Relationship Stigma and HIV Risk Behavior Among Cisgender Men Partnered with Transgender Women: The Moderating Role of Sexual Identity

Tailoring a Skills-Based Serostatus Disclosure Intervention for Transgender Women in South Africa: Protocol for a Usability and Feasibility Study

BACKGROUND

Transgender women have few interventions to support their HIV prevention and treatment outcomes in South Africa. Further, increased focus should be on intervention development that will reduce HIV transmission within HIV-discordant partnerships, especially for transgender women who navigate gender, sexuality, and relationship stigma. The Speaking Out and Allying Relationships (SOAR) intervention has been developed for sexual minority men to address these outcomes in South Africa. It is a behavioral intervention that is delivered in groups via videoconference to develop coping skills to manage HIV-related stress, assist with disclosure to partners, and establish and maintain safer sex practices with partners. Tailoring SOAR may be feasible for transgender women to support their HIV care while reducing transmission within their relationships.

OBJECTIVE

This study aims to (1) adapt SOAR for transgender women and test its usability, then (2) assess its feasibility.

METHODS

To achieve aim 1, we will use a human-centered design approach to tailor the existing SOAR intervention for transgender women. Interviews and a survey will be administered to transgender women (N=15) to assess intervention preferences. Findings will be used to tailor content like roleplays, scenarios, and media to align with transgender women's lived experiences navigating HIV and relationships. Afterward, we will conduct a usability test with 7 (47%) of the 15 participants to determine intervention understanding and satisfaction. Participants will be transgender women living with HIV and in a relationship with a man who has unknown HIV status or is HIV-negative. All participants will be recruited using community-based approaches. In aim 2, we will examine SOAR feasibility using a 1-arm pilot study. Transgender women (N=20) will be recruited using aim 1 methods and eligibility criteria, with participants completing feasibility surveys and interviews, as well as behavioral and biomedical assessments.

RESULTS

Intervention adaptation began in May 2023 with interviews. Feasibility pilot testing was conducted with 14 transgender women, with study completion in January 2025.

CONCLUSIONS

Transgender women need more intervention options that engage their relationships since these can present barriers to HIV treatment outcomes like hindering viral suppression in South Africa. Delivering an existing yet tailored intervention via videoconference expands its reach to transgender women and allows them to engage with others and learn new skills in a secure setting like their homes. SOAR has the potential to improve relationship dynamics and reduce violence, which will in turn enhance HIV treatment and prevention engagement.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52121.

A Cautionary Tale: Digital Clinical Trial Implementation of a Couples-Based HIV Prevention Study among Transgender Women and Their Partners in the United States

This study investigates baseline differences in couples enrolled in the "It Takes Two" HIV prevention intervention for transgender women and their partners, comparing in-person participation pre-COVID-19 and digital participation during the pandemic. Among 52 couples (40% in-person, 60% digital), bivariate analyses revealed that in-person participants were more likely to be African American, have cisgender male partners, report higher unemployment, incarceration histories, greater relationship stigma, and lower relationship quality. The findings highlight the limitations of digital modalities in engaging transgender women of color and those with structural vulnerabilities. The study emphasizes that reliance on digital methods in HIV research jeopardizes the inclusion of those lacking technological access and literacy, especially communities disproportionately impacted by HIV. Researchers must incorporate hybrid or in-person options and engage communities to ensure equity and inclusion, thus overcoming barriers and ensuring comprehensive population reach in HIV prevention studies.

Experiences of discrimination and support among trans men and women partnered with cis men

Trans individuals routinely experience discrimination. In this study, thirty-nine couples consisting of a trans partner and a cis male partner from the San Francisco Bay Area were interviewed about their relationship. The interviews were digitally recorded, transcribed and reviewed for accuracy. Guided by grounded theory, coders began thematic analysis until inter-coder reliability was achieved. Further qualitative coding produced several codes, two of which are focused upon here: namely, discrimination and support. This study highlights discrimination at the institutional level, such as being denied housing and employment, and at the interpersonal level, such as experiencing harassment from strangers and exclusion from queer community spaces. Trans individuals reported becoming desensitised to discrimination, moving to safer geographic locations, and acknowledged cis or straight passing as a privilege and a prevention tactic against discrimination, although this sometime left participants feeling their gender had been invalidated. Although most trans individuals sought support from their cis partners, some cis partners reacted with violence to discrimination, provoking the situation's severity and upsetting their trans partner. Transphobic discrimination is widespread, and it is crucial for frontline health and other service providers to understand the impact it has on both trans individuals and trans/cis couples, and for agencies to offer resources to support these relationships.

Understanding Barriers and Facilitators of Pre-exposure Prophylaxis (PrEP) Among Transgender and Gender Diverse Adults in an Integrated Health Care System

Transgender and gender diverse individuals face health disparities such as higher HIV prevalence, but limited studies have found low PrEP uptake among these populations. To understand both patient and provider perspectives regarding PrEP care for transgender and gender diverse individuals, we conducted a mixed-methods study at Kaiser Permanente Southern California from September 2020 to October 2021. Transgender and gender diverse adults (N = 396) participated in a web-based survey, and qualitative interviews were subsequently conducted with a subset of survey respondents (N = 32) and healthcare providers (N = 8). Among survey respondents, > 75% were familiar with PrEP, and > 40% reported at least one HIV risk factor, but < 5% had taken PrEP. Interview themes included increasing providers' inclusivity in primary care for transgender and gender diverse patients, and reducing logistical barriers and costs associated with PrEP-related visits. To improve PrEP uptake among transgender and gender diverse individuals, barriers across patient, provider, and health system levels must be addressed.

Heterogeneity in HIV/Sexually Transmitted Infection Prevalence and Prevention Among the Partners of Transgender and Nonbinary People

BACKGROUND

Transgender and nonbinary (TNB) people are diverse in their sexual orientation and partnerships. We describe the epidemiology of HIV/sexually transmitted infection (STI) prevalence and prevention utilization among the partners of TNB people in Washington State.

METHODS

We pooled data from five 2017 to 2021 cross-sectional HIV surveillance data sources to generate a large sample of TNB people and cisgender people who had a TNB partner in the past year. We described characteristics of recent partners of trans women, trans men, and nonbinary people and used Poisson regression to assess if having a TNB partner was associated with self-reported HIV/STIs prevalence, testing, and preexposure prophylaxis (PrEP) use.

RESULTS

Our analysis included 360 trans women, 316 trans men, 963 nonbinary people, 2896 cis women, and 7540 cis men. Overall, 9% of sexual minority cis men, 13% of sexual minority cis women, and 36% of TNB participants reported having any TNB partners. There was significant heterogeneity in HIV/STI prevalence, testing, and PrEP use among the partners of TNB people by study participant gender and the gender of their sex partners. In regression models, having a TNB partner was associated with a higher likelihood of HIV/STI testing and PrEP use but was not associated with higher HIV prevalence.

CONCLUSIONS

We observed significant heterogeneity in HIV/STI prevalence and preventative behaviors among the partners of TNB people. Given that TNB people are diverse in their sexual partnerships, there is a need to better understand individual-, dyad-, and structural-level factors that facilitate HIV/STI prevention across these diverse partnerships.

Stigma Experienced by Transgender Women of Color in Their Dating and Romantic Relationships: Implications for Gender-based Violence Prevention Programs

Although transgender women of color, specifically Black and Latina experience gender-based violence in a variety of contexts, one of the most consistently reported is from a dating or romantic partner. This qualitative study sought to understand the manifestations and consequences of stigma experienced by transgender women of color in their dating or romantic relationships. Between January and February 2019, we purposively recruited 33 transgender women of color to participate in five focus group discussions and complete a brief survey. We employed both inductive and deductive approaches to coding and thematic analysis. We identified different forms of anti-transgender interpersonal stigma experienced by transgender women of color seeking romantic relationships and by those in romantic relationships. For those dating and seeking relationships, anti-transgender interpersonal stigma took the form of dehumanizing stereotypes and sexual objectification. While these manifestations of anti-transgender interpersonal stigma persisted for some within relationships, concealment behaviors from partners was the predominant type of anti-transgender interpersonal stigma. Each of these forms of anti-transgender interpersonal stigma had significant gender-based violence consequences, specifically encountering physical violence, experiencing psychological trauma, and engaging in survival strategies. In the current climate of COVID-19, which is exacerbating risks of gender-based violence, there is an urgent need to understand and address the nuanced manifestations of stigma in relationships and their consequences on the lives of transgender women of color. Culturally grounded gender-based violence prevention policies and programs with transgender women should address these forms of stigma and build on community strengths. Findings also highlight the importance of future research and gender-based violence prevention programming with cisgender men in/seeking partnerships with transgender women of color.

Disclosure of HIV-serodiscordant relationships and association with viral suppression: results from the Positive Plus One study

BACKGROUND

Little is known about the effects of disclosure of HIV-serodiscordant relationships on clinical outcomes. We aimed to evaluate the effect of relationship disclosure on HIV viral suppression, and hypothesized that disclosure by HIV-positive and HIV-negative partners would be associated with viral suppression in the HIV-positive partner.

METHODS

We conducted a Canadian national online and telephone-administered survey of HIV-positive and HIV-negative partners in serodiscordant relationships. The primary outcome was self-reported viral suppression. Multivariable analyses were undertaken using Firth logistic regression.

RESULTS

We recruited 540 participants in current serodiscordant relationships (n = 228 HIV-negative; n = 312 HIV-positive). Similar proportions of HIV-positive and HIV-negative partners disclosed their relationship to healthcare professionals (82% v. 76%, p = 0.13). Among HIV-positive partners, disclosure of the relationship to healthcare professionals increased the odds of viral suppression (aOR = 4.7; CI: 2.13, 10.51) after adjusting for age, education, and relationship turmoil due to HIV. Increasing age (aOR = 1.28; 95% CI = 1.07, 1.55) and education (aOR = 2.43; 95% CI = 1.15, 5.26) were also associated with viral suppression. Among HIV-negative partners, relationship disclosure was not associated with viral suppression and HIV-negative heterosexual men were less likely to report that their HIV-positive partners were virally suppressed (aOR = 0.24; CI: 0.09, 0.61).

CONCLUSIONS

Disclosure of HIV-serodiscordant status by HIV-positive participants to healthcare professionals was associated with increased odds of viral suppression. Similar effects were not evident among HIV-negative participants. Future work should explore factors that empower relationship disclosure and incorporate them into supportive services for HIV-serodiscordant relationships.

Stress and coping amongst cisgender male partners of transgender women

The cisgender male partners of transgender women have received little attention beyond their sexual behaviour. This is an issue, as marginalisation and social environments determine sexual behaviour and subsequent health outcomes. This article assesses in-depth interviews with cisgender male partners of transgender women in Atlanta and Baltimore, USA. Analysis suggests men experience minority stress that may lead to ameliorative coping processes such as coming out and LGBTQ group affiliation. Specifically, the interviews identify stressful, marginalising reactions from family and friends concerning men's relationships with transgender women. In turn, men described uniquely supportive ties to LGBTQ communities, which included ongoing relationships with transgender women, having close sexual and gender minority friends, and occupying notably LGBTQ spaces such as Pride events. The LGBTQ social connectivity of the cisgender male partners of transgender women could prove critical to future targeted HIV prevention efforts.

Heterosexual Cisgender Men Partnered with Transgender Women Exhibit Higher HIV/STI Sexual Risk than Their Gay, Bisexual, and Queer Counterparts: Findings from a U.S.-Based Convenience Sample Recruited Online

Cisgender men are frequently vectors for HIV transmission among transgender women. Despite this, the correlates of sexual risk among these men remain under-examined. The purpose of the present study was to explore potential differences in relationship characteristics, sexual risk-taking, and risk-reduction strategies among cisgender men partnered with transgender women. The study utilized secondary screening data provided by adult cis men who reported being in a primary relationship with a trans woman (N = 710). Gay men (18%) were comparatively older, and most likely to report both HIV seropositivity and committed pairings. Heterosexual men (14%) were more likely to report exchange sex, briefer relationships, extra-dyadic sex, lesser serostatus awareness or PrEP uptake. Queer men (7%) were youngest, and most likely to access PrEP. Heterosexual cis men with trans women partners may be subject to unique socio-cultural drivers of sexual risk, such as heteronormative pressures and relationship stigma.

Stigma in place: Black gay men's experiences of the rural South

Black gay men (MSM) in the rural United States South are inequitably burdened by stigmatization and the HIV epidemic. Drawing from twelve oral history interviews with middle-aged and older Black gay narrators from rural North Carolina, this research explores the impact of sexual marginalization and the HIV epidemic on lived experiences of the rural South. Despite describing increasingly empowered views of HIV and sexual health, narrators expressed persistent difficulty managing social determinants of HIV vulnerability-sexual stigma and disconnection from LGBTQ collectivity. Narrators reported better managing sexual marginalization over their lifetimes in urban settings and places outside of the South such as New York (NY). This research suggests stressful structural and interpersonal experiences of stigma may define lived experiences of particular settings.