Jennifer L. Glick

Purpose: We conducted a scoping review to map peer-reviewed literature on HIV research concerning sexual minority women (SMW). Methods: Following guidance from Arksey and O’Malley’s framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews, we searched PubMed, Embase, PsycInfo, Sociological Abstracts, and CINAHL from inception through May 2023. Eligible studies were English language, peer-reviewed studies, containing disaggregated HIV-related data on SMW. Studies were systematically screened, and relevant data were extracted and then summarized. Results: Our search identified 7615 studies; 187 met eligibility requirements. Most studies were quantitative (82%), cross-sectional (74%), used survey data (80%) obtained via convenience sampling (61%), and conducted in the United States (65%). Annual publications increased over time. Overwhelmingly, studies did not report engaging the community in the research process (93%). Demographic reporting in studies varied; about half reported age (52%) and race (52%), two-thirds reported sexual orientation (68%), and only 25% focused exclusively on SMW. Diverse HIV-related findings were addressed: sexual risk behaviors (64%), HIV testing, prevalence, and risk perception (47%), substance use (43%), sexually transmitted infections (29%), health care access (21%), intimate partner violence (17%), mental health (15%), stigma (10%), and incarceration (9%). Conclusions: Our review highlights key methodological and topical gaps. Future SMW HIV research guidance includes focusing on structural-level factors and biomedical interventions; researching understudied regions highly impacted by HIV; including qualitative and quantitative approaches; establishing standardized procedural and reporting guidelines; and increasing research and practice resources to focus on SMW’s unique HIV-related health strengths and vulnerabilities.

Background: Gay, bisexual, and other men who have sex with men (GBMSM) in the United States are disproportionately affected by the HIV epidemic. Long-acting injectable pre-exposure prophylaxis (LAI-PrEP) represents a novel HIV prevention strategy. However, stigma remains a barrier to HIV-related prevention and care. We investigated the role of intersectional stigma in LAI-PrEP preferences among past-year PrEP-naive, HIV-negative US cisgender GBMSM. Methods: The 2022 American Men's Internet Survey enrolled cisgender GBMSM online between October 2022 and October 2023. Using bivariate and multivariable adjusted Poisson regression with robust variance and a modified Intersectional Discrimination Index to examine associations between several forms of stigma—anticipated, day-to-day, social systems exclusion, and violence and harassment—and LAI-PrEP willingness and preference. Results: Among participants (N = 1196), 705 (59.0%) were willing to use any PrEP modality and 393 (32.9%) were willing to use LAI-PrEP, among whom 211 (29.9%) reported a preference for LAI-PrEP. On average, participants experienced 1.8 of 7 anticipated discrimination items, 3.9 of 7 day-to-day discrimination items, 0.2 of 3 social systems exclusion items, and 0.9 of 4 violence/harassment items. Willingness to use LAI-PrEP was associated with anticipated stigma (adjusted prevalence ratio [aPR] = 1.06; 95% confidence interval [CI] = 1.02 to 1.10; P < 0.01). Preference for LAI-PrEP was associated with anticipated stigma (aPR = 1.06; 95% CI = 1.00 to 1.12; P = 0.04), day-to-day (aPR = 1.09; 95% CI = 1.02 to 1.15; P = 0.01) stigma, and violence/harassment (aPR = 1.09; 95% CI = 1.01 to 1.18; p-0.03). Conclusions: Given disproportionate HIV burden among GBMSM, a range of HIV PrEP modality options combined with efforts to address intersectional anticipated and enacted stigma among GBMSM is critical to ensure PrEP access, uptake, and adherence.

Transgender women and transfeminine people (TWTFP) experience disproportionately high HIV prevalence, low HIV pre-exposure prophylaxis (PrEP) coverage, and negative healthcare experiences. Long-acting injectable PrEP (LAI-PrEP) and daily oral-PrEP are delivered under different healthcare interaction protocols. We examined the role of healthcare-related experiences on willingness and preference for LAI-PrEP among a U.S. nationwide sample of sexually active TWTFP aged 15+. Recruitment occurred between 6/2022 and 10/2023 via social media advertisements for a cross-sectional online sexual health survey. Analyses included past-year PrEP naïve TWTFP with no prior HIV diagnosis ( N = 1648). Participants reported LAI-PrEP willingness and ranked PrEP modality preferences; recent healthcare-related experiences were explored as correlates, using adjusted multivariable Poisson regression with robust variance estimation. Among respondents, 26.3% were willing to use LAI-PrEP ( n = 433/1648). Among participants willing to use LAI-PrEP and another modality ( n = 390/433; 90.1%), 45.6% ( n = 178/390) preferred LAI-PrEP. Discussing sexual health with a healthcare provider (HCP) was associated with increased LAI-PrEP willingness (adjusted prevalence ratio [aPR] = 1.34; 95% confidence interval [CI] = 1.12–1.60; p = 0.001); use of oral prescription medication (non-hormonal) was associated with decreased LAI-PrEP willingness (aPR = 0.60; 95% CI = 0.38–0.93; p = 0.022). No significant associations were found between healthcare-related experiences and LAI-PrEP preference. Given that most TWTFP who were willing to use LAI-PrEP were also willing to use oral-PrEP, but nearly half preferred LAI-PrEP, offering multiple PrEP modalities is essential to meet their needs. Associations between sexual health discussions and increased LAI-PrEP willingness highlight the importance of HCP engagement; initiatives which encourage HCPs to initiate LAI-PrEP conversations in supportive ways are crucial. Associations between oral prescription use and decreased LAI-PrEP willingness, coupled with null findings related to injection use, highlight the need for further investigation.

Resumo Objetivou-se estimar a prevalência e identificar fatores associados à sífilis entre adolescentes homens que fazem sexo com homens (AHSH). Estudo transversal, multicêntrico que recrutou 199 AHSH entre 15 e 19 anos por meio do método respondent-driven sampling (RDS) entre dezembro de 2020 e agosto de 2022, com aplicação de questionário e utilização de testes rápidos em Fortaleza e São Paulo. As estimativas foram calculadas por meio do software STATA 17, considerando intervalo de confiança de 95% após a ponderação dos dados em cada cidade e unindo os adolescentes das duas capitais em um único banco. O modelo multivariado foi montado considerando as análises bivariadas com p < 0,20. A prevalência de sífilis foi de 10,9% (IC95%: 6,7-17,3). No modelo final, as maiores chances de infecção por sífilis foram associadas ao AHSH ter recebido dinheiro por relação sexual (RP 2,9; IC95%: 1,1-7,3), ter feito teste rápido para HIV antes do estudo (RP 2,6; IC95%: 1,0-6,7) e ter feito uso de drogas ilícitas nos últimos três meses (RP 4,4; IC95%: 1,2-15,4). Os resultados mostram uma elevada prevalência de sífilis entre AHSH, evidenciando alta vulnerabilidade ao HIV e outras IST. Reforçam a importância de elaborar e executar políticas públicas voltadas aos AHSH visando reduzir sua vulnerabilidade.

Objective: To estimate the prevalence of sexual risk behaviors among adolescent men who have sex with men and to identify factors associated with these behaviors. Methods: Data were collected between December 2020 and July 2022 in Fortaleza and São Paulo, Brazil, using respondent-driven sampling. Study outcomes included inconsistent condom use, multiple sexual partners, and sexualized drug use. Results: The final sample was composed of 287 adolescents. Among participants, 38.0% reported inconsistent condom use, 36.1% reported multiple sexual partners, and 23.8% reported sexualized drug use. Factors associated with inconsistent condom use were not having a steady partner (adjusted prevalence ratio (APR): 0.5), having come out to everyone or almost everyone (APR: 6.3), consuming alcohol weekly (APR: 2.9), looking for family/friends/pharmacy (APR: 0.7), or looking for the public healthcare service when sick (APR: 0.7), and having sexual intercourse with partners of unknown HIV status (APR: 1.6). Factors associated with multiple sexual partners were receiving money in exchange for sex (APR: 1.6), and having sexual intercourse with partners of unknown HIV status (APR: 2.0). Factors associated with sexualized drug use included Catholic religion (APR: 0.2), having a steady partner < 20 years old (APR: 2.0), participating in non-governmental organization activities (APR: 2.5), experiences of violence (APR: 2.7), receiving money in exchange for sex (APR: 1.7), and having sexual intercourse with partners of unknown HIV status (APR: 2.1). Conclusion: These findings highlight the high prevalence of sexual risk behaviors among adolescent men who have sex with men, underscoring the need for targeted prevention strategies and youth-friendly services in diverse urban contexts.

Sexual minority women (SMW) experience higher rates of substance use relative to heterosexual women in the U.S. but remain an under-studied population. SMW who inject drugs (SMWWID) navigate an unpredictable drug market and may experience complex relationships within their social spheres. We explore cisgender SMWWID’s strategies to maintain safety while injecting drugs, and the influence of their social support systems on those strategies. We conducted N = 16 phone-based, semi-structured, in-depth interviews with SMWWID in Baltimore, Maryland between June-October 2021. The interviews explored participants’ sexual orientation and gender identities, social networks and support systems, drug use behaviors and HIV risk, and experiences accessing services. Using an inductive thematic analysis approach, we examined emergent themes related to drug use, social support, safety, and HIV and identified key safety strategies and social support experiences for SMWWID. SMWWID employed various strategies to “stay safe,” which they primarily interpreted as ensuring overdose safety (i.e., using drugs in the presence of others, carrying Naloxone, purchasing strategies), and additionally as infectious disease safety (i.e., avoiding syringe sharing, using sterile syringes) and avoiding threats of violence (i.e., maintaining situational awareness while using drugs). Romantic or sexual partners, family and friends, and the wider community were sources of social support for overdose safety, and family and friends also provided material support (e.g., financial, housing). Syringe sharing with romantic partners and threats of violence from people in the community detracted from SMWWID’s safety. SMWWID in this sample reported strong safety prioritization while using drugs, often facilitated by their social support systems. Harm reduction interventions that consider SMWWID’s relationships, including those that aim to improve social connectedness, may better meet the needs of SMWWID, thereby enhancing safety.

Purpose: Research suggests that sexual minority women (SMW) face elevated HIV risk compared with their heterosexual counterparts. This study examined the association between sexual minority status-defined by identity and behavior-and HIV-related vulnerabilities among heterosexually active low-income women. Methods: This analysis used National HIV Behavioral Surveillance data (n = 5542) collected in 2019 from heterosexually active low-income women in 23 U.S. urban areas. We examined sexual minority identity and behavior and a set of substance use, sexual behavior, health and health care, and social determinants of health indicators commonly associated with heightened HIV transmission risk. Log-linked Poisson regression models generated adjusted prevalence ratios and 95% confidence intervals. Results: Among women who reported sexual minority identity (22.2%; n = 1231), 34.6% (n = 426) reported past-year sex with only men. Of women who reported past-year sex with both women and men (17.8%; n = 985), 18.3% (n = 180) identified as heterosexual. In adjusted models, SMW had significantly higher prevalence of nearly every HIV risk-associated factor examined than their heterosexual counterparts. Risk profiles by identity and behavior were similar. Notably, SMW defined by behavior had similar or higher prevalence of nearly every risk factor than those defined by identity. Conclusions: This study demonstrates disproportionate HIV-related vulnerabilities among SMW compared with their heterosexual counterparts. The findings underscore the importance of measuring multiple dimensions of sexual orientation (identity and behavior), as SMW and their associated risks show important nuances. Implications include tailoring HIV prevention and health promotion interventions to meet the needs of low-income SMW.

Purpose: Transgender and nonbinary people (TNB) experienced a disproportionate burden of poor health and socioeconomic outcomes resulting from the coronavirus disease 2019 (COVID-19) pandemic, largely driven by increased vulnerability due to pervasive structural discrimination. To characterize the extent and nature of TNB inclusivity within COVID-19 research, we conducted a scoping review of studies published in English from 2019-2022 reporting COVID-19 pandemic impacts on TNB individuals in the United States. Methods: We searched PubMed (PubMed.gov), Embase (Elsevier), PsycInfo (EBSCO), Sociological Abstracts (ProQuest), and CINAHL (EBSCO), and TNB-focused organizational websites using search concepts 1) COVID-19, 2) TNB people. Studies were systematically reviewed for inclusion. Findings were extracted then summarized using systematic narrative synthesis. Results: Our search identified 1518 studies; 80 articles (65 peer-reviewed, 15 gray literature) met eligibility criteria. Most studies collected data early in the pandemic (69%) utilizing quantitative methods (79%), survey data (81%), and convenience sampling methods (65%); geographic foci varied. Many studies lacked transparent reporting on TNB involvement (80%), race/ethnicity of TNB subsamples (67%), and gender measurement (30%). The findings addressed COVID-19 (39%), mental health (29%), socioeconomics (26%), health care access (24%), physical health (13%), substance use (11%), violence/discrimination (8%), resiliency/coping (5%), gender identity/expression (5%), and sexual health (4%). Conclusions: A substantial amount of COVID-19 research inclusive of TNB people was conducted during the initial 2.5 years of the pandemic. However, there were key methodological (e.g., standardized measurement, enhanced community involvement) and topical gaps (e.g., social and structural resiliencies), which should be addressed in future research and practice to reduce TNB health disparities related to COVID-19 and future public health crises.

Introduction: Sexual minority women (SMW; women who self-identify as lesbian, queer, etc., as well as heterosexually-identified women who experience attraction to romantic or sexual partnerships with women) and vulnerabilized women (those marginalized due to structural forces such as housing insecurity, violence, sex exchange, drug use, or HIV positive status) experience a range of mental health challenges compared to their heterosexual and general population counterparts. General populations studies show a positive relationship between social support and mental health; less is known about SMW experiencing intersecting multi-layered vulnerabilities. This study characterizes mental health stressors, identifies social support sources and forms, and explores the relationship between social support and mental health among vulnerabilized SMW in Baltimore, MD. Methods: We conducted virtual, in-depth semi-structured interviews with vulnerabilized cisgender SMW (n = 25) between June and October 2021. We utilized an inductive analytical approach to identify central themes and develop a categorization structure. Results are presented using narrative synthesis and illustrative quotes. To understand different forms of mental health-related social support provided across sources, data was sorted into a matrix and analyzed. Results: Vulnerabilized SMW commonly self-reported depression and anxiety. Participants identified three primary mental health stressors: 1) managing identity-related stigma; 2) relationships, loss, and isolation; and 3) financial struggles. The most important type of social support for mental health was non-judgement related to sexual orientation and/or mental health struggles. Family, friends, and partners were providing similar amounts of support, primarily emotional support. Discussion: Vulnerabilized SMW have unique mental health and social support-related experiences and needs, potentially attributed to experiences with multiple marginalization, compounded by struggles with intersecting structural vulnerabilities. More research is warranted to explore different sources and forms of social support as predictors of mental health. Findings indicate need for public health interventions that address sexual orientation and mental health stigma.

Background: Long-acting (LA) injectable preexposure prophylaxis (PrEP) and on-demand PrEP may improve overall PrEP uptake among men who have sex with men (MSM), but little is understood about the PrEP option preferences of MSM in practical scenarios where they may choose between various PrEP options. Objective: This study aims to examine the preferences for starting various PrEP options among a US nationwide online convenience sample of MSM from September 2021 to February 2022. Methods: Participants reporting no prior HIV diagnosis were provided brief descriptions of each PrEP option and were asked, “If [PrEP option] were available from your local doctor and you could access it for free, would you go to your doctor in the next month to start [PrEP option]?” Those who said “yes” to multiple options were asked to rank them in order of preference. MSM currently taking daily oral (DO) PrEP were asked whether they would switch to on-demand or LA PrEP options. Log binomial models were created to examine the association between willingness to start or switch to on-demand and LA PrEP with various sociodemographic and behavioral factors. Results: In the analytic sample (N=7760), among the participants who did not use any PrEP in the past 12 months (n=5108, 66%), 54% (n=2445) reported willingness to start at least 1 PrEP option and 41% (n=1845) of participants showed interest in starting multiple PrEP options. Overall, the highest willingness was reported for on-demand PrEP (n=2235, 44%), followed by DO PrEP (n=2174, 43%) and LA PrEP (n=1482, 29%). LA PrEP was ranked first among those interested in multiple options. Characteristics associated with ranking LA PrEP as a first option to start PrEP versus DO or on-demand PrEP were region of residence (residing in the West vs Northeast), report of sexually transmitted infection diagnosis in the past year, report of illicit drug use other than marijuana in the past year, and prior awareness of LA PrEP. Among current DO PrEP users (n=2379, 31%), 58% (n=1386) were willing to switch to on-demand or LA PrEP, and LA PrEP was ranked first among participants who were open to switching to both options. Willingness to switch to LA PrEP was higher among those who used illicit drugs other than marijuana in the past year, who heard of LA PrEP prior to the survey, and those who took 15 or less doses of oral PrEP in the last 30 days. Conclusions: LA PrEP was the highest-ranked option among most MSM who were willing to try multiple options or switch from DO PrEP. These findings highlight that LA PrEP might fill coverage gaps among MSM who use illicit drugs, have had a recent sexually transmitted infection diagnosis, and have less than optimal DO PrEP adherence.