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.

Brief Report: Young Age and Sex Work Are Associated With HIV Seroconversion Among Transgender Women in São Paulo, Brazil.

BACKGROUND: Transgender women worldwide have the highest prevalence of HIV and the lowest access to prevention among groups at risk of HIV. However, few longitudinal studies have directly measured HIV incidence and identified predictors of HIV acquisition among transgender women. SETTING: São Paulo, Latin America's largest city. METHODS: We conducted a longitudinal study among transgender women in São Paulo. Participants were recruited by a long-chain peer referral process from May 2017 to July 2019. Those aged 18 years and older and who were HIV-negative at baseline were retested every 6 months up to 18 months. HIV incidence was calculated by dividing the number of seroconversions by the person-years (PYs) of follow-up; 95% confidence intervals (CIs) were constructed assuming a Poisson distribution. Conditional maximum likelihood ratios assessed differences in HIV incidence by risk factors. RESULTS: A racially/ethnically diverse sample of 545 HIV-negative transgender women was enrolled. In 485.5 PYs of follow-up, 13 seroconversions were observed, yielding an incidence of 2.68 per 100 PYs (95% CI: 1.43 to 4.58). HIV incidence was significantly higher among transgender women aged 18-24 years (rate ratio 3.85, 95% CI: 1.24 to 12.93) and among those who engaged in sex work in the preceding month (rate ratio 5.90, 95% CI: 1.71 to 26.62). CONCLUSIONS: HIV transmission continues at a high rate among transgender women in Brazil. Factors such as young age, lower level of education, and limited employment opportunities may lead to dependence on sex work that in turn increases HIV risk. Transgender-friendly prevention services, particularly programs delivering pre-exposure prophylaxis, are urgently needed.

Progress toward closing gaps in the hepatitis C virus cascade of care for people who inject drugs in San Francisco.

BACKGROUND: People who inject drugs (PWID) are disproportionately affected by hepatitis C virus (HCV). Data tracking the engagement of PWID in the continuum of HCV care are needed to assess the reach, target the response, and gauge impact of HCV elimination efforts. METHODS: We analyzed data from the National HIV Behavioral Surveillance (NHBS) surveys of PWID recruited via respondent driven sampling (RDS) in San Francisco in 2018. We calculated the number and proportion who self-reported ever: (1) tested for HCV, (2) tested positive for HCV antibody, (3) diagnosed with HCV, (4) received HCV treatment, (5) and attained sustained viral response (SVR). To assess temporal changes, we compared 2018 estimates to those from the 2015 NHBS sample. RESULTS: Of 456 PWID interviewed in 2018, 88% had previously been tested for HCV, 63% tested antibody positive, and 50% were diagnosed with HCV infection. Of those diagnosed, 42% received treatment. Eighty-one percent of those who received treatment attained SVR. In 2015 a similar proportion of PWID were tested and received an HCV diagnosis, compared to 2018. However, HCV treatment was more prevalent in the 2018 sample (19% vs. 42%, P-value 0.01). Adjusted analysis of 2018 survey data showed having no health insurance (APR 1.6, P-value 0.01) and having no usual source of health care (APR 1.5, P-value 0.01) were significantly associated with untreated HCV prevalence. CONCLUSION: While findings indicate an improvement in HCV treatment uptake among PWID in San Francisco, more than half of PWID diagnosed with HCV infection had not received HCV treatment in 2018. Policies and interventions to increase coverage are necessary, particularly among PWID who are uninsured and outside of regular care.

Homelessness, HIV testing, and the reach of public health efforts for people who inject drugs, San Francisco, California.

BACKGROUND: There is a dearth of literature that explicitly examines associations between housing and HIV testing among people who inject drugs (PWID). Thus, the present study investigated the links between housing status and HIV testing for PWID. METHODS: Respondent-driven sampling recruited 382 HIV-negative PWID, who completed structured interviews in San Francisco. Logistic regression determined whether housing statuses in the past 12 months ([1] owned/rented, [2] single-room occupancy hotels [SROs], [3] living with friends/family/partners, [4] shelters, [5] outdoors) were associated with getting HIV tested in the past 12 months while adjusting for sociodemographics and receptive sharing of injection paraphernalia in the past 12 months. RESULTS: PWID who lived in SROs had greater odds of being tested for HIV than PWID who did not live in SROs (aOR = 1.95, CI.95: 1.06-3.60) while adjusting for covariates. Although bivariable analyses indicated that receptively sharing syringes was more common for PWID who lived with others (χ2[3] = 7.94, p = 0.047) or lived outdoors (χ2[3] = 9.50, p = 0.023) than those who did not, respectively, PWID who lived with others (aOR = 1.72, CI.95 = 0.95-3.14) or lived outdoors (aOR = 1.37, CI.95 = 0.74-2.53) did not show greater odds of HIV testing in multivariable analyses. CONCLUSIONS: PWID who lived in SROs had greater odds of HIV testing than PWID who did not live in SROs. Although PWID who lived with others or outdoors showed greater HIV risk, they did not show greater odds of HIV testing. Public health efforts may be reaching PWID in SROs, but more work is needed to reach PWID who live with other people or outdoors.

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.

Young age and sex work are associated with HIV seroconversion among transgender women in São Paulo, Brazil

Background: Transgender women worldwide have among the highest prevalence of HIV and the lowest access to prevention among groups at risk. However, few longitudinal studies have directly measured HIV incidence and identified predictors of HIV acquisition among transgender women. Setting: São Paulo, Latin America's largest city. Methods: We conducted a longitudinal study among transgender women in São Paulo. Participants were recruited by a long-chain peer referral process from May 2017 to July 2019. Those age 18 years and older and HIV-negative at baseline were retested every 6 months up to 18 months. HIV incidence was calculated by dividing the number of seroconversions by the person-years (py) of follow-up; 95% confidence intervals (CI) were constructed assuming a Poisson distribution. Conditional maximum likelihood ratios assessed differences in HIV incidence by risk factors. Results: A racial/ethnically diverse sample of 545 transgender women were enrolled. In 485.5 py of follow-up, 13 seroconversions were observed yielding an incidence of 2.68 per 100 py (95% CI 1.43­4.58). HIV incidence was significantly higher among transgender women age 18 to 24 years (rate ratio 3.85, 95% CI 1.24­12.93) and among those who engaged in sex work in the preceding month (rate ratio 5.90, 95% CI 1.71­26.62). Conclusion: HIV transmission continues at a high rate among transgender women in Brazil. Factors such as young age, lower level of education, and limited employment opportunities may lead to dependence upon sex work which in turn increase HIV risk. Transgender-friendly prevention services, particularly programs delivering pre-exposure prophylaxis (PrEP) are urgently needed.

Food insecurity among formerly homeless youth in supportive housing: A social-ecological analysis of a structural intervention.

A growing body of research indicates that structural interventions to provide permanent supportive housing (PSH) to homeless adults within a Housing First approach can improve their health. However, research is lacking regarding the impact of PSH on youth experiencing homelessness. This article seeks to understand how PSH for youth impacts a basic health need-food security- across multiple levels of the social-ecological environment. In January of 2014, San Francisco, California opened the city's first municipally-funded PSH building exclusively designated for transition-aged youth (ages 18-24). We conducted 20 months of participant observation and in-depth interviews with 39 youth from April 2014 to December 2015. Ethnographic fieldnotes and interview transcripts were analyzed using grounded theory. We present our social-ecological assessment regarding food insecurity for formerly homeless youth in supportive housing. We found that although housing removes some major sources of food insecurity from their lives, it adds others. Many of the participating youth were frequently hungry and went without food for entire days. Mechanisms across multiple levels of the social-ecological model contribute to food insecurity. Mechanisms on the structural level include stigma, neighborhood food resources, and monthly hunger cycles. Mechanisms on the institutional level include the transition into housing and housing policies regarding kitchen use and food storage. Interpersonal level mechanisms include food sharing within social networks. Individual level mechanisms include limited cooking skills, equipment, and coping strategies to manage hunger. Although supportive housing provides shelter to youth, effective implementation of the Housing First/PSH model for youth must ensure their access to an affordable nutritious diet.

Intersectional Discrimination Is Associated with Housing Instability among Trans Women Living in the San Francisco Bay Area.

Trans women face numerous structural barriers to health due to discrimination. Housing instability is an important structural determinant of poor health outcomes among trans women. The purpose of this study was to determine if experiences of intersectional anti-trans and racial discrimination are associated with poor housing outcomes among trans women in the San Francisco Bay Area. A secondary analysis of baseline data from the Trans *National study (n = 629) at the San Francisco Department of Public Health (2016-2018) was conducted. Multivariable logistic regression was used to analyze the association between discrimination as an ordered categorical variable (zero, one to two, or three or more experiences) and housing status adjusting for age, years lived in the Bay Area, and gender identity. We found that the odds of housing instability increased by 1.25 for every categorical unit increase (1-2, or 3+) in reported experiences of intersectional (both anti-trans and racial) discrimination for trans women (95% CI = 1.01-1.54, p-value < 0.05). Intersectional anti-trans and racial discrimination is associated with increased housing instability among trans women, giving some insight that policies and programs are needed to identify and address racism and anti-trans stigma towards trans women. Efforts to address intersectional discrimination may positively impact housing stability, with potential for ancillary effects on increasing the health and wellness of trans women who face multiple disparities.

Successes and final challenges along the HIV care continuum with transwomen in San Francisco.

INTRODUCTION: To examine the HIV care continuum for transwomen living in San Francisco and to determine factors associated with poor HIV-related health outcomes. METHODS: Data were collected from 2016 to 2017 with transwomen in San Francisco. Respondent-driven sampling (RDS) was used to recruit a population-based sample. Bivariate associations were assessed, and RDS-weighted multivariable logistic regression was used to identify associations between exposures and outcomes along the HIV care continuum. RESULTS: Of the 123 self-identified transwomen in this analysis, ages ranged from 23 to 71 years with a majority identifying as Latina (40.8%) and African American (29.2%). An estimate of 14.3% of participants were not engaged in care, 13% were not currently on antiretroviral therapy (ART), 22.2% had a self-reported detectable viral load and 13.5% had unknown viral load. Those using hormones had lower odds of not being on ART compared to those who did not use hormones. Those with unstable housing had a higher relative risk ratio of having a detectable viral load. Those who experienced both anti-trans discrimination and racism had higher odds of not being in HIV care. CONCLUSIONS: San Francisco has made substantial progress engaging transwomen in the HIV care continuum, but the final push to ensure viral suppression will require addressing social determinants. Future interventions to increase HIV care engagement, ART use and viral suppression among transwomen must address housing needs and risks related to the overlapping effect of both anti-trans discrimination and racism.

High and Stable Human Immunodeficiency Virus Prevalence Among Transwomen With Low Income Recruited With Respondent-driven Sampling, San Francisco, 2010-2016.

BACKGROUND: Studies have documented high human immunodeficiency virus (HIV) prevalence among transwomen in the United States; however, to our knowledge, no studies have documented trends in HIV prevalence in this population. METHODS: We used respondent-driven sampling to sample transwomen in San Francisco for 3 HIV prevalence and behavioral surveys in 2010, 2013, and 2016. Our analysis of point estimates and trends were weighted for the sampling method. RESULTS: Human immunodeficiency virus prevalence by serological testing in the survey was 38.8% (95% confidence interval [CI], 32.4-45.2), 33.7% (95% CI, 25.9-41.5), and 31.6% (95% CI, 12.2-38.1) in 2010, 2013, and 2016, respectively. Disparities in higher HIV prevalence by black, Latino, and Asian race/ethnicity and lower education level persisted through 2016. CONCLUSIONS: Based on a statistical test for trend, HIV prevalence among transwomen has remained high and stable from 2010 to 2016. Human immunodeficiency virus infection is still highest at 31.6% compared to any other group in San Francisco. We also observed that older transwomen had significantly higher odds of living with HIV than younger women over the last 2 waves of data collection. Taken together, these trends suggest that there is declining incidence of new HIV infections among low-income transwomen in San Francisco. Moreover, among transwomen, HIV disproportionately affects transwomen of color.