Intercategorical and Intracategorical Experiences of Discrimination and HIV Prevalence Among Transgender Women in San Francisco, CA: A Quantitative Intersectionality Analysis

Intersectional discrimination, mental health, and health care access among transgender women in Brazil

OBJECTIVES

Intersectional discrimination leads to negative health outcomes among transgender (trans) women. To address the need for validated tools to measure experiences of intersectional discrimination, we evaluated the performance of the Intersectional Discrimination Index (InDI) and measured associations with mental health and health care engagement among trans women in São Paulo, Brazil.

METHOD

Using baseline data from the Manas por Manas randomized controlled trial (n = 392), we characterized participant experiences of intersectional discrimination using the InDI-anticipated (InDI-A), day-to-day (InDI-D), and major (InDI-M) discrimination subscales. We evaluated the validity of the InDI-A using confirmatory factor analysis, and reliability using Cronbach's coefficient alpha (Cα) and explored relationships between each subscale, mental health, and health care engagement.

RESULTS

A single-factor solution yielded excellent for InDI-A. All subscales demonstrated good reliability: InDI-A (Cα = .85); InDI-D (lifetime Cα = .84, past-year Cα = .87), InDI-M (lifetime Cα = .78, past-year Cα = .76). A one-unit increase in anticipated discrimination was associated with severe psychological distress, adjusted odds ratio (AOR) = 2.13, 95% confidence interval (CI) [1.57, 2.89], p < .0001, and suicidality (AOR = 1.44, 95% CI [1.08, 1.93], p < .05). Similar patterns emerged for major and day-to-day discrimination. We observed important differences by race. Anticipated discrimination was associated with higher odds of HIV testing (AOR = 1.46, 95% CI [1.08, 1.97], p = .013). Discrimination was not associated with accessing primary care.

CONCLUSION

The InDI is a valid and reliable tool for measuring intersectional discrimination among Brazilian trans women; InDI scores are strongly associated with negative mental health sequelae. Interventions are needed to mitigate structural barriers to care in Brazil, where poor mental health and HIV prevalence are high among trans women. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Comparative- and Cost-Effectiveness Research Determining the Optimal Intervention for Advancing Transgender Women With HIV to Full Viral Suppression (Text Me, Alexis!): Protocol for a Randomized Controlled Trial

BACKGROUND

Many transgender women with HIV achieve suboptimal advancement through the HIV Care Continuum, including poor HIV health care usage, retention in HIV medical care, and rates of viral suppression. These issues are exacerbated by comorbid conditions, such as substance use disorder, which is also associated with reduced quality of life, increased overdose deaths, usage of high-cost health care services, engagement in a street economy, and cycles of incarceration. Thus, it is critical that efforts to End the HIV Epidemic include effective interventions to link and retain transgender women in HIV care through full viral suppression.

OBJECTIVE

This study builds on the promising findings from our two Health Resources and Services Administration-funded demonstration projects, The Alexis Project and Text Me, Girl!, which used peer health navigation (PHN) and SMS text messaging, respectively, for advancing transgender women with HIV to full viral suppression. Though the effectiveness of both interventions has been established, their comparative effectiveness, required resources or costs, cost-effectiveness, and heterogeneous effects on subgroups, including those with substance use disorder, have not been evaluated. Given the many negative personal and public health consequences of untreated or undertreated HIV, and that HIV services for transgender women are frequently delivered in resource-limited, community-based settings, a comprehensive economic evaluation is critical to inform decisions of stakeholders, such as providers, insurers, and policy makers.

METHODS

Text Me, Alexis! is a 3-arm randomized controlled trial. Participants (N=195) will be randomized (1:1:1) into: PHN alone (n=65), SMS text messaging alone (n=65), or PHN+SMS text messaging (n=65). Using the same time points as the Health Resources and Services Administration demonstration projects, the repeated-measures design will assess participants at baseline, 3, 6, 12, and 18 months post randomization. Over the course of the 90 days, participants in the PHN arm will receive unlimited navigation sessions; participants in the SMS text messaging arm will receive 270 theory-based SMS text messages (3 messages daily) that are targeted, tailored, and personalized specifically for transgender women with HIV; and participants in the PHN+SMS text messaging arm will receive a combined PHN and SMS text message intervention. The desired outcome of Text Me, Alexis! is viral suppression and cost-effectiveness.

RESULTS

Recruitment began on April 10, 2024, and the first participant was enrolled on April 11, 2024. Data collection is expected to be completed in July 2027. Primary outcome analyses will begin immediately following the conclusion of the follow-up evaluations.

CONCLUSIONS

Transgender women are a high-priority population for reaching End the HIV Epidemic goals. Findings have the potential to improve individual and population health outcomes by generating significant improvements in viral suppression among transgender women and guiding service provision and public policy.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/65313.

Acceptability and Feasibility of Using Hair Samples for Chronic Stress Measurement Among Transgender Women in Brazil

INTRODUCTION

The ability to objectively measure chronic stress has important implications for research, prevention, and treatment. Cortisol is currently the most used biological marker in the investigation of stress and can be measured via blood, saliva, and urine; however, these methods have disadvantages. The measurement of cortisol in hair is a more recently developed method that quantifies the cumulative production of cortisol over longer periods of time. Given the potential benefits of hair as a chronic stress biometric, research with this novel method is burgeoning, yet rarely involves transgender ("trans") populations, despite high levels of reported stress among trans people due to experiences of stigma and discrimination. Since hair is a key part of gender presentation, trans people might be less likely than cisgender people to donate hair for research. To explore the feasibility and acceptability of hair collection for use as a stress biometric with trans women, we nested a study into an ongoing clinical trial in São Paulo, Brazil, "Manas por Manas" (Sisters for Sisters). Here, we describe the hair biometric substudy protocol, as well as the feasibility and acceptability of collecting hair in the study cohort.

METHODS

We randomly selected a subsample (n = 180) from the Manas por Manas cohort (n = 392), all of whom are trans women, age 18 or older. We messaged participants via phone, WhatsApp, or social media for at least three attempted contacts. Study visits included four components: (1) video introduction, including a demonstration of hair sampling; (2) informed consent; (3) a brief survey with the validated Short Stress Overload Scale (translated to Portuguese) and questions on hair care that could moderate stress hormone results; and (4) hair sample collection. Hair samples were collected and stored using validated protocols. Participants were reimbursed for travel costs.

RESULTS

Between April and December 2022, we messaged with 143 individuals out of the 180 sampled (79%) and invited them to participate in the study. Of those invited to participate, we scheduled study visits with 102 people (71.3% of those invited to participate), of whom 100 attended their study visits and completed all activities. Two people did not attend their study visits and stopped communication. Of those who were invited to participate and declined a study visit, four individuals declined due to the hair sample collection procedures (2.8% of those invited to participate). Other reasons for declining to participate included having moved (n = 7), lack of time (n = 11), not interested in research participation (n = 8), or unknown/stopped responding to messages (n = 11). Most participants reported that they chemically treated their hair to bleach, color, or straighten it, which could impact laboratory assays.

CONCLUSION

We found hair sampling for stress measurement to be feasible and acceptable to our participants. We successfully completed all study activities for our desired sample size, and most recruited individuals volunteered to participate. Reasons provided for declining study participation reflected general barriers to research participation, with only four people declining due to hair sample collection procedures.

HIV and hepatitis C virus infection and co-infection among trans women in San Francisco, 2020

BACKGROUND

Transgender women (hereafter "trans women") face social marginalization, stigma, and discrimination and experience a high burden of HIV. More recently, trans women have been identified as having a high risk for hepatitis C (HCV) infection. The interaction between these two diseases and the risks for HIV/HCV co-infection among trans women are understudied.

OBJECTIVE

To characterize epidemiological, behavioral, and socio-structural interactions between HIV and HCV infections among trans women.

METHODS

This cross-sectional study examined data from a community-based survey of trans women in San Francisco recruited through respondent-driven sampling (RDS) in 2019/2020. Face-to-face interviews collected data on demographics, medical history, drug injection practices, sexual behavior, and socio-structural factors (e.g., poverty, housing insecurity, incarceration, social support). HIV and HCV antibodies were detected using oral fluid rapid tests and prior diagnosis and treatment were collected by self-report. Blood specimens were collected to confirm antibodies using ELISA. Multinomial logistic regression analysis characterized factors associated with HIV infection alone, HCV infection alone, and HIV/HCV co-infection compared to neither infection.

RESULTS

Among 201 trans women recruited, HIV prevalence was 42.3%; HCV infection by history or current seroprevalence was 28.9%; evidence for both HIV and HCV infection was present for 18.9%. Two-thirds of trans women (67.2%) had been incarcerated; 30.8% had ever injected drugs. History of injection drug use and receiving emotional support from family were factors found in common for HIV infection, HCV infection, and HIV/HCV co-infection compared to no infection. Having a sexual partner who injects drugs was associated with HIV infection alone. Not lacking care due to cost and older age were associated with co-infection. Older age was also associated with HCV infection. Of trans women with HIV infection, 91.8% had accessed HIV care, whereas only 62% with HCV had accessed some form of care.

CONCLUSIONS

Our study found high levels of HIV, HCV, and HIV/HCV co-infection among trans women in San Francisco. We found common associations between HIV and HCV through injection practices and emotional support, but having a sexual partner who injects drugs was not associated with HCV infection alone or co-infection. We note a substantial gap in the treatment of HCV for trans women, including those in HIV care, that needs to be urgently addressed.

Parkinson's Disease Inequities in Daily Cognitive Activities: An Intersectional Approach

Objective

Intersectionality approaches to examining differences in Parkinson's disease (PD) based on racialized group, gender identity, and socioeconomic status (SES) are not well covered in the literature. Additionally, the differences in daily cognitive activities for persons diagnosed with PD by racialized group, gender, and SES are undetermined. This study was conducted to explore the differences in PD daily cognitive activities for diverse racialized groups by gender and SES.

Methods

This study was a secondary analysis of the Michael J. Fox Foundation's Fox Insight online clinical dataset. Persons with PD were partitioned into 16 racialized by gender groups (Black women, Indigenous men, Latina/x women, Asian men, etc.) that were used in within-group comparisons of low-, middle-, and high-SES-a new variable comprising education and income.

Results

Intersectional analyses revealed most items differed between low-SES and high-SES except for items associated with Black and Indigenous men, for whom significant differential item functioning was found between mid-SES and high-SES.

Conclusions

These findings revealed that within-group differences exist and may be missed in research in which social factors are adjusted for instead of included in the model.

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

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

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.

Prevalence and correlates of substance use and associations with HIV-related outcomes among trans women in the San Francisco Bay Area

BACKGROUND

Trans women face tremendous social inequities as well as disproportionate rates of HIV and substance use, yet disaggregated substance use data specific to trans women remain limited.

METHODS

We conducted a secondary analysis of baseline data from the Trans*National Study (2016-2017) surveying trans women in the San Francisco Bay Area (n = 629). Multivariable logistic regression was used to analyze socio-demographic and environmental correlates of substance use, and bivariate associations between substance use and HIV-associated outcomes are presented alongside prevalence data.

RESULTS

Over half (52.9%) reported using substances in the prior year, most frequently marijuana, methamphetamine, and crack/cocaine. Those with unmet gender-affirming health care needs, lack of insurance, or a history of experiencing racial violence, transphobic violence, adult housing instability, or extreme poverty had higher odds of substance use. Sex work and condomless anal sex were also independently associated with substance use.

CONCLUSIONS

Among this sample of trans women, substance use and substance use concurrent with sex were highly prevalent, and associated with a number of socioeconomic and health care needs. These findings corroborate the need for holistic and intersectional efforts to reduce substance use and HIV risk.

HIV prevalence, engagement in care, and risk behavior among trans women, San Francisco: Evidence of recent successes and remaining challenges

BACKGROUND

Trans women have high HIV prevalence and lag behind 90-90-90 targets for HIV care. In San Francisco in 2017, 96% of trans women were aware of their status, 75% were on antiretroviral therapy, 88% had viral suppression. Initiatives to address gaps include peer navigators, free gender-affirming surgery, and housing. Our study updates HIV prevalence and engagement in care among trans women.

METHODS

Cross-sectional community-based survey of trans women living in San Francisco sampled by respondent-driven sampling, 7/2019-2/2020 (N = 201). Eligibility was: self-identified trans women or other gender and assigned male at birth; living in San Francisco; English/Spanish-speaking; and 18 years or older.

RESULTS

HIV prevalence was 42.3% (95%CI 35.4.-49.4) and associated with having a partner who injected drugs (adjusted odds ratio [AOR] 3.30, 95%CI 1.58-6.90), ever injected drugs (AOR 2.28, 95%CI 1.06-4.89), cost not a barrier to healthcare (AOR 2.63, 95%CI 1.02-6.67), emotional support from family (AOR 2.85, 95%CI 1.43-5.65), and Black/African-American (AOR 2.59, 95%CI 1.16-5.79). Of trans women with HIV, 92.9% were previously diagnosed, 89.9% were on ART, 91.5% reported viral suppression.

CONCLUSIONS

Trans women met 90-90-90 targets in 2020, at 93-90-92. Interventions need to reach Black/African-American trans women, trans women who inject drugs, and partners of trans women.

Sexual Behaviors Associated with HIV Transmission Among Transgender and Gender Diverse Young Adults: The Intersectional Role of Racism and Transphobia

HIV prevalence and engagement in sexual behaviors associated with HIV transmission are high among transgender people of color. Per intersectionality, this disproportionate burden may be related to both interpersonal and structural racism and transphobia. The goal of this study was to estimate the association between interpersonal and structural discrimination and sexual behaviors among transgender and gender diverse (TGD) U.S. young adults. We used logit models with robust standard errors to estimate the individual and combined association between interpersonal and structural racism and transphobia and sexual behaviors in a national online sample of TGD young adults of color (TYAOC) aged 18-30 years (N = 228). Racism was measured at the interpersonal and structural level using the Everyday Discrimination Scale and State Racism Index, respectively. Transphobia was measured at the interpersonal and structural level using the Gender Minority Stress Scale and the Gender Identity Tally, respectively. We found that interpersonal racism was associated with transactional sex, and interpersonal transphobia was associated with alcohol/drug consumption prior to sex and transactional sex among TYAOC. We also found evidence of a strong joint association of interpersonal and structural racism and transphobia with alcohol/drug consumption prior to sex (OR 3.85, 95% CI 2.12, 7.01) and transactional sex (OR 3.54, 95% CI 0.99, 12.59) among TYAOC. Racism and transphobia have a compounding impact on sexual behaviors among TYAOC. Targeted interventions that reduce discrimination at both the interpersonal and structural level may help reduce the HIV burden in this marginalized population.

HIV-Related Intersectional Stigma and Discrimination Measurement: State of the Science

Background. Across settings, individuals from populations that are multiply stigmatized are at increased risk of HIV and experience worse HIV treatment outcomes. As evidence expands on how intersecting stigmatized identities and conditions influence HIV outcomes, researchers have used diverse quantitative approaches to measure HIV-related intersectional stigma and discrimination. To date, no clear consensus exists regarding how to best quantitatively measure and analyze intersectional stigma and discrimination. Objectives. To review and document existing quantitative measures of HIV-related intersectional stigma and discrimination to inform research, programmatic, and policy efforts. Search Methods. We searched 5 electronic databases for relevant studies. References of included articles were screened for possible inclusion. Additional articles were screened on the basis of consultations with experts in the field. Selection Criteria. We included peer-reviewed studies published between January 1, 2010, and May 12, 2021, that were HIV related and presented 1 or more quantitative measures of stigma and discrimination using an intersectional lens in measure design or analysis. Data Collection and Analysis. Systematic methods were used to screen citations and abstract data via a standardized coding form. Data were analyzed by coding categories stratified according to 2 subgroups: (1) studies incorporating a single intersectional measure and (2) studies that examined intersectional stigma through analytical approaches combining multiple measures. Main Results. Sixteen articles met the inclusion criteria, 7 of which explicitly referenced intersectionality. Ten studies were from the United States. All of the studies included participants living with HIV. Among the 4 studies incorporating a single intersectional stigma measure, 3 explored race and gender stigma and 1 explored gender and HIV stigma. Studies involving analytic approaches (n = 12) mostly examined intersectional stigma via interaction terms in multivariate regression models. Three studies employed structural equation modeling to examine interactive effects or latent constructs of intersectional stigma. Conclusions. Research on the measurement of HIV-related intersectional stigma and discrimination is currently concentrated in high-income settings and generally focuses on the intersection of 2 identities (e.g., race and gender). Efforts are needed to expand appropriate application of intersectionality in the development, adaptation, and use of measures of HIV-related intersectional stigma and discrimination. The use of context-, identity-, or condition-adaptable measures should be considered. Researchers should also carefully consider how to meaningfully engage communities in the process of measurement development. Public Health Implications. The measures and analytic approaches presented could significantly enhance public health efforts in assessing the impact of HIV-related intersectional stigma and discrimination on critical health outcomes. (Am J Public Health. 2022;112(S4):S420-S432. https://doi.org/10.2105/AJPH.2021.306639).

Conceptualizing, Contextualizing, and Operationalizing Race in Quantitative Health Sciences Research

Differences in health outcomes across racial groups are among the most commonly reported findings in health disparities research. Often, these studies do not explicitly connect observed disparities to mechanisms of systemic racism that drive adverse health outcomes among racialized and other marginalized groups in the United States. Without this connection, investigators inadvertently support harmful narratives of biologic essentialism or cultural inferiority that pathologize racial identities and inhibit health equity. This paper outlines pitfalls in the conceptualization, contextualization, and operationalization of race in quantitative population health research and provides recommendations on how to appropriately engage in scientific inquiry aimed at understanding racial health inequities. Race should not be used as a measure of biologic difference, but rather as a proxy for exposure to systemic racism. Future studies should go beyond this proxy use and directly measure racism and its health impacts.VISUAL ABSTRACTAppeared as Annals "Online First" article.