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Sherman ADF, Higgins MK, Balthazar MS, Hill M, Klepper M, Schneider JS, Adams D, Radix A, Mayer KH, Cooney EE, Poteat TC, Wirtz AL, Reisner SL. Stigma, social and structural vulnerability, and mental health among transgender women: A partial least square path modeling analysis. J Nurs Scholarsh 2024; 56:42-59. [PMID: 38228564 PMCID: PMC10792251 DOI: 10.1111/jnu.12906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 03/22/2023] [Accepted: 04/20/2023] [Indexed: 01/18/2024]
Abstract
INTRODUCTION Existing literature suggests that transgender women (TW) may be at high risk for adverse mental health due to stress attributed to combined experiences of stigma and complex social and structural vulnerabilities. Little research has examined how these co-occurring experiences relate to mental health. We aimed to test a theoretically driven conceptual model of relationships between stigma, social and structural vulnerabilities, and mental health to inform future intervention tailoring. DESIGN/METHODS Partial least square path modeling followed by response-based unit segmentation was used to identify homogenous clusters in a diverse community sample of United States (US)-based TW (N = 1418; 46.2% White non-Hispanic). This approach examined associations between latent constructs of stigma (polyvictimization and discrimination), social and structural vulnerabilities (housing and food insecurity, unemployment, sex work, social support, and substance use), and mental health (post-traumatic stress and psychological distress). RESULTS The final conceptual model defined the structural relationship between the variables of interest within stigma, vulnerability, and mental health. Six clusters were identified within this structural framework which suggests that racism, ethnicism, and geography may be related to mental health inequities among TW. CONCLUSION Our findings around the impact of racism, ethnicism, and geography reflect the existing literature, which unfortunately shows us that little change has occurred in the last decade for TW of color in the Southern US; however, the strength of our evidence (related to sampling structure and sample size) and type of analyses (accounting for co-occurring predictors of health, i.e., stigma and complex vulnerabilities, reflecting that of real-world patients) is a novel and necessary addition to the literature. Findings suggest that health interventions designed to offset the negative effects of stigma must include anti-racist approaches with components to reduce or eliminate barriers to resources that contribute to social and structural vulnerabilities among TW. Herein we provide detailed recommendations to guide primary, secondary, and tertiary prevention efforts. CLINICAL RELEVANCE This study demonstrated the importance of considering stigma and complex social and structural vulnerabilities during clinical care and design of mental health interventions for transgender women who are experiencing post-traumatic stress disorder and psychological distress. Specifically, interventions should take an anti-racist approach and would benefit from incorporating social support-building activities.
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Affiliation(s)
| | - Melinda K. Higgins
- Nell Hodson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Monique S. Balthazar
- Nell Hodson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
- Georgia State University Byrdine F. Lewis College of Nursing and Health Professions, Atlanta, Georgia, USA
| | - Miranda Hill
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | | | - Jason S. Schneider
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dee Adams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Asa Radix
- Department of Medicine, Callen-Lorde Community Health Center, New York, New York, USA
| | - Kenneth H. Mayer
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | - Erin E. Cooney
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tonia C. Poteat
- Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Andrea L. Wirtz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sari L. Reisner
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Cooney EE, Saleem HT, Stevenson M, Aguayo‐Romero RA, Althoff KN, Poteat TC, Beckham SW, Adams D, Radix AE, Wawrzyniak AJ, Cannon CM, Schneider JS, Haw JS, Rodriguez AE, Mayer KH, Beyrer C, Reisner SL, Wirtz AL. PrEP initiation and discontinuation among transgender women in the United States: a longitudinal, mixed methods cohort study. J Int AIDS Soc 2023; 26:e26199. [PMID: 38123897 PMCID: PMC10733152 DOI: 10.1002/jia2.26199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 12/01/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION Transgender women in the United States experience high HIV incidence and suboptimal Pre-exposure prophylaxis (PrEP) engagement. We sought to estimate PrEP initiation and discontinuation rates and characterize PrEP discontinuation experiences among a prospective cohort of transgender women. METHODS Using a sequential, explanatory, mixed-methods design, 1312 transgender women at risk for HIV acquisition were enrolled from March 2018 to August 2020 and followed through July 2022 (median follow-up 24 months; interquartile range 15-36). Cox regression models assessed predictors of initiation and discontinuation. In-depth interviews were conducted among 18 participants, including life history calendars to explore key events and experiences surrounding discontinuations. Qualitative and quantitative data were integrated to generate typologies of discontinuation, inform meta-inferences and facilitate the interpretation of findings. RESULTS 21.8% (n = 286) of participants reported taking PrEP at one or more study visits while under observation. We observed 139 PrEP initiations over 2127 person-years (6.5 initiations/100 person-years, 95% CI: 5.5-7.7). Predictors of initiation included identifying as Black and PrEP indication. The rate of initiation among those who were PrEP-indicated was 9.6 initiations/100 person-years (132/1372 person-years; 95% CI: 8.1-11.4). We observed 138 PrEP discontinuations over 368 person-years (37.5 discontinuations/100 person-years, 95% CI: 31.7-44.3). Predictors of discontinuation included high school education or less and initiating PrEP for the first time while under observation. Four discontinuation typologies emerged: (1) seroconversion following discontinuation; (2) ongoing HIV acquisition risk following discontinuation; (3) reassessment of HIV/STI prevention strategy following discontinuation; and (4) dynamic PrEP use coinciding with changes in HIV acquisition risk. CONCLUSIONS PrEP initiation rates were low and discontinuation rates were high. Complex motivations to stop using PrEP did not consistently correspond with HIV acquisition risk reduction. Evidence-based interventions to increase PrEP persistence among transgender women with ongoing acquisition risk and provide HIV prevention support for those who discontinue PrEP are necessary to reduce HIV incidence in this population.
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Affiliation(s)
- Erin E. Cooney
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Haneefa T. Saleem
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Meg Stevenson
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Rodrigo A. Aguayo‐Romero
- Division of Endocrinology, Diabetes, and HypertensionBrigham and Women's HospitalBostonMassachusettsUSA
- Department of MedicineHarvard Medical SchoolBostonMassachusettsUSA
- Fenway HealthThe Fenway InstituteBostonMassachusettsUSA
| | - Keri N. Althoff
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Tonia C. Poteat
- Department of Social MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - S. Wilson Beckham
- Department of HealthBehavior and SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Dee Adams
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Asa E. Radix
- Callen‐Lorde Community Health CenterNew YorkNew YorkUSA
| | - Andrew J. Wawrzyniak
- Department of Psychiatry and Behavioral SciencesUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | | | - Jason S. Schneider
- Department of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
| | - J. Sonya Haw
- Division of Endocrinology, Metabolism and LipidsEmory University School of MedicineAtlantaGeorgiaUSA
| | - Allan E. Rodriguez
- Division of Infectious DiseasesDepartment of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Kenneth H. Mayer
- Department of MedicineHarvard Medical SchoolBostonMassachusettsUSA
- Fenway HealthThe Fenway InstituteBostonMassachusettsUSA
| | - Chris Beyrer
- Duke UniversityGlobal Health InstituteDurhamNorth CarolinaUSA
| | - Sari L. Reisner
- Division of Endocrinology, Diabetes, and HypertensionBrigham and Women's HospitalBostonMassachusettsUSA
- Department of MedicineHarvard Medical SchoolBostonMassachusettsUSA
- Fenway HealthThe Fenway InstituteBostonMassachusettsUSA
- Department of EpidemiologyHarvard TH Chan School of Public HealthBostonMassachusettsUSA
| | - Andrea L. Wirtz
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
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Malone J, Reisner SL, Cooney E, Poteat T, Cannon CM, Schneider J, Radix A, Mayer KH, Haw JS, Althoff KN, Wawrzyniak AJ, Beyrer C, Wirtz AL. Perceived HIV Acquisition Risk and Low Uptake of PrEP Among a Cohort of Transgender Women With PrEP Indication in the Eastern and Southern United States. J Acquir Immune Defic Syndr 2021; 88:10-18. [PMID: 34397742 PMCID: PMC8371736 DOI: 10.1097/qai.0000000000002726] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/03/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Preexposure prophylaxis (PrEP) is effective in preventing HIV among adherent users. However, PrEP uptake among transgender women is low, and current prescribing guidelines from the Centers for Disease Control and Prevention (CDC) are not specific to transgender women. Self-perceived risk of HIV among those who are PrEP-indicated is not well understood. METHODS This cross-sectional analysis included 1293 transgender women screened at baseline from March 2018 to May 2020 for a multisite, prospective cohort study. We compared the prevalence of PrEP indication using current CDC prescribing criteria versus transgender women-specific criteria developed by study investigators with community input. We identified factors associated with study-specific PrEP indication and factors associated with self-perceived low to no HIV risk among those who were PrEP-indicated. We also calculated descriptive statistics to depict the PrEP care continuum. RESULTS PrEP indication prevalence using transgender women-specific criteria was 47% (611), 155 more than who were identified using the CDC criteria. Eighty-three percent were aware of PrEP, among whom 38% had ever used PrEP. Among PrEP ever users, 63% were using PrEP at the time of the study. There were 66% of current PrEP users who reported 100% adherence within the previous 7 days. Among those who were PrEP-indicated, 13% were using and adherent to PrEP at the time of the study. More than half (55%) of PrEP-indicated participants had low or no self-perceived HIV risk. CONCLUSIONS These findings suggest that further guidance is needed for health care providers in prescribing PrEP to transgender women. Greater uptake and adherence are also needed for optimal effectiveness.
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Affiliation(s)
- Jowanna Malone
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Sari L. Reisner
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
- Division of Endocrinology, Diabetes & Hypertension, Brigham and Women’s Hospital, Boston, MA
| | - Erin Cooney
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Tonia Poteat
- Department of Social Medicine, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC
| | | | | | - Asa Radix
- New York University School of Medicine, New York, NY
| | - Kenneth H. Mayer
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- The Fenway Institute, Boston, MA, US
| | - J. Sonya Haw
- Division of Endocrinology, Metabolism, and Lipids, Emory University school of Medicine, Atlanta, GA
| | - Keri N. Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Andrew J. Wawrzyniak
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine
| | - Chris Beyrer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Andrea L. Wirtz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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