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Art therapy is a promising form of therapy to address mental health concerns for refugee youth. This article describes the development and implementation of a pilot evaluation of an art therapy program for refugee adolescents from Burma currently living in the United States. Evaluation activities were based on the Centers for Disease Control and Prevention's evaluation framework and implemented through a partnership of art therapists and public health researchers in North Carolina. Findings indicate that evaluation activities were feasible, acceptable, and provided baseline measures of mental health for the adolescents sampled. Through a discussion of evaluation components and results, this pilot evaluation offers an example of how art therapy organizations can integrate program evaluation using existing evaluation frameworks, while engaging stakeholders and building organizational capacity.

Transgender women experience discrimination in many settings, including in employment. Because employment and health insurance are intertwined in the United States, employment discrimination might be related to lower health insurance coverage and health care use, including gender-affirming care. This analysis used data from transgender women (N = 1,608) in seven urban areas in the United States collected during 2019-2020 to present the prevalence of six discrimination types (employment, housing, bathroom, businesses, health care, and abuse) and to measure the association between employment discrimination (defined as trouble getting a job or fired due to being transgender) and sociodemographic characteristics, health care access, and health care use. Log-linked Poisson regression models were conducted to estimate adjusted prevalence ratios and 95% CIs. Seven in 10 transgender women experienced at least one type of discrimination during the past 12 months. During the same period, 9.9% of transgender women were fired and 32.4% had trouble getting a job because of being transgender. Employment discrimination was associated with younger age and lower socioeconomic status. Having trouble getting a job was associated with health care access and health care use factors, including having no health insurance or having Medicaid only, having an unmet medical need because of cost, never having transgender-specific care, and having an unmet need for gender-affirming procedures. These findings suggest that employment discrimination contributes to transgender women's economic marginalization and their ability to obtain adequate health insurance coverage and achieve their transition goals. These findings might help guide efforts that protect transgender women's right to pursue their work, health, and life goals without discrimination. [ABSTRACT FROM AUTHOR]

Psychosocial and structural syndemic conditions, including polydrug use and experiencing homelessness, frequently co-occur and might jointly increase HIV risk. Limited studies have assessed racial and ethnic differences in exposure to syndemic conditions and behaviors associated with HIV transmission among transgender women. This report examines the relation between syndemic conditions and condomless anal intercourse (CAI) among transgender women in seven urban areas in the United States to develop HIV prevention interventions for transgender women. During 2019-2020, transgender women in seven urban areas were recruited using respondent-driven sampling for a biobehavioral survey. Reported syndemic conditions (psychosocial: polydrug use, sexual violence, and psychological distress; structural: homelessness, incarceration, and exchange sex) were summed to create a syndemic score. Using modified Poisson regression to account for RDS, the study assessed whether the strength of the association between syndemic score and CAI differed by race and ethnicity. To assess additive interaction, the relative excess prevalence owing to interaction (REPI) and 95% CIs for selected pairs of syndemic conditions on CAI prevalence stratified by race and ethnicity were estimated. Of 1,348 transgender women (Black = 546, White = 176, and Hispanic = 626), 55% reported CAI; and 24% reported =3 syndemic conditions. Reporting additional syndemic conditions was associated with CAI for White, Hispanic, and Black participants. The association was significantly stronger for White than Black and Hispanic participants. Limited significant superadditive interactions were found, although the majority were between structural syndemic conditions. Racial and ethnic differences in REPI estimates were observed. Reporting more syndemic conditions was associated with increased CAI across racial and ethnic groups, demonstrating that HIV prevention efforts for transgender women should address structural and psychosocial syndemic conditions. Results differed by race and ethnicity, indicating that syndemic-focused interventions for transgender women should be tailored to racial and ethnic groups. [ABSTRACT FROM AUTHOR]

Transgender women, especially transgender women of color, are disproportionately affected by HIV. However, no surveillance system collects data on HIV risk factors among this population. To address this gap, CDC developed a surveillance system entitled National HIV Behavioral Surveillance Among Transgender Women (NHBS-Trans) to assess behavioral and contextual data through systematic biobehavioral surveillance to monitor behavioral risk factors, prevention usage, and HIV prevalence among transgender women. NHBS-Trans used respondent-driven sampling in seven urban areas in the United States. Trained interviewers used a standardized, anonymous questionnaire to collect information on HIV-related behavioral risk factors, HIV testing, and use of prevention services. Each of the seven participating project areas recruited approximately 200 eligible transgender women and offered anonymous HIV testing. Overall, in the seven project areas, 1,757 participants completed the eligibility screener for NHBS-Trans during 2019-2020; of these, 6.6% were seeds (i.e., a limited number of initial participants who were chosen by referrals from persons and community-based organizations who knew or were part of the local population of transgender women). A total of 1,637 (93.2%) participants were eligible, consented, and completed the interview. Of these, 1,624 (99.2%) agreed to HIV testing. Of the total 1,637 participants, 29 participants did not report identity of woman or transgender woman, resulting in a final sample of 1,608 transgender women. NHBS-Trans project area staff members (n = 14) reported that the survey was timely and addressed a critical need for HIV surveillance in a population that is often overlooked. The MMWR supplement includes this overview report on NHBS-Trans, which describes the methods (history, participant eligibility criteria, questionnaire, data collection, and HIV testing) as well as evaluation of project implementation and the performance of the questionnaire content, specifically the acceptability for transgender women. The other NHBS-Trans reports in the supplement include information on pre-exposure prophylaxis use, psychosocial syndemic conditions and condomless anal intercourse, nonprescription hormone use, homelessness, discrimination and the association between employment discrimination and health care access and use, and social support and the association between certain types of violence and harassment (gender-based verbal and physical abuse or harassment, physical intimate partner abuse or harassment, and sexual violence) and suicidal ideation. NHBS-Trans provides important data related to the goals of the Ending the HIV Epidemic in the U.S. initiative. Findings from NHBS-Trans can help guide community leaders, clinicians, and public health officials in improving access to and use of HIV prevention and treatment services by transgender women. [ABSTRACT FROM AUTHOR]

Key Points: Question: What are the long-term health effects of involuntary displacement of people experiencing homelessness who inject drugs in US cities? Findings: This simulation modeling study of 23 US cities projects that involuntary displacement of people experiencing homelessness may yield substantial increases in morbidity and mortality over a 10-year period. Involuntary displacement is estimated to worsen overdose and hospitalizations, decrease initiations of medications for opioid use disorder, and contribute to deaths among people experiencing homelessness who inject drugs. Meaning: Ceasing involuntary displacement of people experiencing homelessness may mitigate some health-related harms associated with homelessness. Importance: At least 500 000 people in the US experience homelessness nightly. More than 30% of people experiencing homelessness also have a substance use disorder. Involuntary displacement is a common practice in responding to unsheltered people experiencing homelessness. Understanding the health implications of displacement (eg, "sweeps," "clearings," "cleanups") is important, especially as they relate to key substance use disorder outcomes. Objective: To estimate the long-term health effects of involuntary displacement of people experiencing homelessness who inject drugs in 23 US cities. Design, Setting, and Participants: A closed cohort microsimulation model that simulates the natural history of injection drug use and health outcomes among people experiencing homelessness who inject drugs in 23 US cities. The model was populated with city-level data from the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance system and published data to make representative cohorts of people experiencing homelessness who inject drugs in those cities. Main Outcomes and Measures: Projected outcomes included overdose mortality, serious injection–related infections and mortality related to serious injection–related infections, hospitalizations, initiations of medications for opioid use disorder, and life-years lived over a 10-year period for 2 scenarios: "no displacement" and "continual involuntary displacement." The population-attributable fraction of continual displacement to mortality was estimated among this population. Results: Models estimated between 974 and 2175 additional overdose deaths per 10 000 people experiencing homelessness at 10 years in scenarios in which people experiencing homelessness who inject drugs were continually involuntarily displaced compared with no displacement. Between 611 and 1360 additional people experiencing homelessness who inject drugs per 10 000 people were estimated to be hospitalized with continual involuntary displacement, and there will be an estimated 3140 to 8812 fewer initiations of medications for opioid use disorder per 10 000 people. Continual involuntary displacement may contribute to between 15.6% and 24.4% of additional deaths among unsheltered people experiencing homelessness who inject drugs over a 10-year period. Conclusion and Relevance: Involuntary displacement of people experiencing homelessness may substantially increase drug-related morbidity and mortality. These findings have implications for the practice of involuntary displacement, as well as policies such as access to housing and supportive services, that could mitigate these harms. This modeling study examines the potential long-term health effects of involuntary displacement among unsheltered people experiencing homelessness who inject drugs in 23 US cities. [ABSTRACT FROM AUTHOR]

Background: During the 2022 mpox outbreak, nearly all cases have been associated with sexual contact, and many people have presented or were referred to sexually transmitted disease (STD) clinics with anogenital mpox lesions. Additionally, many people at highest risk of mpox were already users of STD clinics. The National Network of STD Clinical Prevention Training Centers (NNPTCs), in partnership with Centers for Disease Control and Prevention (CDC), conducted a survey to understand the impact of the mpox outbreak on sexual health programs. The purpose of the survey was to assess knowledge, practices, and experiences around mpox vaccines, testing, and management to inform public health response efforts, including resource and training development. To our knowledge, this is the most comprehensive nation-wide mpox-related survey of sexual health programs in the United States. Methods: During August 31--September 13, 2022, the eight regional STD training centers facilitated a cross-sectional, web-based survey administered via the Enketo platform. The survey requested a single respondent per clinical site. A cross-sectional descriptive data analysis was then performed. Results: There were 168 survey responses by clinicians (n=131, 78%) and program staff (n=37, 22%). More than half (58%) reported at least somewhat significant mpox-related clinical disruptions. 72% indicated average mpox-related visits lasted >30 minutes, and 22% reported visits lasted ≥one hour. Clinicians reported barriers to mpox testing (82%) and tecovirimat use (42%), and challenges differentiating mpox from other etiologies. Less than half (49%) felt comfortable with mpox pain management and roughly one-third felt uninformed about mpox pre- and post-exposure prophylaxis (29%, 35% respectively). Of those involved in mpox vaccination, 61% reported using equity strategies. When asked to describe these strategies, respondents often described guideline or risk factor-based screenings instead of equity activities. Conclusion: These findings highlight the substantial impact of the 2022 mpox outbreak on sexual health programs in the United States. Critical gaps and barriers are identified that may guide additional mpox training and technical assistance. Specifically, clinicians reported challenges with mpox testing, diagnosis, patient counseling, and management. Further, results suggest a knowledge deficit about implementing mpox vaccine programs with attention to equity, indicating an additional area for education. [ABSTRACT FROM AUTHOR]

We examined the association between mental health issues, social support, and HIV among adolescent sexual minority males (SMM), who are disproportionally affected by HIV. National HIV Behavioral Surveillance among Young Men Who Have Sex with Men (NHBS-YMSM) data among SMM aged 13–18 years were collected in three cities (Chicago, New York City, and Philadelphia). Separate log-linked Poisson regression models were used to estimate associations between mental health issues and social support (general and family), and 3 HIV-related sexual risk behavior outcomes: past-year condomless anal intercourse (CAI) with a male partner, past-year sex with ≥ 4 partners, and first vaginal or anal sex before age 13. Of 547 adolescent SMM, 22% reported ever attempting suicide and 10% reported past-month suicidal ideation. The majority (52%) reported depression and anxiety. Thirty-nine percent reported CAI, 29% reported ≥ 4 sex partners and 22% reported first sex before age 13. Ever attempting suicide, suicidal ideation, and depression and anxiety were associated with CAI. Separately, ever attempting suicide and lack of family support were associated with ≥ 4 sex partners. None of the mental health or support measures were associated with having sex before age 13. General social support was not associated with any sexual risk behaviors. Mental health issues are common among adolescent SMM and associated with sexual risk behaviors. Including mental health support in comprehensive HIV prevention for adolescent SMM could potentially reduce HIV risk in this population. [ABSTRACT FROM AUTHOR]

Approximately one in three women in the United States experience intimate partner violence (IPV). IPV is associated with long-term negative health consequences; therefore, there is a need to examine potential prevention strategies. Evidence suggests that domestic violence protective orders (DVPOs), a legal intervention that prevents contact between two parties for up to 12 months, are an effective secondary prevention tool. However, because judges have relative autonomy in granting or denying DVPOs, research is needed to examine the processes they use to guide their decisions. The aim of the study was to investigate how District Court judges decide whether to issue a DVPO. Using in-depth interviews with 20 North Carolina District Court judges, the present study addressed three research questions: (a) what factors influence judges’ decisions to grant or deny a DVPO, (b) what heuristics or cognitive shortcuts potentially guide their decisions, and (c) what judges worry about when making decisions. Three themes emerged from the data analyses: (a) violent incidents must reach a certain threshold, (b) the presence of children creates competing concerns, and (c) judges worry about the negative impact their decisions may have on the lives of those involved. Recommendations for improving the DVPO issuance process are also discussed. [ABSTRACT FROM AUTHOR]

During January 1, 2020-August 10, 2020, an estimated 5 million cases of coronavirus disease 2019 (COVID-19) were reported in the United States.* Published state and national data indicate that persons of color might be more likely to become infected with SARS-CoV-2, the virus that causes COVID-19, experience more severe COVID-19-associated illness, including that requiring hospitalization, and have higher risk for death from COVID-19 (1-5). CDC examined county-level disparities in COVID-19 cases among underrepresented racial/ethnic groups in counties identified as hotspots, which are defined using algorithmic thresholds related to the number of new cases and the changes in incidence. † Disparities were defined as difference of ≥5% between the proportion of cases and the proportion of the population or a ratio ≥1.5 for the proportion of cases to the proportion of the population for underrepresented racial/ethnic groups in each county. During June 5-18, 205 counties in 33 states were identified as hotspots; among these counties, race was reported for ≥50% of cumulative cases in 79 (38.5%) counties in 22 states; 96.2% of these counties had disparities in COVID-19 cases in one or more underrepresented racial/ethnic groups. Hispanic/Latino (Hispanic) persons were the largest group by population size (3.5 million persons) living in hotspot counties where a disproportionate number of cases among that group was identified, followed by black/African American (black) persons (2 million), American Indian/Alaska Native (AI/AN) persons (61,000), Asian persons (36,000), and Native Hawaiian/other Pacific Islander (NHPI) persons (31,000). Examining county-level data disaggregated by race/ethnicity can help identify health disparities in COVID-19 cases and inform strategies for preventing and slowing SARS-CoV-2 transmission. More complete race/ethnicity data are needed to fully inform public health decision-making. Addressing the pandemic's disproportionate incidence of COVID-19 in communities of color can reduce the community-wide impact of COVID-19 and improve health outcomes., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Background: Limited data exist in the United States on the prevalence of HIV among women who exchange sex., Setting: We estimate HIV prevalence of women who exchange sex from a 2016 survey in Chicago, Detroit, Houston, and Seattle and compare it with the prevalence of HIV among women of low socioeconomic status (SES), who did not exchange sex, and women in the general population., Methods: Women who exchange sex were recruited via respondent-driven sampling among some cities participating in National HIV Behavioral Surveillance, interviewed, and offered HIV testing. We estimate HIV prevalence and, using prevalence ratios, compare it with the prevalence among women of low SES who did not exchange sex in the 2013 National HIV Behavioral Surveillance cycle, and to women in the general population estimated using 2015 National HIV Surveillance data., Results: One thousand four hundred forty women reported exchange sex in 2016. Aggregated HIV prevalence was 4.9% [95% confidence interval (CI): 2.7 to 7.1] among women who exchanged sex, 1.6% (95% CI: 0.3 to 2.8) among women of low SES who did not exchange sex, and 0.6% (95% CI: 0.5% to 0.6%) among women in the general population. HIV prevalence among women who exchanged sex was 3.1 times (95% CI: 1.6 to 5.9) as high as among women of low SES who did not exchange sex, and 8.8 times (95% CI: 7.0 to 11.1) as high as among women in the general population., Conclusion: HIV prevalence was significantly higher among women who exchanged sex compared with women in the general population and women of low SES who did not exchange sex.

Competing Interests: All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. Nivedha Panneer reports stock ownership in Gilead. Shauna Onofrey reports that a family member works for and owns stock in Emergent Biosolutions. No other potential conflicts of interest were disclosed.