An Evaluation of TransLife Care: A Locally Developed Structural HIV Prevention Intervention for Transgender Women in Chicago, Illinois.

Transgender women are disproportionately impacted by HIV infection. We report herein the findings of a pre-post evaluation of the TransLife Care (TLC) project in Chicago, Illinois, on behaviors associated with HIV transmission among transgender women. Participants who received any TLC component versus those who did not were compared using mixed-effects logistic regression with random intercepts across follow-up time points. Ninety-seven participants aged 18 to 59 (median age 24) enrolled; 76.3% were transgender women of color. There was a decrease in condomless sex without consistent PrEP use at 8 months, which was not significantly different between those who did and did not receive the TLC intervention, controlling for calendar time. Evidence does not indicate that the TLC reduces condomless sex without PrEP protection among urban transgender women. However, given the preponderance of evidence of the influence of structural barriers on condomless sex, future research should continue to test the efficacy of structural interventions.

The associations of income and Black-White racial segregation with HIV outcomes among adults aged ≥18 years-United States and Puerto Rico, 2019.

OBJECTIVE(S): To examine associations between Index of Concentration at the Extremes (ICE) measures for economic and racial segregation and HIV outcomes in the United States (U.S.) and Puerto Rico. METHODS: County-level HIV testing data from CDC's National HIV Prevention Program Monitoring and Evaluation and census tract-level HIV diagnoses, linkage to HIV medical care, and viral suppression data from the National HIV Surveillance System were used. Three ICE measures of spatial polarization were obtained from the U.S. Census Bureau's American Community Survey: ICEincome (income segregation), ICErace (Black-White racial segregation), and ICEincome+race (Black-White racialized economic segregation). Rate ratios (RRs) for HIV diagnoses and prevalence ratios (PRs) for HIV testing, linkage to care within 1 month of diagnosis, and viral suppression within 6 months of diagnosis were estimated with 95% confidence intervals (CIs) to examine changes across ICE quintiles using the most privileged communities (Quintile 5, Q5) as the reference group. RESULTS: PRs and RRs showed a higher likelihood of testing and adverse HIV outcomes among persons residing in Q1 (least privileged) communities compared with Q5 (most privileged) across ICE measures. For HIV testing percentages and diagnosis rates, across quintiles, PRs and RRs were consistently greatest for ICErace. For linkage to care and viral suppression, PRs were consistently lower for ICEincome+race. CONCLUSIONS: We found that poor HIV outcomes and disparities were associated with income, racial, and economic segregation as measured by ICE. These ICE measures contribute to poor HIV outcomes and disparities by unfairly concentrating certain groups (i.e., Black persons) in highly segregated and deprived communities that experience a lack of access to quality, affordable health care. Expanded efforts are needed to address the social/economic barriers that impede access to HIV care among Black persons. Increased partnerships between government agencies and the private sector are needed to change policies that promote and sustain racial and income segregation.

A cross-sectional analysis of psychosocial and structural barriers and facilitators associated with PrEP use among a sample of transgender women in Chicago, IL.

BACKGROUND: Expanding pre-exposure prophylaxis (PrEP) among transgender women in the United States is an important strategy to meet national HIV prevention goals, however self-reported use of PrEP is low in this group. METHODS: This study reports the findings of a cross-sectional analysis of the relationship of barriers as well as facilitators to recent PrEP use among transgender women enrolled in an evaluation of the TransLife Care project (Chicago, Illinois), a structural intervention designed to meet basic needs. We computed multivariable prevalence ratios for barriers, facilitators and recent PrEP use, controlling for demographics. RESULTS: Findings suggest that psychosocial and structural barriers, including moderate/high alcohol use, stimulant use, and history of incarceration were all positively associated with recent PrEP use among urban transgender women. In addition, a psychosocial facilitator, gender affirmation, was positively associated with recent PrEP use, while, while collective self-esteem, a was negatively associated with it. Finally, common indications for PrEP have high sensitivity, but low specificity and predictive value for identifying those on PrEP. CONCLUSION: We conclude that despite a large gap in PrEP use among those with indications, individuals experiencing psychosocial and structural barriers are more likely to use PrEP, and facilitators, such as psychological sense of affirmed gender may support its use. TRIAL REGISTRATION: N/A.

"Why You Putting This Drug in Your Body to Fight off Something that You Don't Have?" Perceptions About PrEP Use Among Black and Latino Men Who Have Sex with Men in the U.S. South.

PrEP use has steadily increased since its introduction, yet uptake remains slow among MSM of color in the U.S. South. Findings presented are from a qualitative study conducted in 2016 exploring factors related to remaining HIV negative among Black (n = 99) and Latino (n = 51) MSM in Atlanta, Baton Rouge, New Orleans, Jackson, and Miami. One-hour in-depth interviews were analyzed using a qualitative content analysis approach. MSM perceived PrEP as providing relief from fear and as an insurance policy against HIV infection but were likely to consider themselves at low risk for HIV. Identified factors influencing PrEP use included side effects, medical mistrust, and stigma. Cost and access were not seen as major barriers. Findings suggest MSM of color in the South may view PrEP as too risky for their HIV prevention needs. PrEP providers can address medical mistrust, discuss side effects, and emphasize positive aspects of PrEP use to increase uptake. (150 words).

A Health Equity Approach for Implementation of JYNNEOS Vaccination at Large, Community-Based LGBTQIA+ Events - Georgia, August 27-September 5, 2022.

Gay, bisexual, and other men who have sex with men (MSM) have been disproportionately affected during the 2022 U.S. monkeypox outbreak, with Black or African American (Black) MSM being the most affected demographic group (1). As of September 28, 2022, Georgia had reported 1,784 monkeypox cases; 98% of which occurred in males and 77% among Black persons (2). As of September 13, 2022, 60% of reported cases were among persons with HIV infection, and 50% of persons with monkeypox had a sexually transmitted infection within the past year (3). Because of racial disparities in the incidence of monkeypox cases and a large proportion of cases among MSM in Georgia, early vaccination beginning in July focused on improving equitable access by establishing new and leveraging existing partnerships with community-based organizations that serve affected populations, including persons with HIV infection. Despite these efforts, disparities persisted because of high demand and limited vaccine supply. The Georgia Department of Public Health (DPH) requested CDC support for a vaccine pilot and received an additional allocation of 5,500 doses of JYNNEOS vaccine for administration at events leading up to and throughout a Black gay Pride festival in Atlanta, a multiday event held Labor Day weekend (September 2-5, 2022). The event celebrates lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and other (LGBTQIA+) communities of color and hosts more than 125,000 attendees each year. Before the festival (as of August 24), 17,546 persons had been vaccinated in Georgia, of whom 96% were male, 34% aged 25-36 years, 44% Black, and 8% Hispanic or Latino (Hispanic) (4).

Clusters of Rapid HIV Transmission Among Gay, Bisexual, and Other Men Who Have Sex with Men - United States, 2018-2021.

Gay, bisexual, and other men who have sex with men (MSM) accounted for 68% of new HIV diagnoses in the United States in 2020* (1). Despite advances in treatment and prevention, HIV transmission among MSM continues, in part because of stigma and barriers to accessing prevention and treatment services (2). HIV cluster detection and response, a core strategy of the Ending the HIV Epidemic in the United States initiative,† is an important tool for early identification and response to rapid HIV transmission, including among MSM. To better understand rapid HIV transmission among this population, CDC characterized large HIV molecular clusters detected using analysis of HIV-1 nucleotide sequence data from the National HIV Surveillance System (NHSS).§ Among 38 such clusters first detected during 2018-2019 that had grown to include more than 25 persons by December 2021, 29 occurred primarily among MSM. Clusters primarily among MSM occurred in all geographic regions, and 97% involved multiple states. Clusters were heterogeneous in age, gender identity, and race and ethnicity and had rapid growth rates (median = nine persons added per year). The overall transmission rate at cluster detection was 22 transmission events per 100 person-years, more than six times that of previously estimated national transmission rates (3). Most clusters of rapid HIV transmission occur among MSM. Swift response to reach diverse persons and communities with early, tailored, and focused interventions is essential to reducing HIV transmission (4).

"We in This Fight Together ": HIV Treatment and Prevention Among Couples of HIV-Discordant Black and Latino Men Who Have Sex with Men.

HIV-positive Black and Latino men who have sex with men (MSM) have substantial challenges accessing and engaging in HIV care. Findings presented here are an analysis of 14 HIV-discordant couples (N = 28) from Atlanta, GA; Baltimore, MD; Chicago, IL; Los Angeles, CA; and Washington, DC. One-hour in-depth interviews were conducted. Interviews were analyzed using a qualitative content analysis approach. Most couples reported relationship fears associated with delayed disclosure, HIV care engagement instigated by the HIV-uninfected partner, and varying knowledge and concern about the impacts of HIV infection and risk reduction. Findings suggest an opportunity to jointly educate and treat MSM of color in HIV-discordant relationships to improve engagement in ART and PrEP care and adherence.

Implementing the COVID-19 Rapid Community Assessment on Vaccine Confidence: Lessons Learned From Alabama and Georgia.

Engaging communities is a key strategy to increase COVID-19 vaccination. The Centers for Disease Control and Prevention (CDC) COVID-19 Vaccine Confidence Rapid Community Assessment Guide was developed for community partners to obtain insights about barriers to COVID-19 vaccine uptake and to engage community partners in designing interventions to build vaccine confidence. In spring 2021, 3 CDC teams were deployed to Alabama and Georgia to conduct a rapid community assessment in selected jurisdictions. Data collection included interviews, listening sessions, observations, and street intercept surveys. We identified 3 facilitators and barriers to vaccine uptake: (1) planning and coordination, (2) capacity and implementation, and (3) attitudes and beliefs. We found that the use of the rapid community assessment in Alabama and Georgia was feasible to implement, useful in eliciting unique community concerns and dispelling assumptions, and useful in informing intervention strategies. Our results underscore the importance of community engagement in COVID-19 mitigation strategies.

Evaluating Locally Developed Interventions to Promote PrEP Among Racially/Ethnically Diverse Transgender Women in the United States: A Unique CDC Initiative.

In the United States, transgender women are disproportionately affected by HIV. However, few evidence-based prevention interventions exist for this key population. We describe two promising, locally developed interventions that are currently being implemented and evaluated through the Centers for Disease Control and Prevention Combination HIV Prevention for Transgender Women Project: (a) ChiCAS, designed to promote the uptake of pre-exposure prophylaxis (PrEP), condom use, and medically supervised hormone therapy among Spanish-speaking transgender Latinas, and (b) TransLife Care, designed to address the structural drivers of HIV risk through access to housing, employment, legal services, and medical services, including HIV preventive care (e.g., PrEP use) among racially/ethnically diverse urban transgender women. If the evaluation trials determine that these interventions are effective, they will be among the first such interventions for use with transgender women incorporating PrEP, thereby contributing to the evidence-based resources that may be used to reduce HIV risk among this population.

"To Me, Everybody Is infected": Understanding Narratives about HIV Risk among HIV-negative Black Men Who Have Sex with Men in the Deep South.

For black MSM living in the Deep South, the intersection of sexuality, race, and geography impacts HIV risk substantially. Between July and September 2016, we conducted a qualitative study among HIV-negative black MSM in five southern cities in the US with elevated HIV prevalence. Analysis included assessment of interrater reliability, cluster analysis, and descriptive statistics. We enrolled 99 black MSM (mean age: 33.6; SD = 12.8; range: 17-68 years). Four overarching themes emerged: harboring fear of HIV and the internalization of HIV stigma; scrutinizing potential partners to assess riskiness and HIV status; embracing distance and isolation from those perceived as a threat to HIV status; and exhibiting self-efficacy toward HIV prevention and utilizing risk reduction strategies. Future HIV prevention efforts may benefit by balancing risk and deficit based strategies with those that emphasize resilience, address disenfranchisement via structural interventions, and assess and treat inherent trauma(s).

Improving HIV medical care engagement by attending to status disclosure and social support.

Expeditious linkage and consistent engagement in medical care is important for people with HIV's (PWH) health. One theory on fostering linkage and engagement involves HIV status disclosure to mobilize social support. To assess disclosure and social support's association with linkage and engagement, we conducted a qualitative study sampling black and Latino men who have sex with men (MSM of color) in the U.S. Participants' narratives presented mixed results. For instance, several participants who reported delaying, inconsistent access, or detachment from care also reported disclosing for support purposes, yet sporadic engagement suggests that their disclosure or any subsequent social support have not assisted. The findings contribute to the literature that questions disclosure and social support's influence on care engagement, especially when decontextualized from circumstances and intentions. Our findings suggest the mechanics of disclosure and social support require planned implementation if intending to affect outcomes, especially among MSM of color. From the findings, we explore steps that may bolster interventions seeking to anchor medical care engagement.

PrEP Awareness in the Context of HIV/AIDS Conspiracy Beliefs Among Black/African American and Hispanic/Latino MSM in Three Urban US Cities.

We examined HIV conspiracy beliefs and PrEP awareness in a convenience sample of minority MSM. Participants in three cities completed a behavioral self-assessment on sociodemographics, PrEP awareness, and HIV/AIDS conspiracy beliefs. HIV/AIDS conspiracy beliefs were more common among Black than Latino MSM (58% vs. 42%, p < .05), and among younger men than older men (age 18-29 (50%), 30-39 (22%), 40+ (28%); p < .05). PrEP awareness co-occurred with conspiracy belief less (37%) than with non-belief (63%, p < .05), persisting in multivariable regression (aOR = 0.52, 95% CI = 0.38-0.71). This relationship suggests that current HIV care and prevention messaging is either inaccessible or not credible to some minority subpopulations.

Barriers and Facilitators for Antiretroviral Treatment Adherence Among HIV-Positive African American and Latino Men Who Have Sex With Men.

Some Black/African American and Hispanic/Latino men who have sex with men (MSM) living with HIV do not take antiretroviral therapy (ART). We conducted semistructured interviews with 84 adult, Black/African American and Hispanic/Latino MSM with HIV to understand ART barriers and facilitators. We used chi-square statistics to identify factors associated with ART use (p ≤ .05), and selected illustrative quotes. Over half (51.2%) said they followed their doctor's instructions; however, only 27.4% reported consistently taking ART. Some men delayed ART until overcoming diagnosis denial or becoming very sick. ART use was facilitated by encouragement from others, treatment plans, side effect management, lab test improvements, pill-taking reminders, and convenient care facilities that provide "one-stop shop" services. Men were more likely to take ART when having providers who communicated effectively and were perceived to treat them with respect. Healthcare personnel can use our findings to strengthen services for MSM of color.

Changes in HIV Preexposure Prophylaxis Awareness and Use Among Men Who Have Sex with Men - 20 Urban Areas, 2014 and 2017.

In February 2019, the U.S. Department of Health and Human Services proposed a strategic initiative to end the human immunodeficiency (HIV) epidemic in the United States by reducing new HIV infections by 90% during 2020-2030* (1). Phase 1 of the Ending the HIV Epidemic initiative focuses on Washington, DC; San Juan, Puerto Rico; and 48 counties where the majority of new diagnoses of HIV infection in 2016 and 2017 were concentrated and on seven states with a disproportionate occurrence of HIV in rural areas relative to other states.† One of the four pillars in the initiative is protecting persons at risk for HIV infection using proven, comprehensive prevention approaches and treatments, such as HIV preexposure prophylaxis (PrEP), which is the use of antiretroviral medications that have proven effective at preventing infection among persons at risk for acquiring HIV. In 2014, CDC released clinical PrEP guidelines to health care providers (2) and intensified efforts to raise awareness and increase the use of PrEP among persons at risk for infection, including gay, bisexual, and other men who have sex with men (MSM), a group that accounted for an estimated 68% of new HIV infections in 2016 (3). Data from CDC's National HIV Behavioral Surveillance (NHBS) were collected in 20 U.S. urban areas in 2014 and 2017, covering 26 of the geographic areas included in Phase I of the Ending the HIV Epidemic initiative, and were compared to assess changes in PrEP awareness and use among MSM. From 2014 to 2017, PrEP awareness increased by 50% overall, with >80% of MSM in 17 of the 20 urban areas reporting PrEP awareness in 2017. Among MSM with likely indications for PrEP (e.g., sexual risk behaviors or recent bacterial sexually transmitted infection [STI]), use of PrEP increased by approximately 500% from 6% to 35%, with significant increases observed in all urban areas and in almost all demographic subgroups. Despite this progress, PrEP use among MSM, especially among black and Hispanic MSM, remains low. Continued efforts to improve coverage are needed to reach the goal of 90% reduction in HIV incidence by 2030. In addition to developing new ways of connecting black and Hispanic MSM to health care providers through demonstration projects, CDC has developed resources and tools such as the Prescribe HIV Prevention program to enable health care providers to integrate PrEP into their clinical care.§ By routinely testing their patients for HIV, assessing HIV-negative patients for risk behaviors, and prescribing PrEP as needed, health care providers can play a critical role in this effort.

Barriers and Facilitators for Clinical Care Engagement Among HIV-Positive African American and Latino Men Who Have Sex with Men.

Achieving optimal health among people living with HIV (PLWH) requires linkage to clinical care upon diagnosis, followed by ongoing engagement in HIV clinical care. A disproportionate number of black/African American and Hispanic/Latino men who have sex with men (MSM) living with HIV do not, however, achieve ongoing care. We conducted semistructured interviews in 2014 with 84 urban black/African American and Hispanic/Latino MSM living with HIV to understand their barriers and facilitators to engagement. We classified men as care-engaged or not at the time of the interview, and conducted content analysis of the interview transcripts to identify barriers and facilitators to engagement. Respondent mean age was 42.4 years (range, 20-59). Over half (59.5%, n = 50) were black/African American. Slightly more than a third (38.1%, n = 32) reported not being continuously care-engaged since diagnosis, and 17.9% (n = 15) delayed entry, although they have subsequently entered and remained in care. Sustained engagement began with overcoming denial after diagnosis and having treatment plans, as well as having conveniently located care facilities. Engagement also was facilitated by services tailored to meet multiple patient needs, effective patient-provider communication, and providers who show empathy and respect for their patients. Respondents were less likely to be care-engaged when these factors were absent. It can be difficult for racial and ethnic minority MSM living with HIV to begin and sustain care engagement. To optimize care engagement, our findings underscore the value of (1) convenient multipurpose HIV care facilities that meet patient needs; (2) excellent provider-patient communication that reinforces respect, trust, and HIV treatment literacy; and (3) assisting PLWH to create personalized treatment plans and overcome possible challenges such as diagnosis denial.

Effects of Brief Messages About Antiretroviral Therapy and Condom Use Benefits Among Black and Latino MSM in Three U.S. Cities.

This pilot study examined effects of HIV prevention messages about self and partner benefits of antiretroviral therapy (ART) and condom effectiveness on increased intentions for behavior change. Data were from Messages4Men, a study examining prevention messages among 320 HIV-positive and 605 HIV-negative Black and Latino MSM. Men completed a computer-based assessment after message exposure, and multivariable models controlled for risky sex and demographics. A majority of HIV-positive men reported increased intentions for ART use; 22% reported partner benefit information was new. HIV-positive men with a detectable viral load had significantly greater adjusted odds of reporting intentions for ART use. Over half of HIV-negative MSM reported ART benefit information was new, and 88% reported increased intentions to discuss ART use with infected partners. Black MSM anticipated they would increase condom use in response to the self and partner benefit messages. Tailored messages on benefits of ART are needed for MSM.

The Associations of Resilience and HIV Risk Behaviors Among Black Gay, Bisexual, Other Men Who Have Sex with Men (MSM) in the Deep South: The MARI Study.

Resilience is an understudied intrapersonal factor that may reduce HIV risk among men who have sex with men (MSM). Multivariable Poisson regression models were used to estimate the prevalence ratio (PR) of sexual risk behaviors, HIV prevalence, and history of sexually transmitted infections (STIs) with resilience scores in a population-based study among 364 black MSM in the Deep South. Participants with higher resilience scores had a lower prevalence of condomless anal sex with casual sexual partners in past 12 months (PR = 0.80, p value = 0.001) and during their last sexual encounter (PR = 0.81; p value = 0.009). Resilience was inversely associated with a lower prevalence of condomless anal sex with main sexual partners, participating in a sex party/orgy and having a STI in the past 12 months. Resilience may have a protective effect on HIV among black MSM, especially in the Deep South, and should be further explored in studies with prospective designs.

RESUMEN: La resistencia es un factor intrapersonal que ha sido poco estudiado que puede reducir el riesgo de VIH entre los hombres que tienen sex con hombres (HSH). Modelos de regresión multivariable de Posesión han sido utilizado para estimar el ratio de prevalencia (RP) de los comportamientos sexuales, la prevalencia de VIH, y la historia de infección de transmisión sexual (ITS) en comparación con los resultados de resistencia en un estudio basado en la población entre 364 HSH negros en los estados del sureste de los EEUU. Los participantes con mayor resistencia tuvieron una prevalencia menor de tener sexo anal sin un condón con una pareja sexual casual en los últimos 12 meses (PR = 0.80; p = 0.001) y en su último encuentro sexual (PR = 0.81; p = 0.009). La resistencia fue inversamente asociado con una prevalencia baja de sexo anal sin condón con una pareja sexual principal, participando en una orgía y si tiene un ITS en los últimos 12 meses. La resistencia puede que tenga un efecto protector de VIH con la población HSH negros, especialmente en los estados del sureste de los EEUU, y debe estar mejor investigado con investigaciones prospectivas.

A Rapid Review of eHealth Interventions Addressing the Continuum of HIV Care (2007-2017).

National HIV prevention goals call for interventions that address Continuum of HIV Care (CoC) for persons living with HIV. Electronic health (eHealth) can leverage technology to rapidly develop and disseminate such interventions. We conducted a qualitative review to synthesize (a) technology types, (b) CoC outcomes, (c) theoretical frameworks, and (d) behavior change mechanisms. This rapid review of eHealth, HIV-related articles (2007-2017) focused on technology-based interventions that reported CoC-related outcomes. Forty-five studies met inclusion criteria. Mobile texting was the most commonly reported technology (44.4%, k = 20). About 75% (k = 34) of studies showed proven or preliminary efficacy for improving CoC-related outcomes. Most studies (60%, k = 27) focused on medication adherence; 20% (k = 9) measured virologic suppression. Many eHealth interventions with preliminary or proven efficacy relied on mobile technology and integrated knowledge/cognition as behavior change mechanisms. This review identified gaps in development and application of eHealth interventions regarding CoC.

Health Care Use and HIV-Related Behaviors of Black and Latina Transgender Women in 3 US Metropolitan Areas: Results From the Transgender HIV Behavioral Survey.

PURPOSE: HIV prevalence estimates among transgender women in the United States are high, particularly among racial/ethnic minorities. Despite increased HIV risk and evidence of racial disparities in HIV prevalence among transgender women, few data are available to inform HIV prevention efforts. METHODS: A transgender HIV-related behavioral survey conducted in 2009 in 3 US metropolitan areas (Chicago, Houston, and Los Angeles County), used respondent-driven sampling to recruit 227 black (n = 139) and Latina (n = 88) transgender women. We present descriptive statistics on sociodemographic, health care, and HIV-risk behaviors. RESULTS: Of 227 transgender women enrolled, most were economically and socially disadvantaged: 73% had an annual income of less than $15,000; 62% lacked health insurance; 61% were unemployed; and 46% reported being homeless in the past 12 months. Most (80%) had visited a health care provider and over half (58%) had tested for HIV in the past 12 months. Twenty-nine percent of those who reported having an HIV test in the past 24 months self-reported being HIV positive. Most of the sample reported hormone use (67%) in the past 12 months and most hormone use was under clinical supervision (70%). Forty-nine percent reported condomless anal sex in the past 12 months and 16% reported ever injecting drugs. CONCLUSION: These findings reveal the socioeconomic challenges and behavioral risks often associated with high HIV risk reported by black and Latina transgender women. Despite low health insurance coverage, the results suggest opportunities to engage transgender women in HIV prevention and care given their high reported frequency of accessing health care providers.