Experiences of violence and discrimination among LGBTQ+ individuals during the COVID-19 pandemic: a global cross-sectional analysis.

OBJECTIVES: To characterise the extent to which the levels of violence and discrimination against lesbian, gay, bisexual, transgender and queer (LGBTQ+) people have changed amid COVID-19. DESIGN: Cross-sectional, secondary analysis. SETTING: 79 countries. PARTICIPANTS: All adults (aged ≥18 years) who used the Hornet social networking application and provided consent to participate. MAIN OUTCOME MEASURE: The main outcome was whether individuals have experienced less, or the same or more levels of discrimination and violence from specific groups (eg, police and/or military, government representatives, healthcare providers). RESULTS: 7758 LGBTQ+ individuals provided responses regarding levels of discrimination and violence. A majority identified as gay (78.95%) and cisgender (94.8%). Identifying as gay or queer was associated with increased odds of experiencing the same or more discrimination from government representatives (OR=1.89, 95% CI 1.04 to 3.45, p=0.045) and healthcare providers (OR=2.51, 95% CI 0.86 to 7.36, p=0.002) due to COVID-19. Being a member of an ethnic minority was associated with increased odds of discrimination and violence from police and/or military (OR=1.32, 95% CI 1.13 to 1.54, p=0.0) and government representatives (OR=1.47, 95% CI 1.29 to 1.69, p=0.0) since COVID-19. Having a disability was significantly associated with increased odds of violence and discrimination from police and/or military (OR=1.38, 95% CI 1.15 to 1.71, p=0.0) and healthcare providers (OR=1.35, 95% CI 1.07 to 1.71, p=0.009). CONCLUSIONS: Our results suggest that despite the upending nature of the COVID-19 pandemic, around the world, government representatives, policymakers and healthcare providers continue to perpetuate systemic discrimination and fail to prevent violence against members of the LGBTQ+ community.

Perceived Interruptions to HIV Prevention and Treatment Services Associated With COVID-19 for Gay, Bisexual, and Other Men Who Have Sex With Men in 20 Countries.

BACKGROUND: The coronavirus pandemic has necessitated a range of population-based measures to stem the spread of infection. These measures may be associated with disruptions to other health services including for gay, bisexual, and other men who have sex with men (MSM) at risk for or living with HIV. Here, we assess the relationship between stringency of COVID-19 control measures and interruptions to HIV prevention and treatment services for MSM. SETTING: Data for this study were collected between April 16, 2020, and May 24, 2020, as part of a COVID-19 Disparities Survey implemented by the gay social networking app, Hornet. Pandemic control measures were quantified using the Oxford Government Response Tracker Stringency Index: each country received a score (0-100) based on the number and strictness of 9 indicators related to restrictions, closures, and travel bans. METHODS: We used a multilevel mixed-effects generalized linear model with Poisson distribution to assess the association between stringency of pandemic control measures and access to HIV services. RESULTS: A total of 10,654 MSM across 20 countries were included. Thirty-eight percent (3992/10,396) reported perceived interruptions to in-person testing, 55% (5178/9335) interruptions to HIV self-testing, 56% (5171/9173) interruptions to pre-exposure prophylaxis, and 10% (990/9542) interruptions to condom access. For every 10-point increase in stringency, there was a 3% reduction in the prevalence of perceived access to in-person testing (aPR: 0·97, 95% CI: [0·96 to 0·98]), a 6% reduction in access to self-testing (aPR: 0·94, 95% CI: [0·93 to 0·95]), and a 5% reduction in access to pre-exposure prophylaxis (aPR: 0·95, 95% CI: [0·95 to 0·97]). Among those living with HIV, 20% (218/1105) were unable to access their provider; 65% (820/1254) reported being unable to refill their treatment prescription remotely. CONCLUSIONS: More stringent responses were associated with decreased perceived access to services. These results support the need for increasing emphasis on innovative strategies in HIV-related diagnostic, prevention, and treatment services to minimize service interruptions during this and potential future waves of COVID-19 for gay men and other MSM at risk for HIV acquisition and transmission.

Rapid, application-based survey to characterise the impacts of COVID-19 on LGBTQ+ communities around the world: an observational study.

INTRODUCTION: Emerging evidence indicates that the COVID-19 pandemic, and the responses it has generated, have had disproportionate impacts on lesbian, gay, bisexual, transgender and queer (LGBTQ+) communities. This study seeks to build on existing information and provide regional insight. METHODS: In response, a cross-sectional survey was administered to a global sample of LGBTQ+ individuals (n=13 358) between 16 April and 20 May 2020 via the social networking application Hornet. The survey contained questions that characterise the impact of COVID-19 and associated mitigation strategies on economics, employment, mental health and access to healthcare. RESULTS: 5191 (43.9%) individuals indicated they were somewhat, slightly or unable to meet basic needs with their current income, while 2827 (24.1%) and 4710 (40.1%) felt physically or emotionally unsafe in their living environment, respectively. 2202 individuals (24.7%) stated they are at risk for losing health insurance coverage. 2685 (22.7%) persons reported having skipped or cut meals as there was not enough money. CONCLUSION: Many LGBTQ+persons who responded reported adverse consequences to mental health, economics, interruptions to care and lack of support from their government. This data is part of ongoing analyses but accentuates the unique needs of LGBTQ+ communities that will require targeted, ameliorative approaches.

Prevalence and associations of COVID-19 testing in an online sample of transgender and non-binary individuals.

BACKGROUND: Testing for COVID-19 and linkage to services is fundamental to successful containment and control of transmission. Yet, knowledge on COVID-19 testing among transgender and non-binary communities remains limited. METHODS: Between October 2020 and November 2020, we examined the prevalence and associations of COVID-19 testing in an online sample of transgender and non-binary people (n=536). Multivariable hierarchical logistic regression analyses examined associations between COVID-19 testing and participants' sociodemographic, mental health, substance use, gender affirmation, economic changes and healthcare experiences. RESULTS: Prevalence of COVID-19 testing in this sample was 35.5% (n=190/536). In the final model, transgender and non-binary participants from upper socioeconomic income background and Europe, who reported having active alcohol use disorder, limited access to gender-affirming surgery, had more than 20% reduction in income, and experienced mistreatment in a health facility due to gender identity had significantly increased odds of COVID-19 testing (all p<0.05); those who reported recent tobacco use had significantly lower odds of COVID-19 testing (p=0.007). CONCLUSIONS: These findings highlight structural disparities in COVID-19 testing and reinforce the importance of increasing testing strategies for transgender and non-binary populations.

Gender-affirming care, mental health, and economic stability in the time of COVID-19: A multi-national, cross-sectional study of transgender and nonbinary people.

BACKGROUND: Transgender and nonbinary people are disproportionately affected by structural barriers to quality healthcare, mental health challenges, and economic hardship. This study examined the impact of the novel coronavirus disease (COVID-19) crisis and subsequent control measures on gender-affirming care, mental health, and economic stability among transgender and nonbinary people in multiple countries. METHODS: We collected multi-national, cross-sectional data from 964 transgender and nonbinary adult users of the Hornet and Her apps from April to August 2020 to characterize changes in gender-affirming care, mental health, and economic stability as a result of COVID-19. We conducted Poisson regression models to assess if access to gender-affirming care and ability to live according to one's gender were related to depressive symptoms, anxiety, and changes in suicidal ideation. RESULTS: Individuals resided in 76 countries, including Turkey (27.4%, n = 264) and Thailand (20.6%, n = 205). A majority were nonbinary (66.8%, n = 644) or transfeminine (29.4%, n = 283). Due to COVID-19, 55.0% (n = 320/582) reported reduced access to gender-affirming resources, and 38.0% (n = 327/860) reported reduced time lived according to their gender. About half screened positive for depression (50.4%,442/877) and anxiety (45.8%, n = 392/856). One in six (17.0%, n = 112/659) expected losses of health insurance, and 77.0% (n = 724/940) expected income reductions. The prevalence of depressive symptoms, anxiety, and increased suicidal ideation were 1.63 (95% CI: 1.36-1.97), 1.61 (95% CI: 1.31-1.97), and 1.74 (95% CI: 1.07-2.82) times higher for individuals whose access to gender-affirming resources was reduced versus not. DISCUSSION: The COVID-19 crisis is associated with reduced access to gender-affirming resources and the ability of transgender and nonbinary people to live according to their gender worldwide. These reductions may drive the increased depressive symptoms, anxiety, and suicidal ideation reported in this sample. To improve health of transgender and nonbinary communities, increased access to gender-affirming resources should be prioritized through policies (e.g., digital prescriptions), flexible interventions (e.g., telehealth), and support for existing transgender health initiatives.

Address Exacerbated Health Disparities and Risks to LGBTQ+ Individuals during COVID-19

As of August 12, 2020, there are over 20 million confirmed cases of novel coronavirus disease (COVID-19) worldwide with over 744,000 deaths.1 Due to existing disparities in health outcomes, the consequences of this pandemic for LGBTQ+ individuals could be magnified in scope and severity.2 Gay, bisexual, and other men who have sex with men (MSM), particularly those who inhabit multiple minority identities (that is, racial/ethnic minorities, immigrants), are already at greater risk for suicide, HIV, and unemployment, and commonly face systematic, institutional discrimination in the form of criminalization and other human rights violations.3 Vulnerable subgroups, such as unstably housed or informally employed LGBTQ+ individuals, may struggle to practice social distancing and prescribed sanitation measures. The recommendations presented here are data-driven and informed by a cross-sectional survey implemented by the free gay social networking app, Hornet, from April 16 to May 4, 2020. Hornet has over 25 million global users, and over 4,000 users from more than 150 countries completed this survey.

HIV treatment engagement in the context of COVID-19: an observational global sample of transgender and nonbinary people living with HIV.

BACKGROUND: HIV services, like many medical services, have been disrupted by the COVID-19 pandemic. However, there are limited data on the impacts of the COVID-19 pandemic on HIV treatment engagement outcomes among transgender (trans) and nonbinary people. This study addresses a pressing knowledge gap and is important in its global scope, its use of technology for recruitment, and focus on transgender people living with HIV. The objective of this study is to examine correlates of HIV infection and HIV treatment engagement outcomes (i.e., currently on ART, having an HIV provider, having access to HIV treatment without burden, and remote refills) since the COVID-19 pandemic began. METHODS: We utilized observational data from the Global COVID-19 Disparities Survey 2020, an online study that globally sampled trans and nonbinary people (n = 902) between April and August 2020. We conducted a series of multivariable logistic regressions with lasso selection to explore correlates of HIV treatment engagement outcomes in the context of COVID-19. RESULTS: Of the 120 (13.3%) trans and nonbinary people living with HIV in this survey, the majority (85.8%) were currently on HIV treatment. A smaller proportion (69.2%) reported having access to an HIV provider since COVID-19 control measures were implemented. Less than half reported being able to access treatment without burdens related to COVID-19 (48.3%) and having the ability to remotely refill HIV prescription (44.2%). After adjusting for gender in the multivariable models, younger age and anticipated job loss were significantly associated with not having access to HIV treatment without burden. Outcomes also significantly varied by geographic region, with respondents reporting less access to an HIV provider in nearly every region outside of South-East Asia. CONCLUSION: Our results suggest that currently taking ART, having access to an HIV provider, and being able to access HIV treatment without burden and remotely refill HIV medication are suboptimal among trans and nonbinary people living with HIV across the world. Strengthening support for HIV programs that are well-connected to trans and nonbinary communities, increasing remote access to HIV providers and prescription refills, and providing socioeconomic support could significantly improve HIV engagement in trans and nonbinary communities.

Characterising the impact of COVID-19 environment on mental health, gender affirming services and socioeconomic loss in a global sample of transgender and non-binary people: a structural equation modelling.

BACKGROUND: We characterised the impact of COVID-19 on the socioeconomic conditions, access to gender affirmation services and mental health outcomes in a sample of global transgender (trans) and non-binary populations. METHODS: Between 16 April 2020 and 3 August 2020, we conducted a cross-sectional survey with a global sample of trans and non-binary people (n=849) through an online social networking app. We conducted structural equational modelling procedures to determine direct, indirect and overall effects between poor mental health (ie, depression and anxiety) and latent variables across socioecological levels: social (ie, reduction in gender affirming services, socioeconomic loss impact) and environmental factors (ie, COVID-19 pandemic environment). RESULTS: Anxiety (45.82%) and depression (50.88%) in this sample were prevalent and directly linked to COVID-19 pandemic environment. Adjusted for gender identity, age, migrant status, region, education and level of socioeconomic status, our final model showed significant positive associations between relationships of (1) COVID-19 pandemic environment and socioeconomic loss impact (ß=0.62, p<0.001), (2) socioeconomic loss impact and reduction in gender affirming services (ß=0.24, p<0.05) and (3) reduction in gender affirming services and poor mental health (ß=0.19, p<0.05). Moreover, socioeconomic loss impact and reduction in gender affirming services were found to be partial mediators in this model. CONCLUSION: The study results supported the importance of bolstering access to gender affirming services and strengthening socioeconomic opportunities and programmatic support to buffer the impact of COVID-19 pandemic environment on poor mental health among trans and non-binary communities globally.

Economic, Mental Health, HIV Prevention and HIV Treatment Impacts of COVID-19 and the COVID-19 Response on a Global Sample of Cisgender Gay Men and Other Men Who Have Sex with Men.

There is an urgent need to measure the impacts of COVID-19 among gay men and other men who have sex with men (MSM). We conducted a cross-sectional survey with a global sample of gay men and other MSM (n = 2732) from April 16, 2020 to May 4, 2020, through a social networking app. We characterized the economic, mental health, HIV prevention and HIV treatment impacts of COVID-19 and the COVID-19 response, and examined whether sub-groups of our study population are disproportionately impacted by COVID-19. Many gay men and other MSM not only reported economic and mental health consequences, but also interruptions to HIV prevention and testing, and HIV care and treatment services. These consequences were significantly greater among people living with HIV, racial/ethnic minorities, immigrants, sex workers, and socio-economically disadvantaged groups. These findings highlight the urgent need to mitigate the negative impacts of COVID-19 among gay men and other MSM.

RESUMEN: Existe una necesidad urgente para medir los impactos de COVID-19 entre hombres gay y otros hombres que tienen sexo con hombres (HSH). Hemos conducido una encuesta multifuncional con una prueba mundial de hombres gay y otros HSH (n = 2732) desde el 16 de Abril hasta el 4 de Mayo del 2020, a través de una aplicación de red social. Nosotros caracterizamos los impactos económicos, de salud mental, prevención del VIH y tratamiento del VIH e impactos a COVID-19 y la respuesta de COVID-19, y examinamos si subgrupos de nuestra población de estudio fueron impactados desproporcionadamente por COVID-19. Muchos hombres no tan solo reportaron consecuencias económicas y de salud mental, sino también interrupciones de prevención y de pruebas de VIH, y cuidado del VIH y servicios de tratamiento. Encontramos consecuencias más significantes entre personas viviendo con VIH, grupos raciales/etnicos, migrantes, sexo servidores, y groupos socioeconomicamente disfavorecidos. Los resultados subrayan la necesidad crucial de mitigar los impactos multifacéticos de COVID-19 entre los hombres homosexuales y otros HSH, especialmente para aquellos con vulnerabilidades entrelazadas.