Anticipated Stigma and Social Barriers to Communication Between Transgender Women Newly Diagnosed with HIV and Health Care Providers: A Mediation Analysis.

Purpose: We assessed whether anticipated stigma (i.e., fear of public mistreatment due to gender identity) impacts communication between transgender women (TGW) living with HIV and health care providers. Methods: This is a secondary analysis of baseline data from Trans Amigas, a study conducted in Brazil, 2018. The study population consisted of TGW living with HIV, older than 18 years, residing in the São Paulo metropolitan area. We used multivariable logistic regression (α = 0.05), mediation, and bootstrapping for the analysis. Results: One hundred and thirteen participants completed the study. Fear of public mistreatment had an adjusted odds ratio (aOR) of 7.42 (p = 0.003) for difficulty reporting new symptoms to providers. Concerning fear of public mistreatment, we found that unemployment had an aOR of 3.62 (p = 0.036); sex work, an aOR of 2.95 (p = 0.041); and issues related to name change in documents, an aOR of 2.71 (p = 0.033). For the indirect effect on difficulty reporting new symptoms, mediated by fear of public mistreatment, unemployment had an aOR of 1.52 (confidence interval [CI] = 0.88-2.24); sex work, an aOR of 1.48 (CI = 0.81-2.52); and name change issues, an aOR of 1.47 (CI = 0.96-2.43). Conclusions: Anticipated stigma was associated with communication difficulties between TGW living with HIV and providers. Our data suggest that structural factors associated with anticipated stigma could indirectly impact on difficulty reporting new symptoms. These findings indicate the importance of considering social contexts that intersect with individual experiences when analyzing communication barriers between providers and patients, and the need to strengthen social policies for TGW in Brazil. Clinical Trial Registration number: R34MH112177.

The patient behind the wound assessment and plan.

OBJECTIVE: Hard-to-heal wounds are a common problem, worsened by ageing, and the increased prevalence of diabetes and morbid obesity. The provider-patient relationship has undergone a transformation, from a paternalistic to a mutual participation model, in which 'the physician tries to enter the patient's world to see the illness through the patient's eyes'. The indepth assessment of the impact of psychosocial, physical issues and provider-patient dynamics is crucial to wound healing and patient wellbeing. It can customise future treatment including physical therapy, psychological and social interventions to improve outcomes. METHOD: A new health-related quality of life instrument (HRQOL) proposal based on a survey consisting of 20 questions was completed by patients as a pilot project. The psychosocial, physical and provider-patient dynamics were evaluated. A total wound impact score (WIs) was tabulated, ranging from 20-80 points. A wound assessment and plan (PBW-AP) was created. RESULTS: In our sample of 25 patients, 75% experienced a moderate WIs (50-69) and 5% experienced a severe WIs (31-49). Feeling angry about having a wound was reported by 40% of patients. A majority of patients (60%) thought about their wounds >1 hour per day. Importantly, 24% answered that their primary care physicians never mentioned their wounds. CONCLUSION: It is important for all physicians taking care of patients with hard-to-heal wounds to see 'the patient behind the wound'. The PBW-AP algorithm is an individualised, multidisciplinary assessment and intervention based on a WIs. It is designed not only to identify but also to tackle psychosocial, physical, and provider-patient issues, to improve overall quality of life, patient satisfaction and clinical outcomes. Based on the results, the PBW-AP algorithm was designed to be used at initial and subsequent visits as a roadmap for problem identification and intervention.