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Mallory O Johnson, Jeanne M Sevelius, Samantha E Dilworth, Parya Saberi, Torsten B NeilandsDepartment of Medicine, University of California, San Francisco, CA, USABackground: The Model of Health Care Empowerment (HCE) defines HCE as the process and state of being engaged, informed, collaborative, committed, and tolerant of uncertainty regarding health care. We examined the hypothesized antecedents and clinical outcomes of this model using data from ongoing human immunodeficiency virus (HIV)-related research. The purpose of this paper is to explore whether a new measure of HCE offers direction for understanding patient engagement in HIV medical care. Using data from two ongoing trials of social and behavioral aspects of HIV treatment, we examined preliminary support for hypothesized clinical outcomes and antecedents of HCE in the context of HIV treatment.Methods: This was a cross-sectional analysis of 12-month data from study 1 (a longitudinal cohort study of male couples in which one or both partners are HIV-seropositive and taking HIV medications) and 6-month data from study 2, a randomized controlled trial of HIV-seropositive persons not on antiretroviral therapy at baseline despite meeting guidelines for treatment. From studies 1 and 2, 254 and 148 participants were included, respectively. Hypothesized antecedents included cultural/social/environmental factors (demographics, HIV-related stigma), personal resources (social problem-solving, treatment knowledge and beliefs, treatment decision-making, shared decision-making, decisional balance, assertive communication, trust in providers, personal knowledge by provider, social support), and intrapersonal factors (depressive symptoms, positive/negative affect, and perceived stress). Hypothesized clinical outcomes of HCE included primary care appointment attendance, antiretroviral therapy use, adherence self-efficacy, medication adherence, CD4+ cell count, and HIV viral load.Results: Although there was no association observed between HCE and HIV viral load and CD4+ cell count, there were significant positive associations of HCE scores with likelihood of reporting a recent primary care visit, greater treatment adherence self-efficacy, and higher adherence to antiretroviral therapy. Hypothesized antecedents of HCE included higher beliefs in the necessity of treatment and positive provider relationships.Keywords: human immunodeficiency virus, acquired immune deficiency syndrome, health care empowerment, adherence, compliance

Structural stigma towards gender minority (GM; people whose current gender does not align with sex assigned at birth) people is an important contributor to minority stress (i.e., stress experienced due to one's marginalized GM identity), although existing variables are unclear in their inclusion of social norms, or societal stigma, as a key component of the construct. We examined potential variables representing structural stigma, including variables that are inclusive of societal stigma, to identify those that most strongly relate to minority stress outcomes. We tested variables identified in the literature as measures of structural stigma inclusive of societal stigma (LGBT + Business Climate Index, state voting behaviors, and Google Trends search data), the most commonly used structural stigma variable (State Policy Environment Tally), and proxy variables (region, population density) for comparison. The relationships between structural stigma and minority stress model outcomes were tested in a sample of GM participants from The Population Research in Identity and Disparities for Equality (PRIDE) Study (N = 2,094) 2019 Annual Questionnaire using a structural equation model (SEM). Lower structural stigma (i.e., higher LGBT Business Climate Index) was associated with lower experienced stigma (β= -0.260, p < .01) and lower anticipated stigma (β= -0.433, p < .001). Greater conservative voting behavior was associated with less experienced stigma (β= -0.103, p < .01). Living in a more densely populated county was also associated with lower anticipated stigma (β=-0.108, p < .001) and greater identity outness (β = 0.053, p < .05). Two of the identified structural stigma variables that were inclusive of societal stigma (i.e., LGBT + Business Climate Index, conservative voting behaviors) and one proxy variable (population density) were associated with minority stress outcomes. However, the most commonly used variable for structural stigma (State Policy Environment Tally) was not associated with any outcomes. The State LGBT + Business Climate Index showed the most promise for use as a structural stigma variable in future research. The application of this variable should be investigated further to explore its association with health outcomes and to inform efforts to reduce health equity barriers experienced by GM people through addressing structural stigma in a manner inclusive of societal stigma., Competing Interests: Declarations. Competing interests: JOM has consulted for Sage Therapeutics (5/2017) in a one-day advisory board, Ibis Reproductive Health (a non-for-profit research group; 3/2017-5/2018, 2020-present), Hims Inc. (2019 - present), Folx Inc (2020-present), and Upstream Inc. (2024). MRL has received consulting fees from Hims Inc., Folx, Inc. (2020), Otsuka Pharmaceutical Development and Commercialization, Inc., and the American Dental Association. The remaining authors have no conflicts to disclose. Ethics approval and consent: The present study was reviewed and approved by the Stanford University and University of California San Francisco Institutional Review Boards. All research was conducted while adhering to relevant guidelines and regulations, including the Declaration of Helsinki. Informed consent was obtained at the time of enrollment in The PRIDE Study, where participants were electronically provided the written informed consent document and could affirm or decline electronically. Only participants who affirmed their consent were included in the study., (© 2025. The Author(s).)

This study investigates baseline differences in couples enrolled in the "It Takes Two" HIV prevention intervention for transgender women and their partners, comparing in-person participation pre-COVID-19 and digital participation during the pandemic. Among 52 couples (40% in-person, 60% digital), bivariate analyses revealed that in-person participants were more likely to be African American, have cisgender male partners, report higher unemployment, incarceration histories, greater relationship stigma, and lower relationship quality. The findings highlight the limitations of digital modalities in engaging transgender women of color and those with structural vulnerabilities. The study emphasizes that reliance on digital methods in HIV research jeopardizes the inclusion of those lacking technological access and literacy, especially communities disproportionately impacted by HIV. Researchers must incorporate hybrid or in-person options and engage communities to ensure equity and inclusion, thus overcoming barriers and ensuring comprehensive population reach in HIV prevention studies., Competing Interests: Declarations. Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent: Informed consent was obtained from all individual participants included in the study. Conflicts of Interest: Each of the authors declare that they have no conflict of interest., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: The ability to objectively measure chronic stress has important implications for research, prevention, and treatment. Cortisol is currently the most used biological marker in the investigation of stress and can be measured via blood, saliva, and urine; however, these methods have disadvantages. The measurement of cortisol in hair is a more recently developed method that quantifies the cumulative production of cortisol over longer periods of time. Given the potential benefits of hair as a chronic stress biometric, research with this novel method is burgeoning, yet rarely involves transgender ("trans") populations, despite high levels of reported stress among trans people due to experiences of stigma and discrimination. Since hair is a key part of gender presentation, trans people might be less likely than cisgender people to donate hair for research. To explore the feasibility and acceptability of hair collection for use as a stress biometric with trans women, we nested a study into an ongoing clinical trial in São Paulo, Brazil, "Manas por Manas" (Sisters for Sisters). Here, we describe the hair biometric substudy protocol, as well as the feasibility and acceptability of collecting hair in the study cohort., Methods: We randomly selected a subsample (n = 180) from the Manas por Manas cohort (n = 392), all of whom are trans women, age 18 or older. We messaged participants via phone, WhatsApp, or social media for at least three attempted contacts. Study visits included four components: (1) video introduction, including a demonstration of hair sampling; (2) informed consent; (3) a brief survey with the validated Short Stress Overload Scale (translated to Portuguese) and questions on hair care that could moderate stress hormone results; and (4) hair sample collection. Hair samples were collected and stored using validated protocols. Participants were reimbursed for travel costs., Results: Between April and December 2022, we messaged with 143 individuals out of the 180 sampled (79%) and invited them to participate in the study. Of those invited to participate, we scheduled study visits with 102 people (71.3% of those invited to participate), of whom 100 attended their study visits and completed all activities. Two people did not attend their study visits and stopped communication. Of those who were invited to participate and declined a study visit, four individuals declined due to the hair sample collection procedures (2.8% of those invited to participate). Other reasons for declining to participate included having moved (n = 7), lack of time (n = 11), not interested in research participation (n = 8), or unknown/stopped responding to messages (n = 11). Most participants reported that they chemically treated their hair to bleach, color, or straighten it, which could impact laboratory assays., Conclusion: We found hair sampling for stress measurement to be feasible and acceptable to our participants. We successfully completed all study activities for our desired sample size, and most recruited individuals volunteered to participate. Reasons provided for declining study participation reflected general barriers to research participation, with only four people declining due to hair sample collection procedures., (© 2024 The Author(s). Brain and Behavior published by Wiley Periodicals LLC.)

Academic medical institutions seek to recruit and retain a diverse workforce to foster equitable, supportive environments in which early-stage investigators, especially those who are underrepresented in medicine, can thrive. Intersectionality is a critical theoretical framework rooted in Black feminist activism and scholarship that elucidates how power and privilege are differentially structured for groups at different intersectional sociodemographic positions. As a dynamic method of analyzing multiple axes of power and inequality, intersectionality has the potential to offer a critical lens through which to view the mentor-mentee relationship. In this article, we seek to elaborate upon and extend the concept of intersectional mentoring, elucidate its essential components, and explore its application in the context of mentoring early-stage investigators in academic medicine. We propose that intersectional mentorship requires an orientation toward deep cultural humility, lifetime learning about the impact of systemic oppressions on present-day opportunities and experiences of mentees, and changing systems that perpetuate inequities by centering praxis-the application of principles of intersectionality through action to transform power dynamics in academic culture and institutions. Intersectional mentorship can help build a more equitable and representative workforce to advance intersectionally relevant and innovative approaches to achieving health equity.

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.

Background: Gender minority (GM; individuals whose gender is not aligned with that traditionally associated with the sex that was assigned to them at birth) people have widely reported mistreatment in healthcare settings. Mistreatment is enacted by individuals within society who hold stigmatizing beliefs. However, the relationship between healthcare mistreatment and societal stigma (i.e., the degree to which society disapproves of GM people) is unclear and not measured consistently., Methods: We analyzed data from 2,031 GM participants in The Population Research in Identity and Disparities for Equality (PRIDE) Study's 2019 Annual Questionnaire to determine whether societal stigma was associated with participants' past-year reports of mistreatment (defined as denial of healthcare services and/or lower quality care) in medical or mental healthcare settings. We created a proxy measure of societal stigma by incorporating variables validated in existing literature. Participants reported whether they had experienced mistreatment in medical and mental health settings independently., Results: Healthcare denial and/or lower quality care during the past year was reported by 18.8% of our sample for medical settings and 12.5% for mental health settings. We found no associations between the societal stigma variables and past-year reports of healthcare denial and/or lower quality care in medical or mental healthcare settings., Conclusions: Although a high proportion of GM people reported past-year healthcare mistreatment in both medical and mental health settings, mistreatment had no relationship with societal stigma. Factors other than societal stigma may be more important predictors of healthcare mistreatment, such as healthcare workers' knowledge of and attitudes toward GM people. However, other measures of societal stigma, or different types of mistreatment, may show stronger associations. Identifying key factors that contribute to mistreatment can serve as targets for intervention in communities and healthcare settings., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Despite the elevated prevalence of smoking among gender minority adults, little is known about the factors that influence their tobacco use and cessation., Purpose: We identified and examined factors that influence tobacco use and cessation for gender minority adults, using a conceptual framework based on the Model of Gender Affirmation and Gender Minority Stress Model., Methods: Nineteen qualitative, semi-structured in-depth interviews were conducted with gender minority adults who smoke or no longer smoke and were recruited from the Portland, OR metropolitan area. Interviews were audio-recorded, professionally transcribed, and analyzed utilizing thematic analysis., Results: Four main themes were generated. Gender minority adults smoke to cope with general and gender minority-specific stressors. Smoking was described as a social behavior that was influenced and sustained by community and interpersonal relationships. Smoking cessation was motivated by health concerns (both general and gender minority-specific) and moderated by conducive life circumstances. Recommendations for tobacco cessation interventions highlighted the importance and role of social support. Participants expressed a strong desire for gender minority-specific tobacco cessation programs. There are unique and complex factors that contribute to the higher prevalence of smoking observed among gender minority adults., Conclusions: Tobacco cessation interventions are urgently needed for this population and should be tailored to address the unique factors that impact tobacco use and cessation among gender minority people to increase the likelihood of success., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society of Behavioral Medicine.)

Objectives: Many individuals whose gender does not align with the sex they were assigned at birth (gender diverse [GD] people) report stressful health care encounters. We examined the relationship of these stressors to symptoms of emotional distress and impaired physical functioning among GD people., Study Design: This study was conducted using a cross-sectional design with data from the 2015 United States Transgender Survey., Methods: Composite metrics of health care stressors and physical impairments were developed, and the Kessler Psychological Distress Scale (K-6) provided a measure of emotional distress. Linear and logistic regression were used to analyze the aims., Results: A total of 22,705 participants from diverse gender identity subgroups were included. Participants who experienced at least one stressor in health care during the past 12 months had more symptoms of emotional distress (β = 0.14, P < .001) and 85% greater odds of having a physical impairment (odds ratio = 1.85, P < .001). Transgender men exposed to stressors were more likely than transgender women to experience emotional distress and have a physical impairment, with other gender identity subgroups reporting less distress. Black participants exposed to stressful encounters reported more symptoms of emotional distress than White participants., Conclusions: The results suggest that stressful encounters in health care are associated with symptoms of emotional distress and greater odds of physical impairment for GD people, with transgender men and Black individuals being at greatest risk of emotional distress. The findings indicate the need for assessment of factors that contribute to discriminatory or biased health care for GD people, education of health care workers, and support for GD people to reduce their risk of stressor-related symptoms., (Copyright © 2023 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Incarceration is a significant public health issue that disproportionately impacts transgender (trans) women, particularly those of color. The cycle of incarceration interacts with high levels of substance use, mental illness, and HIV to produce a high disease burden among trans women, but, to date, there are no published studies of trans-specific reentry support interventions. Informed by the Model of Gender Affirmation, we systematically adapted and pilot tested the evidence-based Project START intervention to create Girlfriends Connect (GC), a reentry support intervention for trans women incarcerated in a county jail. Qualitative interviews with trans women (10 prerelease and 6 postrelease) and community social service providers and jail staff ( n  = 7) who serve justice-involved transgender women, as well as input from a community advisory board, informed our adaptation. We then conducted a pilot randomized controlled trial ( n  = 14) and a service implementation project ( n  = 16) of GC to examine its feasibility and acceptability. Lessons learned include the importance of peer facilitators, facilitated referral to gender-affirming community resources, and obtaining programmatic buy-in from jail staff and administration. Results indicate that GC is feasible and acceptable, and holds promise in improving the health of transgender women reentering the community after a period of incarceration.

Background: Transgender women are disproportionately affected by HIV and are less likely to be optimally engaged in care than other groups because of psychosocial challenges. With community collaboration, we developed Healthy Divas, an individual-level intervention to increase healthcare empowerment and gender affirmation to improve engagement in HIV care. Healthy Divas comprises 6 peer-led individual sessions and one group workshop facilitated by a healthcare provider with expertise in HIV care and transgender health., Setting/methods: To test the intervention's efficacy, we conducted a randomized controlled clinical trial in San Francisco and Los Angeles among transgender women living with HIV; control was no intervention. Transgender field staff conducted recruitment. Assessments occurred at baseline and 3, 6, 9, and 12 months postrandomization. The primary outcome was engagement in HIV care, defined as the sum of (1) self-reported HIV care provider visit, past 6 months, (2) knowledge of most recent CD4 count, (3) self-reported antiretroviral therapy adherence ≥90%, and (4) self-reported antiretroviral therapy adherence ≥80%., Results: We enrolled 278 participants; almost half (46%) were African American/Black and one-third (33%) were Hispanic/Latina. At 6 months, participants in the intervention arm had over twice the odds of being in a higher HIV care engagement category than those in the control arm (aOR = 2.17; 95% CI: 1.06 to 4.45; P = 0.04); there were no significant study arm differences in the outcome at the other time points., Conclusions: This trial demonstrates the short-term efficacy of an urgently needed behavioral intervention to improve engagement in HIV care among transgender women living with HIV; ongoing intervention may be needed to maintain positive impact over time., Trial Registration: Clinicaltrials.gov identifier: NCT03081559., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Trans women living with HIV (TWH) have suboptimal HIV care engagement. We pilot tested Trans Amigas, a theory-based, trans-specific peer navigation (PN) intervention to address barriers to care in São Paulo, Brazil. TWH were randomized to the PN intervention (n = 75) or control (n = 38) condition. Control participants were referred to trans-friendly HIV care. Intervention participants were assigned a navigator who conducted nine in-person one-on-one sessions and bi-weekly phone or text check-ins to help participants overcome barriers to care and work towards gender affirmation and healthcare goals. We followed participants for 9 months to determine intervention feasibility, acceptability, and preliminary efficacy in improving retention in care. Analyses were intention to treat (ITT). Intervention acceptability was high: at end line, 85.2% of PN participants said they would continue receiving services and 94.4% would recommend peer navigation to a friend. A priori feasibility criteria were met: 92% of eligible participants enrolled and 70% were retained at 9 months; however, only 47% achieved moderate or better adherence to both in-person and phone/text program components. Though the pilot was not powered for efficacy, ITT findings trended toward significance, with intervention participants 40% more likely to be retained in care at the end of the study. Population-specific peer programming to support care engagement is acceptable, feasible, and can improve HIV outcomes for Trans women living with HIV., (© 2022. The Author(s).)

Introduction: In the era of biomedical HIV prevention and treatment technologies, such as treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP), there is momentum to develop and rigorously evaluate interventions focused on PrEP among those at risk for HIV acquisition and antiretroviral therapy (ART) adherence among people living with HIV. While HIV status-specific interventions focused on PrEP or ART provide valuable information, status-segregated interventions can create, perpetuate, and even increase HIV stigma among transgender women of colour and other marginalized communities in the United States (US)., Discussion: Due largely to community advocacy, discourses that support status-neutral approaches have emerged in the scientific literature. Although US-based funding mechanisms have typically designated awards focused on a specific HIV status, intervention developers and implementing agencies find creative ways to design and implement status-neutral programmes despite such restrictions. We present our experience with intervention research in New York, Detroit, New Orleans, Puerto Rico and the San Francisco Bay Area, all Ending the HIV Epidemic (EHE) priority jurisdictions. Kickin it with the Gurlz' was developed to be status-neutral through two grants due to community demands for a unifying approach. The Transgender Women Engagement and Entry to (TWEET) Care Project was designed to improve HIV care engagement for transgender women living with HIV, but developers realized the importance of including participants of any HIV status. Healthy Divas was designed for transgender women living with HIV but subsequent implementing agencies prioritized adapting it to be status-neutral. These examples support the urgency of designing, implementing and evaluating status-neutral interventions., Conclusions: Community-based organizations strive for inclusivity in their programming and are rightly often reluctant to segregate services based on the HIV status of their clients. As researchers, we have an ethical imperative to work to reduce HIV stigma and respond to the needs of those most impacted by HIV, including transgender women of colour. As such, we call upon funders to develop mechanisms that support the development and testing of HIV status-neutral interventions to reduce HIV stigma and support community building, thereby increasing the possibility of fully realizing the benefits of biomedical HIV prevention and treatment technologies for all., (© 2022 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

This cross-sectional study used 2012 to 2019 Oregon Medicaid claims to estimate the prevalence of PrEP use and identify determinants of high adherence across transgender and cisgender men and women. Gender identity (cisgender woman/man; transgender, assigned female sex at birth [AFAB]; transgender, assigned male sex at birth [AMAB]) was based on medical history and enrollment records. Proportion of days covered ≥ 0.80 was considered high adherence to PrEP. The association between gender identity and PrEP uptake or high adherence was estimated using multivariable logistic regression. 1555 PrEP users, including 171 (11.0%) cis women, 1171 (75.3%) cis men, 67 (4.3%) AFAB, and 146 (9.4%) AMAB individuals, were included. The probability of PrEP use per 10,000 people was highest in transgender groups (AMAB 546.8, 95% CI 462.4-631.3; AFAB 226.5, 95% CI 173.4-279.6), followed by cisgender men (20.6, 95% CI 19.4, 21.8) and women (2.6, 95% CI 2.2, 3.0). High adherence was significantly lower in AMAB recipients (72.6%) than cisgender women (86.0%) and cisgender men (82.2%). Among the 279 PrEP users with female on their enrollment record, 76 (27.2%) were AMAB, while among the 1276 PrEP users with male on their enrollment record, 35 (2.7%) were AFAB. This demonstrates the importance of surveillance methods that take gender identity into account in addition to sex assigned at birth. There were significant differences in PrEP use and adherence by gender identity. PrEP surveillance, outreach, and prescribing practices must consider gender identity-unique risk factors., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Sexual and gender minority (SGM) people-including members of lesbian, gay, bisexual, transgender, and queer communities-remain underrepresented in health research due to poor collection of sexual orientation and gender identity (SOGI) data. We sought to understand the contextual factors affecting how SGM research participants interact with SOGI questions to enhance participant experience and increase the accuracy and sensitivity of research findings. Methods: We recruited SGM adults for in-person semi-structured focus groups or online cognitive interviews from 2016 to 2018. During focus groups and cognitive interviews, we asked participants to respond to SOGI question sets. We employed template analysis to describe the contextual factors that affected SGM participants' responses to SOGI questions. Results: We had a total of 74 participants, including 55 participants organized into nine focus groups and 19 participants in cognitive interviews. Most self-identified as a sexual minority person (88%), and 51% identified as a gender minority person. Two main themes were: (1) the need to know the relevance (of why SOGI questions are asked) and (2) the importance of environmental and contextual cues (communicating physical safety and freedom from discrimination that influenced SOGI disclosure). Conclusions: Contextualizing the relevance of SOGI data sought could help improve the accuracy and sensitivity of data collection efforts. Environmental cues that communicate acceptance and safety for SGM individuals in research settings may support disclosure. Researchers should consider these contextual factors when designing future studies to improve research experiences for SGM individuals and increase the likelihood of future participation.

Background: TRIUMPH (Trans Research-Informed communities United in Mobilization for the Prevention of HIV) was a community-led, transgender-specific pre-exposure prophylaxis (PrEP) demonstration project at 2 community-based clinical sites in California. TRIUMPH used peer health education, community mobilization, and clinical integration of PrEP with hormone therapy to promote PrEP knowledge and acceptability. The goal of this study was to evaluate PrEP uptake, retention, and adherence among TRIUMPH participants and examine site-based differences., Methods: Eligible participants were adult transgender and gender diverse people interested in PrEP. Participants were seen at baseline and at 1, 3, 6, 9, and 12 months for PrEP provision, clinical visits, and HIV testing. PrEP uptake was defined as dispensation of PrEP, PrEP retention was defined as proportion of expected visits completed among those who initiated PrEP, and PrEP adherence was assessed by measuring tenofovir diphosphate concentrations in dried blood spots. Logistic regression models quantified the association of variables with PrEP outcomes., Results: TRIUMPH enrolled 185 participants; the median age was 28 years (interquartile range: 23-35), 7% was Black, and 58% was Latinx. PrEP uptake was as follows: 78% in Oakland and 98% in Sacramento; 91% among trans women, 96% among trans men, and 70% among nonbinary participants. Almost half (47%) rarely/never believed about HIV, and 42% reported condomless sex act in the past 3 months. Participants who reported higher numbers of sex partners were more likely to be retained and adherent; other predictors of adherence included not having a primary partner and not experiencing violence in the past 3 months., Conclusions: This community-led, trans-specific PrEP demonstration project documents high levels of PrEP initiation in a young transgender and gender diverse cohort at risk of HIV acquisition., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Pre-exposure prophylaxis (PrEP) uptake among women in the United States has been low. To increase uptake, we developed a peer outreach and navigation PrEP intervention. Semi-structured qualitative interviews with 32 cisgender women and 3 transgender women were conducted to assess the intervention. We used a thematic approach to identify barriers to, and facilitators of the intervention. Facilitators included interest in PrEP, offer of health and social services, the intervention's women-focused approach, and peer outreach and navigation. Barriers were perceived HIV risk, concerns about medication side effects or interactions, housing insecurity and travel, co-occurring health-related conditions, and caregiving responsibilities. We recommend that future interventions consider packaging PrEP in local community settings, such as syringe exchange programs; include services such as food and housing assistance; use peers to recruit and educate women; integrate a culturally appropriate women's focus; and consider providing same-day PrEP., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Transgender women (assigned "male" at birth but who do not identify as male) are disproportionately impacted by HIV and experience unique barriers and facilitators to HIV care engagement. In formative work, we identified culturally specific and modifiable barriers to HIV treatment engagement among transgender women living with HIV (TWH), including prioritizing transition-related healthcare over HIV treatment, avoiding HIV care settings due to gender-related and HIV stigma, concerns about potential drug interactions with hormones, and inadequate social support. Grounded in the investigators' Models of Gender Affirmation and Health Care Empowerment, we developed the Healthy Divas intervention to optimize engagement in HIV care among TWH at risk for treatment failure and consequential morbidity, mortality, and onward transmission of HIV. Methods and Analysis: We conducted a 2-arm randomized controlled trial (RCT) of the intervention's efficacy in Los Angeles and San Francisco to improve engagement in care among TWH ( N = 278). The primary outcome was virologic control indicated by undetectable HIV-1 level (undetectability = < 20 copies/mL), at baseline and follow-up assessment for 12 months at 3-month intervals. Ethics and Dissemination: This study was approved by University of California, San Francisco Institutional Review Board (15-17910) and Western Institutional Review Board (20181370). Participants provided informed consent before enrolment in the study. We are committed to collaboration with National Institutes of Health officials, other researchers, and health and social services communities for rapid dissemination of data and sharing of materials. The results will be published in peer-reviewed academic journals and scientific presentations. We will make our results available to researchers interested in transgender health to avoid unintentional duplication of research, as well as to others in health and social services communities, including HIV clinics, LGBT community-based organizations, and AIDS service organizations. Clinical Trial Registration: Clinicaltrials.gov, identifier NCT03081559., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Sevelius, Neilands, Reback, Castro, Dilworth, Kaplan and Johnson.)

Abstract: The COVID-19 pandemic disrupted almost all sectors of academic training and research, but the impact on human immunodeficiency virus (HIV) research mentoring has yet to be documented. We present the perspectives of diverse, experienced mentors in a range of HIV research disciplines on the impact of COVID-19 on mentoring the next generation of HIV researchers.In November to December, 2020, we used an online data collection platform to cross-sectionally query previously-trained HIV mentors on the challenges related to mentoring during the pandemic, surprising/positive aspects of mentoring in that context, and recommendations for other mentors. Data were coded and analyzed following a thematic analysis approach.Respondents (180 of 225 mentors invited [80% response]) reported challenges related to relationship building/maintenance, disruptions in mentees' training and research progress, and mentee and mentor distress, with particular concerns regarding mentees who are parents or from underrepresented minority backgrounds. Positive/surprising aspects included logistical ease of remote mentoring, the relationship-edifying result of the shared pandemic experience, mentee resilience and gratitude, and increased enjoyment of mentoring. Recommendations included practical tips, encouragement for patience and persistence, and prioritizing supporting mentees' and one's own mental well-being.Findings revealed gaps in HIV mentors' competencies, including the effective use of remote mentoring tools, how to work with mentees in times of distress, and the prioritization of mentor well-being. Mentors are in a unique position to identify and potentially address factors that may lead to mentees leaving their fields, especially parents and those from underrepresented backgrounds. We discuss implications beyond the COVID-19 pandemic., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

HIV prevalence among transgender women of color (TWC) in the United States of America is high. We enrolled TWC living with HIV (N = 858) to evaluate 1nine HIV care interventions. We examined factors associated with four outcomes at enrollment: linkage to care, ever being on antiretroviral treatment, retention in care and viral suppression. The sample was 49% Hispanic/Latino, 42% Black; average age was 37 years; 77% were ever linked to care, 36% were ever on treatment, 22% were retained in care, and 36% were virally suppressed. Current hormone use was significantly associated with linkage, retention, and viral suppression (all aORs > 1.5), providing evidence for gender-affirming care as an important facilitator of engagement in HIV care. Greater health care empowerment was significantly associated with greater odds of all outcomes (aORs between 1.19 and 1.37). These findings identify potential intervention targets to improve the provision of care and treatment for TWC living with HIV.

Pre-exposure prophylaxis (PrEP) uptake remains woefully low among U.S. women at high risk for HIV acquisition. We evaluated a pilot intervention which involved Peers providing brief PrEP education and counseling at mobile syringe exchange sites and at sex worker and syringe exchange drop-in centers followed by navigation to PrEP care. Peers recruited English-proficient, self-identified women (i.e., cisgender and transgender women and persons with other transfeminine identities) over a 3-month period and delivered the intervention to 52 HIV-negative/status unknown participants. Thirty-eight participants (73.1%) reported PrEP interest, 27 (51.9%) accepted the offer of a PrEP appointment, 13 (25.0%) scheduled a PrEP appointment, 3 (5.8%) attended an initial PrEP appointment, and none were prescribed PrEP. We found a gap between PrEP interest and connecting women to PrEP care. Further study is needed to understand this gap, including exploring innovative approaches to delivering PrEP care to women at highest risk for HIV.

Among transgender and gender diverse people, psychological gender affirmation is an internal sense of valuing oneself as a transgender or gender diverse person, being comfortable with one's gender identity, and feeling satisfied with one's body and gender expression. Gender affirmation can reduce gender dysphoria and mitigate deleterious health effects of marginalization. We sought to create an instrument to measure psychological gender affirmation among transgender women. Following initial item development using qualitative interviews, we used self-administered survey data from two distinct samples ( N1 = 278; N2 = 368) of transgender women living with HIV in the USA. We used data from Study 1 to perform exploratory factor analysis (EFA) and data from Study 2 to perform confirmatory factor analysis (CFA), yielding the five-item single-factor Psychological Gender Affirmation (PGA) scale with high reliability (α = 0.88). This scale is psychometrically sound as demonstrated by its convergent and discriminant validity via correlations with select measures and by its predictive validity through associations in hypothesized directions with measures of mental health and substance use. The PGA scale will aid research on psychological gender affirmation that can in turn inform interventions as well as gender-affirming clinical and social practices to promote the health and well-being of transgender and gender diverse people.

Social interactions where a person is addressed by their correct name and pronouns, consistent with their gender identity, are widely recognized as a basic and yet critical aspect of gender affirmation for transgender people. Informed by the Model of Gender Affirmation, we developed a self-report measure of the importance of social gender affirmation, the Transgender Women's Importance of Pronouns (TW-IP) scale, which measures gender affirmation through the usage of correct pronoun by others. Data were from self-administered surveys in two independent samples of transgender women living with HIV in the US (N1 = 278; N2 = 369). Using exploratory factor analysis with data from Study 1 and confirmatory factor analysis with data from Study 2, we obtained a four-item scale with a single-factor structure and strong reliability (α = 0.95). We present evidence of TW-IP's convergent and discriminant validity through its correlations with select mental health and HIV-related measures. Further, scores on TW-IP were linked in expected directions to several hypothesized mental health and HIV care outcomes, demonstrating its predictive validity. The resulting brief measure of importance of pronouns among transgender women shows strong psychometric properties. Validation evidence offers highly promising opportunities for use of the measure in clinical and research settings.

Introduction: HIV transmission and acquisition risk among transgender women is particularly high in the context of primary partnerships. This project extends a previous pilot couples-focused HIV intervention programme, which was shown to be feasible, acceptable and promising in reducing sexual risk behaviour among transgender women and their partners. This randomised controlled trial (RCT) tests the efficacy of this culturally sensitive HIV prevention programme for HIV-serodiscordant and HIV-negative seroconcordant transgender women and their partners., Methods and Analysis: To finalise the protocol for trial, we used qualitative methods to hone eligibility criteria, refine the intervention and control manuals, and name and brand the intervention ('It Takes Two'). The RCT investigates the effects of the It Takes Two intervention on Composite Risk for HIV (CR-HIV) among 100 couples. CR-HIV is a binary indicator of couple HIV risk using validated measures of sexual behaviour, pre-exposure prophylaxis use among HIV-negative participants and viral suppression among participants living with HIV. Using a two-arm RCT, we will examine intervention effects on CR-HIV at 12-month follow-up comparing transgender women and their partners randomised to the intervention versus control (HIV prevention information only)., Ethics and Dissemination: This study has been reviewed and approved by the University of California, San Francisco (19-28624) and the University of Michigan (HUM00147690) Institutional Review Boards. Participants provide informed consent before taking part of the study activities. Results will be published in peer-reviewed journals and presented at scientific conferences. We will make our results available to the community of researchers and general public interested in transgender health to avoid unintentional duplication of research, as well as to others in the health and social services community, including LGBT community-based organisations, AIDS service organisations and other transgender-serving organisations. The full de-identified dataset and codebook will be shared at the University of Michigan Digital Repository., Trial Registration Number: NCT04067661., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: HIV testing and pre-exposure prophylaxis (PrEP) are effective HIV prevention strategies often underused by transgender people., Methods: Recruitment occurred in 2 phases to identify transgender respondents in a probability sample of adults in the United States. Transgender respondents completed a self-administered paper or web-based survey designed to assess transgender population health. Sexually active respondents (HIV-negative and had sex in the 5 years previously, N = 190) and a subsample of those at risk for sexual HIV acquisition (sex with cisgender men or transgender women, n = 120) were included in analyses., Results: Of the full sample of sexually active respondents, those who were transfeminine were less likely to be familiar with PrEP; most (72%) reported favorable attitudes toward PrEP. Of those at risk for HIV acquisition, 23% had never tested for HIV. Respondents of color were more likely than white respondents to meet Centers for Disease Control and Prevention recommendations for HIV testing. Respondents who met Centers for Disease Control and Prevention recommendations for HIV testing were more likely to report looking online for lesbian, gay, bisexual, and transgender or transgender-specific health information. Few respondents reported currently taking PrEP (3%); those who reported higher levels of nonaffirmation of their gender identity were less likely to currently use PrEP., Discussion: These findings may indicate some success of HIV testing outreach programs that prioritize people at higher risk for acquiring HIV, focusing on those who are vulnerable to structural marginalization. Ongoing public health efforts are needed to increase HIV testing and PrEP awareness among transgender adults, who are disproportionately impacted by HIV.

Transgender women experience disproportionate risk of HIV acquisition and transmission. We piloted 'Sheroes', a peer-led group-level intervention for transgender women of any HIV status emphasizing empowerment and gender affirmation to reduce HIV risk behaviors and increase social support. Participants (N = 77) were randomized to Sheroes (n = 39) or a time- and attention-matched control (n = 38). Sheroes is 5 weekly group sessions; topics include sexuality, communication, gender transition, and coping skills. Control participants attended 5 weekly group movie sessions. At 6-month follow up, HIV-negative and unknown status Sheroes participants reported reductions in condomless intercourse and improved social support compared to control. Among participants living with HIV, both the control and intervention groups reduced their total number of sex partners; this change was sustained at 6-month follow-up for Sheroes participants but not for control participants relative to baseline. Sheroes was deemed highly feasible and acceptable to participants; findings support preliminary efficacy of Sheroes.

Cisgender men partnered with transgender women are an understudied and hard to engage population in HIV prevention efforts. Relationship stigma-the anticipation of negative treatment based on having a relationship with a member of a stigmatized group-has been linked to adverse health behaviors, but it remains unclear whether different sources of relationship stigma (i.e., family, friends, and the general public) are associated with HIV risk behaviors and whether these associations may vary by men's sexual identities (e.g., gay, bisexual, and heterosexual). The current study examined associations between relationship stigma and HIV risk behaviors and whether these associations were moderated by sexual identity. We recruited a convenience sample of 185 cisgender men in primary partnerships with transgender women to participate in a one-time survey. Gay identified men reported greater levels of relationship stigma from the general public compared with heterosexually identified men. In multivariable models, higher levels of relationship stigma from the public were associated with increased odds of engaging in drug use prior to having condomless sex and receiving an STI diagnosis in the last 30 days. There were significant interaction effects such that higher levels of relationship stigma from the public were associated with both indicators of HIV risk for gay identified men but not for heterosexually identified men. Findings support the importance of HIV prevention approaches accounting for relationship stigma from the general public and the diverse sexual identities of men partnered with transgender women when seeking to increase linkage to and engagement in HIV prevention services, including biomedical prevention strategies.

The goals of this study were to: (a) examine associations between interpersonal stigma and psychological distress among a sample of transgender women and their cisgender male partners; and (b) identify whether commitment moderates the association between interpersonal stigma and psychological distress. To address these aims, 191 couples consisting of transgender women and their cisgender male partners completed a one-time survey. Actor-partner interdependence models (APIM) were fit to examine stigma, commitment, and their interaction on psychological distress. More frequent experiences of interpersonal stigma were associated with elevated psychological distress for both partners. For transgender women, higher commitment was associated with lower psychological distress. There was a significant interaction effect such that the association between interpersonal stigma and psychological distress was attenuated by greater commitment for transgender women, but not for their cisgender male partners. Findings provide preliminary support for associations between interpersonal stigma and mental health of both partners, and identify commitment as a potential stress buffer for transgender women., Competing Interests: Conflicts of Interest: Each of the authors declare that they have no conflict of interest Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent: Informed consent was obtained from all individual participants included in the study.

Background: Transgender individuals have a gender identity that differs from the sex they were assigned at birth. The population size of transgender individuals in the United States is not well-known, in part because official records, including the US Census, do not include data on gender identity. Population surveys today more often collect transgender-inclusive gender-identity data, and secular trends in culture and the media have created a somewhat more favorable environment for transgender people., Objectives: To estimate the current population size of transgender individuals in the United States and evaluate any trend over time., Search Methods: In June and July 2016, we searched PubMed, Cumulative Index to Nursing and Allied Health Literature, and Web of Science for national surveys, as well as "gray" literature, through an Internet search. We limited the search to 2006 through 2016., Selection Criteria: We selected population-based surveys that used probability sampling and included self-reported transgender-identity data., Data Collection and Analysis: We used random-effects meta-analysis to pool eligible surveys and used meta-regression to address our hypothesis that the transgender population size estimate would increase over time. We used subsample and leave-one-out analysis to assess for bias., Main Results: Our meta-regression model, based on 12 surveys covering 2007 to 2015, explained 62.5% of model heterogeneity, with a significant effect for each unit increase in survey year (F = 17.122; df = 1,10; b = 0.026%; P = .002). Extrapolating these results to 2016 suggested a current US population size of 390 adults per 100 000, or almost 1 million adults nationally. This estimate may be more indicative for younger adults, who represented more than 50% of the respondents in our analysis., Authors' Conclusions: Future national surveys are likely to observe higher numbers of transgender people. The large variety in questions used to ask about transgender identity may account for residual heterogeneity in our models. Public health implications. Under- or nonrepresentation of transgender individuals in population surveys is a barrier to understanding social determinants and health disparities faced by this population. We recommend using standardized questions to identify respondents with transgender and nonbinary gender identities, which will allow a more accurate population size estimate.

Introduction: Globally, transgender ("trans") women are one of the key populations most disproportionately impacted by HIV. Pre-exposure prophylaxis (PrEP) is the newest and most promising biomedical HIV prevention intervention to date. This paper reviews relevant literature to describe the current state of the science and describes the potential role of PrEP among trans women, including a discussion of unique considerations for maximizing the impact of PrEP for this vulnerable population., Methods: Available information, including but not limited to existing scientific literature, about trans women and PrEP was reviewed and critiqued based on author expertise, including PrEP clinical trials and rollout., Results: To date, PrEP demonstration projects and clinical trials have largely excluded trans women, or have not included them in a meaningful way. Data collection strategies that fail to identify trans women in clinical trials and research further limit the ability to draw conclusions about trans women's unique needs and devise strategies to meet them. Gender-affirming providers and clinic environments are essential components of any sexual health programme that aims to serve trans women, as they will largely avoid settings that may result in stigmatizing encounters and threats to their identities. While there is currently no evidence to suggest drug-drug interactions between PrEP and commonly used feminizing hormone regimens, community concerns about potential interactions may limit interest in and uptake of PrEP among trans women., Conclusions: In scaling up PrEP for trans women, it is essential to engage trans communities, utilize trans-inclusive research and marketing strategies and identify and/or train healthcare providers to provide gender-affirming healthcare to trans women, including transition-related care such as hormone provision. PrEP implementation guidelines must consider and address trans women's unique barriers and facilitators to uptake and adherence., Competing Interests: JMS, MBD and RG are principal investigators on a PrEP demonstration project for transgender people, funded by the California HIV/AIDS Research Program, to which Gilead has donated study drug.

Lessons were learned with trans women who participated (as volunteers and investigators) in trials of HIV pre-exposure prophylaxis (PrEP). Trans women are not men. Compared with men who have sex with men, trans women trial participants were more likely to be involved with transactional sex, had more sexual partners, and were less likely to have PrEP medications detected in blood. Trans women define themselves differently in different cultures. One best practice is to ask at least 2 gender questions: sex assigned at birth and current gender. More information is needed to fully situate PrEP efficacy for trans women, including analysis of drug-drug interactions between PrEP medications and feminizing hormones and PrEP drug penetration into neovaginal tissues. Including trans women in studies is helpful only if their participation is specifically reported, as could occur in a table of baseline characteristics of the enrolled cohort. Gender-affirming care is important to foster appropriate uptake and use of PrEP. Such care includes use of preferred pronouns and names, safety to use the bathroom of choice, and access to gender-affirming hormone therapy and surgery. The consistent finding that PrEP works when taken across diverse populations having diverse practices related to gender, sexual intercourse, and hormone use provides a basis for offering PrEP to people at substantial risk of acquiring HIV although some subgroups may not have been fully represented in trials. Nonetheless, specific PrEP implementation science for trans women (and men) is essential to develop best practices for PrEP delivery and use.

The frequent conflation of transgender ('trans') women with 'men who have sex with men (MSM)' in HIV prevention obscures trans women's unique gender identities, social and behavioural vulnerabilities, and their disproportionately high rates of HIV infection. Pre-exposure prophylaxis (PrEP) is an efficacious biomedical HIV prevention approach. However, trans women are underrepresented in PrEP research, and are often aggregated with MSM without consideration for their unique positions within sociocultural contexts. This study examined PrEP acceptability among trans women via three focus groups and nine individual interviews (total N = 30) in San Francisco. While knowledge of PrEP was low, interest was relatively high once participants were informed. Due to past negative healthcare experiences, ability to obtain PrEP from a trans-competent provider was cited as essential to PrEP uptake and adherence. Participants noted that PrEP could address situations in which trans women experience reduced power to negotiate safer sex, including sex work. Trans-specific barriers included lack of trans-inclusive marketing of PrEP, prioritisation of hormone use, and medical mistrust due to transphobia. Findings underscore the importance of disaggregating trans women from MSM in HIV prevention strategies to mitigate disparate risk among this highly vulnerable population.

Objective: To conduct a cross-sectional study of transgender men who had been pregnant and delivered after transitioning from female-to-male gender to help guide practice and further investigation., Materials and Methods: We administered a web-based survey from March to December 2013 to inquire about demographics, hormone use, fertility, pregnancy experience, and birth outcomes. Participants were not required to have been on hormone therapy to be eligible. We used a mixed-methods approach to evaluate the quantitative and qualitative data., Results: Forty-one self-described transgender men completed the survey. Before pregnancy, 61% (n=25) had used testosterone. Mean age at conception was 28 years with a standard deviation of 6.8 years. Eighty-eight percent of oocytes (n=36) came from participants' own ovaries. Half of the participants received prenatal care from a physician and 78% delivered in a hospital. Qualitative themes included low levels of health care provider awareness and knowledge about the unique needs of pregnant transgender men as well as a desire for resources to support transgender men through their pregnancy., Conclusion: Transgender men are achieving pregnancy after having socially, medically, or both transitioned. Themes from this study can be used to develop transgender-appropriate services and interventions that may improve the health and health care experiences of transgender men.

Background: Transgender women have 49 times the odds of human immunodeficiency virus (HIV) infection compared to other groups, yet they are disproportionately underserved by current treatment efforts., Purpose: This study aimed to examine culturally unique barriers and facilitators to engagement and retention in HIV care and strengthen efforts to mitigate health disparities, guided by the Models of Gender Affirmation and Health Care Empowerment., Methods: Through 20 interviews and five focus groups (n = 38), transgender women living with HIV discussed their experiences and life contexts of engagement in and adherence to HIV care and treatment., Results: Our participants faced substantial challenges to adhering to HIV care and treatment, including avoidance of healthcare due to stigma and past negative experiences, prioritization of hormone therapy, and concerns about adverse interactions between antiretroviral treatment for HIV and hormone therapy. Receiving culturally competent, transgender-sensitive healthcare was a powerful facilitator of healthcare empowerment., Conclusions: Recommendations are offered to inform intervention research and guide providers, emphasizing gender affirming HIV care that integrates transition-related healthcare needs.

Transgender women are 49 times more likely to become HIV infected than other groups, yet they are drastically underserved by current treatment efforts and report lower rates of treatment adherence then other groups. The objective of this study was to explore correlates of antiretroviral (ART) adherence and viral load among HIV-positive transgender women on ART utilizing a cross-sectional survey of a convenience sample of 59 transgender women. In multivariate models of ART adherence, correlates were age, stress appraisal of transphobic experiences, importance of gender affirmation, and adherence to hormone therapy. In multivariate models of self-reported viral load, correlates were stress appraisal of transphobic experiences and being in a relationship. This study provides preliminary evidence of transgender-relevant correlates of ART adherence and viral load.

Experiences of stigma, discrimination, and violence as well as extreme health disparities and high rates of sexual risk behavior and substance use have been well-documented among transgender women of color. Using an intersectional approach and integrating prominent theories from stigma, eating disorders, and HIV-related research, this article offers a new framework for conceptualizing risk behavior among transgender women of color, specifically sexual risk behavior and risky body modification practices. This framework is centered on the concept of 'gender affirmation,' the process by which individuals are affirmed in their gender identity through social interactions. Qualitative data from 22 interviews with transgender women of color from the San Francisco Bay Area in the United States are analyzed and discussed in the context of the gender affirmation framework.

Background: The Model of Health Care Empowerment (HCE) defines HCE as the process and state of being engaged, informed, collaborative, committed, and tolerant of uncertainty regarding health care. We examined the hypothesized antecedents and clinical outcomes of this model using data from ongoing human immunodeficiency virus (HIV)-related research. The purpose of this paper is to explore whether a new measure of HCE offers direction for understanding patient engagement in HIV medical care. Using data from two ongoing trials of social and behavioral aspects of HIV treatment, we examined preliminary support for hypothesized clinical outcomes and antecedents of HCE in the context of HIV treatment., Methods: This was a cross-sectional analysis of 12-month data from study 1 (a longitudinal cohort study of male couples in which one or both partners are HIV-seropositive and taking HIV medications) and 6-month data from study 2, a randomized controlled trial of HIV-seropositive persons not on antiretroviral therapy at baseline despite meeting guidelines for treatment. From studies 1 and 2, 254 and 148 participants were included, respectively. Hypothesized antecedents included cultural/social/environmental factors (demographics, HIV-related stigma), personal resources (social problem-solving, treatment knowledge and beliefs, treatment decision-making, shared decision-making, decisional balance, assertive communication, trust in providers, personal knowledge by provider, social support), and intrapersonal factors (depressive symptoms, positive/negative affect, and perceived stress). Hypothesized clinical outcomes of HCE included primary care appointment attendance, antiretroviral therapy use, adherence self-efficacy, medication adherence, CD4+ cell count, and HIV viral load., Results: Although there was no association observed between HCE and HIV viral load and CD4+ cell count, there were significant positive associations of HCE scores with likelihood of reporting a recent primary care visit, greater treatment adherence self-efficacy, and higher adherence to antiretroviral therapy. Hypothesized antecedents of HCE included higher beliefs in the necessity of treatment and positive provider relationships.

To be truly gender responsive, HIV/AIDS programming for women and girls also needs to be fully gender inclusive. Gender identity is not necessarily determined by one's sex assigned at birth and not everyone is only or always simply "male" or "female." Transgender women (transwomen) and girls are those individuals whose gender identity and/or expression do not align with the "male" sex they were assigned at birth. This definition is inclusive of a diverse population whose identities, language, communities, and behaviors may vary widely. However, based on recent increases in public health literature that aims to elucidate the social context that puts transwomen and girls at risk for adverse health outcomes, we offer some formative considerations for the implementation of gender-responsive and gender-inclusive HIV/AIDS programming in the United States., (Copyright © 2011 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Despite disproportionate rates of HIV among transgender women and evidence that medication adherence is necessary for treatment success and increased likelihood of survival, there has been little investigation into antiretroviral therapy (ART) adherence issues among transgender women. This study examined rates of self-reported ART adherence among transgender women on ART (n = 35) and well-established correlates of nonadherence, including depression, adherence self-efficacy, patient perceptions of interactions with their providers, and perceived adverse side effects of ART compared to other respondents (n = 2,770). Transgender women on ART were less likely to report 90% adherence rates or higher and reported less confidence in their abilities to integrate treatment regimens into their daily lives. When transgender women were compared to other respondents, regardless of the current medication regimen, they reported significantly fewer positive interactions with their health care providers. Training for providers and integration of hormone therapy into HIV care is recommended.

This study identifies contextual factors that predict risky sexual behavior among 153 transgender women who participated in a structured survey soliciting information on demographics, substance use, HIV status, risk behaviors, and other health and psychosocial factors. Multivariate logistic regression models were used to determine predictors. Inconsistent condom use was associated with stimulant use, unstable housing, and recruitment site. Substance use during sex was associated with unstable housing and stimulant use. Sex work was associated with hormone use, gender confirming surgeries, and younger age. When developing interventions for transgender women, it may be useful to focus on predictors of risk behavior rather than predictors of current HIV status (i.e., race/ethnicity as "risk factor"), because these behaviors are the target of interventions aimed at sexual risk reduction. Implications include potential benefits of context-specific interventions, structural interventions addressing barriers to housing and health care, and culturally specific substance abuse treatment programs for transgender women.