limits the generalizability of study results to nonbinary persons. Some of the data on sex-assigned associated complications of both COVID-19 infection and COVID-19 immunizations is presented in this manuscript.

Mapping Community-Engaged Implementation Strategies with Transgender Scientists, Stakeholders, and Trans-Led Community Organizations.

PURPOSE OF REVIEW: Pre-exposure prophylaxis (PrEP) represents one of the most effective methods of prevention for HIV, but remains inequitable, leaving many transgender and nonbinary (trans) individuals unable to benefit from this resource. Deploying community-engaged PrEP implementation strategies for trans populations will be crucial for ending the HIV epidemic. RECENT FINDINGS: While most PrEP studies have progressed in addressing pertinent research questions about gender-affirming care and PrEP at the biomedical and clinical levels, research on how to best implement gender-affirming PrEP systems at the social, community, and structural levels remains outstanding. The science of community-engaged implementation to build gender-affirming PrEP systems must be more fully developed. Most published PrEP studies with trans people report on outcomes rather than processes, leaving out important lessons learned about how to design, integrate, and implement PrEP in tandem with gender-affirming care. The expertise of trans scientists, stakeholders, and trans-led community organizations is essential to building gender-affirming PrEP systems.

Utilization and Costs of Gender-Affirming Care in a Commercially Insured Transgender Population.

Many transgender people need specific medical services to affirm their gender. Gender-affirming health care services may include mental health support, hormone therapy, and reconstructive surgeries. Scant information is available about the utilization or costs of these services among transgender people, which hinders the ability of insurance regulators, health plans, and other health care organizations to plan and budget for the health care needs of this population and to ensure that transgender people can access medically necessary gender-affirming care. This study used almost three decades of commercial insurance claims from a proprietary database containing data on more than 200 million people to identify temporal trends in the provision of gender-affirming hormone therapy and surgeries and to quantify the costs of these services.