Antiretroviral Treatment Interruptions Among Black and Latina Transgender Women Living with HIV: Characterizing Co-occurring, Multilevel Factors Using the Gender Affirmation Framework

Legal gender recognition and the health of transgender and gender diverse people: A systematic review and meta-analysis

Legal gender recognition (LGR) refers to laws, policies, and administrative procedures that enable transgender and gender diverse (TGD) people to update their legal identity documents (ID) to reflect their self-determined gender. We conducted a systematic review and meta-analysis on the health effects of LGR and a nested scoping review of TGD people's LGR-related values and preferences (PROSPERO CRD42023441769). We searched seven databases through April 19, 2024, and organization websites (for grey literature) through August 2023. The effectiveness review included quantitative studies evaluating the effect of LGR (policies or possession of gender-concordant ID) on seven domains of health and well-being. We conducted random-effects meta-analyses when possible and otherwise used narrative synthesis. Study risk of bias and confidence in the cumulative evidence were assessed using the ROBINS-E and GRADE, respectively. We screened 2748 studies and included 24 in the effectiveness review. In meta-analyses, LGR was associated with less suicidal ideation (OR = 0.75; 95 % CI: 0.56-1.00, I2 = 46 %) and psychological distress (e.g., OR for LGR on all versus no ID = 0.53; 95 % CI: 0.40, 0.70, I2 = 17 %). LGR may reduce anticipated discrimination, increase healthcare utilization, reduce gonadectomies, and improve socio-economic status, but the evidence was very uncertain. We included 31 studies on TGD persons' values and preferences. They perceived well-being benefits of LGR, had diverse personal preferences related to safety, and reported financial and policy barriers to LGR. In conclusion, LGR may improve TGD mental health and is perceived to reduce exposure to stigma and discrimination. Higher-quality effectiveness research is needed on other health and well-being outcomes, as well as research to evaluate specific LGR policy provisions.

Structural barriers to sexual and reproductive health care among Black and Latina cisgender and transgender U.S. women who use drugs: a qualitative study

BACKGROUND

Black and Latina women and women who use drugs in the United States (U.S.) face multilevel barriers to receiving sexual and reproductive health (SRH) care that meets their needs. Although prior research has investigated barriers to SRH care among Black and Latina women in general, no study of which we are aware has examined how structural inequities shape the SRH care experiences of Black and Latina women who use drugs in particular in relation to multiple intersecting systems of oppression.

METHODS

Using a stratified purposive sampling strategy, we conducted in-depth interviews (n = 18) with Black and Latina cisgender and transgender women aged 18-45 years who use drugs and had received SRH care in Boston, MA, Providence, RI, or Washington, DC in the last 12 months. Interviews were coded and themes were developed using a template style thematic analysis approach. All study activities were guided by a Community Advisory Board composed of six Black and Latina cisgender and transgender women who use drugs.

RESULTS

Participants reported notable challenges accessing SRH services as a result of a lack of consistent health insurance, limited public transportation, high or unexpected costs, and criminalization by the legal system. Additionally, participants' health care experiences were undermined by sexism, racism, transphobia, classism, heterosexism, fatphobia, and substance use stigma, which resulted in poor quality sexual, reproductive, and other health care and in delaying or avoiding care. In contrast, participants expressed a strong preference for receiving care from health care providers who were respectful, compassionate, and attentive to their needs. Moreover, participants reported more positive experiences receiving SRH care from health care providers who used a person-centered approach, who tended to share their racialized and gender identities, in community-affirming institutions.

CONCLUSIONS

Structural and collective efforts rooted in reproductive justice are urgently needed to address the precarious social and economic conditions, multiple intersecting systems of oppression, and criminal legal and health care practices that negatively impact the lives and SRH care of Black and Latina cisgender and transgender women who use drugs and, instead, foster health, healing, and well-being at the personal, community, and societal level.

HIV seropositivity and viral non-suppression in transgender, non-binary, and gender-diverse people in primary care receiving gender-affirming hormone therapy in the USA between 2013 and 2019 (LEGACY): an observational, longitudinal, cohort study

BACKGROUND

Gender-affirming hormone therapy is medically necessary for many transgender, non-binary, and gender-diverse (trans) individuals and might improve HIV clinical outcomes for trans people. This study evaluated gender-affirming hormone therapy delivered in primary care as an intervention to improve HIV outcomes for trans adults in the USA.

METHODS

LEGACY is a longitudinal cohort of trans adult participants receiving primary care at two US federally qualified health centres: Fenway Health (Boston, MA, USA) and Callen-Lorde Community Health Center (New York, NY, USA). Eligibility criteria were age at least 18 years, gender identity differing from assigned sex at birth, past 12-month medical visit, and signed consent with no research exclusion documented in electronic health record data. Eligible participants contributed electronic health data from 2013 to 2019. The exposure was gender-affirming hormone therapy prescription. Clinical outcomes were HIV seropositivity (all participants) and viral non-suppression (participants with HIV; ≥200 copies per mL) in the past 12 months. Log-Poisson generalised estimating equations assessed the longitudinal association of gender-affirming hormone therapy prescription (puberty blockers, anti-androgens, oestrogens, progesterone, and testosterone) with outcomes, adjusting for individual-level confounders.

FINDINGS

Among the 8109 trans participants in 2019, median age was 29 years (IQR 24-37). 2960 (36·5%) were transgender women, 2541 (31·3%) were transgender men, 1507 (18·6%) were non-binary, and 1101 (13·6%) were another trans identity. 4446 (54·8%) were White, 1323 (16·3%) were Black or African American, 498 (6·1%) were multiracial, and 1663 (20·5%) were Hispanic or Latinx. 2736 (33·7%) of 8109 participants were publicly insured and 451 (5·6%) participants were uninsured. In 2013, 2549 (85·5%) of 2983 participants were prescribed gender-affirming hormone therapy, 272 (9·1%) of 2983 participants were HIV seropositive, and 61 (22·4%) of 272 participants were not virally suppressed. In 2019, 7252 (89·4%) of 8109 participants were prescribed gender-affirming hormone therapy, 560 (6·9%) of 8109 participants were HIV seropositive, and 88 (15·7%) of 560 participants were not virally suppressed. Gender-affirming hormone therapy prescription was associated with reduced rates of HIV seropositivity (adjusted risk ratio [RR] 0·63, 95% CI 0·56-0·70) and viral non-suppression (adjusted RR 0·56, 95% CI 0·45-0·69) across follow-up.

INTERPRETATION

Gender-affirming care is important for optimising HIV outcomes among trans people. Our results underscore the vital role of gender-affirming models of care and access to gender-affirming hormone therapy for trans people.

FUNDING

Patient-Centered Research Outcomes Institute and the National Institutes of Health.

Characterizing disparities in the HIV care continuum among U.S. transgender and cisgender Medicare beneficiaries, 2008-2017

Although HIV is more prevalent among transgender and gender-diverse individuals than cisgender people, a dearth of research has compared the HIV-related care engagement of these populations. Using 2008-2017 Medicare data, we identified TGD (trans feminine and non-binary [TFN], trans masculine and non-binary [TMN], unclassified gender) and cisgender (male, female) beneficiaries with HIV and explored within and between gender group differences in the predicted probability of engagement in the HIV Care Continuum. Transgender and gender-diverse individuals had a higher predicted probability of every HIV-related care outcome vs. cisgender individuals, with TFN individuals showing the highest probability of HIV care visit engagement, sexually transmitted infection screening, and antiretroviral treatment receipt and persistence. Notably, except for sexually transmitted infection screening, cisgender females and TMN people had a slightly lower probability of engaging in HIV-related care than TFN people and cisgender males. Although transgender and gender-diverse beneficiaries living with HIV had better engagement in the HIV Care Continuum than cisgender individuals, findings highlight disparities in engagement for TMN individuals and cisgender females, though engagement was still low for Medicare beneficiaries of all genders. Interventions are needed to reduce HIV care engagement barriers for all Medicare beneficiaries.

'Taking it one day at a time' and 'Reaching back out to help someone': How transgender women living with HIV and community stakeholders navigate violence, oppression, and health through coping and advocacy

BACKGROUND

Transgender women living with HIV face intersectional oppression resulting in consequences for their mental and physical health. Interventions are needed that center the voices of transgender women living with HIV (TWLWH) and community stakeholders engrossed in work on behalf of the transgender community through advocacy and/or work roles.

METHODS

Through a partnership with a trans led and focused program of a community-based health organization and an academic partner, from October 2020 through October 2021, TWLWH and community stakeholders participated in qualitative interviews on trauma, violence, mental health struggles, HIV stigma, gender discrimination, health behaviors (e.g., medication adherence), and their thoughts and recommendations for a proposed intervention. Using a virtual platform (i.e., Zoom or phone) TWLWH and stakeholders were administered a demographics survey via Research Electronic Data Capture (REDCap) and completed individual interviews that were audio recorded. These interviews were analyzed using thematic content analysis.

RESULTS

All TWLWH and 50% of stakeholders were Black. Qualitative findings highlighted the magnitude of violence, stigma, and discrimination faced by TWLWH and the mental, physical, and economic consequences. Also highlighted were the adaptive strategies TWLWH are utilizing to cope, ways in which invested stakeholders (many of lived expertise) are showing up for women, and acceptability and valuable insights for a proposed intervention.

CONCLUSION

TWLWH are navigating a hostile society and multilevel interventions (at the structural, community, interpersonal, and individual levels) centering their voices and those invested in advocating for the community are needed to address the sequelae of oppression they face.

Transgender-Specific Differentiated HIV Service Delivery Models in the South African Public Primary Health Care System (Jabula Uzibone): Protocol for an Implementation Study

BACKGROUND

Almost 60% of transgender people in South Africa are living with HIV. Ending the HIV epidemic will require that transgender people successfully access HIV prevention and treatment. However, transgender people often avoid health services due to facility-based stigma and lack of availability of gender-affirming care. Transgender-specific differentiated service delivery (TG-DSD) may improve engagement and facilitate progress toward HIV elimination. Wits RHI, a renowned South African research institute, established 4 TG-DSD demonstration sites in 2019, with funding from the US Agency for International Development. These sites offer unique opportunities to evaluate the implementation of TG-DSD and test their effectiveness.

OBJECTIVE

The Jabula Uzibone study seeks to assess the implementation, effectiveness, and cost of TG-DSD for viral suppression and prevention-effective adherence.

METHODS

The Jabula Uzibone study collects baseline and 12-month observation checklists at 8 sites and 6 (12.5%) key informant interviews per site at 4 TG-DSD and 4 standard sites (n=48). We seek to enroll ≥600 transgender clients, 50% at TG-DSD and 50% at standard sites: 67% clients with HIV and 33% clients without HIV per site type. Participants complete interviewer-administered surveys quarterly, and blood is drawn at baseline and 12 months for HIV RNA levels among participants with HIV and tenofovir levels among participants on pre-exposure prophylaxis. A subset of 30 participants per site type will complete in-depth interviews at baseline and 12 months: 15 participants will be living with HIV and 15 participants will be HIV negative. Qualitative analyses will explore aspects of implementation; regression models will compare viral suppression and prevention-effective adherence by site type. Structural equation modeling will test for mediation by stigma and gender affirmation. Microcosting approaches will estimate the cost per service user served and per service user successfully treated at TG-DSD sites relative to standard sites, as well as the budget needed for a broader implementation of TG-DSD.

RESULTS

Funded by the US National Institutes of Mental Health in April 2022, the study was approved by the Human Research Ethics Committee at University of Witwatersrand in June 2022 and the Duke University Health System Institutional Review Board in June 2023. Enrollment began in January 2024. As of July 31, 2024, a total of 593 transgender participants have been enrolled: 348 are living with HIV and 245 are HIV negative. We anticipate baseline enrollment will be complete by August 31, 2024, and the final study visit will take place no later than August 2025.

CONCLUSIONS

Jabula Uzibone will provide data to inform HIV policies and practices in South Africa and generate the first evidence for implementation of TG-DSD in sub-Saharan Africa. Study findings may inform the use of TG-DSD strategies to increase care engagement and advance global progress toward HIV elimination goals.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64373.

The Epidemiology of Human Immunodeficiency Virus: Reflections and Insights

The ongoing human immunodeficiency virus (HIV) epidemic reveals sustained health care disparities among Black and Brown people and those living in the United States South. With increased rates of HIV incidence in several geographic regions, we must identify and address the structural barriers that limit advances to end the HIV epidemic. This article will shine a reflective and insightful light on the advances that we have made with HIV treatment and prevention and propose novel ways to close the gap for vulnerable people living with or affected by HIV.

Acceptability of Event-Driven and Long-Acting HIV Pre-Exposure Prophylaxis Formulations Among Transgender Women Engaged in Street-Based Sex Work in Baltimore, Maryland

We assessed acceptability of nonoral HIV pre-exposure prophylaxis (PrEP) formulations among transgender women (TW) engaged in street-based sex work in Baltimore, Maryland. In a K-means cluster analysis, TW (N=36) were partitioned into groups characterized by high interest in long-acting injectable PrEP only (Injectable Enthusiasts, 36%), high interest in injectables and subdermal implants (Long-Acting Acceptors, 36%), and low interest across PrEP formulations (Non-Acceptors, 28%). TW's interest in novel PrEP agents varied widely across formulations (range: 22-66%) and clustered around numerous relational, occupational, and structural factors, highlighting the importance of availing multiple PrEP formulations for this impacted population.

Social and structural drivers of HIV vulnerability among a respondent-driven sample of feminine and non-feminine presenting transgender women who have sex with men in Zimbabwe

INTRODUCTION

We sought to characterize social and structural drivers of HIV vulnerability for transgender women (TGW) in Zimbabwe, where TGW are not legally recognized, and explore differences in vulnerability by feminine presentation.

METHODS

A secondary analysis was conducted with a sub-sample of participants recruited from a 2019 respondent-driven sampling survey that comprised men who have sex with men, TGW and genderqueer individuals assigned male sex at birth, from two cities in Zimbabwe. Survey questionnaires captured information related to socio-demographics, sexual and substance use behaviours, and social and structural barriers to HIV services. Secondary analyses were restricted to participants who identified as female, transfemale or transwomen (236/1538) and were unweighted. Descriptive statistics were used to calculate sample estimates and chi-square and Fisher's exact tests were used to assess differences in vulnerability by feminine presentation.

RESULTS

Among 236 TGW, almost half (45.3%) presented as feminine in the 6 months preceding the survey and 8.5% had ever used hormones to affirm their gender identities. Median age among TGW was 23 years (interquartile range: 20-26). Feminine presenting TGW in our sample had higher prevalence of arrest (15.9% vs. 3.9%), rejection by family/friends (38.3% vs. 14.0%), employment termination (11.2% vs. 3.9%), employment refusal (14.0% vs. 3.9%), denial of healthcare (16.8% vs. 2.3%), physical, sexual or verbal harassment or abuse (59.8% vs. 34.1%), alcohol dependence (32.7% vs. 12.4%), recent transactional sex with a male or TGW partner (30.8% vs. 13.3%) and recent non-injection drug use (38.3% vs. 20.2%) than non-feminine presenting TGW (all p-value <0.05).

CONCLUSIONS

Findings suggest that TGW, particularly feminine presenting TGW, experience social and structural inequities which may contribute to HIV vulnerability. Interventions aimed at addressing inequities, including trans competency training for providers and gender-affirming, psychosocial and legal support services for TGW, might mitigate risk.

Characterizing Disparities in the HIV Care Continuum among Transgender and Cisgender Medicare Beneficiaries

Background

In the US, transgender and gender-diverse (TGD) individuals, particularly trans feminine individuals, experience a disproportionately high burden of HIV relative to their cisgender counterparts. While engagement in the HIV Care Continuum (e.g., HIV care visits, antiretroviral (ART) prescribed, ART adherence) is essential to reduce viral load, HIV transmission, and related morbidity, the extent to which TGD people engage in one or more steps of the HIV Care Continuum at similar levels as cisgender people is understudied on a national level and by gendered subgroups.

Methods and Findings

We used Medicare Fee-for-Service claims data from 2009 to 2017 to identify TGD (trans feminine and non-binary (TFN), trans masculine and non-binary (TMN), unclassified gender) and cisgender (male, female) beneficiaries with HIV. Using a retrospective cross-sectional design, we explored within- and between-gender group differences in the predicted probability (PP) of engaging in one or more steps of the HIV Care Continuum. TGD individuals had a higher predicted probability of every HIV Care Continuum outcome compared to cisgender individuals [HIV Care Visits: TGD PP=0.22, 95% Confidence Intervals (CI)=0.22-0.24; cisgender PP=0.21, 95% CI=0.21-0.22); Sexually Transmitted Infection (STI) Screening (TGD PP=0.12, 95% CI=0.11-0.12; cisgender PP=0.09, 95% CI=0.09-0.10); ART Prescribed (TGD PP=0.61, 95% CI=0.59-0.63; cisgender PP=0.52, 95% CI=0.52-0.54); and ART Persistence or adherence (90% persistence: TGD PP=0.27, 95% CI=0.25-0.28; 95% persistence: TGD PP=0.13, 95% CI=0.12-0.14; 90% persistence: cisgender PP=0.23, 95% CI=0.22-0.23; 95% persistence: cisgender PP=0.11, 95% CI=0.11-0.12)]. Notably, TFN individuals had the highest probability of every outcome (HIV Care Visits PP =0.25, 95% CI=0.24-0.27; STI Screening PP =0.22, 95% CI=0.21-0.24; ART Prescribed PP=0.71, 95% CI=0.69-0.74; 90% ART Persistence PP=0.30, 95% CI=0.28-0.32; 95% ART Persistence PP=0.15, 95% CI=0.14-0.16) and TMN people or cisgender females had the lowest probability of every outcome (HIV Care Visits: TMN PP =0.18, 95% CI=0.14-0.22; STI Screening: Cisgender Female PP =0.11, 95% CI=0.11-0.12; ART Receipt: Cisgender Female PP=0.40, 95% CI=0.39-0.42; 90% ART Persistence: TMN PP=0.15, 95% CI=0.11-0.20; 95% ART Persistence: TMN PP=0.07, 95% CI=0.04-0.10). The main limitation of this research is that TGD and cisgender beneficiaries were included based on their observed care, whereas individuals who did not access relevant care through Fee-for-Service Medicare at any point during the study period were not included. Thus, our findings may not be generalizable to all TGD and cisgender individuals with HIV, including those with Medicare Advantage or other types of insurance.

Conclusions

Although TGD beneficiaries living with HIV had superior engagement in the HIV Care Continuum than cisgender individuals, findings highlight notable disparities in engagement for TMN individuals and cisgender females, and engagement was still low for all Medicare beneficiaries, independent of gender. Interventions are needed to reduce barriers to HIV care engagement for all Medicare beneficiaries to improve treatment outcomes and reduce HIV-related morbidity and mortality in the US.

"Do We Stay or Do We Go?" The Impact of Anti-LGBTQ+ Legislation on the HIV Workforce in the South

The human immunodeficiency virus (HIV) workforce continues to face a crisis, particularly in the southern United States. Adding to known issues of administrative burden and less competitive compensation, recent anti- lesbian, gay, bisexual, transgender and queer (LGBTQ+) legislation threatens the already strained HIV workforce. HIV care providers advocate for all aspects of their patient's lives, including those needing gender-affirming care. The recent legislative targets against transgender patients, which involves many people with HIV, will clearly add to the burden on individual HIV care providers and therefore the HIV workforce. Recruitment and retention efforts in states impacted by these laws will become increasingly difficult without advocacy for the patients we serve. The HIV workforce must work together with LGBTQ+ populations to address these recent laws and promote the well-being of all our patients and colleagues.

Nonprescription Hormone Use Among Transgender Women - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020

Certain transgender women who seek gender-affirming hormone treatment (GAHT) face economic and social barriers that limit or prevent access to medically supervised GAHT. Transgender women facing such barriers might acquire GAHT without prescription, potentially without proper dosage, administration, and health monitoring in the absence of medical supervision. For this report, survey data were analyzed from 1,165 transgender women in seven urban areas in the United States to examine associations between self-reported use of nonprescription GAHT and known correlates of nonprescription GAHT, including cost, insurance coverage for GAHT, homelessness, receiving money or drugs in exchange for sex during the past 12 months (exchange sex), lack of comfort discussing gender with provider, and lack of health care use. After controlling for complex sampling design, transgender women who reported recent health care use or insurance coverage for GAHT were less likely to report nonprescription GAHT, and those reporting recent exchange sex or recent homelessness were more likely to report nonprescription GAHT. Findings suggest that transgender women were more likely to use GAHT without a prescription in situations of economic and social marginalization (e.g., disengagement from health care, lack of insurance or trans-specific health care, homelessness, or engagement in sex work). Public health professionals can use these results to design effective interventions to facilitate prescribed hormone use among transgender women in the United States, although access to housing, trans-affirming health care, and insurance coverage might be needed to prevent nonprescription use.

Assessing Knowledge of, Experience with, and Willingness to Prescribe Hormone Therapy to Transgender Individuals with HIV: A National Survey of HIV Practitioners

Purpose

The purpose of this study was to determine if human immunodeficiency virus (HIV) practitioners offer gender-affirming hormone therapy (GAHT) to their transgender patients living with HIV, as previous studies have shown that these patients are more likely to be virally suppressed and retained in care.

Methods

We conducted an online survey sent to 2570 HIV practitioners who attended an International Antiviral Society-USA event between 2017 and 2019. We also assessed demographics, transgender care training, comfort, prescribing practices, and knowledge.

Results

Respondents (N=385) were mainly primary care (49%) and infectious disease (ID)/HIV (42%) practitioners. Fifty-seven percent prescribed GAHT to transgender people living with HIV, but only 7% received formal training. Thirty-five percent were ID/HIV, 60% were primary care, and 5% were other specialty practitioners. Most felt that it would be beneficial to have formal education in GAHT practices during training (83%). There were statistically significant differences in GAHT education, experiences, knowledge, and interest in future training and prescribing by health care specialty. Commonly cited barriers to providing therapy included lack of training (33%), lack of transgender people living with HIV in practice (18%), and lack of qualified mental health professionals (15%).

Conclusion

This survey is the first to assess GAHT practices among HIV practitioners from across the United States. The majority of those surveyed prescribe GAHT to their transgender patients living with HIV. Although most felt comfortable doing so, few had formal training and knowledge scores were low. We advocate for the integration of GAHT education into formal training programs and offer resources for those who wish to pursue education.

Stigma and HIV Treatment Outcomes Among Transgender Women Sex Workers in the Dominican Republic

Trans women experience multiple forms of intersecting stigma due to trans identity, HIV, and sex work, which can negatively affect their health. There is limited understanding of the relationships between stigma and HIV care and treatment outcomes. We assessed associations between multiple forms and types of stigma and HIV treatment outcomes among trans women who conduct sex work in Santo Domingo, Dominican Republic using cross-sectional survey data. Most participants had received HIV care (91%) and were currently taking anti-retroviral therapy (ART) (84%). Only 64% were virally suppressed. Nearly one-third (32%) had interrupted ART at some point; those who had never interrupted ART were more likely to be suppressed. Drug use was associated with ART interruption. Higher enacted HIV stigma was associated with current ART use. Higher enacted HIV stigma and higher anticipated sex work stigma were associated with ART adherence. Higher trans stigma was associated with being virally suppressed. Findings highlight the importance of addressing multiple forms of stigma at the individual and clinic levels to improve and sustain viral suppression. Future research is needed to assess if unexpected associations between stigma and HIV outcomes reflect processes of resilience. Future research is also needed to assess the pathways between drug use, ART interruption, and viral suppression among trans women.

Brief Report: Interruptions in HIV Prevention and Treatment During the COVID-19 Pandemic: A Cross-Sectional Study of Transgender and Gender Nonbinary Adults in the United States

BACKGROUND

Transgender and gender nonbinary (TNB) people have been disproportionately affected by HIV and the COVID-19 pandemic. This study explored the prevalence of HIV prevention and treatment (HPT) interruptions during the pandemic and identified factors associated with these interruptions.

SETTING

Data were drawn from LITE Connect, a US-based, nationwide, online, self-administered survey designed to examine the experiences of TNB adults during the COVID-19 pandemic. A convenience sample of 2134 participants were recruited between June 14, 2021, and May 1, 2022.

METHODS

The analytic sample was restricted to participants taking antiretroviral medications to prevent or treat HIV before the onset of the pandemic (n = 153). We calculated descriptive statistics as well as Pearson χ 2 bivariate tests and multivariable models to identify factors associated with HPT interruptions during the pandemic.

RESULTS

Thirty-nine percent of participants experienced an HPT interruption. We found a lower odds of HPT interruptions among participants living with HIV [adjusted odds ratios (aOR) 0.45; 95% Confidence Intervals (CI): 0.22, 0.92; P = 0.02] and essential workers [aOR 0.49; 95% CI: 0.23, 1.0; P = 0.06] and higher odds among people with chronic mental health conditions [aOR 2.6; 95% CI: 1.1, 6.2; P = 0.03]. When sex and education were included, we found a lower odds of interruptions among people with higher education. CI widened, but the magnitude and direction of effects did not change for the other variables.

CONCLUSIONS

Focused strategies to address longstanding psychosocial and structural inequities are needed to mitigate HPT treatment interruptions in TNB people and prevent similar challenges during future pandemics.

The Helping Networks of Transgender Women Living with HIV

Transgender women living with HIV face significant barriers to healthcare that may be best addressed through community-centered interventions holistically focused on their HIV-related, gender-related, and other important needs. Community health ambassador (CHA) interventions (education and training programs designed to engage communities and community leaders in health promotion) may be an effective option, though information about the natural helping networks of this vulnerable population is too limited to inform the implementation of this approach. This study uses social network analysis to describe the natural helping networks of transgender women living with HIV, their help-seeking patterns for HIV-related, gender-related, and ancillary resources, and the characteristics of potential network ambassadors. From February to August 2019, transgender women living with HIV in the US (N = 231) participated a 30-min online survey asking them to describe their natural helping networks (N = 1054). On average, participants were embedded within natural helping networks consisting of 4-5 people. They were more likely to seek help from informal network members vs. formal service providers (p < .01), and from chosen family and partners/spouses (p < .05) above other social connections. Older network members (p < .01), other transgender women (p < .05), and those with whom they regularly engaged face-to-face (p < .01) (vs. social technology) were identified as potential network ambassadors for HIV-, gender-related, and other important issues. These findings suggest an opportunity to develop CHA interventions that leverage existing help networks and potential network ambassadors to promote equitable access to HIV, gender-affirming, and other crucial resources among this medically underserved group.

Longitudinal HIV care outcomes by gender identity in the United States

OBJECTIVE

Describe engagement in HIV care over time after initial engagement in HIV care, by gender identity.

DESIGN

Observational, clinical cohort study of people with HIV engaged in routine HIV care across the United States.

METHODS

We followed people with HIV who linked to and engaged in clinical care (attending ≥2 visits in 12 months) in cohorts in the North American Transgender Cohort Collaboration, 2000-2018. Within strata of gender identity, we estimated the 7-year (84-month) restricted mean time spent: lost-to-clinic (stratified by pre/postantiretroviral therapy (ART) initiation); in care prior to ART initiation; on ART but not virally suppressed; virally suppressed (≤200 copies/ml); or dead (pre/post-ART initiation).

RESULTS

Transgender women ( N  = 482/101 841) spent an average of 35.5 out of 84 months virally suppressed (this was 30.5 months for cisgender women and 34.4 months for cisgender men). After adjustment for age, race, ethnicity, history of injection drug use, cohort, and calendar year, transgender women were significantly less likely to die than cisgender people. Cisgender women spent more time in care not yet on ART, and less time on ART and virally suppressed, but were less likely to die compared with cisgender men. Other differences were not clinically meaningful.

CONCLUSIONS

In this sample, transgender women and cisgender people spent similar amounts of time in care and virally suppressed. Additional efforts to improve retention in care and viral suppression are needed for all people with HIV, regardless of gender identity.

Differentiated HIV services for transgender people in four South African districts: population characteristics and HIV care cascade

INTRODUCTION

Transgender people in South Africa are disproportionately affected by HIV, discrimination and stigma. Access to healthcare and health outcomes are poor. Although integrating gender-affirming healthcare with differentiated HIV prevention, care and treatment services has shown improvement in HIV service uptake and health outcomes among transgender people, evidence is lacking on the implementation of differentiated service delivery models in southern Africa. This article describes a differentiated service delivery model across four South African sites and transgender individuals who access these services. We assess whether hormone therapy (HT) is associated with continued use of pre-exposure prophylaxis (PrEP) and viral load suppression.

METHODS

In 2019, differentiated healthcare centres for transgender individuals opened in four South African districts, providing gender-affirming healthcare and HIV services at a primary healthcare level. Routine programme data were collected between October 2019 and June 2021. Descriptive statistics summarized patient characteristics and engagement with HIV prevention and treatment services. We conducted a multivariate logistic regression analysis to determine whether HT was associated with viral load suppression and PrEP continued use.

RESULTS

In the review period, we reached 5636 transgender individuals through peer outreach services; 86% (4829/5636) of them accepted an HIV test and 62% (3535/5636) were linked to clinical services. Among these, 89% (3130/3535) were transgender women, 5% (192/3535) were transgender men and 6% (213/3535) were gender non-conforming individuals. Of those who received an HIV test, 14% (687/4829) tested positive and 91% of those initiated antiretroviral treatment. Viral load suppression was 75% in this cohort. PrEP was accepted by 28% (1165/4142) of those who tested negative. Five percent (161/3535) reported ever receiving HT through the public healthcare system. Service users who received HT were three-fold more likely to achieve viral load suppression. We did not find any association between HT and continued use of PrEP.

CONCLUSIONS

A differentiated HIV and gender-affirming service delivery model at a primary healthcare level is feasible and can enhance service access in South Africa. HT can improve HIV clinical outcomes for transgender people. As trust is established between the providers and population, uptake of HIV testing and related services may increase further.

Stigma, Social Support, and Substance Use in Diverse Men Who Have Sex With Men and Transgender Women Living with HIV in the US Southeast

OBJECTIVES

Human immunodeficiency virus (HIV) rates in the southeast United States are high and substance use is common among people living with HIV (PLWH). This study used baseline data from the weCare intervention study to examine factors associated with the use of alcohol, tobacco, and marijuana among racially and ethnically diverse young gay, bisexual, and other men who have sex with men (GBMSM) and transgender women in the southeast who were newly diagnosed as having HIV, not linked to care, out of care, and/or not virally suppressed.

METHODS

Self-reported data were collected from 196 GBMSM and transgender women living with HIV via Audio Computer-Assisted Self-Interview at enrollment. Measures assessed demographics; stigma; social support; basic and clinical service needs; HIV disclosure; social media use; and recent use of alcohol, tobacco, and marijuana. Logistic regression identified correlates of past 30-day substance use.

RESULTS

In multivariable analysis, increased age and needing basic support services were associated with past 30-day tobacco, cigarette, electronic cigarette, and/or hookah use. Increased HIV-related stigma and needing basic support services were associated with past 30-day marijuana use. Being White and needing clinical support services were associated with infrequent or no past 30-day marijuana use.

CONCLUSIONS

HIV-related stigma and needing basic support services were associated with substance use among GBMSM and transgender women living with HIV in the southeastern United States. Routine screening for basic needs could identify GBMSM and transgender women living with HIV at risk for substance use and offer insight into intervention leverage points.

“I do the she and her”: A qualitative exploration of HIV care providers’ considerations of trans women in gender-specific HIV care

Objectives:

Women of all genders, including cisgender (cis) and transgender (trans) women, experience social and structural drivers of HIV inequities and pervasive barriers to HIV care. Yet, little is known about how HIV care providers address gender diversity in health care. Through a critical feminist lens informed by intersectionality theory, medical anthropology, and critical sociology, we explored (1) how do HIV care providers describe women living with HIV’s care needs and barriers; (2) what are their perspectives on optimal HIV care for women; and (3) to what extent do these conceptualizations include/exclude trans women.

Methods:

Utilizing a community-based exploratory qualitative study design, we conducted 60–90 minute semi-structured individual interviews from March 2019–April 2020 with eight HIV care providers (n = 4 social service providers; n = 4 physicians) practicing across seven counties representative of rural, suburban, and urban Michigan, United States. Data were analyzed utilizing a reflexive thematic approach.

Results:

Three overarching themes emerged: (1) Emphasis on (different) clinical needs: key considerations in cis and trans women’s HIV care; (2) Recognition of the structural: barriers to HIV care affecting women of all genders; and (3) Proposed solutions: piecing together individual, social, and organizational interventions to increase access to HIV care that may benefit women living with HIV of all genders but are disproportionately framed as being for cis women. While HIV care providers recognized both cis and trans women living with HIV’s clinical care needs and structural barriers to care, they rarely envisioned optimal HIV care inclusive of gender affirmation and structural interventions.

Conclusions:

Findings suggest that HIV care providers can avoid reducing gender to biology and making assumptions about reproductive care needs, endocrinological care needs, caregiving responsibilities, and other life circumstances; provide gender-affirming medical care; and address structural barriers to HIV care to enhance intersectional and structurally focused gender-affirming—that is, trans-inclusive—women-centered HIV care.

A "tax" on gender affirmation and safety: costs and benefits of intranational migration for transgender young adults in the San Francisco Bay area

Many transgender (trans) young adults migrate to urban enclaves with known infrastructures to fulfil gender affirmation needs such as obtaining trans-inclusive healthcare and support. This study sought to explore experiences of intranational migration (i.e. migration within a single country) for gender affirmation among trans young adults who relocated to San Francisco. A convenience sample of 61 trans young adults aged 18 to 29 (32% nonbinary, 28% trans women, and 40% trans men; 84% identified as a person of colour) participated in a one-time qualitative interview as part of a larger study. Thematic analysis was used to develop and refine the codes and themes. Three overarching themes became apparent regarding intranational migration and gender affirmation needs: (1) access to basic gender affirmation needs; (2) safety; and (3) the price of gender affirmation. Migration for gender affirmation and safety placed informants at risk for structural vulnerabilities including homelessness, unemployment and racism. Despite these structural vulnerabilities, participants were willing to "pay" the price in order to gain gender affirmation and safety. Findings underscore the importance of moving beyond individual-level risk factors to understand how unmet gender affirmation needs may place trans young adults in structurally vulnerable positions that can affect health and wellness.

Effects of Gender-Affirming Hormone Therapy on Progression Along the HIV Care Continuum in Transgender Women

Background

Progression along the HIV care continuum has been a key focus for improving outcomes for people with HIV (PWH). Transgender women with HIV (TGWWH) have not made the same progress as their cisgender counterparts.

Methods

All PWH identifying as transgender women receiving care at our clinic from 1/1/2015 to 12/31/2019 were identified from the electronic health records (EHRs) using International Classification of Diseases (ICD) codes. Demographics, laboratory data, prescription of gender-affirming hormone therapy (GAHT), and visit history were abstracted from the EHR. Retention in care and viral suppression were defined using Centers for Disease Control and Prevention definitions. The proportions of TGWWH who were consistently retained in care or virally suppressed over time were calculated using a binary response generalized mixed model including random effects and correlated errors.

Results

Of the 76 PWH identified by ICD codes, 2 were excluded for identifying as cisgender and 15 for insufficient records, leaving 59 TGWWH included for analysis. Patients were on average 35 years old and Black (86%), with a median CD4 count of 464 cells/µL. There were 13 patients on GAHT at study entry and 31 receiving GAHT at any point during the study period. Fifty-five percent were virally suppressed at study entry and 86% at GAHT initiation. The proportion of TGWWH who were consistently virally suppressed over time was greater among those receiving GAHT compared with those who were not (P = .04).

Conclusions

Rates of viral suppression were significantly greater among TGWWH receiving GAHT when compared with those who were not. More research to evaluate the reasons behind this effect is needed.

Correlates of Engagement in HIV Care Among Transgender Women of Color in the United States of America

HIV prevalence among transgender women of color (TWC) in the United States of America is high. We enrolled TWC living with HIV (N = 858) to evaluate 1nine HIV care interventions. We examined factors associated with four outcomes at enrollment: linkage to care, ever being on antiretroviral treatment, retention in care and viral suppression. The sample was 49% Hispanic/Latino, 42% Black; average age was 37 years; 77% were ever linked to care, 36% were ever on treatment, 22% were retained in care, and 36% were virally suppressed. Current hormone use was significantly associated with linkage, retention, and viral suppression (all aORs > 1.5), providing evidence for gender-affirming care as an important facilitator of engagement in HIV care. Greater health care empowerment was significantly associated with greater odds of all outcomes (aORs between 1.19 and 1.37). These findings identify potential intervention targets to improve the provision of care and treatment for TWC living with HIV.

Measuring Satisfaction and Comfort with Gender Identity and Gender Expression among Transgender Women: Development and Validation of the Psychological Gender Affirmation Scale

Among transgender and gender diverse people, psychological gender affirmation is an internal sense of valuing oneself as a transgender or gender diverse person, being comfortable with one’s gender identity, and feeling satisfied with one’s body and gender expression. Gender affirmation can reduce gender dysphoria and mitigate deleterious health effects of marginalization. We sought to create an instrument to measure psychological gender affirmation among transgender women. Following initial item development using qualitative interviews, we used self-administered survey data from two distinct samples (N1 = 278; N2 = 368) of transgender women living with HIV in the USA. We used data from Study 1 to perform exploratory factor analysis (EFA) and data from Study 2 to perform confirmatory factor analysis (CFA), yielding the five-item single-factor Psychological Gender Affirmation (PGA) scale with high reliability (α = 0.88). This scale is psychometrically sound as demonstrated by its convergent and discriminant validity via correlations with select measures and by its predictive validity through associations in hypothesized directions with measures of mental health and substance use. The PGA scale will aid research on psychological gender affirmation that can in turn inform interventions as well as gender-affirming clinical and social practices to promote the health and well-being of transgender and gender diverse people.

HIV and women in the USA: what we know and where to go from here

New diagnoses of HIV infection have decreased among women in the USA overall, but marked racial and geographical disparities persist. The federal government has announced an initiative that aims to decrease the number of new infections in the nation by 90% within the next 10 years. With this in mind, we highlight important recent developments concerning HIV epidemiology, comorbidities, treatment, and prevention among women in the USA. We conclude that, to end the US HIV epidemic, substantially greater inclusion of US women in clinical research will be required, as will better prevention and treatment efforts, with universal access to health care and other supportive services that enable women to exercise agency in their own HIV prevention and care. Ending the epidemic will also require eliminating the race, class, and gender inequities, as well as the discrimination and structural violence, that have promoted and maintained the distribution of HIV in the USA, and that will, if unchecked, continue to fuel the epidemic in the future.

A Scoping Review Examining Social and Legal Gender Affirmation and Health Among Transgender Populations

Purpose: Transgender (trans) populations experience health inequities. Gender affirmation refers to psychological, social, legal, and medical validation of one's gender and is a key social determinant of trans health. The majority of research has focused on medical affirmation; however, less is known about the role of social and legal affirmation in shaping trans health. This review aimed to (1) examine how social and legal gender affirmation have been defined and operationalized and (2) evaluate the association between these forms of gender affirmation and health outcomes among trans populations in the United States. Methods: We conducted a systematic search of LGBT Life, PsycInfo, and PubMed using search strings targeting transgender populations and gender affirmation. This review includes 24 of those articles as well as 1 article retrieved through hand searching. We used a modified version of the National Institute of Health Quality Assessment Tool to evaluate study quality. Results: All studies relied on cross-sectional data. Studies measured and operationalized social and legal gender affirmation inconsistently, and some measures conflated social gender affirmation with other constructs. Health outcomes related to mental health, HIV, smoking, and health care utilization, and studies reported mixed results regarding both social and legal gender affirmation. The majority of studies had serious methodological limitations. Conclusion: Despite conceptual and methodological limitations, social and legal gender affirmation were related to several health outcomes. Study findings can be used to develop valid and reliable measures of these constructs to support future multilevel interventions that improve the health of trans communities.

Meeting the needs of young Latino gay, bisexual, and other men who have sex with men (MSM) and transgender women living with HIV through the weCare intervention in the United States (US)

OBJECTIVE

Young gay, bisexual, and other MSM (men who have sex with men) and transgender women in the United States (US) who are living with HIV, and particularly those who are Latino, have low rates of viral suppression. The weCare intervention uses social media to increase HIV care engagement.

METHOD

We used community-based participatory research to develop the intervention as well as theory-based social media messages tailored to each participant's unique context. We analyzed elements and characteristics of weCare, messages sent by the Cyber Health Educator (CHE), and lessons learned to meet the needs of Latino participants living with HIV.

RESULTS

We identified 6 core elements, 5 key characteristics, effective social media messages used in implementation, and 8 important lessons regarding relationships between the CHE and HIV clinics, the CHE and participants, and participants and the health system.

CONCLUSIONS

Social media offers a promising platform to retain young Latino gay bisexual and other MSM and transgender women living with HIV in care and achieve viral suppression.

"I would really want to know that they had my back": Transgender women's perceptions of HIV cure-related research in the United States

Forty-four percent of Black transgender women are living with HIV, and many face challenges with HIV care engagement. An HIV cure has much to offer this population, however little HIV cure-related research has included them. We conducted 19 face-to-face in-depth interviews with 10 Black transgender women living with HIV. Interviews were audio recorded, transcribed verbatim, coded, and analyzed using content analysis. Our interview guide contained three categories: 1) perceptions of HIV cure-related research and participation, 2) perceptions of HIV treatment and treatment interruptions, and 3) considerations for transgender women and HIV cure-related research. Salient themes included skepticism about HIV cure strategies and limited benefits compared with an undetectable viral load. Willingness to interrupt HIV treatment for research was low and linked to being able to go back on the same HIV treatment without consequence when the study ended. Concerns about being a test subject and perceptions of risks versus benefits of various strategies also affected willingness to take part in HIV cure-related research. Centering the dignity and autonomy of research participants as well as building upon and supporting existing social networks were identified as important facilitators for engaging Black transgender women in HIV cure-related research. Specific to Black transgender women, other concerns included the desire for gender-affirming research staff, community-building among transgender women, and safety issues associated with risk of transphobic violence when traveling to study visits. Participants stressed the importance of HIV cure-related researchers providing accessible and complete information and expressing genuine care and concern for transgender communities.

Gender Affirmation through Correct Pronoun Usage: Development and Validation of the Transgender Women's Importance of Pronouns (TW-IP) Scale

Social interactions where a person is addressed by their correct name and pronouns, consistent with their gender identity, are widely recognized as a basic and yet critical aspect of gender affirmation for transgender people. Informed by the Model of Gender Affirmation, we developed a self-report measure of the importance of social gender affirmation, the Transgender Women's Importance of Pronouns (TW-IP) scale, which measures gender affirmation through the usage of correct pronoun by others. Data were from self-administered surveys in two independent samples of transgender women living with HIV in the US (N1 = 278; N2 = 369). Using exploratory factor analysis with data from Study 1 and confirmatory factor analysis with data from Study 2, we obtained a four-item scale with a single-factor structure and strong reliability (α = 0.95). We present evidence of TW-IP's convergent and discriminant validity through its correlations with select mental health and HIV-related measures. Further, scores on TW-IP were linked in expected directions to several hypothesized mental health and HIV care outcomes, demonstrating its predictive validity. The resulting brief measure of importance of pronouns among transgender women shows strong psychometric properties. Validation evidence offers highly promising opportunities for use of the measure in clinical and research settings.

Legal gender marker and name change is associated with lower negative emotional response to gender-based mistreatment and improve mental health outcomes among trans populations

Background

In recent years, Massachusetts (MA) and Rhode Island (RI) joined a growing list of states allowing residents to easily change the gender marker and name on government-identification (ID) documents. This was an important change for transgender and gender diverse (trans) residents, who face frequent mistreatment and thus for whom legal gender affirmation is critical. Little is known about associations between legal gender affirmation and psychological outcomes.

Methods

We examined associations between legal gender affirmation (i.e., having changed gender marker/name on neither, one, or both a passport and state ID), upsetting responses to gender-based mistreatment, and mental health outcomes in a sample of trans MA and RI residents. Analyses controlled for gender identity, age, race/ethnicity, education, employment, income, and insurance status.

Findings

Legal gender affirmation was significantly associated with lower reports of depression, anxiety, somatization, global psychiatric distress, and upsetting responses to gender-based mistreatment.

Conclusions

These data provide corroborate recent studies suggesting having pursued legal gender affirmation may be protective. Findings bolster calls to increase structural support for trans individuals, including enactment of state policies easing legal gender affirmation.