Decreased Anogenital Gonorrhea and Chlamydia in Transgender and Gender Diverse Primary Care Patients Receiving Gender-Affirming Hormone Therapy.

BACKGROUND: Transgender and gender diverse (TGD) adults in the U.S. experience health disparities, including in anogenital sexually transmitted infections (STI). Gender-affirming hormone therapy (GAHT) is known to be medically necessary and improve health. Few studies have assessed the effect of GAHT on STI diagnoses. OBJECTIVE: To evaluate the effect of GAHT delivered in primary care as an intervention to improve STI outcomes for TGD adults. DESIGN: LEGACY is a longitudinal, multisite cohort study of adult TGD primary care patients from two federally qualified community health centers in Boston, MA, and New York, NY. PARTICIPANTS: Electronic health record data for eligible adult TGD patients contributed to the LEGACY research data warehouse (RDW). A total of 6330 LEGACY RDW patients were followed from 2016 to 2019, with 2555 patients providing STI testing data. MAIN MEASURES: GAHT exposure was being prescribed hormones, and the clinical outcome was anogenital gonorrhea or chlamydia diagnoses. Log-Poisson generalized estimating equations assessed the effect of prescription GAHT on primary outcomes, adjusting for age, race, ethnicity, gender identity, poverty level, health insurance, clinical site, and cohort years. KEY RESULTS: The median age was 28 years (IQR = 13); the racial breakdown was 20.4% Black, 8.1% Multiracial, 6.9% Asian/Pacific Islander, 1.8% Other; 62.8% White; 21.3% Hispanic/Latinx; 47.0% were assigned female at birth, and 16.0% identified as nonbinary. 86.3% were prescribed hormones. Among those tested, the percentage of patients with a positive anogenital STI diagnosis ranged annually from 10.0 to 12.5% between 2016 and 2019. GAHT prescription was associated with a significant reduction in the risk of anogenital STI diagnosis (aRR = 0.75; 95% CI = 0.59-0.96) over follow-up. CONCLUSIONS: GAHT delivered in primary care was associated with less STI morbidity in this TGD cohort over follow-up. Patients may benefit from individualized and tailored clinical care alongside GAHT to optimize STI outcomes.

Exploring gender euphoria in a sample of transgender and gender diverse patients at two U.S. urban community health centers.

Transgender and gender diverse (TGD) people are affected by mental health inequities. Gender euphoria-positive emotions or joy in gender-may be associated with positive mental health. Between February 2019-July 2021, we surveyed 2,165 adult TGD patients (median age = 28 years; 29.2 % people of color; 29.6 % nonbinary; 81.0 % taking hormones) evaluating gender euphoria and mental health. Overall, 35.0 % self-reported gender euphoria, 50.9 % gender dysphoria, 23.5 % alcohol misuse, and 44.5 % resilience. Gender euphoria differed by race, gender, insurance, and hormone use, and was associated with reduced gender dysphoria (adjusted Odds Ratio[aOR] = 0.58; 95 % confidence interval [95 %CI] = 0.47-0.72) and alcohol misuse (aOR = 0.75; 95 %CI = 0.60-0.95), and increased resilience (aOR = 1.31; 95 %CI = 1.07-1.61). The construct of gender euphoria may be a promising mental health target.

Digital-Assisted Self-interview of HIV or Sexually Transmitted Infection Risk Behaviors in Transmasculine Adults: Development and Field Testing of the Transmasculine Sexual Health Assessment.

BACKGROUND: The sexual health of transmasculine (TM) people-those who identify as male, men, or nonbinary and were assigned a female sex at birth-is understudied. One barrier to conducting HIV- and sexually transmitted infection (STI)-related research with this population is how to best capture sexual risk data in an acceptable, gender-affirming, and accurate manner. OBJECTIVE: This study aimed to report on the community-based process of developing, piloting, and refining a digitally deployed measure to assess self-reported sexual behaviors associated with HIV and STI transmission for research with TM adults. METHODS: A multicomponent process was used to develop a digital-assisted self-interview to assess HIV and STI risk in TM people: gathering input from a Community Task Force; working with an interdisciplinary team of content experts in transgender medicine, epidemiology, and infectious diseases; conducting web-based focus groups; and iteratively refining the measure. We field-tested the measure with 141 TM people in the greater Boston, Massachusetts area to assess HIV and STI risk. Descriptive statistics characterized the distribution of sexual behaviors and HIV and STI transmission risk by the gender identity of sexual partners. RESULTS: The Transmasculine Sexual Health Assessment (TM-SHA) measures the broad range of potential sexual behaviors TM people may engage in, including those which may confer risk for STIs and not just for HIV infection (ie, oral-genital contact); incorporates gender-affirming language (ie, genital or frontal vs vaginal); and asks sexual partnership characteristics (ie, partner gender). Among 141 individual participants (mean age 27, SD 5 years; range 21-29 years; n=21, 14.9% multiracial), 259 sexual partnerships and 15 sexual risk behaviors were reported. Participants engaged in a wide range of sexual behaviors, including fingering or fisting (receiving: n=170, 65.6%; performing: n=173, 66.8%), oral-genital sex (receiving: n=182, 70.3%; performing: n=216, 83.4%), anal-genital sex (receptive: n=31, 11.9%; insertive: n=9, 3.5%), frontal-genital sex (receptive: n=105, 40.5%; insertive: n=46, 17.8%), and sharing toys or prosthetics during insertive sex (n=62, 23.9%). Overall barrier use for each sexual behavior ranged from 10.9% (20/182) to 81% (25/31). Frontal receptive sex with genitals and no protective barrier was the highest (21/42, 50%) with cisgender male partners. In total, 14.9% (21/141) of participants reported a lifetime diagnosis of STI. The sexual history tool was highly acceptable to TM participants. CONCLUSIONS: The TM-SHA is one of the first digital sexual health risk measures developed specifically with and exclusively for TM people. TM-SHA successfully integrates gender-affirming language and branching logic to capture a wide array of sexual behaviors. The measure elicits sexual behavior information needed to assess HIV and STI transmission risk behaviors. A strength of the tool is that detailed partner-by-partner data can be used to model partnership-level characteristics, not just individual-level participant data, to inform HIV and STI interventions.

Using Implicit Measures of Discrimination: White, Black, and Hispanic Participants Respond Differently to Group-Specific Racial/Ethnic Categories vs. the General Category "People of Color" in the USA.

Recent studies showed that implicit measures are valuable instruments for assessing exposure to discrimination and predicting negative physical conditions. Between March 10, 2020, and April 1, 2020, we conducted three experiments (577 participants) in the USA to evaluate the use of group-specific vs. general race/ethnicity categories in implicit measures of discrimination. We measured implicit discrimination and attitudes towards the general race/ethnicity category "people of color" (POC) and two specific race/ethnicity categories (i.e., "Black people" and "Hispanic people"). Implicit discrimination and attitudes were assessed using the Brief Implicit Association Test (B-IAT). Among participants (mean age = 37, standard deviation = 10.5), 50% identified as White non-Hispanic (NH), 33.3% as Black NH, and 16.7% as Hispanic; 71.7% were female and 72.2% had a bachelor's degree or higher. We found an implicit discrimination towards target groups and an in-group preference among all participant groups only when specific race/ethnicity categories were used in the B-IAT. When the general category POC was used, we observed a discrimination towards POC only for Black NH participants, while White NH participants showed no discrimination. Similarly, Black NH participants showed no in-group preference for POC, but did show an in-group preference for Black people. These results suggest that using the category POC in implicit measures may be inappropriate when evaluating discrimination and attitudes towards Black and Hispanic individuals as it may not capture specific experiences of discrimination and identity in these groups.

"Focus more on what's right instead of what's wrong:" research priorities identified by a sample of transgender and gender diverse community health center patients.

BACKGROUND: Transgender and gender diverse (TGD) individuals disproportionately experience disparate health outcomes compared to their cisgender peers. This study aimed to collect qualitative data from a sample of TGD community health center patients on health research priorities to inform future TGD-centered research in the field of TGD health. METHODS: Between September-November of 2018, four focus groups (two groups in Boston MA, two in New York NY; n = 28 individuals) were held to evaluate community-identified TGD health research priorities with a sample of patients from two community health centers. Thematic analyses were conducted and restricted to social factors impacting health. Findings were incorporated into the development of The LEGACY Project, a longitudinal cohort of TGD patients, assessing the impact of gender-affirming care on health outcomes. RESULTS: Cross-cutting themes about TGD research priorities pertaining to social factors and health included: (1) Embodiment: understanding and investigating the complex and intersectional lived experiences of TGD individuals; (2) Social determinants of health: the impact of structural and interpersonal stigma on TGD health; and (3) Resiliency and health promoting factors: the need to expand public health research beyond disparities to assess resiliency and health promotion in TGD communities. CONCLUSIONS: Participants identified investigating the impact of social influences on health as a research priority for TGD patients. Recalibrating field norms from individual researcher priorities to TGD population-driven research will help ensure investigators address topics that may otherwise be missed or overlooked and may optimize the reach and impact of research in TGD health.

Factors associated with transmasculine adults recently engaging in sexual behavior with partners of unknown STI and HIV status.

The sexual partnerships of transmasculine (TM) adults-those assigned female at birth who identify as transgender men or a masculine spectrum gender identity-and characteristics associated with STI/HIV risk behavior remains understudied. Participants in the current study were TM adults (n = 141) receiving care at a community health center in Boston, Massachusetts between March 2015 and September 2016. Using generalized estimating equations, we examined individual- and partnership-level factors associated with TM adults' odds of engaging in sexual behavior with a sexual partner of unknown STI/HIV status in the past 12 months. TM adults with casual sexual partnerships (vs. monogamous partnerships) and those in partnerships with cisgender men, other TM individuals, or transfeminine partners (vs. cisgender women) had statistically significantly higher odds of engaging in sexual behavior with a partner of unknown STI/HIV status in the past 12 months. Findings may inform future efforts to improve sexual health communication and STI/HIV disclosure between TM adults and their sexual partners.

Patient-centered practices for engaging transgender and gender diverse patients in clinical research studies.

BACKGROUND: The purpose of this formative study was to assess barriers and facilitators to participation of transgender and gender diverse (TGD) patients in clinical research to solicit specific feedback on perceived acceptability and feasibility of research methods to inform creation of a multisite longitudinal cohort of primary care patients engaged in care at two community health centers. METHOD: Between September-November 2018, four focus groups (FGs) were convened at two community health centers in Boston, MA and New York, NY (N = 28 participants across all 4 groups; 11 in Boston and 17 in New York). FG guides asked about patient outreach, acceptability of study methods and measures, and ideas for study retention. FGs were facilitated by TGD study staff, lasted approximately 90 min in duration, were audio recorded, and then transcribed verbatim by a professional transcription service. Thematic analyses were conducted by two independent analysts applying a constant comparison method. Consistency and consensus were achieved across code creation and application aided by Dedoose software. RESULTS: Participants were a mean age of 33.9 years (SD 12.3; Range 18-66). Participants varied in gender identity with 4 (14.3%) men, 3 (10.7%) women, 8 (28.6%) transgender men, 10 (35.7%) transgender women, and 3 (10.7%) nonbinary. Eight (26.6%) were Latinx, 5 (17.9%) Black, 3 (10.7%) Asian, 3 (10.7%) another race, and 5 (17.9%) multiracial. Motivators and facilitators to participation were: research creating community, research led by TGD staff, compensation, research integrated into healthcare, research applicable to TGD and non-TGD people, and research helping TGD communities. Barriers were: being research/healthcare averse, not identifying as TGD, overlooking questioning individuals, research coming from a 'cisgender lens", distrust of how the research will be used, research not being accessible to TGD people, and research being exploitative. CONCLUSION: Though similarities emerged between the perspectives of TGD people and research citing perspectives of other underserved populations, there are barriers and facilitators to research which are unique to TGD populations. It is important for TGD people to be involved as collaborators in all aspects of research that concerns them.

Longitudinal Cohort Study of Gender Affirmation and HIV-Related Health in Transgender and Gender Diverse Adults: The LEGACY Project Protocol.

BACKGROUND: Transgender and gender diverse (TGD) adults in the United States experience health disparities, especially in HIV infection. Medical gender affirmation (eg, hormone therapy and gender-affirming surgeries) is known to be medically necessary and to improve some health conditions. To our knowledge, however, no studies have assessed the effects of gender-affirming medical care on HIV-related outcomes. OBJECTIVE: This study aims to evaluate the effects of medical gender affirmation on HIV-related outcomes among TGD primary care patients. Secondary objectives include characterizing mental health, quality of life, and unmet medical gender affirmation needs. METHODS: LEGACY is a longitudinal, multisite, clinic-based cohort of adult TGD primary care patients from two federally qualified community health centers in the United States: Fenway Health in Boston, and Callen-Lorde Community Health Center in New York. Eligible adult TGD patients contribute electronic health record data to the LEGACY research data warehouse (RDW). Patients are also offered the option to participate in patient-reported surveys for 1 year of follow-up (baseline, 6-month, and 12-month assessments) with optional HIV and sexually transmitted infection (STI) testing. Biobehavioral data from the RDW, surveys, and biospecimen collection are linked. HIV-related clinical outcomes include pre-exposure prophylaxis uptake (patients without HIV), viral suppression (patients with HIV), and anogenital STI diagnoses (all patients). Medical gender affirmation includes hormones, surgeries, and nonhormonal and nonsurgical interventions (eg, voice therapy). RESULTS: The contract began in April 2018. The cohort design was informed by focus groups with TGD patients (n=28) conducted between August-October 2018 and in collaboration with a community advisory board, scientific advisory board, and site-specific research support coalitions. Prospective cohort enrollment began in February 2019, with enrollment expected to continue through August 2020. As of April 2020, 7821 patients are enrolled in the LEGACY RDW and 1756 have completed a baseline survey. Participants have a median age of 29 years (IQR 11; range 18-82). More than one-third (39.7%) are racial or ethnic minorities (1070/7821, 13.68% Black; 475/7821, 6.07% multiracial; 439/7821, 5.61% Asian or Pacific Islander; 1120/7821, 14.32% other or missing) and 14.73% (1152/7821) are Hispanic or Latinx. By gender identity, participants identify as 33.79% (2643/7821) male, 37.07% (2900/7821) female, 21.74% (1700/7821) nonbinary, and 7.39% (578/7821) are unsure or have missing data. Approximately half (52.0%) of the cohort was assigned female sex at birth, and 5.4% (421/7821) are living with HIV infection. CONCLUSIONS: LEGACY is an unprecedented opportunity to evaluate the impact of medical gender affirmation on HIV-related health. The study uses a comprehensive research methodology linking TGD patient biobehavioral longitudinal data from multiple sources. Patient-centeredness and scientific rigor are assured through the ongoing engagement of TGD communities, clinicians, scientists, and site clinical staff undergirded by epidemiological methodology. Findings will inform evidence-based clinical care for TGD patients, including optimal interventions to improve HIV-related outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24198.

The Pre-Exposure Prophylaxis Cascade in At-Risk Transgender Men Who Have Sex with Men in the United States.

Purpose: This analysis was designed to characterize the pre-exposure prophylaxis (PrEP) cascade in a U.S. national sample of transgender men and trans masculine adults who have sex with cisgender men (trans MSM) at-risk for HIV acquisition. Methods: From November to December 2017, 843 HIV-negative trans MSM self-reporting past-6-month receptive sex with a cisgender man were recruited via peer referrals, dating apps, listservs, and social media. A computer-assisted self-interview assessed demographics, health care, and the PrEP cascade. Descriptive statistics and multivariable regression models evaluated factors associated with PrEP uptake and persistence. Results: Mean age was 28.1 years (standard deviation = 7.1); 4.8% were Black, 21.7% Latinx, and 25.6% another race/ethnicity. A total of 84.1% had heard of PrEP, with 67.3% reporting interest. More than half (55.2%) were PrEP indicated, of which 50.8% were PrEP naive. Approximately 1/4 (28.0%) reported PrEP use, of which 65.3% were PrEP persistent. PrEP modality preferences were injectable (51.2%), daily oral pill (22.1%), and anal gel/lube (14.6%). Reasons for PrEP noninterest were no HIV risk (68.5%), cost (24.2%), and side effects (20.1%). Surgical gender affirmation, no health care discrimination, and social media as a primary health information source were associated with increased odds of PrEP uptake and persistence (all p < 0.05). PrEP adherence difficulties were reported by 52.6%, due to busy/inconsistent schedule (53.1%), side effects (27.4%), and too many medical visits (11.6%). Conclusion: PrEP uptake was modest among the trans MSM sampled, given prevalent HIV risk behaviors. The limited PrEP uptake in at-risk trans MSM suggests the need to develop culturally tailored community education and interventions.

The target/perpetrator brief-implicit association test (B-IAT): an implicit instrument for efficiently measuring discrimination based on race/ethnicity, sex, gender identity, sexual orientation, weight, and age.

BACKGROUND: To date, research assessing discrimination has employed primarily explicit measures (i.e., self-reports), which can be subject to intentional and social desirability processes. Only a few studies, focusing on sex and race/ethnicity discrimination, have relied on implicit measures (i.e., Implicit Association Test, IAT), which permit assessing mental representations that are outside of conscious control. This study aims to advance measurement of discrimination by extending the application of implicit measures to multiple types of discrimination and optimizing the time required for the administration of these instruments. METHODS: Between September 27th 2019 and February 9th 2020, we conducted six experiments (984 participants) to assess implicit and explicit discrimination based on race/ethnicity, sex, gender identity, sexual orientation, weight, and age. Implicit discrimination was measured by using the Brief-Implicit Association Test (B-IAT), a new validated version of the IAT developed to shorten the time needed (from ≈15 to ≈2 min) to assess implicit mental representations, while explicit discrimination was assessed using self-reported items. RESULTS: Among participants (mean age = 37.8), 68.6% were White Non-Hispanic; 69% were females; 76.1% were heterosexual; 90.7% were gender conforming; 52.8% were medium weight; and 41.5% had an advanced level of education. Overall, we found implicit and explicit recognition of discrimination towards all the target groups (stronger for members of the target than dominant groups). Some exceptions emerged in experiments investigating race/ethnicity and weight discrimination. In the racism experiment, only people of Color showed an implicit recognition of discrimination towards the target group, while White people were neutral. In the fatphobia experiment, participants who were not heavy showed a slight implicit recognition of discrimination towards the dominant group, while heavy participants were neutral. CONCLUSIONS: This study provides evidence that the B-IAT is a valuable tool for quickly assessing multiple types of implicit discrimination. It shows also that implicit and explicit measures can display diverging results, thus indicating that research would benefit from the use of both these instruments. These results have important implications for the assessment of discrimination in health research as well as in social and psychological science.

Gender identity and sexual orientation development among young adult transgender men sexually active with cisgender men: 'I had completely ignored my sexuality that's for a different time to figure out'.

As awareness of issues faced by transgender individuals increases, many young people have been exposed to a dominant narrative about gender identity. Often these narratives are based on binary constructions about both sexual orientation and gender identity. The lack of diverse, representative cultural narratives has implications for identity development and sexual health. Transgender men who have sex with cisgender men in particular represent an understudied and overlooked population who likely experience unique developmental tasks related to the intersection of socially stigmatised sexual orientation and gender identities. This study explores sexual orientation and gender identity development among a sample of young adult transgender men who have sex with men. In-depth interviews using a modified life history method were conducted with 18 young men. Interview transcripts were coded using open, narrative and focused coding methods. Participants discussed milestones in the development of their sexuality and gender identity that map onto existing models, but also described ways in which these processes overlap and intersect in distinct ways. Findings highlight the need for human development models of sexual orientation and gender identity that integrate multiple identity processes. Implications for future research and practice to increase support for young adult transgender men are discussed.

Enacting power and constructing gender in cervical cancer screening encounters between transmasculine patients and health care providers.

Transmasculine people are at risk of cervical cancer but have lower rates of cervical cancer screening than cisgender women. Disaffirmation of the patient's gender and unequal power dynamics between patient and provider during screening contribute to patient unwillingness to be screened. The mechanisms by which the balance of power may be shifted between patient and provider, and by which gender is constructed during the Pap test, are not well understood. A qualitative study using a modified grounded theory approach was undertaken to analyse patient interview and provider interview and focus group data pertaining to power and gender in the context of cervical cancer screening among transmasculine individuals. The study was conducted at an LGBTQ-focussed health centre in Boston, USA. Processes by which power is enacted included constraining or affirming patient choice, mitigating or exacerbating vulnerability, and self-advocacy. Gendering processes included naming patients and their bodies, invoking gender norms, de-gendering/re-gendering Pap tests, and othering or normalising trans bodies. The interplay between these processes promotes or constrains patient agency over body and health, impacting patient care, patient-provider interaction, and service utilisation. Understanding patient and provider roles in power and gender dynamics are critical for the provision of patient-centred care.

Gender Non-affirmation from Cisgender Male Partners: Development and Validation of a Brief Stigma Scale for HIV Research with Transgender Men Who Have Sex with Men (Trans MSM).

Some transgender men who have sex with men (trans MSM) are vulnerable to HIV infection and face stigma from sexual partners. We evaluated a brief 4-item measure of gender non-affirmation from cisgender male partners. A non-probability sample of American trans MSM (n = 843) reporting past 6-month sexual contact with a cisgender male completed a cross-sectional survey. Psychometric analyses assessed the scale and modeled HIV risk associations. Overall, 78% experienced past 6-month gender non-affirmation from cisgender male partners. The scale demonstrated good reliability (α = 0.78). Convergent validity was supported in associations with psychological distress and anxiety (p < 0.05). Lower frequency of cisgender male partner stigma was associated with increased odds of past 6-month HIV testing and decreased odds of past 6-month condomless receptive sex (all p < 0.01). The gender non-affirmation from cisgender male sexual partners scale found negative associations with protective health behaviors and can be used to better understand the context of trans MSM risk behavior.

High risk and low uptake of pre-exposure prophylaxis to prevent HIV acquisition in a national online sample of transgender men who have sex with men in the United States.

INTRODUCTION: Trans masculine people who have sex with cisgender ("cis") men ("trans MSM") may be at-risk for HIV infection when they have cis MSM partners or share needles for hormone or recreational drug injection. Limited data are available characterizing indications and uptake of pre-exposure prophylaxis (PrEP) in trans MSM. The aim of this study was to assess PrEP indication and uptake as a means of primary HIV prevention for adult trans MSM in the U.S. METHODS: Between November and December 2017, a national convenience sample of trans MSM in the U.S. (n = 857) was recruited using participatory methodologies and completed an online survey of demographics, HIV risk, PrEP, behavioural and psychosocial factors. Self-reported receptive anal sex or frontal/vaginal sex (with or without a condom) with a cis male sex partner in past six months was an eligibility criterion. A multivariable logistic regression procedure was used to model PrEP indications (yes/no) per an interpretation of U.S. Centers of Disease Control and Prevention recommendations among those without HIV (n = 843). RESULTS: The diverse sample was 4.9% Black; 22.1% Latinx ethnicity; 28.4% non-binary gender identity; 32.6% gay-identified; 82.7% on testosterone. Overall, 84.1% had heard of PrEP. Of these, 33.3% reported lifetime PrEP use (21.8% current and 11.5% past). Based on HIV behavioural risk profiles in the last six months, 55.2% of respondents had indications for PrEP. In a multivariable model, factors associated with PrEP indication included where met sex partners, not having sex exclusively with cismen, higher perceived HIV risk, greater number of partners and high cis male partner stigma (all p < 0.05). DISCUSSION: The majority of trans MSM in this sample had a PrEP indication. Stigma was associated with risk for HIV acquisition and represents a critical target for HIV biobehavioural prevention interventions for trans MSM, who appear to be underutilizing PrEP. CONCLUSIONS: Results from this study support the full inclusion of trans MSM in HIV biobehavioural prevention efforts. Public health interventions and programmes are needed to reach trans MSM that attend to general MSM risk factors as well as to vulnerabilities specific to trans MSM, including the context of stigma from cis male sexual partners.

A randomized controlled efficacy trial of behavioral activation for concurrent stimulant use and sexual risk for HIV acquisition among MSM: project IMPACT study protocol.

BACKGROUND: In the United States, problematic stimulant use is a prevalent and difficult to treat problem among men who have sex with men (MSM), as well as a major driver of HIV transmission through the large number of sexual partners and concomitant condomless anal sex (CAS). Evidence-based behavioral studies that address problematic stimulant use in MSM at risk for HIV infection are also lacking. In this paper, we describe the design of a behavioral intervention trial to reduce sexual risk behavior and stimulant use in HIV-uninfected MSM. METHODS: This study, funded by the National Institute on Drug Abuse (NIDA), is a randomized controlled trial (RCT) testing an integrated HIV risk reduction and behavioral activation counseling intervention (IMPACT) for HIV-uninfected, stimulant using MSM in Boston, MA, and Miami, FL. Participants are randomized (2:2:1) to either (1) the IMPACT intervention; (2) a relaxation condition, an active therapy time- and intensity-matched control; or (3) a standard of care risk reduction counseling comparison. At enrollment, all participants receive an HIV test and pre- and post-test counseling. The primary outcome is the difference in the rate of change in the number of self-reported condomless anal sex acts without the protection of consistent Pre-Exposure Prophylaxis (PrEP) use, as well as reductions in stimulant use during the prior 4-months. Major assessments are conducted at baseline, 4-, 8-, and 12-month follow-up visits. DISCUSSION: Effective and sustainable behavioral interventions are sorely needed to reduce HIV acquisition in stimulant using MSM at risk for HIV infection. In this study, we will evaluate the evidence of efficacy of the IMPACT intervention to reduce HIV acquisition in HIV-uninfected, stimulant-using MSM. If found effective, the intervention tested here holds promise for being readily integrated into real-world clinical settings. TRIAL REGISTRATION: ClinicalTrials.gov number NCT03175159 , registered June 5, 2017.

Test performance and acceptability of self- versus provider-collected swabs for high-risk HPV DNA testing in female-to-male trans masculine patients.

BACKGROUND: High-risk human papillomavirus (hrHPV) causes virtually all cervical cancers. Trans masculine (TM) people (those assigned female at birth who identify with a gender other than female) have low uptake of conventional cervical cancer screening. Self-collected hrHPV DNA testing has high levels of acceptability among cisgender (non-transgender) females and may support increased cervical cancer screening uptake in TM individuals. OBJECTIVE: To assess the test performance and acceptability of self-collected vaginal specimens in comparison to provider-collected cervical swabs for hrHPV DNA detection in TM individuals ages 21-64 years. METHODS: Between March 2015-September 2016, 150 TM participants with a cervix (mean age = 27.5 years; SD = 5.7) completed a one-time study visit comprised of a self-report survey, self-collected vaginal HPV DNA swab, clinician-administered cervical HPV swab, and brief interview on acceptability of clinical procedures. Participants were randomized to complete either self- or provider-collection first to minimize ordering effects. Self- and provider-collected samples were tested for 13 hrHPV DNA types using a DNA Hybridization Assay. The primary outcome variable was the concordance (kappa statistic) and performance (sensitivity, specificity) of self-collected vaginal HPV DNA specimens versus provider-collected cervical HPV swabs as the gold standard. RESULTS: Of the 131 participants completing both the self- and provider-collected HPV tests, 21 cases of hrHPV were detected by the provider cervical swab (gold standard; 16.0% hrHPV prevalence); 15 of these cases were accurately detected by the self-collected vaginal swab (71.4% concordance) (Kappa = 0.75, 95% Confidence Interval [CI]: 0.59, 0.92; p<0.001). Compared to the provider-collected cervical hrHPV DNA sample (gold standard), the self-collected vaginal hrHPV DNA test demonstrated a sensitivity of 71.4% (95% CI: 0.52, 0.91; p = 0.0495) and specificity of 98.2% (95% CI: 0.96, 1.00; p<0.0001). Over 90% of participants endorsed a preference for the self-collected vaginal swab over provider-collected cervical swab. CONCLUSION: Self-collected vaginal swabs are highly acceptable to TM as a means to test for hrHPV DNA. Test performance of this self-collection method for hrHPV detection in TM is consistent with previous studies in cisgender females. Self-collected vaginal swab testing for hrHPV DNA represents a reasonable and patient-centered strategy for primary cervical cancer screening in TM patients unwilling to undergo provider collection of specimens via speculum exam.

Sensitive Health Topics With Underserved Patient Populations: Methodological Considerations for Online Focus Group Discussions.

Online focus group discussions provide an anonymous environment to assess sensitive, health-related experiences that may be difficult to discuss utilizing traditional face-to-face modalities, particularly for marginalized populations such as female-to-male trans masculine (TM) transgender individuals. This article reviews the history, advantages, and disadvantages of online focus groups, with an emphasis for research about sensitive issues with stigmatized, rare, and/or geographically dispersed patient populations. The article then evaluates the success of online focus group discussions as a case study using data from four asynchronous online focus groups conducted between September 2015 and February 2016 that explored topics related to sexual health care access with U.S. TM adults ( N = 29). The rationale for selecting an asynchronous online methodology is described along with the unique methodological considerations that emerged in developing the study protocol. We conclude by sharing lessons learned, including innovations for maximizing participant engagement and comfort to elicit rich qualitative data.

"It Can Promote an Existential Crisis": Factors Influencing Pap Test Acceptability and Utilization Among Transmasculine Individuals.

Transmasculine (i.e., female-to-male transgender) individuals have lower rates of cervical cancer screening than nontransgender women and often report negative experiences with the Pap test. Deciding to undergo screening and the test experience itself are characterized by the following processes: negotiating identity as the patient, provider, and insurance company wrestle with the degree of (in)congruence between a patient's masculine gender identity and their conception of the Pap test as feminine; bargaining for health as a Pap test may be required to obtain medical transition services or avoid undesired health outcomes; withstanding acute challenges during the Pap test to body, identity, and privacy; or reframing challenges as affirmation. The degree of distress triggered by the Pap test varied from "routine" to traumatic. Participants affirmed that a trusted, trans-competent health care provider could significantly reduce barriers to regular and satisfactory cervical cancer screening. Data are from 32 in-depth interviews conducted in Boston, Massachusetts, with transmasculine individuals; a modified grounded theory approach informed the analysis.