Syndemic Conditions, HIV Transmission Risk Behavior, and Transactional Sex Among Transgender Women

Posttraumatic Stress Symptoms and HIV Risk-Related Behaviors among Young Sexual and Gender Minorities Assigned Male at Birth: the Moderating Effects of Teenage Childhood Sexual Abuse

Young sexual and gender minorities assigned male at birth (SGM-AMAB) experience significant sexual health disparities. Teenage childhood sexual abuse (CSA) may have lasting effects on adulthood trauma response, including engagement in HIV-related risk behaviors (HRB). This study examined the moderating effects of teenage CSA on the longitudinal associations between posttraumatic symptom clusters and HRB among young SGM-AMAB. The analytic sample comprised SGM-AMAB (N = 487) living in the Chicago metropolitan area, aged 17-32 (M = 24.78) enrolled in the RADAR longitudinal cohort study. Structural equation models (SEM) using Bayes estimation with 10,000 iterations were estimated to examine the moderating effects of any CSA exposure and severity indices (e.g., touching, penetration) on the associations between posttraumatic symptom clusters at Time 1 (T1) and HRB at Time 2 (T2) 6-month follow-up. Model fit was acceptable, χ2 (df = 164) = 450.15, p <.001, RMSEA = 0.06, SRMR = 0.04, CFI = 0.93, TLI = 0.92. Avoidance at T1 predicted fewer condomless sex partners at T2 across CSA models. We observed 15 interaction effects across CSA models and outcomes. The moderating effects of both any CSA (β = 0.20, 95% CI = 0.02 - 0.38) and penetration CSA (β = 0.34, 95% CI = 0.14 - 0.55) changed the direction of the direct effect of avoidance on condomless sex partners, such that avoidance symptoms predicted more condomless sex partners among those with these CSA histories. This study observed patterns of association by posttraumatic symptom cluster, CSA index, and HRB outcome. Future directions and clinical implications are discussed.

Neighborhood Disadvantage, Syndemic Conditions, and PrEP Non-Adherence in Young Sexual and Gender Minority Men

Adherence to Pre-Exposure Prophylaxis (PrEP) among young sexual and gender minority men who have sex with men (YSGMMSM) has been suboptimal for reducing HIV incidence in the United States. Using the syndemic framework, the present study characterized how neighborhood disadvantage and clustering of two or more syndemic conditions (depression, anxiety, polysubstance use, history of arrest, BIPOC racial identity, unemployment) was related to PrEP non-adherence among 212 YSGMMSM aged 16-24. This study is a secondary analysis of an efficacy trial testing a PrEP adherence digital intervention for YSGMMSM combining participant survey and biological PrEP adherence data with measures of neighborhood disadvantage. Using multilevel models, we found that YSGMMSM residing in high-disadvantage neighborhoods were 2.79 (CI = 1.11, 7.00) times more likely to have a cluster of syndemic conditions compared to those in low-disadvantage neighborhoods. YSGMMSM residing in high-disadvantage neighborhoods were 3.14 (OR = 3.14, CI = 1.17, 8.44) times more likely to be PrEP non-adherent. YSGMMSM with two or more syndemic conditions were 2.64 (CI = 1.01, 6.94) times more likely to be PrEP non-adherent compared to those with 0 or 1 condition. Among participants living in high-disadvantage neighborhoods, 38% had a cluster of a syndemic conditions compared 20% in low-disadvantage neighborhoods. Despite this, neighborhood disadvantage did not significantly moderate the relationship between clustering of syndemic conditions and PrEP non-adherence among YSGMMSM. Further research into multilevel syndemic influences on PrEP adherence is needed to develop strategies for improving HIV vulnerability among YSGMMSM.

Experiences of violence and abuse among transgender women in healthcare settings in Uganda: a community-engaged qualitative study

BACKGROUND

People who identify as transgender have a gender identity or expression that differs from the sex they were assigned at birth. Because of this, transgender people may encounter widespread stigma, discrimination, and violence, including in medical facilities. Understanding how these phenomena manifest during healthcare interactions is crucial for enhancing health equity for transgender individuals. Therefore, this study explored the experiences of transgender-related stigma and violence among transgender individuals in Uganda.

METHODS

The study used a community-based qualitative participatory approach, with transgender women actively co-generating the data. Six focus groups were held with 33 transgender women in southwestern and central Uganda. Data were thematically analysed using OpenCode software.

RESULTS

Four key themes emerged for the lived experiences of violence and abuse among transgender women in Uganda. These included: (i) Institutionalized physical violence and violation of bodily autonomy, (ii) Religious impositions and moral policing, (iii) Dehumanising treatment and objectification and (iv) Systemic discrimination and denial of care.

CONCLUSIONS

In conclusion, this study highlights the pervasive violence, abuse, sexual assault and discrimination reported by transgender women in healthcare settings in Uganda. These experiences not only compromise access to quality healthcare but also perpetuate stigma and exacerbate health disparities. Addressing these issues requires comprehensive, trauma-informed care, alongside structural reforms and training for healthcare providers. Ensuring respectful, affirming, and inclusive healthcare environments is essential to safeguarding the rights and well-being of transgender individuals. Additionally, more studies should evaluate the effectiveness of interventions like healthcare provider training and addressing social determinants of health to determine the most impactful strategies for reducing violence.

Intersecting Structural and Psychosocial Conditions: Investigating Injection Drug Use and HIV Among Transgender Women

BACKGROUND

Transgender women continue to face a significant burden of health disparities with HIV infection as a critical public health concern. Substance use is higher among transgender women than among cisgender women. However, little is known about transgender women who inject drugs and risk for HIV in the United States. The objectives were to explore HIV prevalence, injection-related behaviors, and HIV prevention and care outcomes among transgender women who inject drugs and to compare transgender women with a general sample of persons who inject drugs.

METHODS

Participants from the National HIV Behavioral Surveillance were recruited through respondent-driven sampling, interviewed, and tested for HIV infection in 2019-2020. Log-linked Poisson regression models were used to test for associations between injection drug use and selected characteristics.

RESULTS

Among 1561 transgender women, 7% injected drugs in the past 12 months. HIV prevalence was higher among transgender women who inject (adjusted prevalence ratio = 1.5, 95% confidence interval: 1.2 to 1.8) than among those who do not. Multiple psychosocial conditions were associated with injection drug use. Among transgender women with HIV, those who inject were less likely to take antiretroviral therapy (adjusted prevalence ratio = 0.8, 95% confidence interval: 0.7 to 1.0) than those who do not. Methamphetamine was the most commonly injected drug (67%); most accessed a syringe services program (66%).

CONCLUSIONS

Transgender women who inject have substantial challenges related to health outcomes including high HIV prevalence and exposure to psychosocial conditions, such as homelessness, incarceration, and exchange sex, that may exacerbate risks associated with injection drug use. This population may benefit from increased access to nonjudgmental and culturally competent harm reduction services.

Engagement in the HIV Pre-Exposure Prophylaxis Care Cascade in a Statewide Sample of Transgender and Nonbinary Individuals

Although literature regarding HIV prevention among transgender and nonbinary (TNB) people has grown considerably, important gaps remain, particularly in relation to the HIV pre-exposure prophylaxis (PrEP) care cascade. Additional research is needed to understand when and why TNB people exit the PrEP care cascade to inform interventions to better support these populations. Moreover, most studies have focused on transgender women, though transgender men and nonbinary people also experience a disproportionate prevalence of HIV relative to cisgender populations. This study addresses these gaps by exploring engagement in the PrEP care cascade among a statewide convenience sample of 659 transgender women, transgender men, and nonbinary people, and analyzing how gender identity impacts participant likelihood to continue along the cascade. Data come from the 2018 Michigan Trans Health Study and include self-report data on demographics, sexual behavior, and PrEP awareness, information receipt, referral, initiation, and retention. Participants who self-reported vaginal/front hole or anal sex and did not use barriers (n = 318) were considered eligible for PrEP. Only 21.13% of those eligible for PrEP received information about PrEP, 8.18% were referred to PrEP, and 1.57% initiated PrEP use. A significantly greater proportion of transfeminine and participants who identified with multiple/other genders reported receiving PrEP information than those who identified as transmasculine or nonbinary [χ2 (3, n = 311) =11.34, p = .01]. No other significant gender differences were observed. Providers serving TNB individuals must recognize the diversity of individuals who qualify for information on PrEP, provide trans-affirming care when offering PrEP prescriptions, and consider situating PrEP opportunities in TNB serving spaces to reduce access barriers.

Intimate partner violence and its relation to sexual health outcomes across different adult populations: a systematic review

Introduction

Intimate Partner Violence (IPV) significantly impacts adults' wellbeing, causing both physical and psychological harm. IPV has been consistently linked to adverse sexual health outcomes, including an increased risk of sexually transmitted infections, unintended pregnancies, and sexual dysfunction. This systematic review examines the evolving relationship between IPV and sexual health outcomes in adults from 2014 to 2024, addressing gaps in understanding across diverse populations and exploring the complex interplay between violence, sexuality, and health.

Methods

A comprehensive search of multiple databases was conducted for peer-reviewed articles published between January 2014 and February 2024. Studies examining the association between IPV and sexual health variables in adult populations (aged 18 and older) were included. The review followed PRISMA guidelines, and 27 articles met the inclusion criteria after full-text screening and quality assessment.

Results

IPV was consistently associated with poorer sexual health outcomes across diverse populations and contexts. Studies utilized various validated instruments to assess IPV and sexual health. Research primarily focused on cisgender heterosexual women, with limited studies on cisgender heterosexual men, men who have sex with men, and transgender individuals. IPV was linked to an increased risk of sexually transmitted infections, unintended pregnancies, sexual dysfunction, and decreased sexual satisfaction. The relationship between IPV and sexual health was influenced by factors such as gender identity, sexual orientation, and cultural context.

Discussion

The review highlights the complex relationship between IPV and sexual health, emphasizing the need for targeted interventions and culturally sensitive approaches. Significant research gaps exist, particularly regarding lesbian women and non-binary individuals. Future studies should employ mixed-methods approaches and consider intersectionality to provide a more comprehensive understanding of IPV's impact on sexual health across diverse populations.

"They Think Transgender is Like Something on the Side:" Perceptions of Transgender Women of Color of Cisgender Members of the LGBTQIA+ "Community"

Due to multiple minority statuses, transgender women of color are exposed to minority stress through distal (external) stressors from society causing proximal (internal) stress, leading to potentially negative physical and mental health outcomes. Often considered allies to the transgender community, cisgender members of the LGBTQIA+ "community" have historically presented different plights resulting in divergent rights, protections, and societal views. Guided by the minority stress framework, a secondary analysis of individual interviews and focus groups (n = 20) with transgender women of color was performed. Participants shared experiences of distal and proximal minority stressors when discussing the cisgender LGBTQIA+ "community" and mitigating resilience factors. Four main themes emerged: 1) preference for cisgender presentation; 2) discrimination and exclusion; 3) mistrust; and 4) resilience. This is the first study to demonstrate direct mental and physical health risks for transgender women of color associated with discrimination and exclusion by members of the cisgender LGBTQIA+ "community." Negative experiences resulted in health care avoidance, verbal assault, social exclusion, mistrust of providers, and barriers to transgender-affirming care. Future research must consider minority stress to advance the understanding of LGBTQIA+ within-group marginalization and foster equitable opportunities for transgender women of color and other gender minorities.

The Utilization of Syndemic Theory in Transgender Literature: A Structured Literature Review

Purpose

Trans and gender diverse (TGD) people are one of the world's most marginalized populations. Current evidence indicates that ostracism faced by these communities leads to multiple adverse conditions. The synergistic impact of these conditions -a syndemic-has been well established among other marginalized populations. Despite disproportionate rates of syndemic conditions, there is a dearth of literature exploring their effect among TGD people. This review sought to summarize the current literature regarding syndemic conditions among this population.

Methods

A comprehensive search of databases (Medline, Embase, Global Health, PsycInfo, and CINAHL) was conducted; search terms included syndemics, syndemic theory, transgender, sexual minority, and gender minority. References within selected articles were also reviewed. Inclusion criteria for this review included studies that (1) explored the impact of syndemic factors and/or theory among TGD people, (2) were written in English, and (3) published up to December 2020.

Results

The search generated 192 articles; 10 met the inclusion criteria. Substance use, mental health, and victimization were the most prominent syndemic conditions assessed. Current evidence is limited to sexual risk behaviors and provides preliminary support for an association between syndemic conditions and sexual risk behaviors.

Conclusion

Understanding syndemics is vital to developing contextually suitable interventions or TGD people. Future researchers should work toward longitudinal or high-level modeling approaches of syndemic theory to effectively design interventions to improve health outcomes among TGD people. Furthermore, scholars should study the relationship between syndemic conditions and other outcomes to better understand the impact of syndemics on broader health consequences.

Exploring Psychosocial and Structural Syndemic Effects as Predictors of HIV Risk Behaviors Among Black Women (HPTN 064)

Background: Syndemic models have been used in previous studies exploring HIV-related outcomes; however, these models do not fully consider intersecting psychosocial (e.g., substance use, depressive symptoms) and structural factors (unstable housing, concentrated housing vacancy) that influence the lived experiences of women. Therefore, there is a need to explore the syndemic effects of psychosocial and structural factors on HIV risk behaviors to better explain the multilevel factors shaping HIV disparities among black women. Methods: This analysis uses baseline data (May 2009-August 2010) from non-Hispanic black women enrolled in the HIV Prevention Trials Network 064 Women's Seroincidence Study (HPTN 064) and the American Community Survey 5-year estimates from 2007 to 2011. Three parameterizations of syndemic factors were applied in this analysis a cumulative syndemic index, three syndemic groups reflecting the level of influence (psychosocial syndemic group, participant-level structural syndemic group, and a neighborhood-level structural syndemic group), and syndemic factor groups. Clustered mixed effects log-binomial analyses measured the relationship of each syndemic parameterization on HIV risk behaviors in 1,347 black women enrolled in HPTN 064. Results: A higher syndemic score was significantly associated with increased prevalence of unknown HIV status of the last male sex partner (adjusted prevalence ratio (aPR) = 1.07, 95% confidence interval or CI 1.04-1.10), involvement in exchange sex (aPR = 1.17, 95% CI: 1.14-1.20), and multiple sex partners (aPR = 1.07, 95% CI: 1.06-1.09) in the last 6 months. A dose-response relationship was observed between the number of syndemic groups and HIV risk behaviors, therefore, being in multiple syndemic groups was significantly associated with increased prevalence of reporting HIV risk behaviors compared with being in one syndemic group. In addition, being in all three syndemic groups was associated with increased prevalence of unknown HIV status of the last male sex partner (aPR = 1.67, 95% CI: 1.43-1.95) and multiple sex partners (aPR = 1.53, 95% CI: 1.36-1.72). Conclusions: Findings highlight syndemic factors influence the lived experiences of black women.

A Contextualization of Transgender Women and Condom Use Using the HIV Syndemic Framework: Scoping Review

Objective: To contextualize condom use in the transgender women population utilizing the HIV syndemic framework. Methods: Studies reporting condom use frequency and syndemic factors associated with HIV risk in transgender women were systematically searched. We followed the Scoping Reviews (PRISMA-ScR) checklist. Results: Social factors have a proven relationship with using condoms and HIV among transgender women. Syndemic factors, defined as co-occurring adverse factors that interact to contribute to risk behaviors, deserve a specific analysis to develop strategies to face HIV among transgender women. Conclusions: A syndemic perspective allows to generate specific health intervention and prevention policies to protect transgender women.

Structural and Psychosocial Syndemic Conditions and Condomless Anal Intercourse Among Transgender Women - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020

Psychosocial and structural syndemic conditions, including polydrug use and experiencing homelessness, frequently co-occur and might jointly increase HIV risk. Limited studies have assessed racial and ethnic differences in exposure to syndemic conditions and behaviors associated with HIV transmission among transgender women. This report examines the relation between syndemic conditions and condomless anal intercourse (CAI) among transgender women in seven urban areas in the United States to develop HIV prevention interventions for transgender women. During 2019-2020, transgender women in seven urban areas were recruited using respondent-driven sampling for a biobehavioral survey. Reported syndemic conditions (psychosocial: polydrug use, sexual violence, and psychological distress; structural: homelessness, incarceration, and exchange sex) were summed to create a syndemic score. Using modified Poisson regression to account for RDS, the study assessed whether the strength of the association between syndemic score and CAI differed by race and ethnicity. To assess additive interaction, the relative excess prevalence owing to interaction (REPI) and 95% CIs for selected pairs of syndemic conditions on CAI prevalence stratified by race and ethnicity were estimated. Of 1,348 transgender women (Black = 546, White = 176, and Hispanic = 626), 55% reported CAI; and 24% reported ≥3 syndemic conditions. Reporting additional syndemic conditions was associated with CAI for White, Hispanic, and Black participants. The association was significantly stronger for White than Black and Hispanic participants. Limited significant superadditive interactions were found, although the majority were between structural syndemic conditions. Racial and ethnic differences in REPI estimates were observed. Reporting more syndemic conditions was associated with increased CAI across racial and ethnic groups, demonstrating that HIV prevention efforts for transgender women should address structural and psychosocial syndemic conditions. Results differed by race and ethnicity, indicating that syndemic-focused interventions for transgender women should be tailored to racial and ethnic groups.

Syndemic Conditions and Their Association with HIV/STI Sexual Risk Behaviors Among Transgender Women and Cisgender Men Sex Workers in Catalonia: The SexCohort Project

BACKGROUND

Transgender women and cisgender men sex workers are vulnerable to HIV and sexually transmitted infections (STIs). This study aimed to explore in depth the prevalence of syndemic conditions and their association with the sexual risk behaviors for HIV/STI acquisition in cis men and trans women sex workers in Barcelona (Catalonia, Spain).

METHOD

We conducted a study between 2014 and 2018 to determine whether syndemic conditions (frequent alcohol consumption and polydrug use (> 2) during sex with clients; experience of violence; and lack of healthcare access) are associated with HIV/STI sexual risk behaviors. A "syndemic index" was calculated based on the cumulative number of syndemic conditions (0 to 4).

RESULTS

In the last year (2018), 78.8% of cisgender men and 68.1% of transgender women reported at least one syndemic condition. The most prevalent syndemic factor in both cisgender men and transgender women was violence (38.8% and 43.6% respectively). In multivariable analysis, an association was found between condomless anal sex and violence (aOR = 1.81), and frequent alcohol consumption and violence with reporting > 10 clients/week (aOR = 2.73 and 1.88, respectively). The higher the number of syndemic factors, the greater probability of having > 10 clients/week and reporting condomless anal sex with clients.

CONCLUSION

Psychosocial conditions have a syndemic effect on risky sexual behaviors highlighting the need for a more holistic approach to HIV/STI prevention targeting these populations.

Transactional sex among rural, justice-involved Appalachian women who use drugs

PURPOSE

Transactional sex is associated with an array of other health risk behaviors and adverse health outcomes, including HIV. However, despite concerns regarding a potential HIV outbreak, there is limited understanding of transactional sex among rural Appalachians who engage in high-risk behaviors. Thus, the current study describes the prevalence and correlates of transactional sex among a sample of rural, justice-involved Appalachian women who use drugs.

METHODS

Participants (N = 400) were randomly selected, screened, and interviewed face-to-face at 3 rural Appalachian jails in Kentucky. Bivariate analyses were used to examine differences between those who reported trading sex for drugs, money, goods, or services in the year prior to incarceration and those who had not, and multivariable logistic regression was used to examine independent correlates of transactional sex.

FINDINGS

On average, participants were 33 years old with 11 years of education. They were predominantly White (99.0%), about half (43.7%) reported lifetime transactional sex, and 25.9% reported past year transactional sex. Past year transactional sex was positively associated with experiencing money problems, substance use problem severity, injection drug use, unprotected sex with a casual partner, and number of sexual partners in the year prior to incarceration.

CONCLUSIONS

Results suggest that transactional sex is fairly common among rural Appalachian women who use drugs and are justice-involved and may signal other HIV-related risk behaviors. Given limited service availability throughout rural Appalachia, findings emphasize a need for increased access to risk-reduction interventions, including jail-based interventions, to educate vulnerable, hard-to-reach populations on the risks associated with HIV.

High-risk polysubstance use among LGBTQ+ people who use drugs in the United States: An application of syndemic theory

BACKGROUND

Compared to heterosexual and cisgender people, lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) people are more likely to develop problems with high-risk polysubstance use. According to syndemic theory, this disparity in high-risk polysubstance use is produced by the LGBTQ+ community's increased vulnerability to experiencing psychosocial (e.g., discrimination, unwanted sex) and structural (e.g., food insecurity, homelessness) conditions, greater likelihood of coping with concurrent health problems (e.g., human immunodeficiency virus [HIV]), and decreased opportunities to develop protective factors (e.g., social support, resilience).

METHODS

Data from 306 LGBTQ+ participants living in the United States (U.S.) with a lifetime history of alcohol and drug use were analyzed; 21.2% reported lifetime problems with 10 different drugs. Bootstrapped hierarchical multiple regression was used to test demographic correlates and syndemic predictors of high-risk polysubstance use. One-way ANOVA and post-hoc comparison tests were used to test subgroup differences by gender.

RESULTS

Results indicated that income, food insecurity, sexual orientation-based discrimination, and social support were associated with high-risk polysubstance use, explaining 43.9% of the variance of high-risk polysubstance use. Age, race, unwanted sex, gender identity-based discrimination, and resilience were not significant. Group comparison tests revealed that, compared to nonbinary people and cisgender sexual minority men and women, transgender individuals experienced significantly higher levels of high-risk polysubstance use and sexual orientation-based discrimination but significantly lower levels of homelessness and social support.

CONCLUSION

This study provided further evidence for conceptualizing polysubstance use as an adverse outcome of syndemic conditions. Harm reduction strategies, anti-discrimination laws, and gender-affirming residential treatment options should be considered in U.S. drug policy. Clinical implications include targeting syndemic conditions to reduce high-risk polysubstance use among LGBTQ+ people who use drugs.

Coping Strategies as a Moderator for the Association between Intimate Partner Violence and Depression and Anxiety Symptoms among Transgender Women

Evidence suggests that intimate partner violence (IPV) is associated with negative mental health outcomes. There is currently limited research on the impact of IPV on the outcomes of mental health for transgender women. The current study aimed to examine the relationship between intimate partner violence, coping skills, depression, and anxiety in a sample of transgender women. Hierarchical regression analyses were conducted examining the relationship of IPV and depression and anxiety symptoms, where coping skills moderate this relationship. The results suggest that those with experiences of IPV are more likely to have symptoms of depression and anxiety. For individuals with no experiences of IPV and low depression, high levels of emotional processing coping and acceptance coping buffered this relationship. For individuals with more experiences of IPV and more depressive symptoms, coping skills did not show to buffer this relationship. These same coping skills did not show evidence for buffering anxiety symptoms for transgender women with low or high levels of IPV. The results, implications, and limitations of this study and suggestions for further research are discussed.

Syndemic conditions and quality of life in the PISCIS Cohort of people living with HIV in Catalonia and the Balearic Islands: a cross sectional study

BACKGROUND

People living with HIV (PLWH) face structural and psychosocial factors that affect health-related quality of life (HRQoL). We aimed to evaluate how syndemic conditions affected HRQoL in PLWH.

METHODS

A cross-sectional survey was conducted among 861 PLWH, to determine whether syndemic conditions (monthly income; sexual satisfaction; depressive symptoms; social role satisfaction; social isolation; cognitive function; nicotine dependence; perception of stigma) have an effect on HRQoL. A linear regression model and measures of Additive Interaction (AI) were used to determine the effects of syndemic conditions on HRQoL, controlling for other risk factors.

RESULTS

Overall, the most frequently observed were stigma perception (56.9%), poor cognitive function (50.6%) and the perception of social isolation (51.6%). The presence of depressive symptoms was the risk factor most associated with worse Physical Health (PH) (B 3.93, 2.71-5.15) and Mental Health (MH) (B 5.08, 3.81-6.34) in linear regression model. Specifically, an interaction was observed between poor cognitive function and poor satisfaction with social role on worse PH and MH (AI 2.08, 0.14-4.02; AI 2.69, 0.15-5.22, respectively); and low income and perception of stigma (AI 2.98, 0.26-5.71), low income and perception of social isolation (AI 2.79, 0.27-5.32), and low income and poor satisfaction with social role (AI 3.45, 0.99-5.91) on MH.

CONCLUSION

These findings provide evidence that syndemic factors impact HRQoL. HIV prevention programs should screen and address co-occurring health problems to improve patient-centered health care and outcomes.

Psychosocial Problems and Condomless Anal Sex among Transgender Women in Two Cities of China: Study Based on the Syndemic Framework

Studies examining the association between psychosocial problems and condomless anal sex (CAS) among transgender women (TGW) are rare. In this study, close attention was paid to the effect of co-occurring psychosocial problems on sexual risk behaviors. A cross-sectional study, including 247 TGW, was conducted in Kunming and Shenyang, China. The prevalence of condomless anal sex among TGW in the previous 6 months was 30.8%. Most of the psychosocial factors were associated with one another in bivariate logistic regression models. Low self-esteem (ORm = 2.99, 95% CI = 1.25-7.18), sexual compulsivity (ORm = 2.13, 95% CI = 1.13-4.00), and intimate partner violence (ORm = 2.21, 95% CI = 1.19-4.11) were discovered to be related to condomless anal sex in the multivariate regression model. No significant interactive effects of the syndemic factors on condomless anal sex were detected. More programmatic and effective HIV prevention interventions targeting psychosocial problems are required to reduce HIV infection within the population.

Condom use and non-use among transgender women in Colombia: a qualitative analysis based on the IMB model

OBJECTIVE

Review the reasons for condom use and non-use among transgender women in Colombia based on the information, motivation and behavioral skills (IMB) model.

METHOD

Qualitative study in which an iterative process analysis was carried out. A focal group participated in person, and in-depth interviews were conducted virtually.

RESULTS

First study carried out in Colombia on condom use among transgender women under the IMB model. The information component finds that traditional sexual education does not have a positive impact. Regarding motivational aspects, the importance of family support and follow-up and community-based organizations to motivate sexual health care and condom use is highlighted. Regarding behavioral skills, it was found that distrust towards sexual partners and the acquisition of condoms promote their use.

CONCLUSIONS

It is important to create spaces for sexual education delivered by and for the LGBTIQ population, followed by the medical knowledge of health centers, to have positive impacts on the sexual health of transgender women; studies with sexual partners of transgender women are encouraged in order to know the reasons why they request the non-use of condoms.

Stress-Related Growth Among Transgender Women: Measurement, Correlates, and Insights for Clinical Interventions

Although transgender women (TGW), and especially TGW of color, are disproportionately exposed to discrimination and violence, many of them experience stress-related growth. However, little is known about the experience of stress-related growth and its correlates among TGW. Using data from a racially-diverse sample of 210 TGW, the short version of the Stress-Related Growth Scale was modified to assess growth as a result of coming to terms with one's transgender identity among TGW. The psychometric properties of the modified scale were examined, along with its associations with various cognitive, emotional, and social factors. A confirmatory factor analysis revealed a unidimensional factor, along with excellent reliability. A stepwise regression revealed that positive reappraisal, internal locus of control, social support, and emotional expression were associated with greater stress-related growth. Findings suggest that cognitive, emotional, and social resources are related to stress-related growth in TGW. Interventions to foster stress-related growth among TGW are discussed.

Differing Correlates of Incident Bacterial Sexually Transmitted Infections Among a Cohort of Black Cisgender Men Who Have Sex With Men and Transgender Women Recruited in 6 US Cities (HIV Prevention Trials Network 061)

ABSTRACT

Compared with Black cisgender men who have sex with men (MSM), Black transgender women had a higher incidence of bacterial sexually transmitted infections (25.9 [11.1-46.3] vs. 9.6 [8.10-11.3] per 100 person-years), higher rates of income and housing insecurity, and condomless receptive anal intercourse. Further investigation of unique risk pathways among transgender women is critical.

Association of positive psychobehavioral factors and structural disadvantage with condomless sex in men who have sex men with childhood sexual abuse histories

Previous research has highlighted both psychological and structural risk factors as correlates of condomless anal sex, a key pathway to HIV acquisition in men who have sex with men (MSM). Fewer studies have focused on positive psychobehavioral factors, which may be associated with more consistent condom use. This study hypothesized that positive psychobehavioral factors would be associated with more frequent condom use over and above psychological and structural risk factors. MSM with histories of childhood sexual abuse in Boston, MA and Miami, FL (N = 108) completed cross-sectional assessments of psychosocial, structural, and positive psychobehavioral factors. These factors were entered simultaneously in a linear regression model to examine their association with frequency of condomless sex. More recent seroadaptive behavior (B = 0.323, 95% CI = 0.055-0.590, p = .019) and receipt of government benefits to supplement income (B = 0.892, 95% CI = 0.171-1.612, p = .016) were independently associated with higher frequency of condomless sex over and above all other psychosocial, structural, and positive psychobehavioral factors. R² for the final model was 0.270. Ancillary analyses including participants taking and adherent to biomedical HIV prevention suggested an association between higher distress tolerance and lower frequency of condomless sex. Positive psychobehavioral factors may potentially lower risk for HIV in high-risk MSM; however, left unaddressed, structural disadvantage is a potent influence which may limit potential benefits.

Social Determinants of Transactional Sex in a Sample of Young Black and Latinx Sexual Minority Cisgender Men and Transgender Women

PURPOSE

We sought to explore characteristics and risk factors associated with transactional sex in a sample of young black and Latinx sexual minority cisgender men and transgender women of age 15 to 24 years who were living with or at high risk for HIV infection and whether these associations vary by gender identity and HIV status.

METHODS

A total of 454 black and Latinx sexual minority cisgender men and transgender women from Baltimore, MD; Philadelphia, PA; Washington, DC; and St. Petersburg/Tampa, Fl, were recruited to participate in a multisite study that included a 45-minute baseline Web-based survey and HIV-1 rapid testing. Bivariate analysis was used to explore factors associated with transactional sex. Factors significant at p-value <.20 in bivariate analysis were entered into a final logistic regression models; and models were further stratified by gender identity and HIV status.

RESULTS

The mean age was 21.3 (standard deviation = 2.5), with 14.7% (n = 65) identifying as transgender, and 103 youth (22.7%) reporting lifetime transactional sex. Transactional sex was associated with transgender identity, recent unstable housing in the last 12 months, poorer perceived financial well-being, coerced sex, and marijuana use. Differences were noted by gender identity and HIV status, with marijuana use associated with transactional sex in cisgender men and unstable housing and sexual coercion in youth living with HIV.

CONCLUSIONS

Young black and Latinx cisgender men and transgender women are at a high risk for engaging in transactional sex. Transactional sex may create a syndemic for HIV risk exposure through co-occurring and reinforcing conditions of unstable housing, violence, and substance use.

Syndemic violence victimization, alcohol and drug use, and HIV transmission risk behavior among HIV-negative transgender women in India: A cross-sectional, population-based study

Transgender women globally are disproportionately burdened by HIV. Co-occurring epidemics of adverse psychosocial exposures accelerate HIV sexual risk, including among transgender women; however, studies using additive models fail to examine synergies among psychosocial conditions that define a syndemic. We examined the impact of synergistic interactions among 4 psychosocial exposures on condomless anal sex (CAS) among transgender women in India. A national probability-based sample of 4,607 HIV-negative transgender women completed the Indian Integrated Biological and Behavioural Surveillance survey, 2014-2015. We used linear probability regression and logistic regression to assess 2-, 3-, and 4-way interactions among 4 psychosocial exposures (physical violence, sexual violence, drug use, and alcohol use) on CAS. Overall, 27.3% reported physical and 22.3% sexual violence victimization (39.2% either physical or sexual violence), one-third (33.9%) reported frequent alcohol use and 11.5% illicit drug use. Physical violence was associated with twofold higher odds of CAS in the main effects model. Statistically significant two- and three-way interactions were identified, on both the multiplicative and the additive scales, between physical violence and drug use; physical and sexual violence; physical violence, sexual violence, and alcohol use; and physical violence, alcohol use and drug use. Physical and sexual violence victimization, and alcohol and drug use are highly prevalent and synergistically interact to increase CAS among HIV-negative transgender women in India. Targeted and integrated multilevel initiatives to improve the assessment of psychosocial comorbidities, to combat systemic transphobic violence, and to provide tailored, trauma-informed alcohol and substance use treatment services may reduce HIV risk among transgender women.

Sex Workers and Syndemics: A Population Vulnerable to HIV and COVID-19

COVID-19 has disproportionately affected vulnerable populations across the U.S. Street-based sex workers are one vulnerable population whose health and impact of COVID-19 have been understudied to date. The goal of this study was to evaluate findings from a community needs assessment with street-based sex workers on impact of COVID-19 on health behaviors and social circumstances. A brief survey was developed at a community-based harm reduction and recovery services organization. Surveys were administered by peer specialists to street-based sex workers during street outreach in April and May 2020. A total of 46 surveys were analyzed. Many individuals reported continuing to do sex work and use substances during the COVID pandemic. Slightly more than a quarter of individuals (n = 13; 28.3%) indicated using personal protective equipment while doing sex work and described challenges to using precautions when working with clients. Individuals had used marijuana (n = 32, 71.1%), cocaine (n = 17, 39.5%), prescription stimulants (n = 9, 21.4%), methamphetamines (n = 5, 11.9%), prescription opioids (n = 12, 27.3%), street opioids (n = 12, 27.3%), sedatives (n = 11, 25.0%), hallucinogens (n = 3, 6.8%), inhalants (n = 3, 7.0%), or some other substance (n = 4, 8.7%) in the past 30 days. About half (48.8%) reported that COVID-19 had a major impact on their lives. This study is among the first to characterize the impact of COVID-19 on street-based sex workers. From a public health standpoint, this group also represents a high-priority population given their vulnerability and close contact with others, which increases the potential for community spread.

Age of Occurrence and Severity of Childhood Sexual Abuse: Impacts on Health Outcomes in Men Who Have Sex with Men and Transgender Women

Childhood sexual abuse (CSA) is associated with a wide range of health outcomes and is more prevalent among men who have sex with men (MSM) compared to men who have sex with women exclusively and among transgender women (TW) compared to cisgender peers; however, there is a lack of consensus regarding an explanatory theoretical model. This analysis examined these models across health outcomes using baseline data from a longitudinal study of MSM and TW in Chicago (n = 1,035) collected from 2015 to 2019. Severity of CSA was measured for two age ranges (prior to 13 and 13-17). Logistic regression and negative binomial regressions were estimated. Teenage experiences of CSA were associated with alcohol problems, cannabis problems, suicide ideation/attempt, depression, condomless anal sex partners, rectal STI, and HIV. Pre-teenage CSA was associated with alcohol use and depressive symptoms. Significant interactions across age of experience of CSA were found for alcohol problems, cannabis problems, and condomless anal sex partners. Consistent with previous literature, this analysis found CSA to be a significant influence on various health outcomes. No single explanatory framework emerged; however, adolescent exposures may be more closely linked to health outcomes and risk behaviors than pre-teenage or cumulative exposures.

Social Networks and Exchange Sex among Transgender Women

Transgender women are more likely to exchange sex than cisgender individuals. This study investigated how social networks were associated with exchange sex among transgender women in Los Angeles County. From July 2015 to September 2016, transgender women (N = 271; "egos") reported their sexual and substance use behaviors and perceptions of the same behaviors among their peers (N = 2,619; "alters"). Clustered logistic and negative binomial regressions were used to model odds of exchange sex and number of exchange sex partners in the past 6 months, respectively. Transgender women who perceived that any of their peers were engaged in exchange sex were approximately four times more likely to exchange sex themselves and reported three times as many exchange sex partners as those who did not perceive any peers engaged in exchange sex. Perceived ecstasy use among peers was associated with higher odds of exchange sex and more exchange sex partners, whereas perceived marijuana use among peers was associated with lower odds of exchange sex and fewer exchange sex partners. Peer behaviors were strongly associated with both transgender women's likelihood and rate of engagement in exchange sex. Risk reduction interventions with transgender women should attend to network dynamics that are often overlooked in existing programs.

Longitudinal Associations of Syndemic Conditions with Antiretroviral Therapy Adherence and HIV Viral Suppression Among HIV-Infected Patients in Primary Care

Psychosocial syndemic conditions have received more attention regarding their deleterious effects on HIV acquisition risk than for their potential impact on HIV treatment and viral suppression. To examine syndemic conditions' impact on the HIV care continuum, we analyzed data collected from people living with HIV (N = 14,261) receiving care through The Centers for AIDS Research Network of Integrated Clinical Systems at seven sites from 2007 to 2017 who provided patient-reported outcomes ∼4-6 months apart. Syndemic condition count (depression, anxiety, substance use, and hazardous drinking), sexual risk group, and time in care were modeled to predict antiretroviral therapy (ART) adherence and viral suppression (HIV RNA <400 copies/mL) using multilevel logistic regression. Comparing patients with each other, odds of ART adherence were 61.6% lower per between-patient syndemic condition [adjusted odds ratio (AOR) = 0.384; 95% confidence interval (CI), 0.362-0.408]; comparing patients with themselves, odds of ART adherence were 36.4% lower per within-patient syndemic condition (AOR = 0.636 95% CI, 0.606-0.667). Odds of viral suppression were 29.3% lower per between-patient syndemic condition (AOR = 0.707; 95% CI, 0.644-0.778) and 27.7% lower per within-patient syndemic condition (AOR = 0.723; 95% CI, 0.671-0.780). Controlling for the effects of adherence (AOR = 5.522; 95% CI, 4.67-6.53), each additional clinic visit was associated with 1.296 times higher odds of viral suppression (AOR = 1.296; 95% CI, 1.22-1.38), but syndemic conditions were not significant. Deploying effective interventions within clinics to identify and treat syndemic conditions and bolster ART adherence and continued engagement in care can help control the HIV epidemic, even within academic medical settings in the era of increasingly potent ART.

Intimate Partner Violence Among Chinese Transwomen: Associations With Sexual Risk Behaviors and HIV Testing

BACKGROUND

Intimate partner violence (IPV) is an emerging risk factor for HIV infection. Given the high vulnerability of and limited research on transwomen in China, we described IPV, sexual risk behaviors, HIV, and sexually transmitted infection (STIs) testing rates and results, and investigated the pathways that link IPV to HIV infection among this population.

METHODS

We conducted a cross-sectional survey and collected blood samples for HIV and syphilis testing among transwomen in Shanghai, China (n = 199). With logistic regression, we examined sexual risk behaviors and HIV/STI testing history among participants with and without IPV experience.

RESULTS

More than half of the respondents reported IPV (57.3%), and the prevalence of unprotected sex ranged from 51.9% (with sex workers) to 87.8% (oral sex); 85.9% had ever tested for HIV and 49.3% for other STIs. Self-reported positivity results were as follows: HIV (2.3%), herpes simplex virus type 2 (8.3%), gonorrhea (18.8%), and syphilis (17.8%). Laboratory-confirmed positivity values were 5.0% for HIV and 6.5% for syphilis. Respondents with a history of IPV were significantly less likely to report HIV testing in the past 12 months (adjusted odds ratio, 0.20; 95% confidence interval, 0.10-0.38).

CONCLUSIONS

Transwomen self-reported a high prevalence of IPV, which was related to a lower probability of HIV testing. The prevalence of HIV and other STIs was lower than reported in previous studies of Chinese transwomen, whereas the HIV/STI testing rates were higher. Findings suggest transwomen in China are at risk for IPV and need enhanced HIV prevention services to promote HIV testing in an IPV setting.

Psychosocial Problems and Vulnerability to HIV in a Multi-City Prospective Cohort of Young Transgender Women in the United States: A Structural Equation Modeling Study

BACKGROUND

Gender-based stigma contributes to increased HIV prevalence, but little is known about psychosocial mechanisms linking stigma and HIV risk among young transgender women (YTW).

SETTING

This study uses data from Project LifeSkills, a randomized controlled efficacy trial of an empowerment-based HIV prevention intervention for YTW (N = 233). YTW were recruited in Boston, MA, and Chicago, IL, between 2012 and 2015 and completed study assessment visits at baseline and months 4 and 12.

METHODS

Using autoregressive structural equation modeling, we examined whether poor social support and psychological distress at 4 months mediate the prospective relationship between gender-based stigma at baseline and condomless anal and vaginal sex (CAVS) acts at 4 and 12 months; all models were adjusted for treatment arm, HIV serostatus, study site, and sociodemographics.

RESULTS

Gender-based stigma at baseline was directly associated with increased CAVS at 4 months [adjusted incidence rate ratio (aIRR) = 1.18, 95% confidence interval (CI): (1.05 to 1.33)] and 12 months [aIRR = 1.17, 95% CI: (1.02 to 1.34)]. Gender-based stigma was also associated with higher psychological distress at 4 months [b = 0.70, 95% CI: (0.13 to 1.27)], which in turn was marginally associated with increased CAVS at 12 months [aIRR = 1.03, 95% CI: (1.00 to 1.06)]. Contrary to expectations, poor social support at 4 months was associated with decreased CAVS at 12 months [aIRR = 0.40, 95% CI: (0.28 to 0.59)].

CONCLUSIONS

Future HIV prevention interventions with YTW should consider addressing experiences of gender-based stigma and the psychological distress that may ensue from gender-based stigma. More research is needed to understand the influence of poor social support on sexual behaviors in this population.

Associations Between Trauma-Informed Care Components and Multiple Health and Psychosocial Risks Among LGBTQ Survivors of Intimate Partner Violence

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals disproportionately experience intimate partner violence (IPV) and resulting negative health consequences compared to cisgender heterosexual individuals. This study builds on prior recent work by examining specific trauma-informed care (TIC) components most associated with a comprehensive set of health and psychosocial risks among 298 LGBTQ IPV survivors who sought and accessed trauma-related services (e.g., mental health counseling). Results indicated that TIC components are differentially associated with LGBTQ clients' health and well-being. Specifically, greater perceptions of providers who fostered agency and mutual respect were associated with better outcomes, whereas greater perceptions of providers who focused on culture and increasing opportunities to connect with other survivors were related to negative outcomes. These findings underscore the need for providers to prioritize LGBTQ clients' sense of agency and mutual respect and identify for whom focusing on culture and connecting with other LGBTQ survivors might be beneficial.

Estimating HIV transmissions in a large U.S. clinic-based sample: effects of time and syndemic conditions

INTRODUCTION

Little is known about onward HIV transmissions from people living with HIV (PLWH) in care. Antiretroviral therapy (ART) has increased in potency, and treatment as prevention (TasP) is an important component of ending the epidemic. Syndemic theory has informed modelling of HIV risk but has yet to inform modelling of HIV transmissions.

METHODS

Data were from 61,198 primary HIV care visits for 14,261 PLWH receiving care through the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) at seven United States (U.S.) sites from 2007 to 2017. Patient-reported outcomes and measures (PROs) of syndemic conditions - depressive symptoms, anxiety symptoms, drug use (opiates, amphetamines, crack/cocaine) and alcohol use - were collected approximately four to six months apart along with sexual behaviours (mean = 4.3 observations). Counts of syndemic conditions, HIV sexual risk group and time in care were modelled to predict estimated HIV transmissions resulting from sexual behaviour and viral suppression status (HIV RNA < 400/mL) using hierarchical linear modelling.

RESULTS

Patients averaged 0.38 estimated HIV transmissions/100 patients/year for all visits with syndemic conditions measured (down from 0.83, first visit). The final multivariate model showed that per 100 patients, each care visit predicted 0.05 fewer estimated transmissions annually (95% confidence interval (CI): 0.03 to 0.06; p < 0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; p < 0.0005), 0.34 (95% CI: 0.20 to 0.49; p < 0.0005) and 0.22 (95% CI: 0.09 to 0.35; p < 0.005) fewer estimated HIV transmissions/100 patients/year than cisgender men who have sex with men (MSM). Each within-patient syndemic condition predicted 0.18 estimated transmissions/100 patients/year (95% CI: 0.12 to 0.24; p < 0.0005). Each between-syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; p < 0.0005).

CONCLUSIONS

Estimated HIV transmissions among PLWH receiving care in well-resourced U.S. clinical settings varied by HIV sexual risk group and decreased with time in care, highlighting the importance of TasP efforts. Syndemic conditions remained a significant predictor of estimated HIV transmissions notwithstanding the effects of HIV sexual risk group and time in care.

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.

Reduction of Gender Identity Stigma and Improvements in Mental Health Among Transgender Women Initiating HIV Treatment in a Trans-Sensitive Clinic in Argentina

Purpose: Stigma toward transgender women (TGW) increases psychosocial vulnerability, leading to poor mental health and affecting access and retention in HIV care. Trans-sensitive health care (TSHC) has the potential to mitigate this adverse impact. This study aimed to describe baseline characteristics in gender identity stigma (GIS), mental health, and substance use among TGW living with HIV initiating antiretroviral treatment and to analyze changes after 6 months in HIV care in a TSHC clinic in Argentina. Methods: Sixty-one TGW living with HIV responded to the following questionnaires at baseline and after 6 months in TSHC: sociodemographic, experiences of GIS (in health care, police, etc.), Center for Epidemiologic Studies Depression Scale (CES-D) (depression), State Trait Anxiety Inventory (STAI) (anxiety), Drug Abuse Screening Test (DAST-10) (drug use), Alcohol Use Disorders Identification Test (AUDIT) (alcohol use), 8-item Personal Wellbeing Index-Adults (PWI-A) (quality of life [QOL]), Personality Inventory for DSM-5-Brief Form (PID-5-BF) (maladaptive personality traits), and Duke Index (social support). Analyses included Pearson correlations to analyze associations between variables; and paired sample t-tests, to explore changes between baseline and 6 months. Results: A significant proportion experienced episodes of GIS the last year in any context. At baseline, 50.8% showed significant depressive symptoms and 65.6% reported any drug use in the last year. At 6 months, participants experienced a significant reduction of GIS, both enacted and internalized, anxiety, drug, and alcohol use, and improvement in QOL. The remaining mental health indicators were not significantly modified. Conclusion: A TSHC service may have a gender-affirmative impact on TGW initiating HIV care that contributes to reduce GIS and substance use and improve mental health. This highlights the importance that HIV care programs for TGW comply with trans-sensitive essential components to enhance retention.

Intimate Partner Violence in Transgender Populations: Systematic Review and Meta-analysis of Prevalence and Correlates

Background: Transgender individuals experience unique vulnerabilities to intimate partner violence (IPV) and may experience a disproportionate IPV burden compared with cisgender (nontransgender) individuals.Objectives: To systematically review the quantitative literature on prevalence and correlates of IPV in transgender populations.Search Methods: Authors searched research databases (PubMed, CINAHL), gray literature (Google), journal tables of contents, and conference abstracts, and consulted experts in the field. Authors were contacted with data requests in cases in which transgender participants were enrolled in a study, but no disaggregated statistics were provided for this population.Selection Criteria: We included all quantitative literature published before July 2019 on prevalence and correlates of IPV victimization, perpetration, or service utilization in transgender populations. There were no restrictions by sample size, year, or location.Data Collection and Analysis: Two independent reviewers conducted screening. One reviewer conducted extraction by using a structured database, and a second reviewer checked for mistakes or omissions. We used random-effects meta-analyses to calculate relative risks (RRs) comparing the prevalence of IPV in transgender individuals and cisgender individuals in studies in which both transgender and cisgender individuals were enrolled. We also used meta-analysis to compare IPV prevalence in assigned-female-sex-at-birth and assigned-male-sex-at-birth transgender individuals and to compare physical IPV prevalence between nonbinary and binary transgender individuals in studies that enrolled both groups.Main Results: We identified 85 articles from 74 unique data sets (ntotal = 49 966 transgender participants). Across studies reporting it, the median lifetime prevalence of physical IPV was 37.5%, lifetime sexual IPV was 25.0%, past-year physical IPV was 16.7%, and past-year sexual IPV was 10.8% among transgender individuals. Compared with cisgender individuals, transgender individuals were 1.7 times more likely to experience any IPV (RR = 1.66; 95% confidence interval [CI] = 1.36, 2.03), 2.2 times more likely to experience physical IPV (RR = 2.19; 95% CI = 1.66, 2.88), and 2.5 times more likely to experience sexual IPV (RR = 2.46; 95% CI = 1.64, 3.69). Disparities persisted when comparing to cisgender women specifically. There was no significant difference in any IPV, physical IPV, or sexual IPV prevalence between assigned-female-sex-at-birth and assigned-male-sex-at-birth individuals, nor in physical IPV prevalence between binary- and nonbinary-identified transgender individuals. IPV victimization was associated with sexual risk, substance use, and mental health burden in transgender populations.Authors' Conclusions: Transgender individuals experience a dramatically higher prevalence of IPV victimization compared with cisgender individuals, regardless of sex assigned at birth. IPV prevalence estimates are comparably high for assigned-male-sex-at-birth and assigned-female-sex-at-birth transgender individuals, and for binary and nonbinary transgender individuals, though more research is needed.Public Health Implications: Evidence-based interventions are urgently needed to prevent and address IPV in this high-risk population with unique needs. Lack of legal protections against discrimination in employment, housing, and social services likely foster vulnerability to IPV. Transgender individuals should be explicitly included in US Preventive Services Task Force recommendations promoting IPV screening in primary care settings. Interventions at the policy level as well as the interpersonal and individual level are urgently needed to address epidemic levels of IPV in this marginalized, high-risk population.

Technology-Based Stepped Care to Stem Transgender Adolescent Risk Transmission: Protocol for a Randomized Controlled Trial (TechStep)

BACKGROUND

Transgender youth demonstrate significantly higher rates of engagement in sexual risk behaviors relative to their cisgender or gender-conforming counterparts, including high rates of condomless anal intercourse and engagement in sex work. In addition, transgender youth experience increased physical or sexual abuse, victimization, substance use, mental health disorders, incarceration, and homelessness. Owing to these syndemic health disparities, transgender youth are at substantially increased risk of HIV infection.

OBJECTIVE

This protocol aims to describe a randomized controlled trial (RCT), Adolescent Medicine Trials Network 160 TechStep (N=250), which assesses the differential immediate and sustained effects of each of 3 conditions (text messaging, WebApp, or information-only control) for reducing sexual risk behaviors and increasing pre-exposure prophylaxis (PrEP) uptake among high-risk, HIV-negative transgender youth and young adults (aged 15-24 years).

METHODS

Participants will be recruited through web-based (targeted social media sites and apps) and offline (print ads and flyers) advertisements, peer and clinic referrals, and street- and venue-based outreach, and by contacting potential participants who have requested contact for future studies. Participants will be randomized into 1 of the 3 conditions: (1) text messaging, (2) WebApp, or (3) information-only control for 6 months. Assessments will occur at baseline and at 3, 6, and 9 months. Participants who do not show improvements in sexual risk or PrEP uptake at the 3-month assessment will be rerandomized to receive weekly electronic coaching (eCoaching) sessions in addition to their assigned text messaging or WebApp intervention, or remain in the original text messaging or WebApp intervention using a 2:1 ratio. Participants originally assigned to the information-only condition are not eligible for rerandomization.

RESULTS

Funding for TechStep was awarded in June 2017. Phase 1 was approved by the Institutional Review Board (IRB) in April 2018. Recruitment began in November 2018 for phase 1, the formative phase. Initial phase 2 IRB approval came in June 2019. The data collection for phase 2, the RCT, is expected to be completed in April 2021. As of March 2020, 54 participants have been enrolled in TechStep. The final results are anticipated in May 2021.

CONCLUSIONS

By providing culturally responsive, technology-based interventions, TechStep aims to improve sexual health outcomes among HIV-negative transgender youth and young adults at high risk of HIV. TechStep will evaluate the efficacy of technology-based interventions for reducing HIV sexual risk behaviors and increasing PrEP initiation, adherence, and persistence. The suite of technology-based interventions developed in TechStep, and assessed for efficacy in a 3-condition RCT, represents an important advancement in intervention science toward developing tailored and scalable interventions for transgender youth and young adults.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04000724; http://clinicaltrials.gov/ct2/show/NCT04000724.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18326.

Application of the "syndemics" theory to explain unprotected sex and transactional sex: A crosssectional study in men who have sex with men (MSM), transgender women, and non-MSM in Colombia

Introduction:

Men who have sex with men (MSM) and transgender women (TW) in Colombia are highly affected by HIV. To improve understanding of the role of HIV risk behaviors in HIV acquisition, we used the syndemic framework, a useful concept to inform prevention efforts.

Objective:

To examine the effect of four psychosocial conditions, namely, forced sex, history of childhood sexual abuse, frequent alcohol use, and illicit drug use on unprotected sex and the synergistic effects (“syndemic” effects) of these conditions on HIV risk behavior.

Materials and methods:

We enrolled a total of 812 males (54.7% men who have sex with men, MSM; 7.3% transgender women, and 38% non-MSM). The participants were recruited from neighborhoods of low socioeconomic status through free HIV-counseling and-testing campaigns. We performed Poisson regression analysis to test the associations and interactions between the four psychosocial conditions and unprotected sex with regular, occasional, and transactional partners. To test the “syndemic” model, we assessed additive and multiplicative interactions.

Results:

The prevalence of any psychosocial condition was 94.9% in transgender women, 60.1% in MSM, and 72.2% in non-MSM. A higher likelihood of transactional sex was associated in MSM (prevalence ratio (PR)=7.41, p<0.001) and non-MSM (PR=2.18, p< 0.001) with three or all four conditions compared to those with one condition. Additive interactions were present for all combinations of psychosocial problems on transactional sex in MSM. No cumulative effect or additive interaction was observed in transgender women.

Conclusions:

Our study highlights the need for bundled mental health programs addressing childhood sexual abuse, illicit drug use, and frequent alcohol use with other HIV prevention programs.

Sheroes: Feasibility and Acceptability of a Community-Driven, Group-Level HIV Intervention Program for Transgender Women

Transgender women experience disproportionate risk of HIV acquisition and transmission. We piloted 'Sheroes', a peer-led group-level intervention for transgender women of any HIV status emphasizing empowerment and gender affirmation to reduce HIV risk behaviors and increase social support. Participants (N = 77) were randomized to Sheroes (n = 39) or a time- and attention-matched control (n = 38). Sheroes is 5 weekly group sessions; topics include sexuality, communication, gender transition, and coping skills. Control participants attended 5 weekly group movie sessions. At 6-month follow up, HIV-negative and unknown status Sheroes participants reported reductions in condomless intercourse and improved social support compared to control. Among participants living with HIV, both the control and intervention groups reduced their total number of sex partners; this change was sustained at 6-month follow-up for Sheroes participants but not for control participants relative to baseline. Sheroes was deemed highly feasible and acceptable to participants; findings support preliminary efficacy of Sheroes.

Measuring Experiences of Minority Stress for Transgender Women: Adaptation and Evaluation of Internalized and Anticipated Transgender Stigma Scales

Purpose: Transgender women (TGW) experience high rates of stigma based on their gender identity. Research has documented how transgender stigma and other discrimination negatively contribute to health inequities, including higher rates of depression compared with the general population. However, few scales measuring transgender stigma exist, even fewer that specifically assess anticipated or internalized transgender stigma. We sought to validate an adapted transgender stigma scale in a diverse sample of TGW. Methods: We adapted an existing stigma measure to capture experiences of anticipated and internalized transgender stigma for TGW. Adapted measures were completed by 213 diverse TGW. Factor analysis was completed to reduce the number of items in each scale and sociodemographic differences in each construct were explored. Results: The final nine items comprising anticipated transgender stigma and the five items for internalized transgender stigma both showed evidence of adequate model fit, unidimensionality, and internal consistency. The two constructs were moderately correlated with one another (r=0.36, p<0.001). We identified educational and HIV status differences in anticipated transgender stigma but no sociodemographic differences in internalized transgender stigma. Conclusion: We developed brief measures of internalized and anticipated transgender stigma through initial adaptation by TGW themselves and subsequent psychometric evaluation, demonstrating evidence of unidimensionality and internal consistency. These subscales were only moderately associated with one another and may provide unique insights in future research on minority stress among TGW.

Self-Reported Mental and Physical Health Symptoms and Potentially Traumatic Events Among Lesbian, Gay, Bisexual, Transgender, and Queer Individuals: The Role of Shame

OBJECTIVE

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals disproportionately face exposure to potentially traumatic events-adverse experiences that may have a traumatizing effect-and experience shame as a common consequence. Previous research demonstrates associations between shame and psychological and physical health issues among those with exposure to potentially traumatic events in general, with limited attention among LGBTQ individuals specifically. This study determined whether shame partially mediated the relationship between potentially traumatic events exposure and self-reported mental and physical health symptoms among LGBTQ individuals.

METHOD

Participants were 218 self-identified LGBTQ individuals who reported experiencing at least one potentially traumatic event (e.g., childhood sexual abuse). Online surveys assessed the type and frequency of potentially traumatic events exposure, shame, self-reported mental health (depression symptoms, posttraumatic stress disorder symptoms, and substance use), and physical health symptoms (sexual risk behavior, somatic symptoms, and chronic health conditions).

RESULTS

Greater potentially traumatic events exposure was associated with greater shame, and greater shame was associated with worse self-reported mental and physical health. Potentially traumatic events exposure had a direct effect on self-reported mental and physical health, and shame partially mediated this relationship.

CONCLUSION

Shame represents an important and modifiable factor that relates to poor health and may be amenable to change through psychosocial interventions. Given the prevalence of negative self-attribution stemming from potentially traumatic events exposure, in addition to the internalization of stigma among this population, practitioners need to uncover interventions specifically targeting shame when working with LGBTQ individuals.

Social Networks Moderate the Syndemic Effect of Psychosocial and Structural Factors on HIV Risk Among Young Black Transgender Women and Men who have Sex with Men

The interaction between the cumulative effect of psychosocial and structural factors (i.e. syndemic effect) and social networks among young Black transgender women and men who have sex with men (YBTM) remains understudied. A representative cohort of 16-29 year-old YBTM (n = 618) was assessed for syndemic factors [i.e. substance use; community violence; depression; poverty; justice system involvement (JSI)], social network characteristics, condomless anal sex (CAS), group sex (GS), and HIV-infection. The syndemic index significantly increased the odds of CAS, GS, and HIV-infection, and these effects were moderated by network characteristics. Network JSI buffered the effect on CAS, romantic network members buffered the effect on GS, and network age and proportion of family network members buffered the effect on HIV-infection. The proportion of friend network members augmented the effect on GS and HIV-infection. Future research to prevent HIV among YBTM should consider social network approaches that target both structural and psychosocial syndemic factors.

Syndemic Factors and HIV Risk Among Men Who Have Sex with Men in Guangzhou, China: Evidence from Synergy and Moderated Analyses

Syndemic factors tend to co-occur and increase the risks of condomless anal intercourse (CAI), multiple sexual partners (MSP) and HIV vulnerability among men who have sex with men (MSM). This study aimed to test the synergistic effects of syndemic factors on HIV risk and to further explore the moderators between syndemics and HIV risk among Chinese MSM. A cross-sectional study was conducted to recruit MSM in Guangzhou to collect data on syndemic factors (depression, intimate partner violence, childhood sexual abuse [CSA], alcohol, and rush popper use before anal sex). The relative excess risk due to interactions (RERIs) was calculated to test the synergy in adjusted regression models. A moderated analysis was conducted to test the buffer effects of potential resilience factors (education and income). Among the 976 included MSM, individuals experiencing more syndemic factors were more likely to have CAI (odds ratio [OR]= 1.26, 95% confidence interval [CI] 1.11-1.44), MSP (OR= 1.33, 95% CI 1.16-1.52), and HIV infection (OR= 1.46, 95% CI 1.12-1.90). RERIs showed a synergy of depression and rush popper use prior to sex for MSP (1.17, 95% CI 0.03-2.03) and CSA and rush popper use prior to sex for HIV infection (1.72, 95% CI 0.05-3.43). However, no significant association was found for the interaction between the number of syndemic factors and education or income. Our findings support the synergy approach in syndemic studies and highlight the need for comprehensive and multifactorial intervention strategies on sexual health of MSM. Future studies are needed to identify potential resilience factors among Chinese MSM.

A Psychosocial Risk Model of Potentially Traumatic Events And Sexual Risk Behavior Among LGBTQ Individuals

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals face heightened risk of potentially traumatic events (PTEs) exposure, including hate crimes and childhood abuse. Past research demonstrates associations between PTEs exposure and sexual risk behavior; however, examining the indirect effect of PTEs on sexual risk behavior remains understudied among LGBTQ individuals. This study tested a path analysis model to inform interventions targeted to reduce sexual risk behavior, as conceptualized by condomless sex with casual partners without knowing the person's HIV or sexually transmitted infection (STI) status, among LGBTQ individuals with PTEs exposure. Participants completed an online one-time survey and included 207 LGBTQ adults who experienced at least one PTE during the past year. Indirect effect results indicated that PTEs exposure was related to sexual risk behavior through serial associations between shame, loneliness, and substance use. Direct effect estimates indicated that greater PTEs exposure was associated with greater shame, loneliness, substance use, and sexual risk behavior. Greater shame was associated with greater loneliness, which was associated with greater substance use. Also, greater substance use was associated with greater sexual risk behavior. This study adds to the burgeoning body of literature on the relationship between PTEs exposure and sexual risk behavior among LGBTQ individuals. Clinical and counseling interventions for LGBTQ individuals with PTEs exposure should work to address modifiable psychosocial risk factors associated with sexual risk behavior.

Transhealth Information Project: A Peer-Led HIV Prevention Intervention to Promote HIV Protection for Individuals of Transgender Experience

Individuals of transgender experience (ITE) in the United States face an elevated risk of HIV infection. Several conditions have been attributed to the high HIV incidence and prevalence within this group, including experiences of discrimination, unemployment, incarceration, stigma, and elevated rates of sexual risk and substance use. In response to these needs, the Gay and Lesbian Latino AIDS Education Initiative and Prevention Point Philadelphia, two local community-based organizations in Philadelphia, developed the Transhealth Information Project (TIP). TIP is a peer-led six-session hybrid individual- and group-based intervention emphasizing leadership, social and structural interventions, and HIV risk reduction that incorporates other evidence-based practices for HIV prevention and care. Since 2003, TIP has served over 1,500 ITE and linked them to HIV prevention and care services. TIP has an established record of reaching ITE and linking them to HIV prevention services and HIV primary care. TIP’s utilization speaks to the need for interventions to respond to the complex, interacting syndemic factors that cumulatively determine HIV vulnerability among ITE.

Day-Level Associations Between Substance Use and HIV Risk Behavior Among a Diverse Sample of Transgender Women

Purpose: Transgender women in the United States face elevated rates of HIV and of substance use. Studies measuring overall or aggregate levels of substance use have linked use to increased HIV transmission risk behavior (TRB). Although intensive longitudinal studies in other populations have found day-level links between substance use and TRB, no study has yet explored such links among transgender women. This study aimed to fill this gap in the literature. Methods: Utilizing survey and 60-day timeline follow-back interview data from a sample of 214 transgender women in New York City, we tested whether day-level heavy drinking, marijuana use, and/or nonprescription stimulant use were associated with odds of engaging in any sex (vs. no sexual activity) or engaging in TRB (vs. sex without TRB), adjusting for overall levels of use. Results: Multilevel models showed that each of the three substance types was associated with greater odds of engaging in sex on a given day-and more strongly so for heavy drinking among those with higher rates of heavy drinking, and for stimulant use among those with lower rates of stimulant use. Only marijuana use was associated with greater odds of TRB on a given day, but only among those with higher rates of use. Conclusion: These findings substantiate day-level links between substance use and engaging in sexual activity among transgender women, and importantly, between marijuana use and greater likelihood of TRB on a day when sexual activity occurs. This highlights the importance of addressing substance use for sexual health among transgender women especially focusing on marijuana use.