Sari L. Reisner

Background: Transgender women with HIV face higher rates of atherosclerotic cardiovascular disease (ASCVD) than the general population. However, ASCVD risk estimators use binary sex variables that may misclassify their risk. We examined the effects of sex variable inputs in the Predicting Risk of Cardiovascular Disease Events (PREVENT) and Pooled Cohort Equation (PCE) risk calculations and tested for associations of ASCVD risk scores with HIV and hormone use. Setting: Participants were recruited from health centers in Boston, New York, and Washington, DC. Methods: We performed a cross-sectional comparison of PCE and PREVENT scores by sex variable inputs using data from 108 Black and Latina transgender women with HIV. Logistic regression models tested whether hormone duration and time since HIV diagnosis were associated with hyperlipidemia, diabetes, hypertension, or cardiac events. Results: Using an illustrative ≥ 5% risk score as the threshold for statin initiation, 40.6% with PCE versus 9.5% with PREVENT met or exceeded 5% risk when male was entered for all, compared with 17.7% with PCE versus 9.5% with PREVENT when female was entered for all, and 24.0% with PCE versus 8.4% with PREVENT when female was entered for participants taking hormones. Neither years since HIV diagnosis nor hormone duration were associated with ASCVD risk factors or events Conclusion: Use of the PREVENT calculator generates lower ASCVD risk estimates than PCE in transgender women with HIV. Research is needed to determine how best to incorporate gender diversity and intersecting factors into ASCVD risk calculations.

Background: Transgender and nonbinary (TNB) people are exposed to escalating structural violence and discrimination that vary by race and drive negative health outcomes, such as psychological distress. We identified intervenable factors associated with psychological distress and evaluated the moderating role of racialization.Methods: Baseline surveys were collected from December 2023 to March 2025 from 360 TNB adults enrolled in the Creating Access to Resources and Economic Support study. Linear regression examined associations between serious psychological distress (Kessler-6>13), and financial self-efficacy, social support, transgender community connectedness (TCC), major intersectional discrimination, gender-related discrimination, gender non-affirmation, and neighborhood safety. Interactions between race and each factor were tested separately.Findings: Serious psychological distress was common (62.5%). In models adjusted for age, race, and health insurance, major intersectional discrimination (beta=0.265, p<0.001) was associated with greater psychological distress, while financial self-efficacy (beta=-0.204, p<0.001) and TCC (beta=-0.141, p=0.005) were associated with less psychological distress. White race moderated relationships between psychological distress and gender non-affirmation, financial self-efficacy, TCC, and unsafe neighborhoods.Interpretation: Fostering financial self-efficacy, social support, and transgender community connections may help mitigate harms wrought by discriminatory forces. Interventions may be even more beneficial for transgender people of color who experience intersecting oppressions. Nonetheless, systems that perpetuate discrimination must also be dismantled to achieve maximum mental health benefits.

BACKGROUND Transgender men and transmasculine people who have sex with men (TMSM) are at elevated risk for HIV acquisition, have unmet HIV prevention needs, and have low uptake of antiretroviral pre-exposure prophylaxis (PrEP). To our knowledge, there are no published efficacious behavioral interventions to decrease HIV risk specifically for TMSM; this includes peer-delivered strategies that demonstrate high acceptability in this population. OBJECTIVE This paper describes the development, refinement, and optimization of theory-informed, peer-delivered digital interventions—which were feasible to implement and highly acceptable among the participant population—designed to increase PrEP uptake and adherence among adult transmasculine people who have sex with individuals assigned male at birth within the context of a full-scale, randomized factorial trial. METHODS Between March 2023-March 2025, we used an iterative community-engaged approach that included: (1) community and key stakeholder input, (2) theory- and evidence-informed manualized content with iterative refinement, (3) interventionist training and preparation, and (4) process evaluation and fidelity monitoring. Two theoretical frameworks and one theory of behavior change guided content development, structure, format and evaluation: The Healthcare Accessibility Framework, the Gender Affirmation Framework, and the Information, Motivation, and Behavioral Skills Model of behavior change. RESULTS A 4-member Community Advisory Board of transmasculine individuals partnered with the research team to co-design interventions and study procedures. Additional input was obtained through one-on-one key stakeholder consultations with nine topic experts, clinicians, and community experts at partner organizations. Iterative refinement incorporated evidence synthesis, manual drafting, mock sessions, and structured feedback loops resulting in two refined virtually delivered interventions: (1) PrEP4T, a 6-session one-on-one peer navigation intervention (60-90 minutes/session) emphasizing goal setting, harm reduction, and supportive referrals; and (2) LS4TM, a 6-session peer-facilitated group-based behavioral intervention (2 hours/session), focusing on sexual health knowledge, gender affirmation, communication, and social support. A digital standard of care (SOC) resource guide of curated, gender-affirming sexual health, HIV prevention, and community resources was also developed. Interventionist training included approximately 15 hours of knowledge/skill building (asynchronous and live didactic sessions) and at least 12 hours of applied practice (mock sessions with structured feedback). Process evaluation and fidelity relied on participant- and interventionist-completed case reporting forms, reflecting community prioritization of interventionist and participant comfort during sessions. Key lessons learned included the importance of flexible, manualized intervention content structures that support fidelity while allowing personalized adaptation; using gender-affirming language through mirroring and dual phrasing; centering “voice” and “choice” in HIV prevention decision-making; incorporating behavior change scaffolding (e.g., goal setting, elicit-provide-elicit techniques); offering hands-on peer navigation and curated SOC resources to address structural access barriers; and leveraging digital tools to enhance engagement, shared learning, and community connection. CONCLUSIONS Co-designing with transmasculine communities through an iterative, community-engaged development and refinement processes was essential for producing culturally responsive, theoretically-grounded, and gender-affirming HIV prevention interventions. Our findings can inform future peer-delivered and digital HIV prevention strategies tailored to the needs of specific populations, grounded in community partnerships and lived experience. CLINICALTRIAL ClinicalTrials.gov NCT06182280; https://clinicaltrials.gov/ct2/show/NCT06182280 INTERNATIONAL REGISTERED REPORT RR2-10.2196/76831

Background: Prevalent and incident heart failure (HF) and its comorbidities have not been characterized in transgender and gender‐diverse (TGD) populations. This study determines the prevalence and incidence of HF phenotypes by gender identity. Methods: A retrospective cohort analysis was performed using deidentified administrative claims from the Optum Labs Data Warehouse (2006–2022). TGD adults and a sample of demographically similar cisgender comparators were identified using a validated algorithm, and gender identity was categorized as cisgender man, cisgender woman, transmasculine, transfeminine, or unclassified TGD. Prevalent and incident HF, including systolic, diastolic, and unclassified phenotypes, were assessed using diagnosis codes. Multivariable logistic and Cox regression models adjusted for age and comorbidities evaluated associations between gender identity and HF. Results: In this cohort of 57 471 TGD individuals and 298 213 demographically similar cisgender comparators, 17 898 TGD people (31.1%) were transmasculine, 9652 (16.8%) were transfeminine, and 29 921 (52.1%) had unclassified TGD identity. In adjusted models, transmasculine people experienced less prevalent systolic HF than cisgender men (odds ratio, 0.37 [98.75% CI, 0.17–0.83]) and women (odds ratio, 0.42 [98.75% CI, 0.19–0.92]). Transmasculine people experienced less incident diastolic HF relative to cisgender men (hazard ratio [HR], 0.65 [98.75% CI, 0.51–0.82]) and women (HR, 0.66 [98.75% CI, 0.52–0.83]). Transfeminine people experienced more incident diastolic HF than cisgender men (HR, 1.36 [98.75% CI, 1.05–1.77]) and women (HR, 1.38 [98.75% CI, 1.07–1.79]). Conclusions: Prevalent systolic HF and incident diastolic HF differed by gender identity after adjustment for age and clinical comorbidities. Further research is needed to identify underrecognized sex‐ and gender‐based HF risk modifiers.

Introduction: Transgender, nonbinary, and gender diverse young adults (TGD-YA) experience mental health inequities. Negative experiences coming out (disclosing gender identity) and/or understanding gender identity can adversely affect mental health. This formative study explored the perceived effect of race/ethnicity, place, and religion on TGD-YA experiences of coming out/understanding gender. Methods: In August 2022, a U.S. nationwide sample of TGD-YA ages 18–25 years ( n = 104) completed a cross-sectional survey including sociodemographics and coming out/understanding gender experiences. Three questions asked about the extent to which race/ethnicity, place, and religion made it harder to come out/understand gender. Descriptive and bivariate analyses assessed prevalence of each of these and associations of race/ethnicity, place, and family religion. Firth’s penalized logistic regression models were fit for individual-level TGD-YA characteristics; a random-intercept multilevel model was used for contextual-level anti-transgender legislative state policy. Results: Mean age was 21.8 years; 46% were people of color (POC); 66% were nonbinary; 33% resided in the South and 19% Midwest; 34% lived in a state with anti-transgender legislation; 53% reported Christian family religion. TGD-YA who were POC, lived in a state with anti-transgender legislation, and had a Christian family religion had the highest odds of reporting that race/ethnicity, place, and religion, respectively, made it “harder” to come out/understand gender ( p < 0.05). Conclusions: Experiences coming out/understanding gender for TGD-YA were affected by race/ethnicity, geographic context, and family religion. Policy Implications: Findings suggest the need for supportive interventions that address intersectional stigma, including supportive gender-related state policies given the association of state-level anti-transgender legislation with difficulties coming out/understanding gender.

Objectives. To examine the associations between discrimination, violence, and suicidality among travestis and transgender women in Brazil. Methods. We analyzed baseline data from the Transcendendo cohort (2015–2023) in Rio de Janeiro, Brazil, which enrolled travestis and transgender women aged 18 years and older. We assessed lifetime discrimination by using an 8-item scale reflecting transgender-related mistreatment experiences. We also measured physical and sexual violence, sociodemographics, and psychosocial factors. We categorized suicidality as no ideation, ideation only, and ideation with attempts, analyzed using a multivariable ordinal regression model. Results. Among 662 participants, lifetime discrimination (adjusted odds ratio [AOR] = 1.21; 95% confidence interval [CI] = 1.11, 1.32; P < .001) and lifetime sexual assault (AOR = 1.60; 95% CI = 1.17, 2.19; P = .003) were significantly associated with increased odds of suicidality. Participants with positive body self-satisfaction, HIV, and increasing age had lower odds of suicidality. Conclusions. Our findings highlight the need for antidiscriminatory policies and health services tailored to the needs of this community to mitigate suicidality risk among travestis and transgender women in Brazil. ( Am J Public Health. Published online ahead of print December 4, 2025:e1–e9. https://doi.org/10.2105/AJPH.2025.308280 )

Background: Transgender, nonbinary, and gender diverse (TGD) young adults face a disproportionately high mental health burden, including 2- to 4-fold increased risk of suicidality and depressive distress compared to their cisgender peers. Family and community support are protective factors that may mitigate these adverse outcomes, representing key targets for mental health interventions. Objective: This randomized controlled trial (RCT) evaluates the effectiveness of TransHealthGUIDE, a novel digital, app-based education and support intervention aimed at reducing past 3-month suicidal ideation and past 2-week depressive distress among TGD young adults. Participants are randomized 1:1 to an immediate intervention arm or a 6-month deferred intervention arm (waitlist control). Methods: From 2021 to 2024, a multidisciplinary team of academic and community partners conducted formative research and codeveloped a digital app containing 33 self-paced modules, communication, and interactive resources. The content is grounded in the Social Ecological Suicide Prevention Model and the Gender Minority Stress and Resilience Framework, designed to enhance family support and community connection for TGD young adults and their families. TGD young adults (ages 18-24 years) and their caregivers are prospectively enrolled and randomized in 10 US states (California, Connecticut, Illinois, Maryland, Massachusetts, New Jersey, New York, Oregon, Vermont, and Washington, DC). Participants complete self-reported surveys at baseline, 6 months, and 12 months, assessing sociodemographics, family support, community connection, suicidal ideation, depressive distress, and intervention acceptability. App usage and engagement are tracked via metadata. The target sample size is 500 TGD young adults, with 50% (n=250) identifying as people of color and 125 TGD young adult-caregiver dyads. Results: TGD young adult and caregiver communities, including our community advisory board (CAB), have guided all aspects of the project: study design (eg, waitlist control), survey development (eg, self-reported rather than clinician-administered suicidality measures and inclusion of social justice activism as a form of support), intervention content (eg, text, infographics, interviews with TGD people and caregivers, and simulations), and digital app safety features (eg, a quick-exit button for privacy). Recruitment and study screening began on January 21, 2025. As of May 2, 2025, a total of 149 individuals completed a study screener, with 132 (88.6%) of 149 found eligible. Enrollment visits began on April 23, 2025. As of May 2, 2025, five TGD young adults have been enrolled. Ongoing engagement with the CAB will inform iterative improvements throughout the trial. Conclusions: Scalable, app-based interventions tailored to meet the needs of TGD young people hold promise for population-level mental health impact. This RCT—targeting suicidality and depressive distress via education and support for both TGD young adults and their caregivers—addresses a critical gap in mental health interventions for this underserved population. Trial Registration: ClinicalTrials.gov NCT06177600; https://clinicaltrials.gov/study/NCT06177600 International Registered Report Identifier (IRRID): DERR1-10.2196/78619

Background: In the United States, transgender men and transmasculine people who have sex with men (TMSM) face an increased risk of HIV and encounter unique barriers to HIV prevention services, including preexposure prophylaxis (PrEP). Peer-based, digitally delivered support interventions that address these barriers in 1-on-1 or small-group settings may be effective in increasing PrEP engagement. Objective: This study aims to compare the efficacy of digitally delivered individual and small-group peer-based strategies for improving PrEP uptake and adherence among at-risk adult TMSM without HIV. Methods: The Transmasculine One-on-One and Group Empowerment for Targeted HIV Reduction (TOGETHR) study was a digital, open-label, randomized 2×2 factorial trial (1:1:1:1 randomization) of peer-delivered HIV prevention strategies designed to increase PrEP engagement in 300 PrEP-indicated TMSM without HIV. Participants were randomized to 1 of 4 conditions: (A) standard of care (SOC) package (information and PrEP locator tools), (B) SOC + PrEP for TMSM (PrEP4T; individual peer-based HIV prevention intervention), (C) SOC + LifeSkills for TMSM (LS4TM; group peer-based HIV prevention intervention), or (D) SOC + PrEP4T and LS4TM (both individual and group interventions). Interventions were delivered over a 6-week period. The study enrolled adults 18 years or older who were “transgender men or transmasculine,” sexually active with 1 or more partners who had a penis and were assigned male sex at birth, living without HIV, behaviorally at risk for HIV acquisition, and residing in geographic hot spots identified in the US Ending the HIV Epidemic initiative. Results: Study protocols and procedures were codeveloped with our community advisory board, including eligibility criteria, operationalization of geographic stratification, study branding, and detailed recruitment plans. Recruitment and enrollment began on April 1, 2024, and as of March 20, 2025, 103 TMSM had been enrolled. The median age was 26 (IQR 24-31) years. Among the 103 participants, 39 (37.9%) identified as Black, Indigenous, and People of Color, and 18 (17.5%) as Latine; 36 (35.0%) identified as “transgender man or trans man”; 31 (30.1%) as transmasculine; and 15 (14.6%) as nonbinary, genderqueer, or gender nonconforming. Additionally, 69 (67.0%) had at least a four-year college degree, and only 7 (6.8%) had no health insurance. Granger causality tests indicated that recruitment activities via social media (P=.006) and transgender-inclusive dating platforms (P=.02) were most effective and predicted higher baseline enrollment survey completion 2 weeks later. On March 21, 2025, the National Institutes of Health terminated the grant award, citing gender ideology and stating, “it is the policy of NIH not to prioritize such research programs.” Conclusions: This study was part of a critical research pathway to identify effective strategies for preventing HIV acquisition in TMSM, a group traditionally underserved in HIV prevention, and to inform prevention packages that incorporate peer-delivered interventions. Strong engagement with the TMSM community was central to the study’s success and provided valuable insights for future HIV prevention research and practice. Trial Registration: ClinicalTrials.gov NCT06182280; https://clinicaltrials.gov/ct2/show/NCT06182280 International Registered Report Identifier (IRRID): DERR1-10.2196/76831