HIV care outcomes among transgender persons with HIV infection in the United States, 2006-2021

Enhancing HIV Prevention Efforts in the Criminal Legal System: A Comprehensive Review and Recommendations

BACKGROUND

Despite encouraging declines in the overall rate of new transmission globally, HIV prevention efforts targeting individuals in the criminal legal system continue to significantly lag behind rates identified in the general population. Prevention efforts targeting this group worldwide remain geographically uneven and differ across the continuum of legal system involvement (diversion, arrests, community supervision, and post-release), which is attributed to social, structural, and systemic barriers. These gaps are noted to disproportionately impact minoritized and other transmission-burdened populations within the criminal legal system (e.g., men who have sex with men).

OBJECTIVE

Given these challenges, this literature review examines HIV prevention efforts targeting individuals in the criminal legal system across the globe.

METHODS

This review identifies current reach and gaps in prevention care and proposes strategies for improvement.

RESULTS

Recommendations include updating and utilizing long-term platforms for sustained HIV prevention interventions, developing a global compendium for regions outside the U.S., enhancing targeted interventions in high-risk areas, and integrating HIV prevention with other health services while addressing stigma.

CONCLUSIONS

These actions are critical for ensuring that interventions remain up-to-date, sustainable, and culturally responsive, effectively addressing the unique needs of diverse populations and criminal legal system contexts. These measures are also vital for meeting the U.N. 95-95-95 targets for HIV testing, treatment, and viral suppression, ultimately contributing to the goal of ending the HIV epidemic among this high-need population.

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.

The Situated Vulnerabilities and Resiliencies Framework: a call for integrated strategies to address global HIV inequities for transgender, non-binary, and gender diverse populations

Transgender, non-binary, and gender diverse (trans) populations are burdened by the risk of HIV acquisition. Achieving global UNAIDS 95-95-95 targets by 2030 among trans populations requires conceptual frameworks to understand HIV epidemic drivers and optimise effective strategies to curb HIV inequities in trans populations. The Situated Vulnerabilities and Resiliencies Framework describes and explains HIV inequities in these populations. The HIV epidemic among trans populations is situated in multilevel biopsychosocial contexts, and these populations are made vulnerable to HIV through fundamental causes and conditions that render them at risk for risk. Key considerations include pathways that are linked to sex and gender, all-population and trans-specific exposures, developmental context, syndemic dynamics, and intersectionality. The framework highlights the need to deploy integrated strategies and interventions that are neutral to HIV status and grounded in health and human rights, work with trans communities, and use strengths-based approaches leveraging situated resiliencies (ie, salutogenic factors such as collective agency and trans kinships) to reduce pervasive stigma and advance HIV equity in trans populations.

Drug-drug interactions between gender-affirming hormone therapy and antiretrovirals for treatment/prevention of HIV

Transgender persons face a greater burden of HIV compared to cisgender counterparts. Concerns around drug-drug interactions (DDIs) have been cited as reasons for lower engagement in HIV care and lower pre-exposure prophylaxis (PrEP) uptake among transgender populations. It is therefore imperative for hormone therapy, PrEP and antiretroviral therapy providers to understand the DDI potential between these therapies. Studies of tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) PrEP with feminizing hormone therapies (FHTs) show reduced plasma tenofovir concentrations, but intracellular concentrations of tenofovir-diphosphate are not reduced. Efficacy of PrEP is expected to be maintained despite this interaction. Masculinizing hormone therapies have no effect on tenofovir concentrations but may increase FTC to a nonclinically relevant extent. No interactions between FHT and cabotegravir or tenofovir alafenamide have been demonstrated. Administration of TDF/FTC PrEP has no effect on hormone levels in transmen or transwomen. PrEP is expected to be effective and safe in transpersons and should be provided to high-risk individuals regardless of gender affirming hormone use. Enzyme inducing/inhibiting antiretroviral therapy may decrease or increase, respectively, the concentrations of FHT and masculinizing hormone therapy. Unboosted integrase inhibitors or enzyme neutral non-nucleoside reverse transcriptase inhibitors are not expected to affect and are not affected by gender affirming hormones and can be considered in transmen and transwomen. Overlapping toxicities including weight gain, dyslipidaemia, cardiovascular disease and bone density effects should be considered, and antiretroviral modifications can be made to minimize toxicities. Interactions between supportive care medications should be assessed to avoid chelation interactions and hyperkalaemia.

Including transgender populations in mathematical models for HIV treatment and prevention: current barriers and policy implications

INTRODUCTION

Mathematical models of HIV have been uniquely important in directing and evaluating HIV policy. Transgender and nonbinary people are disproportionately impacted by HIV; however, few mathematical models of HIV transmission have been published that are inclusive of transgender and nonbinary populations. This commentary discusses current structural challenges to developing robust and accurate trans-inclusive models and identifies opportunities for future research and policy, with a focus on examples from the United States.

DISCUSSION

As of April 2024, only seven published mathematical models of HIV transmission include transgender people. Existing models have several notable limitations and biases that limit their utility for informing public health intervention. Notably, no models include transgender men or nonbinary individuals, despite these populations being disproportionately impacted by HIV relative to cisgender populations. In addition, existing mathematical models of HIV transmission do not accurately represent the sexual network of transgender people. Data availability and quality remain a significant barrier to the development of accurate trans-inclusive mathematical models of HIV. Using a community-engaged approach, we developed a modelling framework that addresses the limitations of existing model and to highlight how data availability and quality limit the utility of mathematical models for transgender populations.

CONCLUSIONS

Modelling is an important tool for HIV prevention planning and a key step towards informing public health interventions, programming and policies for transgender populations. Our modelling framework underscores the importance of accurate trans-inclusive data collection methodologies, since the relevance of these analyses for informing public health decision-making is strongly dependent on the validity of the model parameterization and calibration targets. Adopting gender-inclusive and gender-specific approaches starting from the development and data collection stages of research can provide insights into how interventions, programming and policies can distinguish unique health needs across all gender groups. Moreover, in light of the data structure limitations, designing longitudinal surveillance data systems and probability samples will be critical to fill key research gaps, highlight progress and provide additional rigour to the current evidence. Investments and initiatives like Ending the HIV Epidemic in the United States can be further expanded and are highly needed to prioritize and value transgender populations across funding structures, goals and outcome measures.

A Quantitative Intersectionality Analysis of HIV/STI Prevention and Healthcare Access Among Transgender and Nonbinary People

BACKGROUND

Transgender and nonbinary people experience substantial barriers to accessing healthcare, including prevention of HIV and other sexually transmitted infections (HIV/STI), due to structural inequities. We examined differences in insurance, HIV/STI prevalence, testing, and preexposure prophylaxis use among transgender and nonbinary people living in Washington State by race and ethnicity and gender.

METHODS

We pooled data from five 2019-2021 Washington State HIV/STI surveillance data sources to obtain a large and diverse sample of 1648 transgender and nonbinary participants. We calculated the risk difference (RD) for each outcome and used Poisson regression to estimate a surrogate measure of additive interaction-attributable proportion (AP)-that measures the proportion of the excess prevalence of the outcome observed at the intersection of gendered and racialized experience, beyond that expected from gender or race and ethnicity alone.

RESULTS

Participants reported overall high levels of poverty (29% incomes <$15,000 and 7% unstable housing). Certain groups, especially racial/ethnic minority transgender women, were disproportionately impacted by HIV/STIs (RDs from 20% to 43% and APs from 50% to 85%) and less likely to currently have insurance (RDs from 25% to 39% and APs from 74% to 93%) than that expected based on gendered or racialized experience alone.

CONCLUSIONS

Our findings highlight the heterogeneity in insurance access, HIV/STI positivity, and prevention utilization within transgender communities. We observed that a large proportion of increased HIV/STI prevalence among racial/ethnic minority transgender women was attributable to the intersection of gender and race and ethnicity. Our findings highlight the importance of trans-inclusive models of HIV/STI prevention that address multilevel barriers rooted in cissexism and structural racism.

Global and Regional Estimate of HIV-Associated Stroke Burden: A Meta-Analysis and Population Attributable Modeling Study

BACKGROUND

This study aimed to determine the correlation between human-immunodeficiency-virus (HIV) infection and stroke, as well as to estimate the global, regional, and national burden of HIV-associated stroke.

METHODS

A registered meta-analysis was performed by searching PubMed, Embase, and Web of Science for relevant literature up to October 31, 2022. The pooled relative risk of stroke in HIV-infected people was calculated using a random-effects model. HIV prevalence and disability-adjusted life years (DALYs) datasets were obtained from the Joint United Nations Program on HIV and AIDS, and the Global Health Data Exchange, respectively. The population attributable fraction was estimated and delivered to calculate the HIV-associated DALYs of stroke from 1990 to 2019, at the global, regional, and national levels. Pearson correlation analysis were conducted to assess the correlation between the age-standardized rate or estimated annual percentage changes and the sociodemographic index.

RESULTS

Out of 10 080 identified studies, 11 were included in this meta-analysis. Compared with individuals without HIV-infection, the pooled relative risk of stroke in HIV-infected individuals was 1.40 (95% CI, 1.18-1.65). From 1990 to 2019, the global population attributable fraction of HIV-associated stroke increased almost 3-fold, while the HIV-associated DALYs increased from 18 595 (95% CI, 7485-31 196) in 1990 to 60 684 (95% CI, 24 281-101 894) in 2019. Meanwhile, HIV-associated DALYs varied by region, with Eastern and Southern Africa having the highest value of 126 160 in 2019. Moreover, countries with middle social development index were shouldering the highest increase trend of the HIV-associated DALYs age-standardized rates.

CONCLUSIONS

HIV-infected individuals face a significantly higher risk of stroke, and the global burden of HIV-associated stroke has increased over the past 3 decades, showing regional variations. Eastern and Southern Africa bear the highest burden, while Eastern Europe and Central Asia have seen significant growth. Health care providers, researchers, and decision-makers should give increased attention to stroke prevention and management in HIV-endemic areas.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: CRD42022367450.

The Black women first initiative: using implementation science to examine bundled interventions to improve care and treatment coordination for Black women with HIV

BACKGROUND

Black cisgender and transgender women are disproportionately affected by the HIV epidemic compared to women of other racial and ethnic identities. Twelve demonstration sites across the United States are adapting, implementing and evaluating a comprehensive bundle of two or more evidence informed interventions to improve health and outcomes and quality of life for Black women with HIV.

METHODS

Guided by Greenhalgh's Conceptual Model of Diffusion of Innovations in Health Service Organizations and Proctor's model for use of implementation strategies and evaluating implementation, service and client outcomes, this mixed methods study documents outcomes at the client, organization, and system level. Participant eligibility for the bundled interventions includes: individuals who are 18 years or older, identify as Black or African-American, identify as cisgender or transgender female and have a diagnosis of HIV. Qualitative data are collected systematically through a series of annual site visits and a standardized monthly call form to assess the barriers and facilitators to the implementation process and the key determinants impacting the intervention uptake and implementation strategies. Quantitative data collection for the implementation, service and client outcomes is conducted through a pre-post prospective study to examine the impact on Black women's health and well-being. Implementation outcomes include: the reach to Black women with HIV, adoption of interventions across the sites and their community; the fidelity to the components of the bundled interventions; the costs of the intervention; and the sustainability of the intervention in the organization and community. Primary service and client outcomes are improved linkage to and retention in HIV care and treatment, increased and sustained viral suppression, improved quality of life and resilience, and stigma reduction.

DISCUSSION

The study protocol presented is specifically designed to advance the evidence for adopting culturally responsive and relevant care into clinic and public health settings to improve the health and well-being for Black women with HIV. In addition the study may advance the implementation science field by furthering what is known about the ways in which bundled interventions can address barriers to care and facilitate the uptake of organizational practices to improve health.

Content validation of a new measure of patient-reported barriers to antiretroviral therapy adherence, the I-Score: results from a Delphi study

Background

Over a third of people living with HIV (PLHIV) have suboptimal adherence to antiretroviral therapy (ART). Measures of barriers to ART adherence often lack comprehensiveness. To help manage ART adherence barriers in HIV care, we are developing a new patient-reported outcome measure (PROM) of these barriers (the I-Score).

Methods

We assessed the content validity of 100 items (distinct barriers) to retain only those most relevant to both PLHIV and HIV health/social service providers. A web-based Delphi was conducted in Canada and France, collecting data from December 2018 to October 2019. Items were evaluated on relevance (the combined rated importance and actionability for HIV care of items among both PLHIV and providers); comprehensibility (rated item clarity); comprehensiveness (examined against our conceptual framework); cross-cultural equivalence (based on comparisons by questionnaire language (English, French) and country of residence). Pearson’s chi-square tests were used for comparisons by language, country, gender, and stakeholder group (PLHIV, providers).

Results

Panelists included 40 PLHIV and 57 providers (66% response rate). Thirty-one items were retained based on consensus thresholds for relevance (minimum: 50% for PLHIV, 60% for providers) and showed good comprehensibility and comprehensiveness, when compared to our conceptual framework (representation of: 6/6 domains, 15/20 subdomains). No significant difference in relevance based on language or country was found among retained items, suggestive of cross-cultural equivalence. Among all 100 items, only 6 significant differences on relevance were observed for gender. For 62 items, the relevance ratings of PLHIV and providers differed significantly, with providers showing greater endorsement of all items but one.

Discussion

The Delphi led to a much-needed item reduction. Remaining items highlight the panel’s multidimensional priorities for the PROM on ART adherence barriers, with few, if any, differences by language, country, and gender. While the analyses may lack generalizability and power, the sample size is considered adequate for a PROM validation study.

Conclusion

Retained items showed good content validity. The different patterns of item endorsement observed underscore the utility of engaging multiple stakeholder groups in PROM development for use in clinical practice. The greater endorsement of items by providers versus patients merits further investigation, including the implications of such differentials for measure development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00435-0.