Scoping Literature Review: Experiences of Sexual and Gender Minority Older Adults, With Diagnoses of Dementia, Who Use Residential Long-Term Services and Supports

The number of sexual and gender minority (SGM) older adults utilizing residential long-term supports and services (LTSS) will increase in the forthcoming decades. Paradoxically, while requiring more LTSS services than their non-SGM counterparts, SGM older adults are less likely to access these services, partly due to fears of discrimination. Furthermore, SGM older adults living with Alzheimer's disease and related dementias (AD/ADRD) present unique challenges and opportunities for LTSS facilities. This article provides a scoping review on the intersection between experiences of SGM older adults with AD/ADRD who use residential LTSS. This review identified three themes: (1) the experiences of discrimination among SGM residents in LTSS facilities, (2) the need for comprehensive staff training in residential LTSS to ensure proper care of SGM populations, and (3) the crucial role of inclusive facility policies. As the number of SGM older adults is expected to increase, further research is necessary.

Glutamylation of Npm2 and Nap1 acidic disordered regions increases DNA mimicry and histone chaperone efficiency

Histone chaperones-structurally diverse, non-catalytic proteins enriched with acidic intrinsically disordered regions (IDRs)-protect histones from spurious nucleic acid interactions and guide their deposition into and out of nucleosomes. Despite their conservation and ubiquity, the function of the chaperone acidic IDRs remains unclear. Here, we show that the Xenopus laevis Npm2 and Nap1 acidic IDRs are substrates for TTLL4 (Tubulin Tyrosine Ligase Like 4)-catalyzed post-translational glutamate-glutamylation. We demonstrate that to bind, stabilize, and deposit histones into nucleosomes, chaperone acidic IDRs function as DNA mimetics. Our biochemical, computational, and biophysical studies reveal that glutamylation of these chaperone polyelectrolyte acidic stretches functions to enhance DNA electrostatic mimicry, promoting the binding and stabilization of H2A/H2B heterodimers and facilitating nucleosome assembly. This discovery provides insights into both the previously unclear function of the acidic IDRs and the regulatory role of post-translational modifications in chromatin dynamics.

A Peer-to-Peer Collaborative Learning Approach for the Implementation of Evidence-Informed Interventions to Improve HIV-Related Health Outcomes

The nationwide scale-up of evidence-based and evidence-informed interventions has been widely recognized as a crucial step in ending the HIV epidemic. Although the successful delivery of interventions may involve intensive expert training, technical assistance (TA), and dedicated funding, most organizations attempt to replicate interventions without access to focused expert guidance. Thus, there is a grave need for initiatives that meaningfully address HIV health disparities while addressing these inherent limitations. Here, the Health Resources and Services Administration HIV/AIDS Bureau (HRSA HAB) initiative Using Evidence-Informed Interventions to Improve HIV Health Outcomes among People Living with HIV (E2i) piloted an alternative approach to implementation that de-emphasized expert training to naturalistically simulate the experience of future HIV service organizations with limited access to TA. The E2i approach combined the HAB-adapted Institute for Healthcare Improvement's Breakthrough Series Collaborative Learning Model with HRSA HAB's Implementation Science Framework, to create an innovative multi-tiered system of peer-to-peer learning that was piloted across 11 evidence-informed interventions at 25 Ryan White HIV/AIDS Program sites. Four key types of peer-to-peer learning exchanges (i.e., intervention, site, staff role, and organization specific) took place at biannual peer learning sessions, while quarterly intervention cohort calls and E2i monthly calls with site staff occurred during the action periods between learning sessions. Peer-to-peer learning fostered both experiential learning and community building and allowed site staff to formulate robust site-specific action plans for rapid cycle testing between learning sessions. Strategies that increase the effectiveness of interventions while decreasing TA could provide a blueprint for the rapid uptake and integration of HIV interventions nationwide.

Training Health Center Staff in the Provision of Culturally Responsive Care for Sexual and Gender Minority Patients: Results of a Randomized Controlled Trial

Purpose: The study was designed to evaluate whether an educational intervention to train the health center (HC) staff to optimize care for sexual and gender minority (SGM) patients could improve documentation of sexual orientation and gender identity (SOGI) and increase preventive screenings. Methods: Twelve HCs were matched and randomized to either receive a tailored, multicomponent educational intervention or a 1-hour prerecorded webinar. Documentation of SGM status and clinical testing was measured through analysis of data that HCs report annually. Nonparametric statistics were used to assess associations between baseline HC characteristics and outcome measures. Results: The HCs were geographically, racially, and ethnically diverse. In all but one HC, <10% of the patients were identified as SGM. Intervention HCs underwent between 3 and 10 trainings, which were highly acceptable. In 2018, 9 of 12 HCs documented SO and 11 of 12 documented GI for at least 50% of their patients. Five of 6 intervention HCs increased SO documentation by 2020, compared to 3 of 6 control HCs (nonsignificant, NS). Five intervention HCs increased GI documentation, although generally by less than 10%, compared to 2 of the controls (NS). Intervention HCs tended to increase documentation of preventive services more than control HCs, but the changes were NS. Conclusions: An educational intervention designed to train the HC staff to provide culturally responsive services for SGM patients was found to be acceptable, with favorable, but nonsignificant changes. Further refinement of the intervention using a larger sample of HCs might demonstrate the effectiveness of this approach. Clinical trial registration #: NCT03554785.

Assessing the Impact of the 340B Drug Pricing Program: A Scoping Review of the Empirical, Peer-Reviewed Literature

Policy Points The 340B Drug Pricing Program accounts for roughly 1 out of every 100 dollars spent in the $4.3 trillion US health care industry. Decisions affecting the program will have wide-ranging consequences throughout the US safety net. Our scoping review provides a roadmap of the questions being asked about the 340B program and an initial synthesis of the answers. The highest-quality evidence indicates that nonprofit, disproportionate share hospitals may be using the 340B program in margin-motivated ways, with inconsistent evidence for increased safety net engagement; however, this finding is not consistent across other hospital types and public health clinics, which face different incentive structures and reporting requirements.

CONTEXT

Despite remarkable growth and relevance of the 340B Drug Pricing Program to current health care practice and policy debate, academic literature examining 340B has lagged. The objectives of this scoping review were to summarize i) common research questions published about 340B, ii) what is empirically known about 340B and its implications, and iii) remaining knowledge gaps, all organized in a way that is informative to practitioners, researchers, and decision makers.

METHODS

We conducted a scoping review of the peer-reviewed, empirical 340B literature (database inception to March 2023). We categorized studies by suitability of their design for internal validity, type of covered entity studied, and motivation-by-scope category.

FINDINGS

The final yield included 44 peer-reviewed, empirical studies published between 2003 and 2023. We identified 15 frequently asked research questions in the literature, across 6 categories of inquiry-motivation (margin or mission) and scope (external, covered entity, and care delivery interface). Literature with greatest internal validity leaned toward evidence of margin-motivated behavior at the external environment and covered entity levels, with inconsistent findings supporting mission-motivated behavior at these levels; this was particularly the case among participating disproportionate share hospitals (DSHs). However, included case studies were unanimous in demonstrating positive effects of the 340B program for carrying out a provider's safety net mission.

CONCLUSIONS

In our scoping review of the 340B program, the highest-quality evidence indicates nonprofit, DSHs may be using the 340B program in margin-motivated ways, with inconsistent evidence for increased safety net engagement; however, this finding is not consistent across other hospital types and public health clinics, which face different incentive structures and reporting requirements. Future studies should examine heterogeneity by covered entity types (i.e., hospitals vs. public health clinics), characteristics, and time period of 340B enrollment. Our findings provide additional context to current health policy discussion regarding the 340B program.

Lessons Learned from the U.S. Public Health Response to the 2022 mpox Outbreak

In mid-2022, an mpox outbreak occurred in the United States and more than 100 countries, disproportionately affecting men who have sex with men (MSM). Initially, the U.S. public health system failed to deploy tests, treatment, and vaccines effectively. Key federal policy changes in August 2022, along with risk reduction among many MSM, led to a steady reduction in new diagnoses by December 2022. Mpox outbreaks occurred among MSM in Chicago and France in May 2023, and vaccination rates remain low. This perspective analyzes the U.S. response to the 2022 outbreak, and it identifies the lessons learned that may guide mpox management moving forward.

Glutamylation of Npm2 and Nap1 acidic disordered regions increases DNA charge mimicry to enhance chaperone efficiency

Histone chaperones-structurally diverse, non-catalytic proteins enriched with acidic intrinsically disordered regions (IDRs)-protect histones from spurious nucleic acid interactions and guide their deposition into and out of nucleosomes. Despite their conservation and ubiquity, the function of the chaperone acidic IDRs remains unclear. Here, we show that the Xenopus laevis Npm2 and Nap1 acidic IDRs are substrates for TTLL4 (Tubulin Tyrosine Ligase Like 4)-catalyzed post-translational glutamate-glutamylation. We demonstrate that, to bind, stabilize, and deposit histones into nucleosomes, chaperone acidic IDRs function as DNA mimetics. Our biochemical, computational, and biophysical studies reveal that glutamylation of these chaperone polyelectrolyte acidic stretches functions to enhance DNA electrostatic mimicry, promoting the binding and stabilization of H2A/H2B heterodimers and facilitating nucleosome assembly. This discovery provides insights into both the previously unclear function of the acidic IDRs and the regulatory role of post-translational modifications in chromatin dynamics.

FDA's 2023 Policy Update-Promoting Safety and Inclusivity in Blood Donation

This Viewpoint discusses the US Food and Drug Administration’s 2023 policy update to its blood donation guidelines for men who have sex with men.

"Going Back in the Closet": Addressing Discrimination Against Sexual and Gender Minority Residents in Long-Term Services and Supports by Providing Culturally Responsive Care

Sexual and gender minority (SGM) older adults face discrimination in long-term services and supports (LTSS). Yet, SGM older adults use LTSS disproportionately higher relative to their non-SGM counterparts. The discrimination is compounded by existing disparities, resulting in worse health outcomes and well-being for SGM older adults. Guided by socioecological model, we posit that training LTSS staff in SGM responsive care and implementing SGM anti-discrimination policies will be needed to improve care. Considering accessibility and turnover challenges, training should be online, interactive, and easily accessible. Studies that assess interventions for SGM responsive care are needed to guide policy and practice.

Prevalence of Self-Reported Kidney Disease in Older Adults by Sexual Orientation: Behavioral Risk Factor Surveillance System Analysis (2014-2019)

SIGNIFICANCE STATEMENT

Studies discusses CKD disparities by age, race and ethnicity, and socioeconomics. However, despite well-documented disparities in CKD risk factors in LGBT+ adults, limited literature addresses CKD prevalence in this population. This analysis uses Behavioral Risk Factor Surveillance System (2014-2019) data to compare self-reported kidney disease prevalence in LGBT+ older adults (older than 50 years) with their heterosexual peers. Our findings indicate that LGBT+ older adults have higher rates of self-reported kidney disease and a higher incidence of CKD risks including smoking, activity limitations, adverse health outcomes, and limited access to health care, housing, and employment. These results support increasing access to screening for CKD risk factors, providing culturally responsive health care, and addressing societal drivers of vulnerability in older LGBT+ adults.

BACKGROUND

Existing research documents disparities in CKD by age, race and ethnicity, and access to health care. However, research on CKD in lesbian, gay, bisexual, and trans (LGBT+) older adults, despite their higher rates of diabetes, heart disease, smoking, and alcohol use, is limited.

METHODS

Pooled data from the Behavioral Risk Factor Surveillance System (2014-2019) for 22,114 LGBT+ adults and 748,963 heterosexuals aged 50 and older were used to estimate the prevalence of self-reported kidney disease. Logistic regressions were used to compare older adults by sexual orientation.

RESULTS

Older LGBT+ men (adjusted odds ratio=1.3; 95% confidence interval [CI], 1.09-1.54) were more likely than their heterosexual counterparts to report kidney disease, after controlling for sociodemographic factors, health behaviors, access to health care, and self-reported coronary heart disease, HIV, and diabetes; LGBT+ men and women also reported higher incidences of known risk factors for CKD. For example, both LGBT+ men (odds ratio [OR]=1.39; [95% CI], 1.26-1.54) and LGBT+ women (OR=1.39; [95% CI], 1.25-1.55) were more likely to be smokers and have a higher incidence of activity limitations, adverse health outcomes, and limited access to health care, housing, and employment.

CONCLUSION

These results support increasing access to screenings for CKD risk factors, providing preventative education and culturally responsive and affirming care, and addressing other societal drivers of vulnerability in older LGBT+ adults. The findings also support the value of interventions that address the interaction between CKD risk factors and the social marginalization that older LGBT+ adults experience.

Recruiting, Facilitating, and Retaining a Youth Community Advisory Board to Inform an HIV Prevention Research Project with Sexual and Gender Minority Youth

Sexual and gender minority (SGM) youth are at disproportionate risk of acquiring HIV, and as such, SGM youth should be meaningfully engaged in research aimed at developing effective, tailored HIV interventions. Youth Community Advisory Boards (YCABs) are an important element of community-engaged research and support the development of community-informed interventions. This article describes recruitment, facilitation, and retention of a YCAB composed of SGM youth in Greater Boston, to inform a national HIV prevention research project. These lessons can serve as a guide to future researchers who want to form YCABs as part of community-engaged research.

HIV Care Continuum Interventions for Transgender Women: A Topical Review

Transgender women experience a disproportionate prevalence of HIV and barriers to linkage to care, retention in care, medication adherence, and viral suppression. As part of a national cooperative agreement funded by the Health Resources and Services Administration's HIV/AIDS Bureau, we searched the literature from January 1, 2010, through June 1, 2020, for English-language articles on interventions designed to improve at least 1 HIV care continuum outcome or address 1 barrier to achieving HIV care continuum outcomes among transgender women diagnosed with HIV in the United States. To be included, articles needed to identify transgender women as a priority population for the intervention. We found 22 interventions, of which 15 reported quantitative or qualitative outcomes and 7 reported study protocols. Recent interventions have incorporated a range of strategies that show promise for addressing pervasive structural and individual barriers rooted in societal and cultural stigma and discrimination against transgender people. Cross-cutting themes found among the interventions included meaningful community participation in the design and implementation of the interventions; culturally affirming programs that serve as a gateway to HIV care and combine gender-affirming care and social services with HIV care; interventions to improve behavioral health outcomes; peer-led counseling, education, and navigation; and technology-based interventions to increase access to care management and online social support. Ongoing studies will further elucidate the efficacy and effectiveness of these interventions, with the goal of reducing disparities in the HIV care continuum and bringing us closer to ending the HIV epidemic among transgender women in the United States.

Victimization Within and Beyond the Prison Walls: A Latent Profile Analysis of Transgender and Gender Diverse Adults

Background: Transgender and gender diverse (TGD) people are disproportionately incarcerated in the United States relative to the general population. A dearth of quantitative research has explored victimization as a risk factor for incarceration as well as the victimization experiences of formerly incarcerated TGD populations. Methods: In 2019, 574 TGD adults completed an online survey assessing sociodemographics, victimization across settings, and incarceration history. Latent class analysis was used to identify two sets of latent subgroups based on respondent's victimization experiences: 1) lifetime victimization (low; moderate; and high) and 2) classes of victimization while incarcerated (low; moderate; and high). Bivariate and multivariable logistic regression analyses examined sociodemographic, mental health, and lifetime victimization experiences associated with lifetime incarceration (Outcome 1). Among those with incarceration histories, bivariate hierarchical logistic regression analyses also explored the association between gender identity, race/ethnicity, HIV status, visual gender non-conformity, and class of victimization during incarceration (Outcome 2) . Results: Participants' mean age was 31.4 (SD = 11.2), 43.4% had a non-binary gender identity, 81.5% were White, non-Hispanic, 2.1% were living with HIV, and 13.2% had been incarcerated. In the multivariable model for Outcome 1, high levels of victimization, age, being a racial/ethnic minority, being a trans woman, living with HIV, and past-12-month polysubstance use were all associated with increased odds of lifetime incarceration (p-values < 0.05). In the bivariate hierarchical logistic regression analyses for Outcome 2, living with HIV and having a visually gender non-conforming expression were significantly associated with elevated odds of experiencing high levels of victimization while incarcerated (p-values < 0.05). Conclusion: Findings document the relationships between victimization and incarceration among TGD people as well as identify the subpopulations at greater risk for incarceration and experiencing victimization while incarcerated. Efforts are needed to prevent victimization across the life course, including while incarcerated and support TGD individuals in coping with the negative sequelae of victimization and incarceration experiences.

Wide Variability in Documentation of Sexual Orientation, Gender Identity, and Preventive Health Screenings in a Diverse Sample of U.S. Community Health Centers

Purpose: This study was conducted to characterize documentation of sexual orientation and gender identity (SOGI) and provision of screening and preventive services in a diverse sample of community health centers (CHCs). Methods: Twelve CHCs provided data submitted to the Health Resources and Services Administration (HRSA) in 2018 from their Uniform Data System (UDS) reports. Prevalence of SOGI documentation, screenings, and preventive services were calculated. Sociodemographic correlates of documentation were analyzed using Fisher's exact test and Wilcoxon rank sum/Mann-Whitney U test. Results: Patient data recording sexual orientation (SO) were missing in 2%-93% of UDS reports from the 12 CHCs, and gender identity (GI) data were missing from 0% to 96% of UDS reports. CHCs were most likely to report body mass index and tobacco screening and least likely to report hepatitis A or B vaccination, independent of SO or GI. Transgender females were less likely to have mammography documented than cisgender females. Transgender males were less likely to have anal Pap tests, be vaccinated for hepatitis B, or be referred for risky alcohol use compared to cisgender males. Patients who identified as "another gender" were less likely to be referred for risky alcohol use, undergo mammography or anal Pap testing, or receive hepatitis A vaccination than cisgender people. Individuals who did not disclose their GI were less likely to be vaccinated for hepatitis A or B than cisgender people. Conclusion: SOGI status was often not documented by a diverse array of CHCs. However, when SOGI status was documented, we saw evidence of disparities in preventive interventions and referrals, particularly for transgender patients. Clinical trial registration number: NCT03554785.

Uncertainty and Confusion Regarding Transgender Non-discrimination Policies: Implications for the Mental Health of Transgender Americans

Introduction

Recent policies have restricted the rights of the US transgender people; there is a need to explore transgender people's knowledge and attitudes regarding such policies and related mental health.

Methods

In 2019, 580 transgender adults living in the Northeastern US completed a survey assessing demographics, knowledge/attitudes toward transgender-related policies, and mental health. Multivariable logistic regression models, adjusted for age, gender, race, and prior abuse, were fit to examine the association of concerns about the implementation of discriminatory policies and depression, anxiety, and post-traumatic stress disorder (PTSD).

Results

Many participants were confused about the status of federal and state protections for transgender people, and 48.4% were concerned that their state would pass policies that took away transgender rights. In adjusted models, compared to participants who were not concerned, those who were concerned about the enactment of state-level, anti-transgender policies had greater odds of depression, anxiety, and PTSD (p < 0.05).

Conclusions

Our findings highlight the uncertainty around changing policies and potential mental health implications as well as the need to ensure legal protections for transgender Americans.

Policy Implications

There are several pending lawsuits seeking to overturn Trump-era policies that restrict the rights of transgender individuals. At the same time, lawmakers in several states are pushing anti-transgender legislation. Findings from this study can be cited as part of future and ongoing legal and legislative efforts from advocates seeking to ensure equal protections for transgender people under state and federal law.

Barriers and opportunities for the mental health of LGBT older adults and older people living with HIV: a systematic literature review

OBJECTIVE

LGBT older adults and older people living with HIV (PLWH) experience a disproportionate burden of behavioral health conditions compared to their heterosexual, cisgender, and HIV-negative peers. This study intends to systematically review the literature regarding accessing mental health care among LGBT older adults and older PLWH.

METHODS

This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement framework. Three databases were searched using Boolean search strings, and inclusion/exclusion criteria were developed and applied to the search outcomes to appropriately narrow results. Article quality and evidence of bias were evaluated using the National Heart, Lung, and Blood Institute (NHLBI) quality-assessment tool, and the Critical Appraisal Skills Program (CASP) assessment tool, two instruments used to help reviewers in assessing for internal validity of studies. Two independent researchers coded the articles for themes, and consensus was reached on theme grouping through an iterative process.

RESULTS

Out of 2,031 articles initially screened, 28 met all inclusion criteria and advanced to final analysis. Several key themes emerged, including a lack of provider competency in caring for LGBT patients, lower rates of insurance coverage, greater mental health burden, social and structural determinants of health, policy solutions, and technology and health literacy.

CONCLUSION

There were several domains identified in the literature as barriers to accessing mental healthcare, as well as opportunities to better attend to the mental health needs of these populations. Provider training, implementing health technology solutions, and enacting public policy changes could improve mental health outcomes.

Interventions for Integrating Behavioral Health Services into HIV Clinical Care: A Narrative Review

The integration of behavioral health services within human immunodeficiency virus (HIV) care settings holds promise for improving substance use, mental health, and HIV-related health outcomes for people with HIV. As part of an initiative funded by the Health Resources and Services Administration’s HIV/AIDS Bureau, we conducted a narrative review of interventions focused on behavioral health integration (BHI) in HIV care in the United States (US). Our literature search yielded 19 intervention studies published between 2010 and 2021. We categorized the interventions under 6 approaches: collaborative care; screening, brief intervention, and referral to treatment (SBIRT); patient-reported outcomes (PROs); onsite psychological consultation; integration of addiction specialists; and integration of buprenorphine/naloxone (BUP/NX) treatment. All intervention approaches appeared feasible to implement in diverse HIV care settings and most showed improvements in behavioral health outcomes; however, measurement of HIV outcomes was limited. Future research studies of BHI interventions should evaluate HIV outcomes and assess facilitators and barriers to intervention uptake.

The 2016 United States presidential election's impact on families with transgender adolescents in New England

During and after the 2016 United States (U.S.) presidential election, discriminatory policies and stigmatizing rhetoric have been increasingly directed toward the transgender community at state and national levels. Transgender and/or nonbinary (TNB) adolescents, already at elevated risk for poorer health relative to their cisgender (nontransgender) peers, may have been adversely impacted by the shifting sociopolitical climate. This secondary analysis used qualitative data from the Trans Teen and Family Narratives Project to investigate how perceived shifts in the sociopolitical climate following the 2016 election affected families with TNB adolescents in the New England region of the U.S. (states of Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont). Data included two waves of semistructured interviews conducted with TNB adolescents and their caregivers and siblings (N = 20 families, 60 family members). Two coders analyzed transcripts using a thematic analysis approach. Emergent themes included: contemporary life for trans people in America (e.g., being discriminated against and dehumanized), perceptions of the national sociopolitical climate (e.g., anger toward political figures), forms of resistance and advocacy (e.g., confronting misinformation), and factors amplifying or buffering effects of the sociopolitical climate (e.g., the formation of alliances or coalitions within the family). Findings indicate the 2016 election spurred the redefinition of communication boundaries within, and outside, the immediate family, particularly regarding online communication and social media. TNB adolescents and their families anxiously anticipated changes in the sociopolitical climate and their foreseen impact on TNB adolescents' rights and safety. Implications for family therapy, intervention design, and policy reform are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Housing Needs of Sexual and Gender Minority Older Adults: Implications for Policy and Practice

This study identifies the interconnected needs and concerns of sexual and gender minority (SGM) older adults, with a particular focus on housing, healthcare, transportation, and social support. Data were gathered through seven groups with a sample of SGM-identified adults age 55 and over (N = 50) and analyzed using thematic analysis. The participants seek affordable and inclusive housing options. They identified that access to transportation is paramount in maintaining social support and accessing healthcare. Findings underscore the need for strategies to serve the housing needs of low-income SGM-identified older adults in a nondiscriminatory way, train housing providers in culturally responsive care, meet transportation needs, and provide SGM-inclusive community-based services that reduce isolation.

73 THE NEW CHRONIC DISEASE MANAGEMENT PROGRAMME FOR GENERAL PRACTITIONERS: MAKING THE CASE FOR ITS REVISION TO INCLUDE DEMENTIA

Background

A significant component of the new contract for general practitioners is the chronic disease management programme (CDMP for GPs). Although dementia can be framed as a chronic disease, it was not included in this programme. Its exclusion raises a number of questions including: Should dementia be framed as a chronic disease? Is it feasible to include dementia in a future revised CDMP for GPs? What are the likely benefits and potential risks?

Methods

This presentation focuses on two elements of a larger mixed-methods study, namely: (i) in-depth analysis of the CDMP for GPs, involving a review of the programme’s three main components to test the feasibility of extending it to incorporate dementia; and (ii) qualitative content analysis of data from semi-structured interviews with 12 stakeholders whose expertise is in dementia, chronic disease or both. Both elements were informed by a literature review.

Results

No consensus was found about whether dementia should be framed as a chronic disease. Results showed that it is feasible to extend the annual preventative programme of the CDMP for GPs to include additional modifiable dementia risk factors. While opportunistic case finding for identifying undiagnosed dementia cannot be recommended, a tool is available that would enable GPs identify people with dementia for enrolment on the structured treatment programme. Expected benefits from including dementia in the CDMP for GPs include integrated care pathways, better GP access and record-keeping and greater emphasis on primary and secondary prevention. Expected risks include excessive costs, caregiver burden, increased GP workload and sub-optimal care due to lack of specialist dementia training.

Conclusion

There is a compelling case to support dementia risk reduction in the CDMP for GPs. However, the programme’s current emphasis on self-management and rigidly planned visits could prove problematic for people with dementia and would need substantial revision.

Small mammal sampling incidents related to wild boar (Sus scrofa) in natural peri–urban areas

The wild boar (Sus scrofa) has recently shown continuous population increases in many countries, leading to a rise in conflicts with human activities, including habituation to people and urban areas. Wild boar can disrupt the sampling of small mammals by reducing the number of potential captures. In this study we analysed whether sampling incidents recorded within a small mammal monitoring programme (SEMICE, www.semice.org) might be related to the density of wild boar in a network of protected parks. Our results suggested a peri–urban effect that was independent of wild boar densities in the protected parks; the number of damaged traps increased (rendering them inoperable for captures) and potentially resulted in underestimates of small mammals due to fewer functioning traps in the study area. We hypothesised that this high rate of damage to traps in a small and localised area in a peri–urban park could be related to wild boar associating human presence with greater opportunities to obtain food items of anthropogenic origin.

Sexual Orientation and Gender Identity Data Collection at US Health Centers: Impact of City-Level Structural Stigma in 2018

Objectives. To examine the relationship between city-level structural stigma pertaining to sexual orientation and gender identity (SOGI) and completeness of patient SOGI data collection at US federally qualified health centers (FQHCs). Methods. We used the Human Rights Campaign's Municipal Equality Index to quantify city-level structural stigma against sexual and gender minority people in 506 US cities across 49 states. We ascertained the completeness of SOGI data collection at FQHCs from the 2018 Uniform Data System, which describes FQHC patient demographics and service utilization. We included FQHCs in cities captured by the structural stigma index in multinomial generalized linear mixed models to examine the relationship between city-level structural stigma and SOGI data completeness. Results. FQHCs in cities with more protective sexual orientation nondiscrimination policies reported more complete patient sexual orientation data (adjusted odds ratio [AOR] = 1.6; 95% confidence interval [CI] = 1.2, 2.1). This association was also found for gender identity nondiscrimination policies and gender identity data collection (AOR = 1.7; 95% CI = 1.3, 2.2). Conclusions. Municipal sexual and gender minority nondiscrimination laws are associated with social and municipal environments that facilitate patient SOGI data collection.(Am J Public Health. 2021;111(11):2059-2063. https://doi.org/10.2105/AJPH.2021.306414).

Interventions for addressing trauma among people with HIV: a narrative review

Traumatic experiences are disproportionately prevalent among people with HIV and adversely affect HIV-related health outcomes. As part of a national cooperative agreement funded by the Health Resources and Services Administration's HIV/AIDS Bureau, we searched the literature for interventions designed to address trauma among people with HIV in the U.S. Our search yielded 22 articles on 14 studies that fell into five intervention categories: expressive writing, prolonged exposure therapy, coping skills, cognitive-behavioral approaches integrated with other methods, and trauma-informed care. Thematic elements among the interventions included adaptating existing interventions for subpopulations with a high burden of trauma and HIV, such as transgender women and racial/ethnic minorities; addressing comorbid substance use disorders; and implementing organization-wide trauma-informed care approaches. Few studies measured the effect of the interventions on HIV-related health outcomes. To address the intersecting epidemics of HIV and trauma, it is critical to continue developing, piloting, and evaluating trauma interventions for people with HIV, with the goal of wide-scale replication of effective interventions in HIV settings.

Acceptability and Feasibility of Collecting Sexual Orientation and Expanded Gender Identity Data in Urology and Oncology Clinics

Purpose: We evaluated the acceptability and feasibility of collecting sexual orientation and gender identity (SOGI) data in oncology and urology clinical settings. Methods: We surveyed 101 urology and 104 oncology clinic patients with a standardized sexual orientation question with six response options, "lesbian, gay, or homosexual;" "straight or heterosexual;" "bisexual;" "something else;" "do not know;" and "choose not to disclose." Next, we added the sexual orientation question and an expanded gender identity question to the electronic medical record (EMR) and analyzed data on the first 450 urology and 103 oncology patients. Acceptability and feasibility were assessed based on responses to the survey and patient intake forms. Results: In the acceptability survey, only 3% of urology and 4% of oncology patients selected "choose not to disclose." Over 90% of patients in both clinics assessed the sexual orientation question as understandable and easy to answer. In all, 79% of urology and 73% of oncology patients stated they would answer it in their EMR, but only 56% of urology and 54% of oncology patients described the information as important. Sexual minority patients were as likely as heterosexual patients to state they would answer the question. Only 5% of patients selected "choose not to disclose" for sexual orientation, and <1% for the expanded gender identity question. Conclusion: Adding SOGI questions to the EMR appears to be acceptable and feasible and the sexual orientation question was understandable to a large majority of urology and oncology patients. ClinicalTrials.gov ID: NCT03343093.

Acceptability and Feasibility of Collecting Sexual Orientation and Expanded Gender Identity Data in Urology and Oncology Clinics

Purpose: We evaluated the acceptability and feasibility of collecting sexual orientation and gender identity (SOGI) data in oncology and urology clinical settings. Methods: We surveyed 101 urology and 104 oncology clinic patients with a standardized sexual orientation question with six response options, "lesbian, gay, or homosexual;" "straight or heterosexual;" "bisexual;" "something else;" "do not know;" and "choose not to disclose." Next, we added the sexual orientation question and an expanded gender identity question to the electronic medical record (EMR) and analyzed data on the first 450 urology and 103 oncology patients. Acceptability and feasibility were assessed based on responses to the survey and patient intake forms. Results: In the acceptability survey, only 3% of urology and 4% of oncology patients selected "choose not to disclose." Over 90% of patients in both clinics assessed the sexual orientation question as understandable and easy to answer. In all, 79% of urology and 73% of oncology patients stated they would answer it in their EMR, but only 56% of urology and 54% of oncology patients described the information as important. Sexual minority patients were as likely as heterosexual patients to state they would answer the question. Only 5% of patients selected "choose not to disclose" for sexual orientation, and <1% for the expanded gender identity question. Conclusion: Adding SOGI questions to the EMR appears to be acceptable and feasible and the sexual orientation question was understandable to a large majority of urology and oncology patients. ClinicalTrials.gov ID: NCT03343093.

Transgender-related discrimination and substance use, substance use disorder diagnosis and treatment history among transgender adults

BACKGROUND

Substantial research gaps exist regarding the relationship between transgender-related discrimination and substance use outcomes for transgender adults, with few studies accounting for other experiences of victimization.

METHODS

Transgender adults (N = 600) from Massachusetts and Rhode Island completed a survey online or in-person. Multivariable linear and logistic regression models examined the association between lifetime experiences of transgender-related discrimination using the validated 11-item Everyday Discrimination Scale (theoretical range = 0-44) and substance use outcomes: past 12-month substance use frequency, lifetime substance use disorder (SUD) diagnosis, and substance use treatment (SUTx) history. All models were adjusted for age, gender identity, race, survey modality, childhood physical/sexual abuse, intimate partner violence, and discrimination attributable to other reasons than being transgender.

RESULTS

The mean transgender-related discrimination score was 20.8 (SD = 9.6, range = 0-44). Overall, 11.8 % of the sample had a SUD diagnosis and 11.0 % had received SUTx. In separate multivariable models adjusted for sociodemographic and victimization experiences, the highest quartile of transgender-related discrimination was significantly associated with higher past 12-month substance use (B = 1.44; aR² = 0.13; p = .009), SUD diagnosis (aOR = 3.64; 95 % CI = 1.46-9.07; p = .006), and lifetime treatment history (aOR = 3.93; 95 % CI = 1.50-10.21; p = .005).

CONCLUSIONS

There was a significant positive association between experiencing high levels of transgender-related discrimination and substance use outcomes among the transgender adults sampled. Longitudinal research is needed to understand the specific mediators driving these relationships and to address the implications of transgender-related discrimination on SUD treatment utilization.

INI1/SMARCB1 Rpt1 domain mimics TAR RNA in binding to integrase to facilitate HIV-1 replication

INI1/SMARCB1 binds to HIV-1 integrase (IN) through its Rpt1 domain and exhibits multifaceted role in HIV-1 replication. Determining the NMR structure of INI1-Rpt1 and modeling its interaction with the IN-C-terminal domain (IN-CTD) reveal that INI1-Rpt1/IN-CTD interface residues overlap with those required for IN/RNA interaction. Mutational analyses validate our model and indicate that the same IN residues are involved in both INI1 and RNA binding. INI1-Rpt1 and TAR RNA compete with each other for IN binding with similar IC50 values. INI1-interaction-defective IN mutant viruses are impaired for incorporation of INI1 into virions and for particle morphogenesis. Computational modeling of IN-CTD/TAR complex indicates that the TAR interface phosphates overlap with negatively charged surface residues of INI1-Rpt1 in three-dimensional space, suggesting that INI1-Rpt1 domain structurally mimics TAR. This possible mimicry between INI1-Rpt1 and TAR explains the mechanism by which INI1/SMARCB1 influences HIV-1 late events and suggests additional strategies to inhibit HIV-1 replication.

Exploring the Association Between the Quality of HIV Care in Nursing Homes and Hospitalization

ABSTRACT

Persons living with HIV/AIDS (PLWH) are living long enough to need age-related and HIV-related nursing home (NH) care. Nursing home quality of care has been associated with risk for hospitalization, but it is unknown if quality of HIV care in NHs affects hospitalization in this population. We assessed HIV care quality with four national measures adapted for the NH setting. We applied the measures to 2011-2013 Medicare claims linked to Minimum Data Set assessments of resident health, prescription dispensing data, and national reports of NH characteristics. Cox proportional hazards models calculated the risk of all-cause and HIV/AIDS-related hospitalization by HIV care compliance. We identified 1,246 PLWH in 201 NHs with 382 all-cause and 63 HIV/AIDS-related hospitalizations. Nursing home HIV care compliance varied from 24.9% to 64.7%. After regression adjustment, we could detect no difference in all-cause or HIV/AIDS-related hospitalizations by NH HIV care compliance. We postulate that the lack of association may be due to inappropriate HIV care quality measures that do not accurately represent NHs ability to care for PLWH. There is urgent need to create valid NH HIV care quality measures.

Negative Transgender-Related Media Messages Are Associated with Adverse Mental Health Outcomes in a Multistate Study of Transgender Adults

Purpose: The purpose of this study was to examine the extent to which transgender people have observed negative transgender-related messages in the media and the relationship between negative media message exposure and the mental health of transgender people. Methods: In 2019, 545 transgender adults completed an online survey assessing demographics, negative transgender-related media messages, violence, and mental health. Separate multivariable logistic regression models examined the association of frequency of negative media exposure and clinically significant symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and global psychological distress. Results: Mean age of the sample was 31.2 years (standard deviation [SD] = 11.2). Nearly half identified as nonbinary (42.2%), 82.0% were White, non-Hispanic, 56.9% had a college degree, and 67.0% were financially insecure. The majority reported experiencing childhood abuse (60.6%) and abuse in adulthood (58.0%). The mean frequency of exposure to negative transgender-related media was 6.41 (SD = 2.9) with 97.6% of the sample reporting exposure to negative media depictions of transgender people across a range of mediums. In separate multivariable models adjusted for age, gender identity, race, education, income, and childhood/adult abuse, more frequent exposure to negative depictions of transgender people in the media was significantly associated with clinically significant symptoms of depression (adjusted odds ratio [aOR] = 1.18; 95% confidence interval [CI] = 1.08-1.29; p = 0.0003); anxiety (aOR = 1.26; 95% CI = 1.14-1.40; p < 0.0001); PTSD (aOR = 1.25; 95% CI = 1.16-1.34; p < 0.0001); and global psychological distress (aOR = 1.28; 95% CI = 1.15-1.42; p < 0.0001). Conclusion: Exposure to negative media messages from multiple sources necessitates multilevel interventions to improve the mental health of transgender people and curb stigma at its source.

Legal gender marker and name change is associated with lower negative emotional response to gender-based mistreatment and improve mental health outcomes among trans populations

Background

In recent years, Massachusetts (MA) and Rhode Island (RI) joined a growing list of states allowing residents to easily change the gender marker and name on government-identification (ID) documents. This was an important change for transgender and gender diverse (trans) residents, who face frequent mistreatment and thus for whom legal gender affirmation is critical. Little is known about associations between legal gender affirmation and psychological outcomes.

Methods

We examined associations between legal gender affirmation (i.e., having changed gender marker/name on neither, one, or both a passport and state ID), upsetting responses to gender-based mistreatment, and mental health outcomes in a sample of trans MA and RI residents. Analyses controlled for gender identity, age, race/ethnicity, education, employment, income, and insurance status.

Findings

Legal gender affirmation was significantly associated with lower reports of depression, anxiety, somatization, global psychiatric distress, and upsetting responses to gender-based mistreatment.

Conclusions

These data provide corroborate recent studies suggesting having pursued legal gender affirmation may be protective. Findings bolster calls to increase structural support for trans individuals, including enactment of state policies easing legal gender affirmation.

Assessing the Quality of Human Immunodeficiency Virus Care in Nursing Homes

BACKGROUND

Quality of human immunodeficiency virus (HIV) care in nursing homes (NHs) has never been measured.

DESIGN

A cross-sectional study.

SETTING

NHs.

PARTICIPANTS

A total of 203 NHs and 1375 persons living with HIV.

MEASUREMENTS

Medicare claims from 2011 to 2013 were linked to assessments of resident health, prescription dispensing data, and national reports of NH characteristics. Five nationally validated HIV care quality measures (prescription of antiretroviral therapy; CD4/viral load monitoring; frequency of medical visits; gaps in medical visits; and Pneumocystis pneumonia prophylaxis) were adapted and applied to NHs. Logistic regression predicted compliance by organizational factors. Random intercept logistic regression predicted if persons living with HIV received care by person and organizational factors.

RESULTS

Compliance ranged from 43.3% (SD = 31.1%) for CD4/viral load monitoring to 92.4% (SD = 13.6%) for gaps in medical visits. More substantiated complaints against an NH decreased the likelihood of high compliance with CD4/viral load monitoring (odds ratio [OR] = 0.846; 95% confidence interval [CI] = 0.726-0.986), while NH-reported incidents increased the likelihood of high compliance with pneumocystis pneumonia prophylaxis (OR = 1.173; 95% CI = 1.044-1.317). Differences between NHs explained 21.2% or less of variability in receipt of care.

CONCLUSIONS

Since 2013, the population with HIV and NH HIV care quality has inevitably evolved; however, this study provides previously unknown baseline metrics on NH HIV care quality and highlights significant challenges when measuring HIV care in NHs. J Am Geriatr Soc 68:1226-1234, 2020.

Access to Health Services Among Young Adult Gay Men in New York City

This research is a cross-sectional study of young adult gay men (YAGM), ages 18 to 29, that aims to understand their health-care access including: having a primary care provider (PCP), frequency of health-care visits, and instances of foregone health care. Surveys were conducted with a modified time-space sample of 800 YAGM in New York City (NYC). Surveys were conducted between November 2015 and June 2016. This study examined associations between sociodemographic characteristics and health-care access using multivariable logistic regression models. In multivariable logistic regression models, there were higher odds of having a PCP among participants enrolled in school (Adjusted Odds Ratio [AOR] = 1.85, 95% CI [1.18, 2.91], p < .01) and covered by insurance (AOR = 21.29, 95% CI [11.77, 38.53], p < .001). Modeling indicated higher odds of more than one health visit in the past 12 months for non-White participants (AOR = 2.27, 95% CI [1.43, 3.63], p < .001), those covered by insurance (AOR = 3.10, 95% CI [1.06, 9.04], p < .05), and those who disclosed their sexual orientation to their PCP (AOR = 2.99, 95% CI [1.58, 5.69], p < .001). Participants with insurance were less likely to report instances of foregone care (AOR = 0.21, 95% CI [0.21, 0.13], p < .001). Understanding the facilitators and barriers to health-care access among YAGM populations is of critical importance, as many YAGM between the ages of 18 and 29 are establishing their access to health care without parental guidance. Health-care access, including the decision to forego care, can represent a missed opportunity for primary prevention and early diagnosis of health issues, as well as more effective, less invasive, and less costly treatments.

Advantages of Molecular Weight Identification during Native MS Screening

Native mass spectrometry detection of ligand-protein complexes allowed rapid detection of natural product binders of apo and calcium-bound S100A4 (a member of the metal binding protein S100 family), T cell/transmembrane, immunoglobulin (Ig), and mucin protein 3, and T cell immunoreceptor with Ig and ITIM (immunoreceptor tyrosine-based inhibitory motif) domains precursor protein from extracts and fractions. Based on molecular weight common hits were detected binding to all four proteins. Seven common hits were identified as apigenin 6-C-β-D-glucoside 8-C-α-L-arabinoside, sweroside, 4',5-dihydroxy-7-methoxyflavanone-6-C-rutinoside, loganin acid, 6-C-glucosylnaringenin, biochanin A 7-O-rutinoside and quercetin 3-O-rutinoside. Mass guided isolation and NMR identification of hits confirmed the mass accuracy of the ligand in the ligand-protein MS complexes. Thus, molecular weight ID from ligand-protein complexes by electrospray ionization Fourier transform mass spectrometry allowed rapid dereplication. Native mass spectrometry using electrospray ionization Fourier transform mass spectrometry is a tool for dereplication and metabolomics analysis.

Advocacy for Gender Affirming Care: Learning from the Injectable Estrogen Shortage

Hormone therapy is medically necessary for many transgender individuals. The U.S. Food and Drug Administration (FDA) and pharmaceutical companies' failure to guarantee a supply of injectable estrogen in 2016 and 2017 for transgender individuals is a violation of their right to comprehensive medical treatment, free of discrimination. A series of advocacy actions eventually led to all formulations of injectable estrogen being restored to market; however, long-term solutions to supply interruptions of injectable estrogen are needed. Long-term solutions should address the lack of federally funded research and, consequently, evidence-based practice on hormone therapy for gender affirmation.

Dynamic intramolecular regulation of the histone chaperone nucleoplasmin controls histone binding and release

Nucleoplasmin (Npm) is a highly conserved histone chaperone responsible for the maternal storage and zygotic release of histones H2A/H2B. Npm contains a pentameric N-terminal core domain and an intrinsically disordered C-terminal tail domain. Though intrinsically disordered regions are common among histone chaperones, their roles in histone binding and chaperoning remain unclear. Using an NMR-based approach, here we demonstrate that the Xenopus laevis Npm tail domain controls the binding of histones at its largest acidic stretch (A2) via direct competition with both the C-terminal basic stretch and basic nuclear localization signal. NMR and small-angle X-ray scattering (SAXS) structural analyses allowed us to construct models of both the tail domain and the pentameric complex. Functional analyses demonstrate that these competitive intramolecular interactions negatively regulate Npm histone chaperone activity in vitro. Together these data establish a potentially generalizable mechanism of histone chaperone regulation via dynamic and specific intramolecular shielding of histone interaction sites.

High Rates of Access to Health Care, Disclosure of Sexuality and Gender Identity to Providers Among House and Ball Community Members in New York City

The House and Ball community is an important cultural manifestation of resiliency for Black and Latino gay and bisexual men and transgender women. Participants at the August 2013 House of Latex Ball in New York City were surveyed about insurance coverage, health care access, experiences in health care, and housing instability. The sample (n = 367) was 58% Black/African American and 20% Hispanic/Latino, with a mean age of 31. Fifty-five percent were gay and bisexual men. Although only 6% identified as transgender, nearly one half were gender nonconforming. Strong majorities had health insurance, were in regular medical care, and were "out" to their providers. Some were unstably housed and had recently exchanged sex for shelter or money. High rates of health care access and disclosure indicate resiliency and agency. Unstable housing and income insecurity may be structural drivers of vulnerability for this population to HIV infection and other health risks.

An end to lifetime blood donation ban in Israel for MSM would be a major step toward a science-based policy that reduces stigma

In recent years, countries around the world have revised their blood donation policies regarding gay and bisexual men, and other men who have sex with men (MSM). The United States lifted the lifetime ban on MSM from donating blood in 2015, replacing it with a 1 year deferral policy allowing MSM to donate if they abstain from sex for 12 months. Other countries followed suit, while Italy and Spain have implemented deferral policies based on individual risk assessments regardless of sexual orientation. If Israel were to adopt a one year deferral policy for MSM, as recommended by Drs. Ginsberg et al. in this issue, the increase in risk to the blood supply would be minimal. Moving to a 1 year deferral policy would be an important step forward, but it could still be seen as stigmatizing to gay and bisexual men. We recommend that Israel consider a deferral policy based on individual risk assessment rather than a blanket deferral for all MSM. MSM can engage in low- and high-risk sexual behaviors. Those who consistently engage in low-risk behaviors, such as using condoms and pre-exposure prophylaxis consistently, pose little risk to the blood supply. An individual risk assessment policy would screen potential donors of all sexual orientations for low-, medium-, and high-risk behaviors. Potential donors identified as high-risk, such as injection drug users, would justifiably be subject to lengthy or permanent bans. MSM who engage in low-risk sexual behaviors would be allowed to donate without deferral. Medium-risk donors, such as men who have recently had unprotected anal sex with another man, would be subject to a deferral period of 1 month, which is in line with the window period of current HIV screening technology. Most fourth generation HIV tests can detect HIV within a month, and the nucleic acid test used to screen blood can detect HIV in just 9–11 days. Various studies have developed questions for ascertaining HIV risk among MSM which could be used in blood donor questionnaires. Using tablets or other technology that enhances privacy to conduct the blood donor questionnaire could improve collection of this sensitive information.

Stigma, medical mistrust, and perceived racism may affect PrEP awareness and uptake in black compared to white gay and bisexual men in Jackson, Mississippi and Boston, Massachusetts

Gay and bisexual men and other men who have sex with men (MSM) account for more than two thirds of new HIV infections in the U.S., with Black MSM experiencing the greatest burden. Antiretroviral pre-exposure prophylaxis (PrEP) can reduce MSM's vulnerability to HIV infection. Uptake of PrEP has been limited, particularly among racial and ethnic minority MSM. Four semi-structured focus groups with gay and bisexual men and other MSM at risk for HIV infection were convened in Boston and Jackson in late 2013. The analysis plan utilized a within-case, across-case approach to code and analyze emerging themes, and to compare results across the two cities. Participants recruited in Jackson were primarily Black gay men, while Boston participants were mostly non-Hispanic White gay men. Participants in both sites shared concerns about medication side effects and culturally insensitive health care for gay men. Jackson participants described stronger medical mistrust, and more frequently described experiences of anti-gay and HIV related stigma. Multiple addressable barriers to PrEP uptake were described. Information about side effects should be explicitly addressed in PrEP education campaigns. Providers and health departments should address medical mistrust, especially among Black gay and bisexual men and other MSM, in part by training providers in how to provide affirming, culturally competent care. Medicaid should be expanded in Mississippi to cover low-income young Black gay and bisexual men and other MSM.