Caregiving Among Older Black Same-Gender-Loving Women During the COVID-19 Pandemic: Findings From Qualitative Research

BACKGROUND AND OBJECTIVES

Few data on caregiving during the coronavirus disease 2019 pandemic use an intersectional lens to attend to how multiple social categories, such as gender, age, race, and sexual orientation, shape caregiving experiences. This analysis sought to explore caregiving experiences of aging Black same-gender-loving women.

RESEARCH DESIGN AND METHODS

Sixteen focus groups were conducted with 4-8 participants each (N = 102) from across the United States. Audio-recorded discussions lasted for approximately 90 min and were transcribed verbatim. Two analysts coded transcripts for discussions related to caregiving and used content analysis to identify themes.

RESULTS

Participants engaged in caregiving for children, parents, family, friends, and neighbors. They provided physical, economical, instrumental, and/or secondary caregiving; and sometimes received care themselves. The pandemic heavily affected their stress level and mental health as well as their intimate partner relationships. Discussions mostly offered descriptions of increased caregiving difficulty caused by the pandemic. However, a few participants identified ways the pandemic made caregiving easier; changed caregiving without making it easier or harder; or thwarted their ability to provide care.

DISCUSSION AND IMPLICATIONS

Older Black same-gender-loving women described some pandemic caregiving experiences that diverged from the existing literature, demonstrating the importance of considering how gender, race, age, and sexual orientation affect caregiving experiences during a pandemic fraught with health inequities. Ensuring the multiply marginalized caregivers have access to the practical and emotional support they need is critical for advancing health equity and preparing for future pandemics.

Health status of transgender people globally: A systematic review of research on disease burden and correlates

BACKGROUND AND OBJECTIVES

Transgender and gender diverse (trans) health research has grown rapidly, highlighting the need to characterize the scientific evidence base. We conducted a systematic review of peer-reviewed research on disease burden and correlates in trans adolescents and adults over a 20-month period to identify knowledge gaps and assess methodological characteristics including measurement of gender identity, community engagement, and study quality.

DATA SOURCES, ELIGIBILITY CRITERIA, AND SYNTHESIS METHODS

We searched seven databases using terms related to (a) transgender populations and (b) health or disease. Eligible studies were in English, French, or Spanish and reported original quantitative data on mental health or substance use conditions, infectious diseases, or non-communicable conditions in at least 25 trans individuals aged 15+. Quality assessment was performed in duplicate on a 10% sample of articles and findings were summarized using narrative synthesis.

RESULTS

The 328 included studies were conducted in 45 countries, with most from North America (54%) and limited research from South Asia (3%), Sub-Saharan Africa (3%), and the Middle East and North Africa (2%). Most studies used cross-sectional designs (73%) and convenience sampling (65%). Only 30% of studies reported any form of community engagement. Mental health and substance use disorders were the most studied area (77% of studies) and non-communicable conditions the least (16%). Available data indicated that trans populations experience high disease burden with considerable heterogeneity within and across settings. Of 39 articles assessed for quality, 80% were rated as fair, 18% as poor, and 3% as good quality.

CONCLUSIONS AND IMPLICATIONS

Geographic, gender-specific, and topical gaps remain in trans health, but we found more research from African countries, with transmasculine people, and on non-communicable conditions than previous syntheses. Areas for growth in trans health research include community engagement, non-binary health, chronic and age-related conditions, and health determinants.

REGISTRATION

PROSPERO CRD42021234043.

Computational phenotyping within electronic healthcare data to identify transgender people in the United States: A narrative review

PURPOSE

With the expansion of research utilizing electronic healthcare data to identify transgender (TG) population health trends, the validity of computational phenotype (CP) algorithms to identify TG patients is not well understood. We aim to identify the current state of the literature that has utilized CPs to identify TG people within electronic healthcare data and their validity, potential gaps, and a synthesis of future recommendations based on past studies.

METHODS

Authors searched the National Library of Medicine's PubMed, Scopus, and the American Psychological Association PsycInfo's databases to identify studies published in the United States that applied CPs to identify TG people within electronic healthcare data.

RESULTS

Twelve studies were able to validate or enhance the positive predictive value (PPV) of their CP through manual chart reviews (n = 5), hierarchy of code mechanisms (n = 4), key text-strings (n = 2), or self-surveys (n = 1). CPs with the highest PPV to identify TG patients within their study population contained diagnosis codes and other components such as key text-strings. However, if key text-strings were not available, researchers have been able to find most TG patients within their electronic healthcare databases through diagnosis codes alone.

CONCLUSION

CPs with the highest accuracy to identify TG patients contained diagnosis codes along with components such as procedural codes or key text-strings. CPs with high validity are essential to identifying TG patients when self-reported gender identity is not available. Still, self-reported gender identity information should be collected within electronic healthcare data as it is the gold standard method to better understand TG population health patterns.

Food Insecurity Is High in a Multi-Site Cohort of Transgender Women Vulnerable to or Living with HIV in the Eastern and Southern United States: Baseline Findings from the LITE Cohort

The prevalence and correlates of food insecurity-the unavailability of food and limited access to it-have not been adequately considered among transgender women (TW), particularly alongside other health-related conditions burdening this population, such as HIV infection. This study examined the prevalence and correlates of food insecurity among TW. Between 2018 and 2020, 1590 TW in the Eastern and Southern U.S. completed a multi-site baseline assessment (socio-behavioral survey and HIV testing). Descriptive statistics were calculated and multivariable Poisson models with robust error variance were used to estimate prevalence ratios and 95% confidence intervals for correlates of food insecurity (dichotomized as sometimes-to-always vs. seldom-to-never running out of food). Eighteen percent of TW were living with HIV and nearly half of participants (44%) reported food insecurity. Correlates of food insecurity included being Black, multiracial, or another race/ethnicity; having < college education, low income, unstable housing, and high anticipated discrimination; and a history of sex work and sexual violence (all p < 0.05). Food insecurity was highly prevalent among TW. Current programs to provide food support do not adequately meet the needs of TW. HIV pr evention and care programs may benefit from addressing food insecurity.

Tucking Practices and Attributed Health Effects in Transfeminine Individuals

Tucking is the gender-affirming practice of putting the penis and scrotum between the buttocks and moving the testes up into the inguinal canals. Our study explores tucking and health effects among transfeminine adults (n=79). Most (74.7%) had practiced tucking and among them, 67.2% had tucked ≥7 years. When tucking, the majority (84.5%) tucked daily and almost half (44.8%) ≥17 h/day. Half (50.0%) reported concern about the health effects of tucking. Itching, rash, and testicular pain were the most commonly reported health effects. Health care providers should use a harm reduction approach in addressing tucking-related concerns and supporting patients who tuck.

Access to healthcare among transgender women living with and without HIV in the United States: associations with gender minority stress and resilience factors

BACKGROUND

Transgender women (TW) experience significant inequities in healthcare access and health disparities compared to cisgender populations. Access to non-transition related healthcare is understudied among TW. We aimed to assess the association between access to care and gender minority stress and resilience factors among TW living with and without HIV in eastern and southern United States.

METHODS

This study was a cross-sectional analysis of baseline data drawn from a cohort of 1613 adult TW from the LITE Study. The cohort permitted participation through two modes: a site-based, technology-enhanced mode and an exclusively online (remote) mode. Exploratory and confirmatory factor analyses determined measurement models for gender minority stress, resilience, and healthcare access. Structural equation modeling was used to assess the relationships between these constructs. Models were evaluated within the overall sample and separately by mode and HIV status.

RESULTS

Higher levels of gender minority stress, as measured by anticipated discrimination and non-affirmation were associated with decreased access to healthcare. Among TW living with HIV, higher levels of anticipated discrimination, non-affirmation, and social support were associated with decreased healthcare access. Among TW living without HIV in the site-based mode, resilience was positively associated with positive healthcare experiences and inversely associated with barriers to healthcare access. Among TW living without HIV in the online mode, anticipated discrimination was associated with barriers to healthcare access; resilience was positively associated with positive healthcare experiences and inversely associated with barriers to healthcare access.

CONCLUSIONS

Gender minority stress was associated with increased barriers to healthcare access among TW in the US, regardless of HIV status. Resilience factors did not mediate this effect. Interventions aiming to increase healthcare access among TW can be aided by efforts to mitigate drivers of gender minority stress and improve patient experiences in healthcare facilities.

As Much As I Can - Utilizing Immersive Theatre to Reduce HIV-Related Stigma and Discrimination Toward Black Sexual Minority Men

BACKGROUND

Despite advances in biomedical HIV prevention modalities such as pre-exposure prophylaxis to prevent the transmission of HIV, racial/ethnic and sexual/gender minority populations are disproportionately impacted by HIV epidemic. Alarming rates of HIV have persisted among Black gay and bisexual men, particularly in Southern states.

METHODS

Utilizing data from the ViiV ACCELERATE! initiative, we explored the impact of As Much As I Can, an immersive theatre production, on HIV-related stigma behaviors. A self-administered post-performance survey was conducted with a cohort (n = 322) of randomly selected audience members.

RESULTS

Overall, the results showed participants had a highly favorable experience, rating the performance with a mean score of 9.77/10. Respondents indicated they intended to change behaviors to promote HIV prevention education and to reduce stigma and discrimination including: (1) Say something if I hear stigmatizing language against people living with HIV (75.4%), (2) Say something if I hear anti-gay language (69.7%) and (3) Tell others about HIV prevention options (e.g., PrEP, PEP, condoms (64.1%). The findings show there is an association between HIV-related behavior intention and linkage to HIV care. Respondents who reported they were more likely to say something about HIV stigma were almost three times (O.R. 2.77; 95% C.I. 0.98-7.8) more likely to indicate they would follow up with a healthcare professional.

CONCLUSIONS

This study suggests that immersive theatre is an effective method for communicating HIV prevention education and reducing HIV-related structural stigma and discrimination that increases HIV vulnerability for Black sexual minority men.

Engaging Black sexual minority women in breast cancer research: Lessons in community partnerships

BACKGROUND

Black sexual minority women (BSMW) face significant breast cancer health inequities and are underrepresented in health research because of historical and present-day exclusion. However, there exists no peer-reviewed literature on best practices for the inclusion of BSMW in cancer research. "Our Breast Health: The Access Project" was a national primary data collection study in June 2018 through October 2019 that aimed to identify facilitators and barriers to breast cancer care among BSMW, and that successfully recruited the highest number of BSMW for any national breast cancer screening study at the time of its publication.

METHODS

The present analysis highlights best practices for reaching BSMW by examining by how effective various recruitment sources were at recruiting BSMW. Recruitment partners were grouped into several categories: (1) cancer focused, (2) Black women or sexual minority women focused, (3) BSMW focused, (4) social media, and (5) other. Then logistic regression was used to estimate the odds that a particular recruitment source category could recruit BSMW compared with other categories.

RESULTS

Partnerships with community-based organizations led by and intended for BSMW were the most successful at recruiting BSMW, demonstrating the importance of an intersectional approach to recruitment. Community-based organizations focused on BSMW specifically were 26 times more successful in recruiting BSMW to the study compared with recruiting Black women who were not sexual minorities (odds ratio, 26.43 [95% CI, 7.50-93.10]).

CONCLUSIONS

Successful recruitment enables breast cancer research grounded in the perspectives of BSMW, which can generate key findings that have the potential to remedy longstanding health inequities for this population.

Piloting the Sexual and Gender Minority Cancer Curricular Advances for Research and Education (SGM Cancer CARE) Workshop: Research Training in the Service of SGM Cancer Health Equity

The purpose of this study is to describe the context, curriculum design, and pilot evaluation of the educational program "Sexual and Gender Minority Cancer Curricular Advances for Research and Education" (SGM Cancer CARE), a workshop for early-career researchers and healthcare providers interested in gaining knowledge and skills in sexual and gender minority (SGM) cancer research and healthcare advocacy. A needs assessment of a sample of clinicians and researchers (n = 104) and feedback from an Advisory Board informed the curriculum design of the SGM Cancer CARE workshop. Four SGM-tailored modules, focusing on epidemiology, clinical research, behavioral science and interventions, and community-based participatory approaches, were developed and tested in a 2.5-day virtual format among 19 clinicians and researchers. A fifth module to provide feedback to participants on brief presentations about their SGM cancer research ideas or related efforts was added later. A mixed-methods evaluation comprised of pre- and post-modular online evaluation surveys and virtual focus groups was used to determine the degree to which the workshop curriculum met participant needs. Compared to pre-module evaluations, participants reported a marked increase in SGM cancer research knowledge in post-module scores. Quantitative results were supported by our qualitative findings. In open field response survey questions and post-workshop focus groups, participants reported being extremely pleased with the content and delivery format of the SGM Cancer CARE workshop. Participants did regret not having the opportunity to connect with instructors, mentors, and colleagues in person. The SGM Cancer CARE curriculum was shown to increase the knowledge, skills, and level of preparedness of early-career clinicians and scientists to conduct culturally relevant and appropriate research needed to improve care for SGM persons across the cancer care continuum from prevention to survivorship.

Validation of an administrative algorithm for transgender and gender diverse persons against self-report data in electronic health records

OBJECTIVE

To adapt and validate an algorithm to ascertain transgender and gender diverse (TGD) patients within electronic health record (EHR) data.

METHODS

Using a previously unvalidated algorithm of identifying TGD persons within administrative claims data in a multistep, hierarchical process, we validated this algorithm in an EHR data set with self-reported gender identity.

RESULTS

Within an EHR data set of 52 746 adults with self-reported gender identity (gold standard) a previously unvalidated algorithm to identify TGD persons via TGD-related diagnosis and procedure codes, and gender-affirming hormone therapy prescription data had a sensitivity of 87.3% (95% confidence interval [CI] 86.4-88.2), specificity of 98.7% (95% CI 98.6-98.8), positive predictive value (PPV) of 88.7% (95% CI 87.9-89.4), and negative predictive value (NPV) of 98.5% (95% CI 98.4-98.6). The area under the curve (AUC) was 0.930 (95% CI 0.925-0.935). Steps to further categorize patients as presumably TGD men versus women based on prescription data performed well: sensitivity of 97.6%, specificity of 92.7%, PPV of 93.2%, and NPV of 97.4%. The AUC was 0.95 (95% CI 0.94-0.96).

CONCLUSIONS

In the absence of self-reported gender identity data, an algorithm to identify TGD patients in administrative data using TGD-related diagnosis and procedure codes, and gender-affirming hormone prescriptions performs well.

Health-care providers' perspectives on an HIV patient navigation training to improve uptake of PrEP among Black sexual minority men

This article examines implementational factors associated with an HIV patient navigation training intervention for health care professionals working with Black sexual minority men to improve access to and uptake of HIV prevention services among Black MSM. Utilizing qualitative analysis to better understand healthcare professionals' perceptions of the training program, we conducted a thematic content analysis based on constructs from Professional Network and Reach Model-Systems Model Approach (PNRSMA) framework. Data analysis revealed four major themes: 1) Knowledge and skill building, 2) Novel and Innovation, 3) Barriers to Implementation, and 4) Recommendations and Future Directions. Implementation factors such as appropriate facilitators, content, mode of delivery, learning strategies, and understanding structural barriers were important to training success. Participants highlighted innovation strategies such as the use of social media and interactive communication (e.g. role-playing and bi-directional communication) enhanced learning and skill-building. The expansion of training to include other affected groups such as women and bisexual individuals and increasing the duration of the training emerged as areas for improvement and effectiveness. Our analysis of an HIV patient navigation training revealed important findings to improve the implementation process to increase uptake of PrEP and other HIV prevention, care and treatment services.

Assessing and Addressing the Risk of Venous Thromboembolism Across the Spectrum of Gender Affirming Care: A Review

OBJECTIVE

Accumulating evidence demonstrates that gender affirming hormone therapy (GAHT) improves mental health outcomes in transgender persons. Data specific to the risks associated with GAHT for transgender persons continue to emerge, allowing for improvements in understanding, predicting, and mitigating adverse outcomes while informing discussion about desired effects. Of particular concern is the risk of venous thromboembolism (VTE) in the context of both longitudinal GAHT and the perioperative setting. Combining what is known about the risk of VTE in cisgender individuals on hormone therapy (HT) with the evidence for transgender persons receiving HT allows for an informed approach to assess underlying risk and improve care in the transgender community.

OBSERVATIONS

Hormone formulation, dosing, route, and duration of therapy can impact thromboembolic risk, with transdermal estrogen formulations having the lowest risk. There are no existing risk scores for VTE that consider HT as a possible risk factor. Risk assessment for recurrent VTE and bleeding tendencies using current scores may be helpful when assessing individual risk. Gender affirming surgeries present unique perioperative concerns, and certain procedures include a high likelihood that patients will be on exogenous estrogens at the time of surgery, potentially increasing thromboembolic risk.

CONCLUSIONS AND RELEVANCE

Withholding GAHT due to potential adverse events may cause negative impacts for individual patients. Providers should be knowledgeable about the management of HT in transgender individuals of all ages, as well as in the perioperative setting, to avoid periods in which transgender individuals are off GAHT. Treatment decisions for both anticoagulation and HT should be individualized and tailored to patients' overall goals and desired outcomes, given that the physical and mental health benefits of gender affirming care may outweigh the risk of VTE.

Hormone Prescription and HIV Screening/Preventive Practices Among Clinicians Providing Care for Transgender Individuals

Purpose

Through a survey-based approach, we sought to investigate regional differences in gender-affirming hormone therapy (GAHT) prescribing practices, as well as HIV screening and prevention practices among clinicians providing care to transgender individuals.

Methods

Our survey was disseminated between December 2019 and January 2021 to clinicians who prescribe GAHT within New England (United States). Between-group differences in GAHT prescribing and HIV screening/prevention practices were evaluated by practice setting and subspecialty.

Results

Of the 20 survey respondents, 55% practiced in health care settings affiliated with an academic institution, 45% practiced in a community-based health care setting, and 30% were Endocrinologists. Clinicians in community-based health care settings reported more frequently prescribing oral 17β-estradiol (p=0.02) and spironolactone (p=0.007) for feminizing GAHT compared with clinicians in health care settings affiliated with an academic institution, who reported more frequently prescribing leuprolide (p=0.03). For masculinizing GAHT, clinicians from health care settings affiliated with an academic institution reported more frequently prescribing topical testosterone (p=0.03). There were no significant between-group differences in reported barriers to initiation or reasons for stopping GAHT. While non-Endocrinologists reported "often" or "always" offering HIV screening, most Endocrinologists reported "rarely" or "never" offering HIV screening and "rarely" or "never" offering pre-exposure or postexposure prophylaxis to their transgender patients.

Conclusions

Regional GAHT prescribing practices varied by setting. Additional research is needed to better understand whether these differences translate to differences in GAHT efficacy and side-effects. Further, HIV screening/prevention practices varied by subspecialty. Integrated GAHT and HIV screening/prevention across subspecialties could help reduce the disproportionate burden of HIV faced by the transgender community.

OLDER BLACK LESBIANS' NEEDS AND EXPECTATIONS IN RELATION TO LONG-TERM CARE FACILITY USE

The older adult sexual minority (SM) population encompasses a vast array of individuals from diverse backgrounds. However, there is a dearth of gerontological research that focuses on the experiences of SM subgroups, particularly older Black lesbians. The purpose of this study was to explore older Black lesbians’ needs and expectations in relation to the utilization of long-term care (LTC) facilities. We conducted secondary data analysis using data from 14 focus groups (n=100) that discussed health and aging with older Black lesbians. Transcriptions were analyzed in NVivo 12 using content analysis and structural coding. Three major themes were identified in relation to needs and expectations for LTC facility use: (1) consideration of or plans established to utilize a LTC facility, (2) concern for care facility environment, and (3) a desire to build one’s own community instead of LTC use. Within these themes, prominent topics included having to rely on LTC due to a lack of family or social support, the possibility of being isolated and stifling their lesbian identity and creating communities of mutual support to avoid facility-based care. These findings illustrate how older Black lesbians are planning for a potential need for LTC, their concerns about utilizing LTC, and alternative approaches to avoid LTC use. There remains a continued need for LTC communities that are inclusive and supportive of SM older adults as well as more SM-only communities where older adults can live openly and authentically.

2085. PrEP Interest and Preferences Among US Black and Hispanic Men – A National Survey

Background

Use of daily oral HIV pre-exposure prophylaxis (DO PrEP) has increased steadily in the past several years, but patterns of racial disparities have emerged in PrEP uptake. Although Black and Hispanic people are disproportionately affected by HIV in the US, they constitute a minority among those accessing DO PrEP. Newly available prevention options, such as long-acting injectable (LA) PrEP may help close the gap in unmet need for PrEP; however, interest in LA PrEP has not been evaluated specifically among racial/ethnic minority groups. Awareness, willingness, and usage of PrEP as well as HIV prevention preferences were assessed among sexually active adult men in the US.

Methods

Participants were recruited through a geographically targeted social media campaign and completed a self-administered, cross-sectional, online survey on demographics, sexual health and behavior, healthcare access, PrEP awareness and usage, and PrEP intention and preferences. Eligible participants met the following criteria: cisgender men, self-identified Black race and/or Hispanic ethnicity, 18 years or older, reporting unknown or HIV-negative status, currently residing in the US, and reporting anal or vaginal sex in the past six months. Descriptive statistics were calculated using SAS v9.4.

Results

From November to December 2021, 1365 men completed the survey (median age: 29.0 years; Black non-Hispanic: 43.1%, Black Hispanic: 40.3%, White Hispanic: 10.2%, Other Hispanic: 6.4%). A majority had heard of DO PrEP (66.6%) and LA PrEP (47.5%) as a way to prevent HIV; however, a smaller proportion had spoken to a healthcare provider (HCP) about PrEP (42.1%), had ever used PrEP (24.7%), or were currently taking PrEP (16.3%) (Figure 1). A large majority (74.0%) reported interest in using LA PrEP. When asked about their preferred PrEP option, 60.2% chose LA PrEP and 7.4% chose DO PrEP, while 27.5% stated that they preferred neither PrEP option. Figure 1.

795. Awareness and Interest in PrEP Options Among US Cisgender Women – A National Survey

Background

Cisgender women continue to have low pre-exposure prophylaxis (PrEP) uptake in the US, despite making up almost 20% of new HIV infections. The gap between the number of women who would benefit from PrEP and those who use PrEP highlights the unmet need for HIV prevention in women. As new prevention options, such as long-acting (LA) injectable PrEP, become available, it is important to understand PrEP awareness and preferences among women to help meet this need. Awareness, willingness, and usage of PrEP as well as HIV prevention preferences were assessed among sexually active women in the US.

Methods

Cisgender women were recruited through a geolocation targeted social media campaign and completed a self-administered, cross-sectional, online survey on demographics, sexual health and behavior, healthcare access, PrEP awareness and history, and PrEP intention and preferences. Eligible participants were cisgender women, 18 years or older, who reported an unknown or HIV-negative status, currently resided in the US, and reported vaginal or anal sex in the past six months. Descriptive statistics were calculated using SAS v9.4.

Results

From November to December 2021, 961 participants completed the survey (median age: 28.0 years; Black non-Hispanic: 34.7%; Black Hispanic: 19.9%; White non-Hispanic: 21.3%; White Hispanic: 12.0%; Another race: 9.1%). A majority had heard of PrEP (70.6%) and LA PrEP (50.1%) as a way to prevent HIV; however, a smaller proportion had spoken to a healthcare provider (HCP) about PrEP (37.8%), had ever used PrEP (19.7%), or were currently on PrEP (9.3%). While PrEP awareness was high across all racial and ethnic groups, PrEP discussions with an HCP and PrEP usage was lowest among Black, non-Hispanic women (Figure 1). Most participants (78.8%) expressed intent to regularly use any HIV prevention method and 66.0% reported likelihood of using LA PrEP if it were available. Condoms were the most favored prevention option (46.7%) followed by HCP administered LA PrEP (24.3%), vaginal ring (9.0%), self-administered LA PrEP (8.8%), and oral PrEP (6.7%).

Conclusion

Although most women demonstrated high PrEP awareness and interest, many had never discussed PrEP with an HCP. The availability of LA PrEP may be an important opportunity for HCPs to discuss a preferred PrEP option with women.

Disclosures

Tonia Poteat, PhD, MPH, PAC, Merck & Co. Inc: Advisor/Consultant|Viiv Healthcare: Advisor/Consultant Supriya Sarkar, PhD, MPH, ViiV Healthcare: Salary|ViiV Healthcare: Stocks/Bonds Leigh Ragone, MS, GlaxoSmithKline: Stocks/Bonds|ViiV Healthcare: Employment Keith Rawlings, MD, ViiV Healthcare: Employee Alex R. Rinehart, PhD, ViiV Healthcare: Stocks/Bonds Vani Vannappagari, MBBS, MPH, PhD, ViiV Healthcare: I am full time employee of ViiV Healthcare and receive GlaxoSmithKline stock as part of my compensation package|ViiV Healthcare: Stocks/Bonds.

Older Black Lesbians' Needs and Expectations in Relation to Long-Term Care Facility Use

There is a dearth of long-term care research that focuses on the expectations and experiences of older sexual minority (SM) adults. That research dwindles further when examining subgroups within that population such as older Black lesbians. The purpose of this study was to explore older Black lesbians' needs and expectations in relation to the utilization of long-term care (LTC) facilities. We conducted secondary data analysis using data from 14 focus groups that discussed health and aging with older Black lesbians. Transcriptions were analyzed in NVivo using deductive content analysis and structural coding. Three themes were identified in relation to needs and expectations for LTC facility use: (1) consideration or established plans to utilize a LTC facility, (2) concern for care facility environment, and (3) a desire to build one's own community. These findings illustrate how older Black lesbians are planning for a potential need for LTC, their concerns about utilizing LTC, and alternative approaches to avoid LTC use. There remains a continued need for LTC communities that are inclusive and supportive of SM older adults as well as more SM-only communities where older adults can live openly and authentically.

Abuse in the Continua: HIV Prevention and Care Outcomes and Syndemic Conditions Associated with Intimate Partner Violence Among Black Gay and Bisexual Men in the Southern United States

Intimate partner violence (IPV) has been implicated in HIV acquisition and worse HIV outcomes. Limited research focuses on the experiences of Black gay and bisexual men. Using data from cross-sectional surveys in Baltimore, Maryland, and Jackson, Mississippi, we analyzed the association between IPV victimization and HIV-related outcomes among 629 adult Black gay and bisexual men, among whom 53% self-reported a negative result at last HIV test. 40% of participants reported lifetime physical, sexual, and/or psychological IPV victimization, and 24% past-year victimization. Recent and lifetime IPV were associated with recent clinical diagnosis of STI (adjPrR: 1.44; 95%CI: 1.08-1.92) and ART medication interruptions (adjPrR: 1.59; 95%CI: 1.25-2.01), respectively. Physical IPV was inversely associated with current PrEP use (adjPrR: 0.35; 95%CI: 0.13-0.90). Recent IPV was independently correlated with depression symptomatology (adjPrR: 2.36; 95%CI: 1.61-3.47) and hazardous alcohol use (adjPrR: 1.93; 95%CI: 1.42-2.61), with evidence of interactions. IPV-HIV relationships were intersected by internalized stigma, housing instability, poverty, and lack of insurance. Tailored IPV services are urgently needed for comprehensive HIV services for Black gay and bisexual men in the U.S.

Interdisciplinary clinicians' attitudes, challenges, and success strategies in providing care to transgender people: a qualitative descriptive study

BACKGROUND

Access to clinicians competent in transgender health remains a significant barrier and contributor toward health inequity for transgender people. Studies on access and barriers to care have predominantly evaluated transgender patients' perceptions, but scant research has included the perspectives of clinicians.

AIMS

We conducted a qualitative study to explore how clinicians (meaning physicians and advanced practice providers, in this paper) in the United States: (1) attain and utilize information, (2) perceive barriers and facilitators, and (3) understood gaps in their professional training, in regard to practicing transgender health care.

METHODS

A Qualitative Descriptive approach guided our conventional content analysis of field notes and interviews with clinicians within a parent study that explored health care access among transgender adults. Transcripts were coded into meaning units that were iteratively abstracted into themes. Standard measures were performed to promote the trustworthiness of the analysis and reduce bias.

RESULTS

Participants (n = 13) consisted of physicians (n = 8), physician assistants (n = 3), and nurse practitioners (n = 2). The majority were women (n = 11), identified as White (n = 9), cisgender (n = 13), and ages ranged from 31 - 58 years. Five main themes were identified: (1) Knowledge Acquisition: Formal and Informal Pathways to Competency; (2) Perceived Challenges and Barriers: I didn't know what I was doing; (3) Power to Deny: Prescriptive Authority and Gatekeeping; (4) Stigma: This is really strange, and I can't really understand it; (5) Reflections: Strategies for Success, Rewards, and Personal Motivations.

DISCUSSION

Clinicians gained a sense of comfort and competence with mentorship, self-directed learning, clinical experience, and person-centered, harm-reduction approaches. Stigma, bias, and structural-level factors were barriers to providing care. This study offers a unique perspective of clinicians' motivations and strategies for providing gender-affirming care and elucidates how stigma impacts the delivery of gender-affirming care.

Testing whether the combination of victimization and minority stressors exacerbate PTSD risks in a diverse community sample of sexual minority women

Informed by minority stress and intersectionality frameworks, we examined: 1) associations of sexual identity and race/ethnicity with probable diagnosis of post-traumatic stress disorder (PTSD-PD) among sexual minority women (SMW; e.g., lesbian, bisexual); and 2) potential additive and interactive associations of minority stressors (discrimination, stigma consciousness, and internalized homonegativity) and potentially traumatic childhood and adulthood events (PTEs) with PTSD-PD. Data come from a large and diverse community sample of SMW (N = 662; age range: 18-82; M = 40.0, SD = 14.0). The sample included 35.8% Black, 23.4% Latinx, and 37.2% White participants. Logistic regressions tested associations of sexual identity and race/ethnicity, minority stressors, and PTEs with PTSD-PD. More than one-third of SMW (37.2%) had PTSD-PD with significantly higher prevalence among bisexual, particularly White bisexual women, than lesbian women. Discrimination, stigma consciousness, and internalized homonegativity were each associated with higher odds of PTSD-PD, but only internalized homonegativity was additively associated with PTSD-PD in mutually adjusted models above and beyond effects of PTEs. No evidence for interactive effects between PTEs and minority stressors was found. In a diverse community sample of sexual minority women, PTSD is strongly associated with potentially traumatic childhood events and with minority stressors above and beyond the associations with other potentially traumatic events and stressors in adulthood. Our findings suggest a strong need for therapists to address the effects of stigma and homophobia in treatment for PTSD, as these minority stressors likely maintain and exacerbate the effects of past traumas.

Addressing Racism's Role in the US HIV Epidemic: Qualitative Findings From Three Ending the HIV Epidemic Prevention Projects

BACKGROUND

Racist socio-political and economic systems in the United States are root causes of HIV disparities among minoritized individuals. However, within HIV implementation science literature, there is scarce empirical research on how to effectively counter racism. This article names racism and White supremacy as key challenges to the success of the Ending the HIV Epidemic (EHE) initiative and delineates opportunities to integrate anti-racism into HIV interventions.

METHODS

Formative data were synthesized from 3 EHE studies in California, North Carolina, and South Carolina. Each study engaged with community stakeholders to inform pre-exposure prophylaxis interventions. Key informant interviews and focus groups were used to query individuals-including Black individuals-about implementation challenges. Although racism was not an a priori focus of included studies, discourse on race and racism emerged as key study findings from all projects.

RESULTS

Across diverse stakeholder groups and EHE locales, participants described racism as a threat to the success of the EHE initiative. Institutional and structural racism, intersectional stigma, and maltreatment of minoritized individuals within healthcare systems were cited as challenges to pre-exposure prophylaxis scale-up. Some recommendations for addressing racism were given-yet these primarily focused on the individual level (eg, enhanced training, outreach).

CONCLUSIONS

EHE implementation scientists should commit to measurable anti-racist actions. To this end, we present a series of recommendations to help investigators evaluate the extent to which they are taking actionable steps to counter racism to improve the adoption, implementation, and real-world impact of EHE interventions for people of color.

Eliciting critical hope in community-based HIV research with transgender women in Toronto, Canada: methodological insights

Critical hope centres optimism and possibilities for change in the midst of struggles for social justice. It was a central tenet of early participatory pedagogy and HIV research. However, critical hope has been overlooked in contemporary HIV research that largely focuses on risk and biomedical interventions in ways that obscure collective agency and community strengths. We conducted a community-based study with transgender (trans) women of colour in Toronto, Canada to adapt an evidence-based HIV prevention intervention. Participants resisted a focus on HIV, instead calling researchers to centre journeys to self-love in contexts of social exclusion. In response, we piloted three arts-based, participatory methods generated with community collaborators: (i) affirmation cards sharing supportive messages with other trans women, (ii) hand-held mirrors for reflecting and sharing messages of self-acceptance and (iii) anatomical heart images to visualize coping strategies. Participants generated solidarity and community through shared stories of self-acceptance within contexts of pain, exclusion and loss. Narratives revealed locating agency and self-acceptance through community connectedness. Critical hope was a by-product of this participatory process, whereby participants shared personal and collective optimism. Participatory and arts-based methods that centre self-acceptance and solidarity can nurture resistance to pathologizing discourses in HIV research. Centring critical hope and participant-generated methodologies is a promising approach to transformative health promotion and intervention research. These methodological insights can be engaged in future participatory work with other marginalized groups facing dominant biomedical risk discourses. Critical hope holds potential as a participatory health promotion strategy for envisioning possibilities for sustainable change.

Barriers to accessing and engaging in healthcare as potential modifiers in the association between polyvictimization and mental health among Black transgender women

BACKGROUND

Black transgender women endure pervasive polyvictimization (experiencing multiple forms of violence throughout the lifespan). Polyvictimization is associated with poor mental health. Black transgender women also face barriers in access to healthcare, but the extent that such barriers modify the association between polyvictimization and poor mental health has not been described using convergent mixed-methods analysis.

METHODS

This convergent mixed-methods secondary analysis employs an intersectional lens and integrates two inter-related datasets to describe barriers to healthcare and the extent that such barriers modify the association between polyvictimization and mental health among Black transgender women. Investigators used survey data (n = 151 participants) and qualitative interview data (n = 19 participants) collected from Black transgender women (age 18 years and older) in Baltimore, MD and Washington, DC between 2016 and 2018. Analyses include thematic content analysis, bivariate analysis, joint display, and multivariate linear regression analysis examining mediation and moderation.

RESULTS

Joint display illuminated three domains to describe how barriers to healthcare present among Black transgender women-Affordability, Accessibility, and Rapport and Continuity. Independent t-tests revealed significantly higher polyvictimization, Post Traumatic Stress Disorder (PTSD), and depression scores among participants who reported at least one barrier to healthcare (BHI) compared to those who reported no barriers. BHI significantly moderated and partially mediated the association between polyvictimization and PTSD symptom severity and BHI fully mediated the association between polyvictimization and depressive symptom severity-when accounting for age and location.

DISCUSSION

Findings highlight the importance of access to healthcare in modifying the association between polyvictimization and PTSD and depression symptom severity among Black transgender women. Findings call for immediate interventions aimed at reducing barriers to healthcare and improved training for clinical providers serving Black transgender women.

Transgender and Gender Diverse Community Connection, Help-Seeking, and Mental Health Among Black Transgender Women Who Have Survived Violence: A Mixed-Methods Analysis

Black transgender women are disproportionately affected by violence and poor care-delivery, contributing to poor mental health. Little is known regarding the effect of transgender and gender diverse (TGD) community connection (TCC) on health. This analysis (a) explores relationships between TCC, polyvictimization, and mental health and (b) analyzes how TCC influenced help-seeking following violent experiences among Black transgender women. Mixed-methods data from 19 Black transgender women were analyzed using correlational and thematic content analyses. Findings suggest that TCC is associated with improved help-seeking and mental health among Black transgender women, highlighting a need for longitudinal research to identify approaches for leveraging TCC.

Considerations for Increasing Racial, Ethnic, Gender, and Sexual Diversity in HIV Cure-Related Research with Analytical Treatment Interruptions: A Qualitative Inquiry

Despite disproportionate incidence and prevalence of HIV among transgender individuals, cisgender women, and racial and ethnic minority groups, all remain underrepresented in HIV cure research. As HIV cure trials are scaled up, there is emerging research on ways to mitigate risks of HIV acquisition for sexual partners of analytical treatment interruption (ATI) trial participants. As such, it is imperative that HIV cure researchers consider the implications of implementing ATIs in populations that are disproportionately affected by HIV, but largely underrepresented in trials to date. In this qualitative study, we sought to derive triangulated perspectives on the social and ethical implications regarding ATIs and partner protection strategies during ATIs among under-represented populations. We conducted 21 in-depth interviews with 5 types of informants: bioethicists, community members [people living with HIV (PLWH) and their advocates], biomedical HIV cure researchers, sociobehavioral scientists, and HIV care providers. We analyzed the data using conventional content analysis and reduced the data to important considerations for implementing ATI trials in diverse communities and settings. Our study revealed the following key themes: (1) attention must be paid to gender and power dynamics in ATI trials; (2) ATI trials should be designed and implemented through the lenses of intersectionality and equity frameworks; (3) ATI trials may have both positive and negative effects on stigma for PLWH and their partners; and (4) partnership dynamics should be considered when designing ATI protocols. Our study generated actionable considerations that could be implemented in ATI trials to promote their acceptability to communities that have been underrepresented in HIV cure research to date. Research teams must invest in robust community and stakeholder engagement to define best practices. Paying attention to representation and equity will also promote better and more equitable implementation of HIV cure strategies once these become ready for rollout.

Intersectional Structural Stigma, Community Priorities, and Opportunities for Transgender Health Equity: Findings from TRANSforming the Carolinas

In this manuscript, "Intersectional Structural Stigma, Community Priorities, and Opportunities for Transgender Health Equity," Poteat and Simmons outline the legal and policy barriers that impede efforts to end the HIV epidemic among transgender people in the South. They present qualitative and quantitative data from a community engaged research study conducted with transgender adults and other key stakeholders as well as finding from an analysis of policies impacting transgender people in both states. Violence prevention and decriminalization are highlighted as key policy initiatives that would advance health equity for transgender people.

Cardiovascular Disease Risk Among Transgender People with HIV

PURPOSE OF REVIEW

Transgender individuals are at disproportionate risk for HIV infection, with prevalence rates highest among transgender women of color. Antiretroviral therapy (ART)-treated people with HIV (PWH) are at increased risk for cardiovascular disease (CVD), in relation to persistent systemic immune activation and metabolic dysregulation. The purpose of this review is to examine parameters which may affect CVD risk among transgender PWH.

RECENT FINDINGS

Among transgender women and men, prospective longitudinal studies have shown that gender-affirming hormonal therapy (GAHT) is associated with select deleterious cardiometabolic effects such as increases in visceral adipose tissue. Retrospective studies among transgender women and men suggest an increase in CVD risk, such as venous thromboembolism, cerebrovascular accidents, and myocardial infarction. Studies among transgender PWH adhering to GAHT and ART suggest heightened systemic immune activation/inflammation. Prospective longitudinal studies assessing factors associated with increased CVD events among transgender PWH are needed to guide the development of CVD prevention strategies in this at-risk population.

I'm not putting on that floral gown: Enforcement and resistance of gender expectations for transgender people with cancer

OBJECTIVES

Understanding barriers to care for transgender people with cancer is necessary to increase oncologic care access. Little has been published regarding the experiences of transgender people with cancer. We sought to explore these experiences, assess barriers to oncologic care, and elucidate potential solutions.

METHODS

Using an interpretive descriptive approach, we conducted two group interviews with transgender people who had been diagnosed with cancer and one with physicians who treat patients with cancer. Two investigators independently analyzed verbatim transcripts and, together, refined themes, resolving disagreements with consensus. Member checking and peer debriefing were used to confirm and elaborate on findings.

RESULTS

Seven people who had been diagnosed with cancer and five physicians who treat people with cancer participated in group interviews. Themes included: (a) experiences with cancer may uniquely impact transgender people; (b) enforcement of clinician and systemic gender expectations creates barriers to cancer care; and (c) resistance to gender expectations may facilitate care.

CONCLUSIONS

Gender expectations create barriers to oncologic care, which can be resisted by patients, clinicians, and institutions.

IMPLICATIONS FOR PRACTICE

Clinicians and institutions should create gender-inclusive oncologic spaces, demonstrate allyship, and support patient autonomy to decrease barriers to care for transgender people with cancer.

Living While Black, Gay, and Poor: The Association of Race, Neighborhood Structural Disadvantage, and PrEP Utilization Among a Sample of Black Men Who Have Sex With Men in the Deep South

Utilizing the Andersen Healthcare Utilization Model, we examined the role of neighborhood context on pre-exposure prophylaxis (PrEP) utilization among a sample of Black men who have sex with men (MSM) residing in a medium-sized city in the Deep South. Data were derived from a sample of 142 Black MSM aged 18-64 years who were eligible for PrEP from a community-based study known as "ACCELERATE!" We used multilevel structural equation modeling to assess PrEP use. Social support, sexual risk, and health care access were predictive of PrEP use. Notably, residing in a neighborhood with concentrated poverty was associated with decreased PrEP use. Our findings reveal neighborhood structural disadvantage is associated with decreased PrEP use among Black MSM, after adjusting of individual-level sociodemographic characteristics. There is an urgent need to develop HIV prevention interventions and programs that explicitly address structural-level factors to eliminate racial/ethnic differences in HIV.

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

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.

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

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.

Advancing Intersectional Discrimination Measures for Health Disparities Research: Protocol for a Bilingual Mixed Methods Measurement Study

Background

Guided by intersectionality frameworks, researchers have documented health disparities at the intersection of multiple axes of social status and position, particularly race and ethnicity, gender, and sexual orientation. To advance from identifying to intervening in such intersectional health disparities, studies that examine the underlying mechanisms are required. Although much research demonstrates the negative health impacts of perceived discrimination along single axes, quantitative approaches to assessing the role of discrimination in generating intersectional health disparities remain in their infancy. Members of our team recently introduced the Intersectional Discrimination Index (InDI) to address this gap. The InDI comprises three measures of enacted (day-to-day and major) and anticipated discrimination. These attribution-free measures ask about experiences of mistreatment because of who you are. These measures show promise for intersectional health disparities research but require further validation across intersectional groups and languages. In addition, the proposal to remove attributions is controversial, and no direct comparison has ever been conducted.

Objective

This study aims to cognitively and psychometrically evaluate the InDI in English and Spanish and determine whether attributions should be included.

Methods

The study will draw on a preliminary validation data set and three original sequentially collected sources of data: qualitative cognitive interviews in English and Spanish with a sample purposively recruited across intersecting social status and position (gender, sexual orientation, race and ethnicity, socioeconomic status, age, and nativity); a Spanish quantitative survey (n=500; 250/500, 50% sexual and gender minorities); and an English quantitative survey (n=3000), with quota sampling by race and ethnicity (Black, Latino/a/x, and White), sexual or gender minority status, and gender.

Results

The study was funded by the National Institute on Minority Health and Health Disparities in May 2021, and data collection began in July 2021.

Conclusions

The key deliverables of the study will be bilingual measures of anticipated, day-to-day, and major discrimination validated for multiple health disparity populations using qualitative, quantitative, and mixed methods.

International Registered Report Identifier (IRRID)

PRR1-10.2196/30987

Revitalizing HIV Prevention Programs: Recommendations From Those Most Impacted by the HIV in the Deep South

PURPOSE

The incidence of new HIV infections is disproportionately high among Black men who have sex with men (BMSM) in Mississippi. Community-based organizations received funding through the ACCELERATE! initiative to implement interventions aimed at increasing BMSM's access to HIV prevention, treatment and care interventions.

APPROACH

We conducted a mixed methods evaluation of the ACCELERATE! initiative to assess its impact. We also explored factors that act as barriers to and facilitators of BMSM's engagement in HIV prevention interventions.

SETTING

Interviews were conducted between July 2018 and February 2020.

PARTICIPANTS

Thirty-six BMSM and 13 non-grantee key informants who worked in the field of HIV in Mississippi participated.

METHOD

The qualitative data from the interview transcripts was analyzed using an iterative, inductive coding process.

RESULTS

We identified 10 key recommendations that were most common across all participants and that were aligned with UNAIDS Global AIDS Strategy strategic priorities. Several recommendations address the reduction of HIV- and LGBT-stigma. Two of the most common recommendations were to increase representation of the target population in health promotion program leadership and to include HIV with other Black health issues in community-based health education programs rather than singling it out. Another recommendation called for programs aimed at addressing underlying factors associated with HIV-risk behaviors, such as mental illness.

CONCLUSION

Our results indicate that HIV education interventions in the Deep South need to be revitalized to enhance their reach and effectiveness.

HIV Prevention Among Cisgender Men Who have Sex with Transgender Women

Cisgender men who have sex with transgender women face elevated risk for HIV, yet are understudied in prevention research. We conducted in-depth interviews with 19 men who have sex with transgender women in Baltimore, Maryland and Atlanta, Georgia to explore perspectives on HIV prevention. Participants used several strategies to reduce HIV risk: condoms, frequent HIV testing, communication about HIV status with partners, and limiting the types of sex acts performed. While condom use was inconsistent, it was preferred over pre-exposure prophylaxis, in part due to medical distrust. HIV self-testing was generally viewed unfavorably. Although most participants were referred to the study by their transgender women partners, they recommended reaching other men who have sex with transgender women in bars, nightclubs, online, and through social media. HIV prevention interventions should be inclusive of the needs and experiences of men who have sex with transgender women.

U.S. transgender women's preferences for microeconomic interventions to address structural determinants of HIV vulnerability: a qualitative assessment

Background

Transgender women in the United States (U.S.) experience a disproportionate burden of HIV infection and challenges to engagement in HIV prevention and care. This excess burden is driven by structural and economic inequities. Microeconomic interventions may be effective strategies for reducing HIV inequities for this population. However, few studies have explored transgender women’s preferences for microeconomic interventions to address structural determinants of HIV vulnerability.

Methods

We conducted individual interviews with 19 adult transgender women in 2 U.S. cities (Richmond, VA and St. Louis, MO) who reported one or more sexual risk behaviors and recent economic hardship related to employment/income, housing, or food security. Interviews were recorded, transcribed, and analyzed using thematic content analysis.

Results

The majority (74%) of transgender women were racial/ethnic minorities with mean age of 26.3 years. 89% were currently economically vulnerable; and 23% were employed full-time. 37% reported living with HIV. Participants expressed strong support for unrestricted vouchers, with many expressing the need for funds to support gender-affirming interventions. Assistance with how to budget and save and support for job acquisition, career planning, and employment sustainment were also preferred, including access to non-stigmatizing employment. Visible transgender leadership, group empowerment, and small (rather than large) numbers of participants were considered important aspects of intervention design for transgender women, including outreach through existing transgender networks to facilitate inclusion. Incorporating HIV counseling and testing to reduce vulnerability to HIV was acceptable. However, transgender women enrolled in the study preferred that HIV not be the focus of an intervention.

Conclusions

Flexible microeconomic interventions that support gender affirming interventions, improve financial literacy, and provide living-wage non-stigmatizing employment are desired by economically vulnerable transgender women. While not focused on HIV, such interventions have the potential to reduce the structural drivers of HIV vulnerability among transgender women.

Assessing and Addressing Cardiovascular Health in People Who Are Transgender and Gender Diverse: A Scientific Statement From the American Heart Association

There is growing evidence that people who are transgender and gender diverse (TGD) are impacted by disparities across a variety of cardiovascular risk factors compared with their peers who are cisgender. Prior literature has characterized disparities in cardiovascular morbidity and mortality as a result of a higher prevalence of health risk behaviors. Mounting research has revealed that cardiovascular risk factors at the individual level likely do not fully account for increased risk in cardiovascular health disparities among people who are TGD. Excess cardiovascular morbidity and mortality is hypothesized to be driven in part by psychosocial stressors across the lifespan at multiple levels, including structural violence (eg, discrimination, affordable housing, access to health care). This American Heart Association scientific statement reviews the existing literature on the cardiovascular health of people who are TGD. When applicable, the effects of gender-affirming hormone use on individual cardiovascular risk factors are also reviewed. Informed by a conceptual model building on minority stress theory, this statement identifies research gaps and provides suggestions for improving cardiovascular research and clinical care for people who are TGD, including the role of resilience-promoting factors. Advancing the cardiovascular health of people who are TGD requires a multifaceted approach that integrates best practices into research, health promotion, and cardiovascular care for this understudied population.

Racial, ethnic, and gender disparities in hospitalizations among persons with HIV in the United States and Canada, 2005-2015

OBJECTIVE

To examine recent trends and differences in all-cause and cause-specific hospitalization rates by race, ethnicity, and gender among persons with HIV (PWH) in the United States and Canada.

DESIGN

HIV clinical cohort consortium.

METHODS

We followed PWH at least 18 years old in care 2005-2015 in six clinical cohorts. We used modified Clinical Classifications Software to categorize hospital discharge diagnoses. Incidence rate ratios (IRR) were estimated using Poisson regression with robust variances to compare racial and ethnic groups, stratified by gender, adjusted for cohort, calendar year, injection drug use history, and annually updated age, CD4+, and HIV viral load.

RESULTS

Among 27 085 patients (122 566 person-years), 80% were cisgender men, 1% transgender, 43% White, 33% Black, 17% Hispanic of any race, and 1% Indigenous. Unadjusted all-cause hospitalization rates were higher for Black [IRR 1.46, 95% confidence interval (CI) 1.32-1.61] and Indigenous (1.99, 1.44-2.74) versus White cisgender men, and for Indigenous versus White cisgender women (2.55, 1.68-3.89). Unadjusted AIDS-related hospitalization rates were also higher for Black, Hispanic, and Indigenous versus White cisgender men (all P < 0.05). Transgender patients had 1.50 times (1.05-2.14) and cisgender women 1.37 times (1.26-1.48) the unadjusted hospitalization rate of cisgender men. In adjusted analyses, among both cisgender men and women, Black patients had higher rates of cardiovascular and renal/genitourinary hospitalizations compared to Whites (all P < 0.05).

CONCLUSION

Black, Hispanic, Indigenous, women, and transgender PWH in the United States and Canada experienced substantially higher hospitalization rates than White patients and cisgender men, respectively. Disparities likely have several causes, including differences in virologic suppression and chronic conditions such as diabetes and renal disease.

Beyond Black and White: race and sexual identity as contributors to healthcare system distrust after breast cancer screening among US women

OBJECTIVE

Healthcare system distrust (HCSD) has been linked to poor breast cancer outcomes. Previous HSCD analyses have focused on Black-White disparities; however, focusing only on race ignores the complex set of factors that form identity. We quantified the contributions of race and sexual minority (SM) identity to HCSD among US women who had received breast cancer screening.

METHODS

This cross-sectional study used intersectionality decomposition methods to assess the degree to which racial and SM identity contributed to disparate responses to the validated 9-item HCSD Scale. The sample included online survey participants identifying as a Black or White woman living in the US, with a self-reported abnormal breast cancer screening result in the past 24 months and/or breast cancer diagnosis since 2011.

RESULTS

Of 649 participants, 49.4% of Black SM women (n = 85) were in the highest HCSD tertile, followed by 37.4% of White SM women (n = 123), 24.4% of Black heterosexual women (n = 156), and 19% of White heterosexual women. Controlling for age, 72% of the disparity in HCSD between Black SM women and White heterosexual women was due to SM status, 23% was due to racial identity, and 3% was due to both racial and SM identity.

CONCLUSIONS

SM identity emerged as the largest driver of HCSD disparities; however, the combined racial and SM disparity persisted. Excluding sexual identity in HCSD studies may miss an important contributor. Interventions designed to increase the HCS's trustworthiness at the provider and system levels should address both racism and homophobia.

"In the Bible Belt:" The role of religion in HIV care and prevention for transgender people in the United States South

Within the United States South, the socio-religious norms that shape life for many residents may have public health implications. Drawing from 12 key informant interviews, this study explores the role of religious institutions in HIV care and prevention access among transgender people of color in Southern cities. Findings suggest that while religious anti-transgender stigma is pervasive, the regional importance of faith-based beliefs and institutions necessitates targeted faith-based initiatives for the population. Broadly, findings suggest regional environments may demand interventions that negotiate historically marginalizing relationships between at-risk groups and dominant cultural institutions.

A scoping review of the integration of empowerment-based perspectives in quantitative intersectional stigma research

The genesis of the concept of intersectionality was a call to dismantle interlocking systems of oppression - racial, sexual, heterosexual, and class-based - in order to realise liberation of Black women and other women of colour. Intersectionality holds the radical potential to amplify collective efficacy, community solidarity, and liberation. The extension of intersectionality into stigma research has resulted in an increased focus on intersectional stigma in quantitative research. This raises questions regarding how the radical and liberatory potential of intersectionality is applied in stigma research. Specifically, empowerment-based perspectives may be overlooked in quantitative intersectional stigma research. We conducted a scoping review to document if and how empowerment-based perspectives were included in intersectional stigma quantitative studies. We identified and included 32 studies in this review that examined varied stigmas, most commonly related to race, gender, HIV and sexual orientation. In total 13/32 (40.6%) of these studies reported on empowerment-based factors; most of these examined social support and/or resilience. Taken together, findings suggest that the quantitative intersectional stigma research field would benefit from expansion of concepts studied to include activism and solidarity, as well as methodological approaches to identify the protective roles of empowerment-based factors to inform health and social justice-related programmes and policy.

Health and health care access in the US transgender population health (TransPop) survey

BACKGROUND

Probability and nonprobability-based studies of US transgender persons identify different disparities in health and health care access.

OBJECTIVES

We used TransPop, the first US national probability survey of transgender persons, to describe and compare measures of health and health access among transgender, nonbinary, and cisgender participants. We directly compared the results with 2015 US Transgender Survey (USTS) data and with previously published analyses from the Behavioral Risk Factor Surveillance System (BRFSS).

METHODS

All participants were screened by Gallup Inc., which recruited a probability sample of US adults. Transgender people were identified using a two-step screening process. Eligible participants completed self-administered questionnaires (transgender n = 274, cisgender n = 1162). We obtained weighted proportions/means, then tested for differences between gender groups. Logistic regression was performed to evaluate associations. Bivariate analyses were conducted using the weighted USTS data set for shared variables in USTS and TransPop.

RESULTS

Transgender participants were younger and more racially diverse compared to the cisgender group. Despite equally high insurance coverage, transgender people more often avoided care due to cost concerns. Nonbinary persons were less likely to access transgender-related health care providers/clinics than transgender men and women. Transgender respondents more often rated their health as fair/poor, with more frequently occuring poor physical and mental health days compared to cisgender participants. Health conditions including HIV, emphysema, and ulcer were higher among transgender people. TransPop and USTS, unlike BRFSS-based analyses, showed no differences in health or health access.

DISCUSSION

Transgender persons experience health access disparities centered on avoidance of care due to cost beyond insured status. Health disparities correspond with models of minority stress, with nonbinary persons having distinct health/health access patterns. Despite different sampling methods, USTS and TransPop appear more similar than BRFSS studies regarding health/health access.

CONCLUSION

Future research should elucidate health care costs for transgender and nonbinary people, while addressing methodology in national studies of transgender health.

Influence of Stress, Gender, and Minority Status on Cardiovascular Disease Risk in the Hispanic/Latino Community: Protocol for a Longitudinal Observational Cohort Study

BACKGROUND

Hispanic/Latino sexual and gender minorities (SGM) are the fastest growing ethnic group of SGM in the United States. Cardiovascular disease (CVD) is a leading cause of morbidity and mortality among Hispanics/Latinos. SGM inequities in CVD risk have been identified as early as young adulthood, and minority stress has been identified as a potential mediator. Yet, the small number of ethnic or racial minority participants in SGM studies have precluded the examination of the intersections of sexual orientation, gender identity, and race and ethnicity.

OBJECTIVE

Minority stress models conceptualize relationships between stressors in minority groups and health outcomes. In this study, we will (1) examine the influence of sexual orientation and gender identity on CVD risk among all Hispanic Community Health Study/Study of Latinos (HCHS/SOL) participants at visit 3 (2021-2024; N~9300); (2) model pathways from sexual orientation and gender identity to CVD risk through stigma, discrimination, and stress in a 1:2 matched subcohort of SGM and non-SGM participants at visit 3 (n~1680); and (3) examine the influence of resilience factors on sexual orientation or gender identity and CVD risk relationships among subcohort participants at visit 3 (n~1680).

METHODS

This study will leverage existing data from the parent HCHS/SOL study (collected since 2008) while collecting new data on sexual orientation, gender identity, stigma, discrimination, stress, coping, social support, and CVD risk. Data analysis will follow the SGM minority stress model, which states that excess stigma against SGM populations leads to minority stress that increases CVD risk. In this model, coping and social support serve as resilience factors that can mitigate the impact of minority stress on CVD risk. Cross-sectional and longitudinal regression models as well as structural equation models will be used to test these relationships.

RESULTS

This study was funded by the National Heart, Lung, and Blood Institute in March 2020. Recruitment is scheduled to begin in the first quarter of 2021 and continue through 2024.

CONCLUSIONS

Understanding the influence of stigma-induced stress on CVD risk among Hispanic/Latino SGM has significant implications for the development of culturally specific CVD risk reduction strategies. Study findings will be used to build on identified Hispanic/Latino cultural strengths to inform adaptation and testing of family and community acceptance interventions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/28997.

Violence Experiences in Childhood and Adolescence Among Gay Men and Transgender Women Living in Perú: A Qualitative Exploration

The overall goal of this study was to qualitatively explore the different types of violence experienced by gay men (GM) and transgender women (TW) living in Peru during childhood and adolescence, as well as their potential consequences and sources of protection. Participants were selected using purposive sampling. Recruitment took place in a community-based organization in Lima, Peru. In all, 32 GM and 23 TW participated in a total of four Focus Group Discussions (FGD) and 25 in-depth interviews (IDI). Qualitative data collection was conducted between July and October 2016. Four FGD took place with GM (n = 21) and one with TW (n = 9). In addition, 11 IDI with GM and 14 with TW were conducted. Data were analyzed using descriptive inductive analysis. Three main types of violence were experienced in childhood and adolescence: (a) violence occurring in the home or otherwise perpetrated by family members, (b) school-based violence, and (c) sexual violence. Both GM and TW experience violence within and outside school and home. School systems should make teachers and parents aware of the impact of homophobic and transphobic bullying and violence. Certain modifications in schools, such as having all-gender bathrooms and promoting activities that are not grounded in gender roles, could be very effective at reducing homophobic and transphobic violence. Schools should also address sexual violence more actively, among both male and female students. Parents' attitudes toward homosexuality and gender diversity need to be addressed by future interventions.

Characterising HIV and STIs among transgender female sex workers: a longitudinal analysis

OBJECTIVES

Though highly vulnerable to HIV and STIs, transgender female sex workers (TFSWs) are understudied in the US HIV and STI response. This study examined the correlates of laboratory-confirmed STIs among a cohort of 62 TFSWs followed over the course of 1 year and explored associations between specimen site and self-reported engagement in insertive and receptive anal intercourse.

METHODS

Participants completed an interviewer-administered computer-assisted personal interview at baseline, 3-, 6-, 9- and 12-month visits where self-administered anal swabs and urine samples for gonorrhea, chlamydia and trichomoniasis were also collected. HIV testing was conducted at baseline, 6-month and 12-month visits.

RESULTS

Baseline HIV prevalence was 40.3% with no HIV seroconversions over follow-up. Baseline prevalence of gonorrhea, chlamydia and trichomoniasis was 9.7%, 17.7% and 14.5%, respectively. In the multivariable regression modelling, recent arrest was significantly associated with testing positive for any STI (adjusted risk ratio (RR) 1.77; 95% CI: 1.10 to 2.84). Insertive anal sex with clients was associated with increased risk of testing positive for an STI via urine specimen (RR 3.48; 95% CI: 1.14 to 10.62), while receptive anal sex was not significantly associated with specimen site.

CONCLUSION

Our findings confirm a high prevalence of STIs among TFSWs and highlight the importance of addressing structural drivers such as criminal justice involvement as well as the need to ensure screening for STIs at all anatomical sites regardless of self-reported sites of potential exposure. More research is needed to better understand HIV and STI vulnerabilities and appropriate interventions for TFSWs in the USA.