Patterns of sexual behaviour and sexual healthcare needs among transgender individuals in Melbourne, Australia, 2011-2014

"You are not a man": a multi-method study of trans stigma and risk of HIV and sexually transmitted infections among trans men in Uganda

INTRODUCTION

Transgender (trans) men in sub-Saharan Africa are a hidden and vulnerable population who may engage in sex work due to socio-economic exclusion and lack of alternative employment opportunities. Little is known about HIV and sexually transmitted infection (STI) risk among trans men in this setting. We conducted a multi-method study to characterize HIV/STI risk among trans men in Uganda.

METHODS

Between January and October 2020, we enrolled 50 trans men into a cross-sectional study through snowball sampling. Data were collected on socio-demographic characteristics, sexual practices and depression. We conducted 20 qualitative interviews to explore: (1) descriptions of sexual practices that could increase HIV/STI exposure; (2) experiences of accessing public healthcare facilities; (3) perceptions of HIV or STI testing; (4) HIV and STI service delivery; and (5) drug and alcohol use. We used an inductive content analytic approach centring on descriptive category development to analyse the data.

RESULTS

The median age was 25 years (interquartile range 23-28). The prevalence of HIV, syphilis and hepatitis B was 4%, 6% and 8%, respectively. We observed multiple levels of intersecting individual, interpersonal and structural stigmas. (1) Trans men reported transphobic rape motivated by interpersonal stigma that was psychologically traumatizing to the survivor. The resultant stigma and shame hindered healthcare access. (2) Structural stigma and economic vulnerability led to sex work, which increased the risk of HIV and other STIs. Sex work stigma further compounded vulnerability. (3) Individualized stigma led to fear of disclosure of gender identity and HIV status. Concealment was used as a form of stigma management. (4) Multiple levels of stigma hampered access to healthcare services. Preference for trans-friendly care was motivated by stigma avoidance in public facilities. Overall, the lived experiences of trans men highlight the intertwined relationship between stigma and sexual health.

CONCLUSIONS

In this sample from Uganda, trans men experienced stigma at multiple levels, highlighting the need for gender-sensitive healthcare delivery. Stigma reduction interventions, including provider training, non-discrimination policies, support groups and stigma counselling, could strengthen uptake and utilization of prevention services by this marginalized population.

The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis

Introduction

Transgender individuals are at risk for HIV. HIV risks are dynamic and there have been substantial changes in HIV prevention (e.g., pre-exposure prophylaxis [PrEP]). It is thus time to revisit HIV prevalence and burden among transgender individuals. The objective of this systematic review and meta-analysis was thus to examine worldwide prevalence and burden of HIV over the course of the epidemic among trans feminine and trans masculine individuals.

Methods

We conducted an updated systematic review by searching PsycINFO, PubMed, Web of Science, and Google Scholar, for studies of any research design published in in a peer-reviewed journal in any language that reported HIV prevalence among transgender individuals published between January 2000 and January 2019. Two independent reviewers extracted the data and assessed methodological quality. We then conducted a meta-analysis, using random-effects modelling, to ascertain standardized prevalence and the relative burden of HIV carried by transgender individuals by country and year of data collection, and then by geographic region. We additionally explored the impact of sampling methods and pre-exposure prophylaxis (PrEP).

Results

Based on 98 studies, overall standardized HIV prevalence over the course of the epidemic, based on weights from each country by year, was 19.9% (95% CI 14.7% - 25.1%) for trans feminine individuals (n = 48,604) and 2.56% (95% CI 0.0% - 5.9%) for trans masculine individuals (n = 6460). Overall OR for HIV infection, compared with individuals over age 15, was 66.0 (95% CI 51.4–84.8) for trans feminine individuals and 6.8 (95% CI 3.6–13.1) for trans masculine individuals. Prevalence varied by geographic region (13.5% - 29.9%) and sampling method (5.4% - 37.8%). Lastly, PrEP effects on prevalence could not be established.

Conclusion

Trans feminine and trans masculine individuals are disproportionately burdened by HIV. Their unique prevention and care needs should be comprehensively addressed. Future research should further investigate the impact of sampling methods on HIV prevalence, and monitor the potential impact of PrEP.

Vaccine Candidates for the Control and Prevention of the Sexually Transmitted Disease Gonorrhea

The World Health Organization (WHO) has placed N. gonorrhoeae on the global priority list of antimicrobial resistant pathogens and is urgently seeking the development of new intervention strategies. N. gonorrhoeae causes 86.9 million cases globally per annum. The effects of gonococcal disease are seen predominantly in women and children and especially in the Australian Indigenous community. While economic modelling suggests that this infection alone may directly cost the USA health care system USD 11.0–20.6 billion, indirect costs associated with adverse disease and pregnancy outcomes, disease prevention, and productivity loss, mean that the overall effect of the disease is far greater still. In this review, we summate the current progress towards the development of a gonorrhea vaccine and describe the clinical trials being undertaken in Australia to assess the efficacy of the current formulation of Bexsero^® in controlling disease.

Duration of gargling and rinsing among frequent mouthwash users: a cross-sectional study

OBJECTIVE

To examine the rinsing and gargling mouthwash practices among frequent mouthwash users to determine if there are differences in use between gender, sexual orientation and sex work status.

DESIGN

Cross-sectional study.

SETTING

Data obtained from patients attending a sexual health centre located in Melbourne, Australia.

PARTICIPANTS

200 frequent mouthwash users (four or more times per week), 50 for each of the following patient groups: men who have sex with men (MSM), female sex workers (FSW), females who are not sex workers and men who have sex with women only (MSW). Participants were observed and audio recorded using mouthwash.

PRIMARY AND SECONDARY OUTCOME MEASURES

Descriptive analyses were conducted to calculate the median age, time rinsing and gargling, amount of mouthwash used and proportion of participants who rinsed, gargled or both, as determined from the audio files. Kruskal-Wallis H test and χ² test were used to examine differences between the patient groups.

RESULTS

Median age was 28 years (IQR: 24-33). During the study, most (n=127; 63.5%) rinsed and gargled, but 70 (35.0%) rinsed only and three (1.5%) gargled only. Median time rinsing was 13.5 s (IQR: 8.5-22.0 s), gargling was 4.0 s (IQR: 2.5-6.0 s) and the median total duration was 17.0 s (IQR: 11.5-25.8 s). Median duration of mouthwash did not differ significantly between the groups (females not sex workers: 18.8 s (IQR: 12.5-24.5 s); FSW: 14.0 s (9.0-22.0 s); MSM: 22.3 s (13.0-26.5 s); MSW: 15.8 s (12.0-25.0 s); p=0.070) but males used mouthwash longer than females (median 20.3 s compared with 15.5 s; p=0.034). The median volume of mouthwash used was 20 mL (IQR: 15-27 mL). And most (n=198; 99.0%) did not dilute mouthwash with water.

CONCLUSION

Over a quarter of frequent users do not gargle mouthwash at all (35%) and used it for a substantially shorter period of time than it was used in the randomised trial (1 min) where it was shown to be effective at inhibiting Neisseria gonorrhoeae growth. Our findings suggest that many frequent mouthwash users do not follow the manufacturer instructions for using mouthwash and may not use mouthwash in a way that was shown to reduce the growth of oropharyngeal gonorrhoea.

Epidemiology of gonorrhoea: a global perspective

Although understanding the local epidemiology of gonorrhoea is critical for local efforts, understanding the multinational epidemiology may support development of national and international prevention and control policies and strategies. In this paper, current epidemiology of gonorrhoea is reviewed through an international lens and with a focus on selected populations. The World Health Organization (WHO) estimates that ~87 million new gonococcal infections occurred among people aged 15-49 years in 2016. Gonorrhoea rates are rising in many countries. Gay, bisexual and other men who have sex with men, racial or ethnic minorities, Indigenous populations and sex workers appear to bear disproportionate burdens of gonorrhoea. International travel can facilitate spread of gonorrhoea, including resistant strains, across international borders. Critical gaps in epidemiological knowledge are highlighted, including data on gonorrhoea among transgender persons and the burden of extragenital gonorrhoea. Even as further data are gathered, action - informed by currently available data - is needed now to confront this growing international threat.

Prevalence of Sexually Transmitted Infections and Human Immunodeficiency Virus in Transgender Persons: A Systematic Review

Purpose: Despite reportedly high rates of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) among transgender people, laboratory-proven prevalence of these infections in this population has not been systematically reviewed. We performed a systematic review and meta-analysis of the medical literature involving laboratory-proven HIV and STI diagnoses among transgender people.

Methods: A systematic review of the English literature regarding laboratory-proven HIV and/or STI testing in transgender populations within the last 50 years was performed. Preliminary meta-analyses assessing the prevalence of HIV and STIs among both transgender men and transgender women were performed. Given the heterogeneity of included studies, these analyses were difficult to interpret and not included in our results.

Results: Our literature review identified 25 studies, representing 11 countries. All of these studies included transgender women, with 9 (36%) including data on transgender men. HIV was the most commonly studied STI, with prevalence ranging from 0% to 49.6% in transgender women and 0% to 8.3% in transgender men. For syphilis, gonorrhea, and chlamydia, respectively, prevalence ranged from 1.4% to 50.4%, 2.1% to 19.1%, and 2.7% to 24.7% in transgender women and from 0% to 4.2%, 0% to 10.5%, and 1.2% to 11.1% in transgender men. Site-specific testing practices for gonorrhea and chlamydia were variable. No studies reported prevalence data on trichomoniasis.

Conclusion: The literature describing STIs and transgender people primarily focuses on transgender women and HIV. Data involving HIV and STIs among transgender men are lacking. These findings highlight opportunities for the future study of epidemiology of HIV/STIs in transgender men and the relevance of STIs in transgender people.

Sexually transmissible infections among transgender men and women attending Australian sexual health clinics

OBJECTIVES

To estimate rates of HIV infection, chlamydia, gonorrhoea, and infectious syphilis in transgender men and women in Australia; to compare these rates with those for cisgender people.

DESIGN

Cross-sectional, comparative analysis of de-identified health data.

SETTING, PARTICIPANTS

We analysed data for 1260 transgender people (404 men, 492 women, 364 unrecorded gender), 78 108 cisgender gay and bisexual men, and 309 740 cisgender heterosexual people who attended 46 sexual health clinics across Australia during 2010-2017.

MAIN OUTCOME MEASURES

First-visit test positivity for sexually transmitted infections (STIs), stratified by patient group and year; demographic and behavioural factors associated with having STIs.

RESULTS

14 of 233 transgender men (6.0%) and 34 of 326 transgender women (10%) tested during first clinic visits were chlamydia-positive; nine transgender men (4%) and 28 transgender women (8.6%) were gonorrhoea-positive. One of 210 tested transgender men (0.5%) and ten of 324 tested transgender women (3.1%) were diagnosed with infectious syphilis; 14 transgender men (3.5%) and 28 transgender women (5.7%) were HIV-positive at their first visit. The only significant change in prevalence of an STI among transgender patients during the study period was the increased rate of gonorrhoea among transgender women (from 3.1% to 9.8%). Compared with cisgender gay and bisexual men, transgender men were less likely (adjusted odds ratio [aOR], 0.46; 95% CI, 0.29-0.71; P = 0.001) and transgender women as likely (aOR, 0.98; 95% CI, 0.73-1.32; P = 0.92) to be diagnosed with a bacterial STI; compared with heterosexual patients, transgender men were as likely (aOR, 0.72; 95% CI, 0.46-1.13; P = 0.16) and transgender women more likely (aOR, 1.56; 95% CI, 1.16-2.10; P = 0.003) to receive a first-visit bacterial STI diagnosis.

CONCLUSIONS

The epidemiology of STIs in transgender people attending Australian sexual health clinics differs from that of cisgender patients. Gender details must be captured by health data systems to facilitate appropriate delivery of sexual health care.

Treponema pallidum Induces the Secretion of HDVSMC Inflammatory Cytokines to Promote the Migration and Adhesion of THP-1 Cells

The pathological features of syphilis, a disease caused by Treponema pallidum (T. pallidum), are characterized by vascular involvement with endarteritis and periarteritis. Little is known about the interactions of infiltrating immunocytes with human dermal vascular smooth muscle cells (HDVSMCs) in arterioles during the immunopathogenesis of syphilis. In the present study, we demonstrated that stimulation of HDVSMCs with T. pallidum resulted in the upregulated gene transcription and protein expression of interleukin (IL)-6, monocyte chemoattractant protein-1 (MCP-1), and intercellular adhesion molecule-1 (ICAM-1) in a dose- and time-dependent manner. Moreover, the migration and adhesion of THP-1 cells to HDVSMCs were significantly suppressed by anti-MCP-1 and anti-ICAM-1 neutralizing antibodies, respectively. Further studies revealed that T. pallidum activated the NF-κB signaling pathway in HDVSMCs. Inhibition of NF-κB suppressed T. pallidum-induced IL-6, MCP-1, and ICAM-1 expression. In addition, the migration and adhesion of THP-1 cells to T. pallidum-treated HDVSMCs were significantly decreased by pretreatment with an NF-κB inhibitor. These findings demonstrate that T. pallidum induces the production of IL-6, MCP-1, and ICAM-1 in HDVSMCs and promotes the adherence and migration of THP-1 cells to HDVSMCs through the NF-κB signaling pathway, which may provide new insight into the pathogenesis of T. pallidum infection.

Transcendendo: A Cohort Study of HIV-Infected and Uninfected Transgender Women in Rio de Janeiro, Brazil

Purpose: Worldwide, the burden of adverse health conditions is substantial among travestis and transgender women (trans women). Transcendendo, the first trans-specific cohort in a low- or middle-income country, is an open cohort established in August 2015 to longitudinally evaluate the health aspects of trans women aged ≥18 years in Rio de Janeiro, Brazil.

Methods: Study visits occur on an annual basis. Data on sociodemographics, behavioral, gender transition, affirmation procedures, hormone use, discrimination, violence, clinical and mental health, HIV prevention, and care (for those HIV-infected) are collected. Physical examination, anthropometric measurements, and laboratory tests are performed.

Results: As of July 2017, 322 trans women were enrolled in the cohort with a median age of 31.5 years (interquartile range 25.7–39.5), of whom 174 (54%) were HIV-infected. The Transcendendo baseline information reinforces the scenario of marginalization and deprivation surrounding trans women. Most participants had low income (62.0% were living with below US$ 10.00/day), showed a very high engagement in sex work (78.6%), and reported increased occurrence of sexual (46.3%) and physical (54.0%) violence. Pre-exposure peophylaxis (PReP) was used by 18.8% of the HIV-uninfected trans women, only through research participation. Positive screening for depression (57.8%) and problematic use of tobacco (56.6%), cannabis (28.9%), cocaine (23.8%), and alcohol (21.5%) were high. Almost all participants (94.8%) reported hormone use at some point, mostly without medical supervision (78.7%).

Conclusion: Our results describe a context of exclusion experienced by trans women, exposing vulnerabilities of this population in a middle-income country, with poor access to trans-specific care, HIV prevention and care, and mental health care. Addressing transgender experiences and needs can help the development of strategies to diminish stigma, improve health care environment, guide future research on trans morbidities, substance use, and trans-specific interventions to support health-related recommendations. Ultimately, it contributes to close the gaps concerning transgender health and reinforces that trans care cannot be disentangled from the social environment that surrounds trans women.