Factors Associated with Transgender and Gender Diverse People's Experience of Sexual Coercion, and Help-Seeking and Wellbeing Among Victims/Survivors: Results of the First Australian Trans and Gender Diverse Sexual Health Survey.

Purpose: Our study examined factors associated with transgender and gender diverse ("trans") people's experience of sexual coercion, as well as the factors associated with help-seeking and wellbeing among victims/survivors. Methods: We analyzed cross-sectional data from the first Australian Trans and Gender Diverse Sexual Health Survey, conducted in 2018. Logistic regressions were undertaken to identify factors associated with sexual coercion, help-seeking, and wellbeing. Results: Of the sample of 1448 participants, 53.4% had been sexually coerced, which was associated with older age, Aboriginal or Torres Strait Islander descent, nonbinary gender, being presumed female gender at birth, currently living publicly some or all the time as their affirmed gender, having regular sex, and use of drugs to enhance or alter sexual experiences. Protective factors included having a higher income and access to gender affirming care. Help-seeking was reported among 49.5% of victims/survivors and was associated with having more trans friends. Wellbeing among victims/survivors was associated with being older, residing in regional/remote areas, having higher levels of education and annual income, being presumed female gender at birth, having stronger satisfaction with one's sex life, and good health care access. Wellbeing was not associated with help-seeking. Conclusion: Sexual coercion was prevalent among participants, but help-seeking behavior was low. Protective factors identified underscore the importance of socioeconomic supports, access to health and gender affirming care, and peers. Accessible peer-led and culturally safe preventive and trauma-focused supports should also be considered for trans people who experience sexual coercion.

HIV treatment-as-prevention and its effect on incidence of HIV among cisgender gay, bisexual, and other men who have sex with men in Australia: a 10-year longitudinal cohort study.

BACKGROUND: Although HIV treatment-as-prevention reduces individual-level HIV transmission, population-level effects are unclear. We aimed to investigate whether treatment-as-prevention could achieve population-level reductions in HIV incidence among gay, bisexual, and other men who have sex with men (GBM) in Australia's most populous states, New South Wales and Victoria. METHODS: TAIPAN was a longitudinal cohort study using routine health record data extracted from 69 health services that provide HIV diagnosis and care to GBM in New South Wales and Victoria, Australia. Data from Jan 1, 2010, to Dec 31, 2019, were linked within and between services and over time. TAIPAN collected data from all cisgender GBM who attended participating services, resided in New South Wales or Victoria, and were 16 years or older. Two cohorts were established: one included HIV-positive patients, and the other included HIV-negative patients. Population prevalence of viral suppression (plasma HIV viral load <200 RNA copies per µL) was calculated by combining direct measures of viral load among the HIV-positive cohort with estimates for undiagnosed GBM. The primary outcome of HIV incidence was measured directly via repeat testing in the HIV-negative cohort. Poisson regression analyses with generalised estimating equations assessed temporal associations between population prevalence of viral suppression and HIV incidence among the subsample of HIV-negative GBM with multiple instances of HIV testing. FINDINGS: At baseline, the final sample (n=101 772) included 90 304 HIV-negative and 11 468 HIV-positive GBM. 59 234 patients in the HIV-negative cohort had two or more instances of HIV testing and were included in the primary analysis. Over the study period, population prevalence of viral suppression increased from 69·27% (95% CI 66·41-71·96) to 88·31% (86·37-90·35), while HIV incidence decreased from 0·64 per 100 person-years (95% CI 0·55-0·76) to 0·22 per 100 person-years (0·17-0·28). Adjusting for sociodemographic characteristics and HIV pre-exposure prophylaxis (PrEP) use, treatment-as-prevention achieved significant population-level reductions in HIV incidence among GBM: a 1% increase in population prevalence of viral suppression corresponded with a 6% decrease in HIV incidence (incidence rate ratio [IRR] 0·94, 95% CI 0·93-0·96; p<0·0001). PrEP was introduced in 2016 with 17·60% uptake among GBM that year, which increased to 36·38% in 2019. The relationship between population prevalence of viral suppression and HIV incidence was observed before the availability of PrEP (IRR 0·98, 95% CI 0·96-0·99; p<0·0001) and was even stronger after the introduction of PrEP (0·80, 0·70-0·93; p=0·0030). INTERPRETATION: Our results suggest that further investment in HIV treatment, especially alongside PrEP, can improve public health by reducing HIV incidence among GBM. FUNDING: National Health and Medical Research Council of Australia.

Sexual experience, relationships, and factors associated with sexual and romantic satisfaction in the first Australian Trans & Gender Diverse Sexual Health Survey.

Background: Sexual and romantic satisfaction are important aspects of sexual health and wellbeing, but they have not been thoroughly investigated among transgender and gender diverse ('trans') people in Australia. Aims: To address this gap and improve sexual health and wellbeing, we assessed the sexual behavior and relationships of a national sample of trans people in Australia, and factors associated with sexual and romantic satisfaction. Methods: We conducted a national survey of trans people from Australia in October-November 2018. Results: The sample included 1,613 trans participants, of whom 353 (21.9%) were men, 397 (24.6%) were women and 863 (53.5%) were non-binary. Over 70% of the sample had been sexually active in the previous year, and 56.9% were in a relationship, but only 32.4% were satisfied with the sexual aspects and 47.1% with the romantic aspects of their lives. Sexual satisfaction was associated with younger age, being asexual, having more trans friends, more frequent sex, and using illicit drugs in the context of sexual activity. Anxiety or fear about sex was associated with less sexual satisfaction, as was being in an open relationship. Romantic satisfaction was associated with younger age, having non-binary partners, and being in a current relationship (particularly a monogamous one). Recent distress, anxiety, or fear about sex were associated with less romantic satisfaction. Conclusion: Participants reported a broad range of sexual relationships, but low levels of satisfaction with the sexual and romantic aspects of their lives. The findings underscore the importance of supportive partners, access to social support and peer networks of trans people, as well as access to mental health support and sex-positive, trans affirming counseling in sexual health services.

Examining the Geospatial Distribution of Health and Support Services for Transgender, Gender Nonbinary, and Other Gender Diverse People in New York City.

A geospatial analysis of services that support transgender and gender diverse ("trans") people in New York City (NYC) was conducted to investigate associations with neighborhood-level sociodemographic characteristics. In June 2019, there were 5.3 services for every 100,000 of the general NYC population; controlling for other covariates, they were more commonly located in neighborhoods with larger populations of non-Hispanic Black (rate ratio [RR]=1.02, 95% confidence interval [CI]: 1.00-1.04), Hispanic/Latino (RR=1.03, 95% CI: 1.00-1.06), and gay/lesbian people (RR=1.53, 95% CI: 1.03-2.34). These findings suggest that the distribution of trans-focused services in NYC is proximal to communities that are most in need, but research should examine proximity to trans people specifically and distribution in nonurban areas.

Higher Sexually Transmissible Infection Test Yield Among Men Who Have Sex With Men Attending a Community-Based Testing Site Compared With a Clinical Service In Sydney, Australia.

ABSTRACT: From January 2014 to December 2015, the overall yield of sexually transmitted infections testing among asymptomatic MSM was two-fold higher at a community-based versus clinic-based service. Compared with the clinic-based service, yield of chlamydia (9.0% vs 4.9%; P = 0.010), gonorrhea (6.5% vs 3.1%; P < 0.001), and infectious syphilis (0.9% vs 0.1%; P = 0.024) were all higher at the community-based service.

"What will we do if we get infected?": An interview-based study of the COVID-19 pandemic and its effects on the health and safety of sex workers in the United States.

Emerging evidence suggests that sex workers face unique and profound risks arising from the COVID-19 pandemic. To illuminate the pandemic's effects on sex worker health and safety and identify intervention opportunities, from May-August 2020 in-depth interviews were conducted with a purposive sample of 15 sex workers, four service providers and two individuals who were both. Sampled sex workers included eight people of color, eight cisgender women, five cisgender men, three non-binary people, and one transgender woman. Using Conservation of Resources Theory to define impacts on sex worker resources and resulting health and safety implications, a deductive thematic analysis was conducted. Seven resources were threatened due to the pandemic: work opportunity, sex work venues, social support, health services, money, food, and housing. The loss of these resources was exacerbated by stigma - notably sex work criminalization - and significantly undermined health and safety by increasing food and housing instability, increasing risks of violence, and diminishing safer sex negotiation. Six resources were activated in response: social support, digital skills, health knowledge, non-sex work employment, money, and resilience. While social support had numerous benefits, investing digital skills and non-sex work employment were generally of limited impact. The pandemic's negative health and safety effects were most profound at the intersections of race, gender, class, and migration status. These findings suggest sex workers need urgent and ongoing support, with investments in social support and sex work decriminalization likely to have the greatest effects on health and safety relative to and beyond the COVID-19 pandemic.

Sustaining success: a qualitative study of gay and bisexual men's experiences and perceptions of HIV self-testing in a randomized controlled trial.

BACKGROUND: HIV self-testing was proved as an effective tool for increasing testing frequency in gay and bisexual men at high risk of infection. Questions remain about understanding why HIVST encouraged testing and how such success can be translated to programmatic implementation. METHODS: We conducted a qualitative investigation of how FORTH participants experienced and perceived HIVST. Stratified sampling was used to recruit gay and bisexual men participating in the FORTH HIVST intervention to take part in interviews, focusing on infrequent testers and those who had received inaccurate HIVST results. RESULTS: Our analysis identified several prominent themes organized into two overarching domains from the 15 interviews: (i) aspects of HIVST contributing to HIV testing frequency, and (ii) sustaining HIVST into the future. Participants also believed that their use of HIVST in the future would depend on the test kit's reliability, particularly when compared with highly reliable clinic-based testing. CONCLUSION: HIVST increases the frequency of HIV testing among gay and bisexual men due, in part, to the practical, psychological, and social benefits it offers. To capitalize fully on these benefits, however, strategies to ensure the availability of highly reliable HIVST are required to sustain benefits beyond the confines of a structured research study.

Improvements in transition times through the HIV cascade of care among gay and bisexual men with a new HIV diagnosis in New South Wales and Victoria, Australia (2012-19): a longitudinal cohort study.

BACKGROUND: Most studies assessing the HIV care cascade have typically been cross-sectional analyses, which do not capture the transition time to subsequent stages. We aimed to assess the longitudinal HIV cascade of care in Australia, and changes over time in transition times and associated factors. METHODS: In this longitudinal cohort study, we included linked data for gay and bisexual men (GBM) with a new HIV diagnosis who attended clinics participating in the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance in New South Wales and Victoria between Jan 1, 2012, and Dec 31, 2019. We assessed three cascade transition periods: diagnosis to linkage to care (stage 1 transition); linkage to care to antiretroviral therapy (ART) initiation (stage 2 transition); and ART initiation to virological suppression (viral load ≤200 copies per mL; stage 3 transition). We also calculated the probability of remaining virologically suppressed after the first recorded viral load of less than 200 copies per mL. We used the Kaplan-Meier method to estimate transition times and cumulative probability of stage transition. FINDINGS: We included 2196 GBM newly diagnosed with HIV between 2012 and 2019 contributing 6747 person-years of follow-up in our analysis. Median time from HIV diagnosis to linkage to care (stage 1 transition) was 2 days (IQR 1-3). Median time from linkage to care to ART initiation (stage 2 transition) was 33 days (30-35). Median time from ART initiation to first recorded virological suppression (stage 3 transition) was 49 days (47-52). The cumulative probability of ART initiation within 90 days of linkage to care increased from 36·9% (95% CI 32·9-40·6) in the 2012-13 calendar period to 94·1% (91·2-96·0) in the 2018-19 calendar period and cumulative probability of virological suppression within 90 days of ART initiation increased from 54·3% (48·8-59·3) in the 2012-13 calendar period to 82·9% (78·4-86·4) in the 2018-19 calendar period. 91·6% (90·1-93·1) of GBM remained virologically supressed up to 2 years after their first recorded virological suppression event. INTERPRETATION: In countries with high cross-sectional cascade estimates such as Australia, the impact of treatment as prevention is better estimated using longitudinal cascade analyses. FUNDING: National Health and Medical Research Council Australia.

Effect on genital warts in Australian female and heterosexual male individuals after introduction of the national human papillomavirus gender-neutral vaccination programme: an analysis of national sentinel surveillance data from 2004-18.

BACKGROUND: In Australia, the government-funded human papillomavirus (HPV) vaccination programme was introduced in April, 2007, for girls and young women, and in February, 2013, for boys. As of Dec 31, 2018, all Australian-born female individuals younger than 38 years and male individuals younger than 21 years have been eligible for the free quadrivalent or nonavalent HPV vaccine. We aimed to examine the trends in genital wart diagnoses among Australian-born female and heterosexual male individuals who attended sexual health clinics throughout Australia before and after the introduction of the gender-neutral HPV vaccination programme in February, 2013. METHODS: We did a serial cross-sectional analysis of genital wart diagnoses among Australian-born female and heterosexual male individuals attending a national surveillance network of 35 clinics between Jan 1, 2004, and Dec 31, 2018. We calculated prevalence ratios of genital warts, using log-binomial regression models, for the female-only vaccination period (July 1, 2007, to Feb 28, 2013), gender-neutral vaccination period (March 1, 2013, to Dec 31, 2018), and the whole vaccination period (July 1, 2007, to Dec 31, 2018) compared with the pre-vaccination period (Jan 1, 2004, to June 30, 2007). FINDINGS: We included 121 038 men and 116 341 women in the analysis. Overall, we observed a 58% reduction (prevalence ratio 0·42, 95% CI 0·40-0·44) in genital wart diagnoses in female individuals and a 45% reduction (0·55, 0·53-0·57) in genital wart diagnoses in heterosexual male individuals after the introduction of the vaccination programme in 2007. The largest reduction in genital warts was observed in younger individuals, and there was a decreasing magnitude of reduction with increasing age (80%, 72%, 61%, 41%, and 16% reductions in female individuals aged 15-20 years, 21-25 years, 26-30 years, 31-35 years, and ≥36 years, respectively; 70%, 61%, 49%, 37%, and 29% reductions in male individuals aged 15-20 years, 21-25 years, 26-30 years, 31-35 years, and ≥36 years, respectively). Significant reductions observed in female individuals (0·32, 0·28-0·36) and male individuals (0·51, 0·43-0·61) aged 15-20 years in the female-only vaccination period were followed by a more substantial reduction in female individuals (0·07, 0·06-0·09) and male individuals (0·11, 0·08-0·15) aged 15-20 years in the gender-neutral vaccination period. INTERPRETATION: The national gender-neutral HPV vaccination programme has led to substantial and ongoing reduction in genital warts among Australian female and heterosexual male individuals, with a marked reduction in young individuals who received the vaccine at school. FUNDING: Seqirus Australia and the Australian Government Department of Health.

The Complexities of Categorizing Gender: A Hierarchical Clustering Analysis of Data from the First Australian Trans and Gender Diverse Sexual Health Survey.

Purpose: This study used self-reported gender among trans and gender diverse people in Australia to identify and describe broad, overarching gender categories that encompass the expansive ways in which gender can be defined and expressed. Methods: Data were collected as part of the Australian Trans and Gender Diverse Sexual Health Survey hosted in October 2018. Participant self-identification with nonexclusive gender categories were analyzed using algorithm-based hierarchical clustering; factors associated with gender clusters were identified using logistic regression analyses. Results: Usable data were collected from 1613 trans and gender diverse people in Australia, of whom 71.0% used two or more labels to describe their gender. Three nonexclusive clusters were identified: (i) women/trans women, (ii) men/trans men, and (iii) nonbinary. In total, 33.8% of participants defined their gender in exclusively binary terms (i.e., men/women, trans men/trans women), 40.1% in nonbinary terms, and 26.0% in both binary and nonbinary terms. The following factors were associated with selecting nonbinary versus binary gender labels: presumed female gender at birth (adjusted odds ratio [aOR]=2.02, 95% confidence interval [CI]=1.60-2.54, p<0.001), having a majority of sexual and/or gender minority friends (aOR=2.46, 95% CI=1.49-3.10, p<0.001), and having spent more than half of one's life identifying as trans and/or gender diverse (aOR=1.75, 95% CI=1.37-2.23, p<0.001). Conclusion: Trans and gender diverse people take up diverse and often multiple gender labels, which can be broadly categorized as binary and nonbinary. Systems of health care and research must be adapted to include nonbinary people while remaining amenable to further adaptation.

Cisgenderism and transphobia in sexual health care and associations with testing for HIV and other sexually transmitted infections: Findings from the Australian Trans & Gender Diverse Sexual Health Survey.

Transgender and gender diverse people have unique risks and needs in the context of sexual health, but little is known about sexual health care for this population. In 2018, a national, online survey of sexual health and well-being was conducted with trans and gender diverse people in Australia (n = 1,613). Data from this survey were analysed to describe uptake of sexual health care and experiences of interpersonal and structural cisgenderism and transphobia. Experiences of cisgenderism and transphobia in sexual health care were assessed using a new, four-item scale of 'gender insensitivity', which produced scores ranging from 0 (highly gender sensitive) to 4 (highly gender insensitive). Logistic and linear regression analyses were conducted to determine if experiences of gender insensitivity in sexual health care were associated with uptake and frequency of HIV/STI testing in the 12 months prior to participation. Trans and gender diverse participants primarily accessed sexual health care from general practice clinics (86.8%), followed by publicly funded sexual health clinics (45.6%), community-based services (22.3%), and general hospitals (14.9%). Experiences of gender insensitivity were common overall (73.2% of participants reported ≥2 negative experiences) but most common in hospitals (M = 2.9, SD = 1.3) and least common in community-based services (M = 1.3, SD = 1.4; p<0.001). When controlling for sociodemographic factors, social networks, general access to health care, and sexual practices, higher levels of gender insensitivity in previous sexual health care encounters were associated with a lower likelihood of recent HIV/STI testing (adjusted prevalence ratio = 0.92, 95% confidence interval [CI]:091,0.96, p<0.001) and less-frequent HIV/STI testing (B = -0.07, 95%CI:-0.10,-0.03, p = 0.007). Given the high rates of HIV and other STIs among trans and gender diverse people in Australia and overseas, eliminating cisgenderism and transphobia in sexual health care may help improve access to diagnostic testing to reduce infection rates and support the overall sexual health and well-being of these populations.

Sexual Identity, Sexual Behavior and Pre-exposure Prophylaxis in Black Cisgender Sexual Minority Men: The N2 Cohort Study in Chicago.

This study investigated sexual identity and behavior and their potential associations with PrEP use and attitudes in cisgender Black gay and bisexual men. A total of N = 173 (mean age 25.2) participants from the Neighborhoods and Networks (N2) Study in Chicago were included. Of these, 104 were gay-identified and reported sex with men only (GSMO), 26 were gay-identified and reported sex with men and women (GSMW), 8 were bisexual-identified and reported sex with men only (BSMO), and 35 were bisexual-identified and reported sex with men and women (BSMW). Reporting sex with men and women in the past 6 months, RR = 0.39, 95% CI [0.17, 0.89], identifying as bisexual, RR = 0.52, 95% CI [0.29, 0.92], and the combination of the two, RR = 0.24, 95% CI [0.07, 0.76] were significantly associated with lower rates of current oral PrEP use. Black bisexual-identifying men who reported sex with men and women were significantly more likely to have discontinued oral PrEP, RR = 2.50, 95% CI [1.14, 5.50], than Black gay-identified men who reported sex with men only. Participants who had not used oral PrEP before reported lower levels of interest in long-acting injectable PrEP than those who were currently using oral PrEP, RR = 0.56, 95% CI [0.40, 0.79]. No other significant differences were found. Overlooking the combination of sexual identity and behavior may mischaracterize PrEP rates and miss uniquely vulnerable subgroups. Black gay and bisexual men who had not used oral PrEP may be particularly disinterested in long-acting injectable PrEP.

Geographic Density and Uptake of Pre-exposure Prophylaxis (PrEP) Among Young Gay, Bisexual and Other Sexual Minority Men: A Global Positioning System (GPS) Study.

The geographic availability of pre-exposure prophylaxis (PrEP) providers is one important factor that significantly affects PrEP uptake. While most previous studies have employed spatial accessibility in static residential neighborhood definitions or self-reported healthcare accessibility, we examined the associations of the objectively measured geographic density of PrEP services with current PrEP use, using global positioning system (GPS) among sexual minority men (SMM) in New York City. 250 HIV-negative SMM participated in a 2-week GPS monitoring (January 2017-January 2018). Geographic PrEP density was measured as total numbers of PrEP providers in (1) individual activity space defined as daily path area of GPS points, (2) residential street network buffers and (3) census tract and ZIP code of residential locations. Geographic PrEP density within GPS-based activity space was positively associated with current PrEP use (prevalence ratio for 50-m activity space = 1.10, 95% confidence interval: [1.02, 1.18]). PrEP provider counts in residential buffer areas and administrative neighborhoods were not associated with PrEP use. Although it is not generalizable beyond New York City, our finding suggests the importance of daily mobility pattern in HIV prevention and PrEP implementation strategies.

A New Method for Estimating the Incidence of Infectious Diseases.

Ambitious World Health Organization targets for disease elimination require monitoring of epidemics using routine health data in settings of decreasing and low incidence. We evaluated 2 methods commonly applied to routine testing results to estimate incidence rates that assume a uniform probability of infection between consecutive negative and positive tests based on 1) the midpoint of this interval and 2) a randomly selected point in this interval. We compared these with an approximation of the Poisson binomial distribution, which assigns partial incidence to time periods based on the uniform probability of occurrence in these intervals. We assessed bias, variance, and convergence of estimates using simulations of Weibull-distributed failure times with systematically varied baseline incidence and varying trend. We considered results for quarterly, half-yearly, and yearly incidence estimation frequencies. We applied the methods to assess human immunodeficiency virus (HIV) incidence in HIV-negative patients from the Treatment With Antiretrovirals and Their Impact on Positive and Negative Men (TAIPAN) Study, an Australian study of HIV incidence in men who have sex with men, between 2012 and 2018. The Poisson binomial method had reduced bias and variance at low levels of incidence and for increased estimation frequency, with increased consistency of estimation. Application of methods to real-world assessment of HIV incidence found decreased variance in Poisson binomial model estimates, with observed incidence declining to levels where simulation results had indicated bias in midpoint and random-point methods.

Sexual health and COVID-19: protocol for a scoping review.

BACKGROUND: Global responses to the COVID-19 pandemic have exposed and exacerbated existing socioeconomic and health inequities that disproportionately affect the sexual health and well-being of many populations, including people of color, ethnic minority groups, women, and sexual and gender minority populations. Although there have been several reviews published on COVID-19 and health disparities across various populations, none has focused on sexual health. We plan to conduct a scoping review that seeks to fill several of the gaps in the current knowledge of sexual health in the COVID-19 era. METHODS: A scoping review focusing on sexual health and COVID-19 will be conducted. We will search (from January 2020 onwards) CINAHL, Africa-Wide Information, Web of Science Core Collection, Embase, Gender Studies Database, Gender Watch, Global Health, WHO Global Literature on Coronavirus Disease Database, WHO Global Index Medicus, PsycINFO, MEDLINE, and Sociological Abstracts. Grey literature will be identified using Disaster Lit, Google Scholar, governmental websites, and clinical trials registries (e.g., ClinicalTrial.gov , World Health Organization, International Clinical Trials Registry Platform, and International Standard Randomized Controlled Trial Number Registry). Study selection will conform to the Joanna Briggs Institute Reviewers' Manual 2015 Methodology for JBI Scoping Reviews. Only English language, original studies will be considered for inclusion. Two reviewers will independently screen all citations, full-text articles, and abstract data. A narrative summary of findings will be conducted. Data analysis will involve quantitative (e.g., frequencies) and qualitative (e.g., content and thematic analysis) methods. DISCUSSION: Original research is urgently needed to mitigate the risks of COVID-19 on sexual health. The planned scoping review will help to address this gap. SYSTEMATIC REVIEW REGISTRATIONS: Systematic Review Registration: Open Science Framework osf/io/PRX8E.

Investigating the effects of COVID-19 on global male sex work populations: a longitudinal study of digital data.

OBJECTIVES: Recommendations of 'social distancing' and home quarantines to combat the global COVID-19 pandemic have implications for sex and intimacy, including sex work. This study examined the effects of COVID-19 on male sex work globally and investigated how men who sold sex responded to and engaged with the virus in the context of work. METHODS: This study made use of an existing database of deidentified data extracted from the online profiles maintained by male sex workers on a large, international website. Website engagement metrics were calculated for the periods before (September to December 2019) and during COVID-19 (January to May 2020); Poisson regression analyses were used to assess changes over time before and after, while a content analysis was undertaken to identify modes of engagement with the virus. RESULTS: Data were collected from 78 399 profiles representing 19 388 individuals. In the 'before' period, the number of active profiles was stable (inter-rate ratio (IRR)=1.01, 95% CI 0.99 to 1.01, p=0.339) but during COVID-19 decreased by 26.3% (IRR=0.90, 95% CI 0.89 to 0.91, p<0.001). Newly created profiles also decreased during COVID-19 (59.4%; IRR=0.71, 95% CI 0.69 to 0.74, p<0.001) after a period of stability. In total, 211 unique profiles explicitly referenced COVID-19; 185 (85.8%) evoked risk reduction strategies, including discontinuation of in-person services (41.2%), pivoting to virtual services (38.9%), COVID-19 status disclosure (20.9%), enhanced sanitary and screening requirements (12.3%) and restricted travel (5.2%). Some profiles, however, seemed to downplay the seriousness of COVID-19 or resist protective measures (14.7%). CONCLUSIONS: These findings support the contention that COVID-19 has dramatically impacted the sex industry; globally, male sex workers may be facing considerable economic strain. Targeted education and outreach are needed to support male sex workers grappling with COVID-19, including around the most effective risk reduction strategies. Those involved with the sex industry must have access to state-sponsored COVID-19 financial and other aid programmes to support individual and public health.

High financial hardship and mental health burden among gay, bisexual and other men who have sex with men.

Prior research has documented the ways in which financial hardships negatively impact health, particularly mental health. However, this association between financial hardships and mental health outcomes has rarely been examined in sexual minorities. The purpose of this study was to examine associations between financial hardships and mental health burdens among a sample of gay, bisexual and other men who have sex with men (MSM) in Paris, France. Participants (n = 580) completed a cross-sectional survey advertised on a geosocial networking application. Participants responded to measures of mental health, financial hardship, and socio-demographics. Modified Poisson models were used to estimate risk ratios (RRs) and 95% confidence intervals (CI) for the associations between financial hardship and the following outcomes: 1) depressive symptoms, 2) anxiety symptoms, and 3) psychological distress. After adjusting for socio-demographics, high financial hardships were associated with depressive symptoms (aRR: 1.48, 95% CI: 1.04, 2.11) and psychological distress (aRR: 1.56, 95% CI: 1.09, 2.23). Analyses also demonstrated that stress acts as a mediating variable. These preliminary results suggest that future interventions to reduce financial hardships may have positive effects on the mental health of such a population.

Sex workers are returning to work and require enhanced support in the face of COVID-19: results from a longitudinal analysis of online sex work activity and a content analysis of safer sex work guidelines.

Sex workers confront unique challenges in the face of COVID-19. Data from an international sex work website popular with cisgender men and transgender men and women suggest that, after a period of physical distancing, many sex workers are returning to in-person work: from May to August 2020, active sex work profiles increased 9.4% (P < 0.001) and newly created profiles increased by 35.6% (P < 0.001). Analysis of sex work and COVID-19 guidelines published by five community-based organisations found that they focused on altering sexual practices, enhancing hygiene and pivoting to virtual work. To capitalise on these guidelines, funding and research for implementation and evaluation are needed to support COVID-19 risk reduction strategies for sex workers.