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BACKGROUND AND AIMS: Solitary drug use (SDU) can amplify risks of fatal overdose. We examined competing risks and drivers of SDU, as well as harm reduction strategies implemented during SDU episodes, among women who inject drugs (WWID). DESIGN: A cross-sectional qualitative study, including telephone and face-to-face in-depth interviews. SETTING: Baltimore City, MD, USA. PARTICIPANTS: Twenty-seven WWID (mean age = 39 years, 67% white, 74% injected drugs daily) recruited via outreach and street intercept (April–September 2021). MEASUREMENTS: Interviews explored the physical (i.e. indoor/private, outdoor/public) and social (i.e. alone, accompanied) risk environments in which drug use occurred. Guided by the principles of emergent design, we used thematic analysis to interrogate textual data, illuminating women’s preferences/motivations for SDU and strategies for minimizing overdose risks when using alone. FINDINGS: Many participants reported experiences with SDU, despite expressed preferences for accompanied drug use. SDU motivations clustered around three primary drivers: (1) avoiding opioid withdrawal, (2) preferences for privacy when using drugs and (3) safety concerns, including threats of violence. Participants nevertheless acknowledged the dangers of SDU and, at times, took steps to mitigate overdose risk, including naloxone possession, communicating to peers when using alone (‘spotting’) and using drugs in public spaces. CONCLUSIONS: WWID appear to engage frequently in SDU due to constraints of the physical and social environments in which they use drugs. They express a preference for accompanied drug use in most cases and report implementing strategies to mitigate their overdose risk, especially when using drugs alone.

The COVID-19 pandemic continues driving unprecedented disruptions to health care provision, including HIV pre-exposure prophylaxis (PrEP) services. We explored service provider experiences promoting and prescribing PrEP to marginalized populations during the COVID-19 pandemic in Baltimore, Maryland. In February to April 2021, we facilitated four virtual focus group discussions with 20 PrEP providers, representing various professional cadres and practice settings. Employing an iterative, team-based thematic analysis, we identified salient enablers and constraints to PrEP promotion, initiation, and maintenance in the COVID-19 era, along with innovative adaptations to PrEP service delivery. Discussants described attenuated demands for PrEP early in the pandemic, exemplified by high PrEP discontinuation rates. This was attributed to changes in clients' sexual behaviors and shifting priorities, including caregiving responsibilities, during the pandemic. Substantial systems-level disruptions impacting PrEP provision were identified, including outreach service suspension, personnel shortages, and facility restrictions on face-to-face visits. Providers emphasized that these disruptions, though occurring early in the pandemic, had protracted impacts on PrEP accessibility. The transition to telemedicine rendered health care services, including PrEP, more accessible/convenient to some clients and expeditious to providers. However, structural barriers to telehealth engagement (telephone/internet access), coupled with limitations of the virtual care environment (difficulty establishing rapport), impeded efforts to equitably promote and prescribe PrEP. Expanding the PrEP outreach workforce and availing alternatives to telemedicine (e.g., community-based PrEP provision, specimen self-collection) could facilitate PrEP care continuity, especially as COVID-19 transitions from an acute to a protracted health crisis.

Pre-exposure prophylaxis (PrEP) is a vital component of comprehensive HIV prevention among female sex workers (FSW). There are limited PrEP interventions targeting FSW in the U.S., who have high HIV risk. Formative research was conducted to inform PEARL (Promoting Empowerment And Risk Reduction), a PrEP intervention for FSW in Baltimore, MD, including a community forum, key informant interviews with providers, and focus group discussions with FSW. FSW and providers acknowledged challenges to building rapport and establishing continuity in care settings. FSW reported low PrEP awareness, with high interest once aware. FSW and providers reported uptake barriers including perceived financial issues, lack of PrEP awareness, and mistrust of the pharmaceutical industry. Concerns were raised about substance use and daily PrEP adherence. Developing a tailored PrEP intervention for FSW necessitates multiple perspectives (e.g. FSW, service providers). Resumen La profilaxis preexposición (PrEP) es un componente vital de la prevención integral del VIH para las trabajadoras sexuales (TSF). En los Estados Unidos, hay pocas intervenciones de PrEP dirigidas a las TSF, quienes experiencian un riesgo elevado de contraer el VIH. Se realizó una investigación formativa para informar a PEARL (Promoción del empoderamiento y la reducción de riesgos), una intervención de PrEP para TSF en Baltimore, MD-la cual incluyó un foro comunitario, entrevistas con proveedores de servicios a las TSF y discusiones entre grupos focales de TSF. TSF y proveedores de servicio reconocieron los retos de mantener buenas relaciones y establecer continuidad en los servicios de salud. TSF exhibieron conocimiento limitado sobre la PrEP, pero expresaron gran interés en la PrEP después de estar informadas. TSF y los proveedores de servicios hablaron de barreras aceptando a la PrEP, incluyendo problemas financieros percibidos, falta de conocimiento sobre la PrEP y desconfianza en la industria farmacéutica. Se expresaron preocupaciones sobre el uso de sustancias y la adherencia diaria a la PrEP. El desarrollo de una intervención de PrEP personalizada para TSF requiere varias perspectivas (por ejemplo, TSF, proveedores de servicios).

Among women who exchange sex (WES), social cohesion is associated with multi-level HIV-risk reduction factors, and client condom coercion (CCC) is associated with increased HIV-risk. Sexual minority WES (SM-WES) face exacerbated HIV-risk, yet relevant research is scant. We examined the role of sexual orientation in the relationship between social cohesion and CCC among cisgender WES (n = 384) in Baltimore, Maryland using stratified logistic regression, controlling for potential confounders. Forty-five percent of WES experienced CCC. SM-WES reported significantly higher social cohesion than heterosexual WES. The relationship between social cohesion and CCC differed by sexual orientation. Among SM-WES, higher social cohesion was independently associated with decreased odds of experiencing CCC, controlling for food insecurity, crack use, police harassment, and method of finding clients. Among heterosexual WES, no significant association was found. Ongoing research and practice with WES should (1) collect sexual orientation data to allow for deeper understanding and tailored interventions, (2) leverage and nurture social cohesion and (3) tailor interventions to populations with attention to sexual orientation.Among women who exchange sex (WES), social cohesion is associated with multi-level HIV-risk reduction factors, and client condom coercion (CCC) is associated with increased HIV-riskEntre las mujeres que intercambian sexo (WES), la cohesión social atenúa el riesgo de VIH, y la coerción del uso del condón por parte de clientes (CCC) amplifica el riesgo de VIH. Las WES de minorías sexuales (SM-WES) experiencian un riesgo elevado de VIH, pero las investigaciónes relevantes son pocas. En este papel, examinamos la contribución de la orientación sexual en modificando la relación entre la cohesión social y la CCC entre WES cisgénero (n = 384) en Baltimore, Maryland, utilizando regresión logística estratificada, ajustando por posibles factores de confusión. Cuarenta y cinco por ciento de WES reportaron experiencias de CCC. SM-WES exhibieron cohesión social significativamente más alta que las WES heterosexuales. La relación entre la cohesión social y CCC fue moderada por la orientación sexual. Entre SM-WES, la cohesión social se asoció independientemente con menores probabilidades de reportar experiencias de CCC, ajustando por la inseguridad alimentaria, el uso de crack, el acoso policial y el método de encontrar a clientes. Entre las WES heterosexuales, la misma asociación no fue significativa. La investigación y la práctica con WES deben 1) recopilar datos de orientación sexual para permitir una comprensión más profunda e intervenciones personalizadas, 2) aprovechar y fomentar la cohesión social y 3) adaptar las intervenciones a estas poblaciones con atención a la orientación sexual.

Pre-exposure prophylaxis (PrEP) is a promising but underutilized HIV prevention tool among people who inject drugs (PWID). We developed and piloted an intervention to bolster PrEP promotion competencies among frontline harm reduction workers (FHRW) serving PWID clients in Baltimore, Maryland. Between December 2021 and February 2022, we developed and facilitated four trainings, which included didactic and practice-based/role-playing components, with 37 FHRW from four organizations. FHRW completed three structured surveys (pretest, posttest, 6-week posttest) and in-depth interviews (n = 14) to measure changes in PrEP promotion competencies attributable to training participation. PrEP knowledge and self-efficacy increased significantly (p 0.001) from pretest to posttest, sustained through 6-week posttest. The proportion of FHRW discussing PrEP with clients doubled during the evaluation period (30-67%, p = 0.006). Feeling empowered to discuss PrEP and provision of population-tailored PrEP information were facilitators of PrEP promotion, while limited client interaction frequency/duration, privacy/confidentiality concerns, and anticipated PrEP stigma by clients inhibited PrEP promotion. Our capacity-strengthening intervention successfully increased PrEP knowledge, self-efficacy, and promotion among FHRW, affirming the adaptability and feasibility of integrating our training toolkit into FHRW practice across implementation settings.

Women in the USA represent 15% of new HIV diagnoses but only 5% of pre-exposure prophylaxis (PrEP) users. We sought to characterise communicative appeals and messaging frames used in US visual media to cultivate PrEP demand among cisgender and transgender women using content analysis methodology. We catalogued and coded media items (images and videos) from US PrEP marketing campaigns featuring women. Production and content characteristics were abstracted, and communicative appeals from media items were qualitatively coded in duplicate. We then descriptively summarised production and content characteristics and identified discrete subgroups of media items, clustering around specific messaging frames, through qualitative thematic analysis. Racial/ethnic minorities and sexual/gender minority women were heavily featured, and numerous media items leveraged cognitive and social communicative appeals to promote PrEP. We identified three unique messaging frames emerging from coded media items, portraying PrEP as: (1) necessary prevention (protection frame), (2) a desirable yet accessible commodity (aspiration frame), and (3) a conduit to sexual autonomy (empowerment frame). To effectively communicate PrEP information and promote PrEP to women, PrEP marketing should leverage alternative appeals (subjective norms, self-efficacy), address anticipated barriers to uptake (stigma, cost, medication interactions), and deconstruct misconceptions of PrEP use(rs).

Background HIV prevalence among people who use drugs (PWUD) in Baltimore, Maryland, is higher than among the general population. Pre-exposure prophylaxis (PrEP) is a widely available medication that prevents HIV transmission, yet its usefulness is low among PWUD in Baltimore City and the United States. Community-level interventions to promote PrEP uptake and adherence among PWUD are limited. Objective We describe the development of a capacity-strengthening intervention designed for frontline harm reduction workers (FHRWs) to support PrEP awareness-building and promotion among PWUD. Methods Our study was implemented in 2 phases in Baltimore City, Maryland. The formative phase focused on a qualitative exploration of the PrEP implementation environment, as well as facilitators and barriers to PrEP willingness and uptake, among cisgender women who use drugs. This work, as well as the existing literature, theory, and feedback from our community partners, informed the intervention development phase, which used an academic-community partnership model. The intervention involved a 1-time, 2-hour training with FHRWs aimed at increasing general PrEP knowledge and developing self-efficacy promoting PrEP in practice (eg, facilitating PrEP dialogues with clients, supporting client advancement along a model of PrEP readiness, and referring clients to PrEP services). In a separate paper, we describe the conduct and results of a mixed methods evaluation to assess changes in PrEP-related knowledge, attitudes, self-efficacy, and promotion practices among FHRWs participating in the training. Results The pilot was developed from October to December 2021 and implemented from December 2021 through April 2022. We leveraged existing relationships with community-based harm reduction organizations to recruit FHRWs into the intervention. A total of 39 FHRWs from 4 community-based organizations participated in the training across 4 sessions (1 in-person, 2 online synchronous, and 1 online asynchronous). FHRW training attendees represented a diverse range of work cadres, including peer workers, case managers, and organizational administrators. Conclusions This intervention could prevent the HIV burden among PWUD by leveraging the relationships that FHRWs have with PWUD and by supporting advancement along the PrEP continuum. Given suboptimal PrEP uptake among PWUD and the limited number of interventions designed to address this gap, our intervention offers an innovative approach to a burgeoning public health problem. If effective, our intervention has the potential to be further developed and scaled up to increase PrEP awareness and uptake among PWUD worldwide.

We conducted the first scoping literature review on ART uptake and adherence among Female Sex Workers (FSW), following PRISMA-ScR guidelines. Searches were conducted in PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting an ART uptake or adherence result among FSW aged 18 or older; peer-reviewed; published in English between 1996 and 2018. Our search identified 6,735 studies; 30 met eligibility requirements. ART uptake ranges from 0 to 100% and adherence ranges from 50-90%, depending on measurement methods. Uptake and adherence influencing factors are mapped onto a social ecological model (SEM). Knowledge and beliefs, substance use, food insecurity and sex-work engagement were negatively associated, while older age, relationships and social support were positively associated with ART uptake and adherence. Standardised methods to measure uptake and adherence prevalence must be established for data comparison. Evidence regarding ART uptake and adherence barriers and facilitators span multiple SEM levels, although more research is needed regarding structural and occupational level influencers. Results suggest that the multi-level ART uptake and adherence barriers faced by FSW require complex multi-level evidence-based interventions. Study findings can inform ART interventions, future research, and offer guidance to other support services with FSW, such as PrEP interventions.

Background Research suggests sexual minority female sex workers (SM-FSW) face elevated structural vulnerability and HIV risk compared to their heterosexual counterparts. Structural vulnerabilities reflect societal level factors (e.g., sexism, homophobia, racism) that constrain an individual’s agency, particularly related to health outcomes. This study examines the association between SM status by identity and behavior, structural vulnerability, and HIV risk among a sample of street-based FSW. Methods The current study utilizes baseline data from the SAPPHIRE study, a prospective cohort of cis gender and transgender FSW in Baltimore, MD, recruited through targeted time-location sampling from April 2016 to January 2017. The current analysis focuses on cisgender women. The baseline survey ascertained demographics, substance use, intimate partner violence (IPV), and sex work characteristics. Multivariable models were constructed using self-identity and behaviorally defined SM status as independent variables with vulnerability outcomes (e.g., injection drug use, injection speedball, binge drinking, homelessness, physical IPV, ever had a pimp, and being a minor at sex work entry (age < 18)) as dependent variables. Results Of the participants (n = 247), 25.5% (n = 63) self-identified as a SM by identity (e.g., gay or bisexual), and 8.5% (n = 21) reported SM behavior (e.g., same-gender sexual behavior) in the past 3 months. In multivariable logistic regression models, SM status by identity was associated with increased odds of injection drug use, binge drinking, homelessness, physical IPV, and being a minor at sex work entry. SM status by behavior was associated with increased odds of binge drinking, homelessness, ever having a pimp, and being a minor at sex work entry. Conclusion The study indicates disproportionate structural vulnerability and heightened HIV risk among SM-FSW, as compared to their heterosexual counterparts, with differences in their profile by sexual identity and behavior. Findings suggest a need for nuanced interventions tailored to these populations.

We describe patterns of polysubstance use and associations with HIV risk-related behaviors among women engaged in street-based transactional sex, an understudied yet important population and area of research. This sample was restricted to cisgender women who reported drug use (n = 244) in the baseline of the longitudinal SAPPHIRE cohort study. Latent class analysis (LCA) was conducted using drug use measures (route of administration (injection/non-injection); type of drug (specific opioids, stimulants)) and selection based on fit statistics and qualitative interpretation of the classes. Polysubstance use was prevalent (89% ≥ 2), and 68% had injected drugs in the past 3 months. A three-class solution was selected: Class 1 (“heroin/cocaine use”, 48.4% of sample), Class 2 (“poly-opioid use”, 21.3%), and Class 3 (“poly-route, polysubstance use”, 30.3%). Class 3 was significantly younger, and Class 2 was disproportionately non-White. Women reported high levels of housing (63%) and food (55%) insecurity, condomless sex with clients (40%), and client-perpetrated violence (35%), with no significant differences by class. Obtaining syringes from syringe services programs differed significantly by class, despite injection behaviors in all classes. Tailored HIV and overdose prevention programming that considers drug use patterns would strengthen their impact.

Despite growing availability, HIV pre-exposure prophylaxis (PrEP) uptake and adherence remains suboptimal among female sex workers (FSW) in the United States. Using cross-sectional data from a survey of 236 street-based cisgender FSW in Baltimore, Maryland, we examined interest in event-driven and long-acting PrEP formulations. Latent class analysis identified discrete patterns of interest in five novel PrEP agents. Multinomial latent class regression then examined factors associated with probabilistic class membership. A three-class solution emerged as the best-fit latent class model: Injectable Acceptors (~ 24% of sample), Universal Acceptors (~ 18%), and Non-Acceptors (~ 58%). Compared to Non-Acceptors, Universal Acceptors had significantly (p < 0.05) higher odds of reporting condomless vaginal sex with clients, client condom coercion, and client-perpetrated physical violence. Relative to Non-Acceptors, Injectable Acceptors were distinguished by significantly higher rates of condomless vaginal sex with clients and injection drug use. Expanding PrEP options for FSW could help overcome barriers to PrEP initiation and persistence.

HIV prevalence among cisgender female sex workers (FSW) and/or women who use drugs (WWUD) is substantially higher compared to similarly aged women. Consistent with PRISMA guidelines, we conducted the first systematic review on the pre-exposure prophylaxis (PrEP) continuum among FSW and/or WWUD, searching PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting a PrEP related result among FSW and/or WWUD aged 18 + ; peer-reviewed; and published in English between 2012 and 2018. Our search identified 1365 studies; 26 met eligibility requirements, across the following groups: FSW (n = 14), WWUD (n = 9) and FSW-WWUD (n = 3). Studies report on at least one PrEP outcome: awareness (n = 12), acceptability (n = 16), uptake (n = 4), and adherence (n = 8). Specific barriers span individual and structural levels and include challenges to daily adherence, cost, and stigma. Combining health services and long-acting PrEP formulas may facilitate better PrEP uptake and adherence. The limited number of studies indicates a need for more research.

Housing is an important social determinant of physical and mental health. Transgender and gender non-conforming individuals (T/GNCI) face a unique constellation of discrimination and compromised social services, putting them at risk for housing insecurity, homelessness, and its associated public health concerns. This study explores housing insecurity among T/GNCI in New Orleans, LA, where the infrastructural landscape is marked by an underinvestment in housing stock and disaster capitalism. In-depth interviews were conducted with T/GNCI (n = 17) living in New Orleans, identified through purposive sampling. Semi-structured guides were used to elicit personal stories and peer accounts of insecure housing experiences and coping strategies. Interviews were audio recorded and transcribed. Data was coded, sorted, and analyzed for key themes using NVIVO 11. Respondents discussed an array of circumstances that contribute to housing insecurity, including intersectional stigma and discrimination coupled with gentrification and a changing housing landscape in the city. Housing was intricately intertwined with employment and other structural issues; vulnerability in one realm was closely tied to insecurity in the others. Social support and queer family structures emerged as a key source of resilience, coping, and survival. The study supports an increase of resources for T/GNC housing access and interventions that address the cyclical discrimination, housing, and employment issues this population faces with a consideration of the historical and current structural barriers impeding their access to safe, stable, long-term housing.

Background The opioid epidemic is one of the greatest public health crises of our times, driven increasingly by synthetic opioids such as fentanyl in the heroin supply. The implementation of drug checking in community settings has the potential to reduce the burden of fatal overdose, provide harm reduction education around safer drug consumption, and increase health access among people who use drugs (PWUD). To inform program development, we explored stakeholder opinions on drug checking technologies and implementation considerations. Methods This study, from the larger FORECAST study, utilized semi-structured in-depth interviews (n = 32) with a range of stakeholders in Baltimore, Boston, and Providence, many of whom were service providers. Stakeholders represented various roles and levels in organization types including harm reduction, public health, peer groups, and advocates. Interviews were audio recorded and transcribed. Data were coded using a priori codes; the coded text was analyzed for key themes. Results Stakeholders responded positively to drug checking technology, though they shared apprehensions regarding service implementation. Primary topics requiring consideration included: utility in fentanyl endemic areas, trust and rapport between providers and PWUD, legality and policy concerns. Additional considerations included: technology accuracy, cost, ease of distribution, and service delivery setting. Conclusions Stakeholders overwhelmingly supported the concept of drug checking with the goals of providing needed risk reduction information and resources to PWUD and serving as a point for greater engagement in services. Programs need to be tailored to local circumstances. Law enforcement buy-in and policy change will be critical aspects of providing drug checking services.

ObjectivesTo 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.DesignCross-sectional, secondary analysis.Setting79 countries.ParticipantsAll adults (aged ≥18 years) who used the Hornet social networking application and provided consent to participate.Main outcome measureThe 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).Results7758 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).ConclusionsOur 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.

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.

Cisgender female sex workers (FSW) have low rates of health care utilization and persistent health disparities. The study utilizes baseline data from a structural intervention to understand health care access with cisgender FSW with substance use histories (n=370) in Baltimore, Maryland. The four outcome categories measuring health care access in the past 6 months were: no health care use/barrier to care (16% of sample), no use/no barrier (24%), use/barrier (25%), use/no barrier (36%, most able to access care). Using multinomial logistic regression, we found client-perpetrated violence, depressive symptoms, non-medical prescription opioid use, and history of drug use disclosure to providers associated with higher odds of being in groups with diminished health care access compared to use/no barrier. Co-locating mental health and violence support with existing services used and trusted by FSW may remove structural and logistical barriers to care. Integrating harm reduction in health care settings can destigmatize substance use, fostering openness for substance use disclosure.

Background: Housing is an important social determinant of health (SDOH). Transgender people face a unique blend of discrimination and compromised social services, putting them at risk for housing insecurity and associated public health concerns. Aims: This targeted ethnography explores housing insecurity as a SDOH among transgender people in the U.S. Methods: In-depth interviews were conducted with transgender people (n = 41) throughout the U.S.A., identified through purposive sampling. A semi-structured guide was used to elicit personal stories and peer accounts of insecure housing experiences and coping strategies. Interviews were audio recorded and transcribed. Data was coded, sorted, and analyzed for key themes. Results: Responses revealed pervasive housing insecurity and inter-related challenges. Respondents discussed how intersecting identities create unique constellations of vulnerability, which “intersect like a star.” Financial insecurity and interpersonal rejection were lead housing insecurity causes, often resulting in psychological strain, which was sometimes addressed with substances and sexual risk-taking. These factors were cyclically accompanied by financial and employment insecurity and a cascade of unmet social needs. Social support facilitated coping. Discussion: Findings support increasing transgender housing security intervention resources that address intersecting and cyclical discrimination, trauma, housing, employment, and health issues.

ObjectivesThough highly vulnerable to HIV and STIs, transgender female sex workers (TFSW) are understudied in the U.S. HIV and STI response. This study examined the correlates of laboratory-confirmed STIs among a cohort of 62 TFSW followed over the course of one year and explored associations between specimen site and self-reported engagement in insertive and receptive anal intercourse.MethodsParticipants 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 trichomonas were also collected. HIV testing was conducted at baseline, 6-, and 12-month visits.ResultsBaseline HIV prevalence was 40.3% with no HIV seroconversions over follow-up. Baseline prevalence of gonorrhea, chlamydia, and trichomonas was 9.7%, 17.7%, and 14.5%, respectively. In the multivariable regression modeling, recent arrest was significantly associated with testing positive for any STI (aRR 1.77; 95% CI: 1.10-2.84). Insertive anal sex with clients was associated with increased risk of testing positive for an STI via urine specimen (RR 3.48; 95% CI: 1.14-10.62), while receptive anal sex was not significantly associated with specimen site.ConclusionOur findings confirm a high prevalence of STIs among TFSW 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 TFSW in the U.S.KEY MESSAGESTransgender female sex workers in the U.S. face substantial vulnerability to HIV and STIs, and interventions to reduce their risk for HIV and STI acquisition are needed.Engagement with criminal justice significantly increases the risk for STIs among transgender women engaged in street-based sex work, suggesting the need to address factors that lead to disproportionate arrest and incarceration of transgender women.Screening for STIs among transgender women should include all potential sites of exposure, regardless of reported sexual positioning.

Objective To assess the state of peer-reviewed literature surrounding uptake and adherence of antiretroviral therapy (ART) among HIV-positive women who use drugs (WWUD). Methods Consistent with PRISMA-ScR guidelines, we conducted a scoping literature review on ART uptake and adherence among WWUD, searching PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting at least one ART uptake or adherence related result among WWUD aged 18 or older; peer-reviewed; published in English between 1996–2018. Results Our search identified 6735 studies; 86 met eligibility requirements. ART uptake ranged from 30 % to 76 % and adherence ranged from 27 % to 95 %. Substance use, co-morbid psychiatric disorders, and side effects emerged as the primary ART uptake and adherence barriers among this population. Few facilitators were identified. Conclusion This study is the first scoping review to look at ART uptake and adherence among WWUD globally. The wide range in uptake and adherence outcomes indicates the need for gold standard assessments, which may differ between high and low resource settings. This study offers rich insight into uptake and adherence barriers and facilitators, primarily at the intrapersonal level. More research is needed to examine interventions that focus on additional levels of the SEM (e.g., community and policy levels). These review findings can inform ART interventions, future research, and offer guidance to other support services with WWUD, such as PrEP interventions.

Purpose: This study examines the associations between discrimination experiences (types and locations) and care postponement among trans-feminine individuals in the United States. Methods: This secondary, cross-sectional study utilized a subset of the data from the National Transgender Discrimination Survey (n = 2248), specifically for trans-feminine individuals. In this analysis, we examined the relationship between discrimination and primary care postponement. Results: Twenty-six percent (26.25%) of the study sample reported delaying preventive care due to fear of discrimination; 23.98%–46.66% of respondents reported past experiences of discrimination (setting dependent). Discrimination in health and non-health settings and different types of discrimination—being denied services, verbally harassed, or physically assaulted—were all significantly associated with delaying care; respondents reporting discrimination were up to 20 times more likely to postpone care. While discrimination at a health location had the strongest association with care postponement (adjusted odds ratio = 9.65, confidence interval = 7.60–12.24), discrimination in all non-health-related locations was also important. Individuals reporting discrimination in greater numbers of locations and multiple types of discrimination were more likely to postpone care. Conclusion: To promote preventive care-seeking, these results affirm the importance of interventions that promote discrimination-free environments for gender minorities.

ObjectivesThough 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.MethodsParticipants 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.ResultsBaseline 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.ConclusionOur 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.

Death from fentanyl-related overdose is now a leading cause of mortality among US adults. We sought to characterize fentanyl preference among street-based people who use drugs (PWUD).Cross-sectional surveys were administered to PWUD (N = 308) who illicitly used heroin or prescription opioids in the prior six months. Recruitment occurred in 2017 in three US east coast cities with high overdose mortality: Baltimore, Boston, and Providence. Our main outcome was preference for fentanyl (yes/no); exposures included sociodemographics, drug use, and overdose history. Pearson's χ2, Shapiro-Wilk-Mann rank-sum tests, and tiered log-binomial regression determined sociodemographic and exposure-related factors associated with fentanyl preference.Preference for nonmedical use of fentanyl was reported by 27% (n = 83) of the sample. Fentanyl preference was associated with non-Hispanic white race (adjusted risk ratio (ARR) = 1.68, 95% confidence interval (CI):1.18-2.40), daily illicit drug use (aRR = 2.2, CI:1.71-2.87), and overdose ≥1 year ago (aRR = 1.33, CI:1.18-1.50). Age (in decades; aRR = 0.77, CI:0.61-0.98) and overdose1 year ago (aRR = 0.92, CI:0.87-0.97) were associated with a decreased likelihood of preference. In our model excluding sociodemographics, initiating opioid use with non-prescribed opioids was associated with fentanyl preference (aRR = 1.48, CI:1.26-1.73).In three cities with high levels of opioid use and overdose, a quarter of street based PWUD reported preferring fentanyl. An opioid use age cohort effect and disproportionate access to prescription opioids by race could be contributing to preference. Frequency of opioid use, not route of administration, was associated with preference. Our data demonstrate the need to consider preferences for fentanyl when targeting services and interventions for PWUD.

Pre-exposure prophylaxis (PrEP) has the potential to be an empowering HIV prevention tool among female sex workers (FSW), yet little is known about PrEP awareness and interest in this population. Sex workers and Police Promoting Health in Risky Environments (SAPPHIRE) is a prospective cohort study of street-based FSW in Baltimore, MD. A cross-sectional analysis explored awareness and interest in PrEP among HIV-negative FSW. Multivariable Poisson regressions modeled associations between individual, interpersonal, and structural variables and PrEP awareness and interest. Of n = 232 FSW, 66% were white, half were less than 35 years old, 59% injected drugs daily, and 66% sold sex daily. Only 21% of FSW were aware of PrEP, though 74% were interested. PrEP awareness was associated with experiencing client condom coercion [adjusted incidence rate ratio (aIRR) = 0.50, 95% CI: 0.28–0.90] and condomless sex with an intimate partner (aIRR = 0.54, 95% CI: 0.30–0.98). PrEP interest was associated with perceiving PrEP as “very easy” to take (aIRR = 1.91, 95% CI: 1.49–2.45) and moving to an unfamiliar geographic area to sell sex (aIRR = 1.20, 95% CI: 1.04–1.39). Women who had a current gonorrhea or chlamydia infection were less likely to be interested in PrEP (aIRR = 0.75, 95% CI: 0.59–0.95). Though PrEP awareness among FSW is low, there are FSW who are significantly more likely to express interest in PrEP and outreach efforts should target these women. Results suggest that women-controlled HIV prevention methods may be important for reducing incidence among FSW.

Purpose: Gender Minority (GM) individuals experience healthcare access barriers, including financial concerns and discrimination, which influence their health seeking behaviors. This study explores the alternative navigation strategies used by GM individuals to cope with these barriers and access care, both biomedical and complementary and alternative medicine (CAM). Methods: In-depth interviews were conducted with GM individuals (n=18) and healthcare providers (n=5) identified through purposive sampling. Semistructured guides were used to elicit information about healthcare seeking strategies and experiences. Transcribed interview data were coded, sorted, and analyzed for key themes. Results: Commonly discussed healthcare access barriers included the following: identifying a competent provider, costs and insurance obstacles, and anticipated discrimination. Respondents expressed a need for gender-affirming care within the biomedical system, and alternative navigation strategies to overcome access barriers, including travelling abroad for surgical procedures, ordering hormones online, and sharing with friends. Respondents discussed CAM principally related to emotional health, preferring CAM to biomedical offerings. Utilizing social networks to access all care modalities was common. Conclusions: The healthcare-seeking behavior of GM individuals demonstrates great resilience. This population is committed to accessing gender-affirming care regardless of the associated risks of care outside of provider supervision. The healthcare community needs to eliminate access barriers and support harm reduction strategies. CAM for emotional health support and the role of social networks in accessing care resources should be better integrated into care for this population.

Gender minority health disparity research is limited by binary gender measurement practices. This study seeks to broaden current discourse on gender identity measurement in the USA, including measurement adoption challenges and mitigation strategies, thereby allowing for better data collection to understand and address health disparities for people of all genders. Three data sources were used to triangulate findings: expert interviews with gender and sexuality research leaders; key-informant interviews with gender minorities in New Orleans, LA; and document analysis of relevant surveys, guides and commentaries. Ten key dilemmas were identified: 1) moving beyond binary gender construction; 2) conflation of gender, sex and sexual orientation; 3) emerging nature of gender-related language; 4) concerns about item sensitivity; 5) research fatigue among gender minorities; 6) design and analytical limitations; 7) categorical and procedural consistency; 8) pre-populated vs. open-field survey items; 9) potential misclassification; and 10) competing data collection needs. Researchers must continue working toward consensus concerning better practices is gender measurement and be explicit about their methodological choices. The existence of these dilemmas must not impede research on important health issues affecting gender minorities.

Limited research has examined the ways in which public health training programs equip students to address health disparities affecting the lesbian, gay, bisexual, and transgender (LGBT) community and other sexual and gender minority (SGM) populations. This study outlines the availability of public health curricula on SGM health topics, and the prevalence of LGBT and SGM-inclusive institutional support services across CEPH-accredited U.S. schools of public health. Content analysis of all course offerings related to gender and sexuality revealed a limited focus on sexual and gender minority health: just 4.7% of courses contained keywords indicating that LGBT or SGM health topics were covered. Similar analysis of institutional support services available at U.S. schools of public health found that only 25% of schools had LGBT student organizations, and just 19% had an office of diversity that specifically advertised LGBT or SGM-inclusive programming or services on the institution's Web site. Finally, only two of 52 schools offered an educational certificate centered on LGBT health. These findings illustrate a significant need for enhanced curricular content and institutional support services that equip public health students to address SGM health disparities. Improvement in this area may encourage future health care professionals to work to reduce these disparities, to improve SGM persons' experiences in health care settings, and to generate further research in this area.

Regulators of G protein signaling (RGS) are a family of proteins that attenuate the activity of the trimeric G proteins. RGS proteins act as GTPase-activating proteins (GAPs) for the alpha subunits of several trimeric G proteins, much like the GAPs that regulate the activity of monomeric G proteins such as Ras. RGS proteins have been cloned from many eukaryotes, and those whose biochemical activity has been characterized regulate the members of the Gi family of G proteins; some forms can also act on Gq proteins. In an ongoing effort to elucidate the role of Gzalpha in cell signaling, the yeast two-hybrid system was employed to identify proteins that could interact with a mutationally activated form of Gzalpha. A novel RGS, termed RGSZ1, was identified that is most closely related to two existing RGS proteins termed RetRGS1 and GAIP. Northern blot analysis revealed that expression of RGSZ1 was limited to brain, and expression was particularly high in the caudate nucleus. Biochemical characterization of recombinant RGSZ1 protein revealed that RGSZ1 was indeed a GAP and, most significantly, showed a marked preference for Gzalpha over other members of the Gialpha family. Phosphorylation of Gzalpha by protein kinase C, an event known to occur in cells and that was previously shown to influence alpha-betagamma interactions of Gz, rendered the G protein much less susceptible to RGSZ1 action.

Gz is a member of the family of trimeric guanine nucleotide-binding regulatory proteins (G proteins), which plays a crucial role in signaling across cell membranes. The expression of Gz is predominately confined to neuronal cells and platelets, suggesting an involvement in a neuroendocrine process. Although the signaling pathway in which Gz participates is not yet known, it has been linked to inhibition of adenylyl cyclase. We have found that arachidonate and related unsaturated fatty acids suppress guanine nucleotide binding to the alpha subunit of Gz. This inhibition of nucleotide binding by cis-unsaturated fatty acids is specific for Gz alpha; other G protein alpha subunits are relatively insensitive to these lipids. The IC50 for inhibition by the lipids closely corresponds to their critical micellar concentrations, suggesting that the interaction of the lipid micelle with Gzalpha is the primary event leading to inhibition. The presence of the acidic group of the fatty acid is critical for inhibition, as no effect is observed with the corresponding fatty alcohol. While arachidonic acid produces near-complete inhibition of both GDP and guanosine 5-(3-O-thio)triphosphate binding by Gzalpha, release of GDP from the protein was unaffected. Furthermore, the rate of inactivation of Gzalpha by arachidonate is essentially identical to the rate of GDP release from the protein, indicating that GDP release is required for inactivation. These observations indicate that the mechanism of inactivation of Gzalpha by unsaturated fatty acids is through an interaction of an acidic lipid micelle with the nucleotide-free form of the protein. Although the physiologic significance of this finding is unclear, similar effects of unsaturated fatty acids on other proteins involved in cell signaling indicate potential roles for these lipids in signal modulation. Additionally, the ability of arachidonate to inactivate this adenylyl cyclase-inhibitory G protein provides a molecular mechanism for previous findings that treatment of platelets with arachidonate results in elevated cAMP levels.

As part of a program to elucidate signaling processes controlled by the heterotrimeric G protein Galphaz, a human fetal brain cDNA library was screened for proteins that specifically interact with the activated form of Galphaz. One of the most-encountered molecules in this screen was Eya2, a member of the Eyes absent family of proteins. Mammalian Eya proteins are predominantly cytosolic proteins that are known to interact with members of the Sine oculis (Six) family of homeodomain transcription factors. This interaction facilitates the translocation of Eya into the nucleus, where the Eya/Six complex regulates transcription during critical stages of embryonic development. In vitro binding studies confirmed that Galphaz interacts with Eya2 in an activation-dependent fashion; furthermore, most other members of the Galphai family including Galphai1, Galphai2, and Galphai3 were found to interact with Eya2. It is interesting that one of the most abundant Galphai proteins, Galphao, did not interact with Eya2. Coexpression of the activated forms of Galphai1, Galphai2, and Galphai3, but not Galphao, with Eya2 recruited Eya2 to the plasma membrane, prevented Eya2 translocation into the nucleus, and abrogated Eya2/Six4-mediated transcription. In addition, Eya2 impinged on G protein-mediated signaling, as evidenced by its ability to relieve Galphai2-mediated inhibition of adenylyl cyclase. These results demonstrate that the interaction between the Galphai proteins and Eya2 may impact on seemingly disparate regulatory events involving both classes of proteins.

G(z) is a member of the G(i) family of trimeric G proteins whose primary role in cell physiology is still unknown. In an ongoing effort to elucidate the cellular functions of G(z), the yeast two-hybrid system was employed to identify proteins that specifically interact with a mutationally activated form of Galpha(z). One of the molecules uncovered in this screen was Rap1GAP, a previously identified protein that specifically stimulates GTP hydrolytic activity of the monomeric G protein Rap1 and thus is believed to function as a down-regulator of Rap1 signaling. Like G(z), the precise role of Rap1 in cell physiology is poorly understood. Biochemical analysis using purified recombinant proteins revealed that the physical interaction between Galpha(z) and Rap1GAP blocks the ability of RGSs (regulators of G protein signaling) to stimulate GTP hydrolysis of the alpha subunit, and also attenuates the ability of activated Galpha(z) to inhibit adenylyl cyclase. Structure-function analyses indicate that the first 74 amino-terminal residues of Rap1GAP, a region distinct from the catalytic core domain responsible for the GAP activity toward Rap1, is required for this interaction. Co-precipitation assays revealed that Galpha(z), Rap1GAP, and Rap1 can form a stable complex. These data suggest that Rap1GAP acts as a signal integrator to somehow coordinate and/or integrate G(z) signaling and Rap1 signaling in cells.