Nadia Dowshen

Background: Transgender individuals face disproportionate HIV burden yet experience significant barriers to accessing biomedical HIV prevention. We assessed awareness, experience, and willingness among trans adults to use pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) when integrated with telehealth-delivered gender-affirming hormone care (GAC). Methods: We conducted a cross-sectional survey of clients receiving GAHC via a national subscription-based telehealth platform between October 2023 and January 2024. Using stratified sampling to ensure inclusion of transgender men (TGM) and those residing in rural areas, we assessed PrEP/PEP awareness, prior use, barriers, and willingness to use these services if recommended by their GAC provider. Multivariable logistic regression identified factors associated with stated willingness (yes/no). Results: Among 387 respondents (from 2506 survey invitations, 15.4% response rate), 54.8% identified as transgender women (TGW), 45% were between the ages of 18 and 25, and 74% identified as white, and 13% resided in rural areas. Pre-exposure prophylaxis awareness was moderate among TGW (56%) and TGM (69%), while PEP awareness was 24% among TGW and 31% among TGM. Only 2% of TGW were using PrEP (0% of TGM), and 0% had used PEP. Despite limited prior utilization, 67% expressed willingness to use PrEP and 66% willingness to use PEP if recommended by their GAC provider. Public insurance (vs private) and self-reported HIV worry (vs not worried) were associated with willingness to use both PrEP (public insurance: aOR 3.64, P = .022; HIV worry: aOR 2.57, P = .002) and PEP (public insurance: aOR 3.48, P = .032; HIV worry: aOR 2.41, P = .004). Prior awareness of PEP was also associated with willingness to use it (aOR 2.06, 95% CI 1.08–3.94, P = .030). Conclusions: Among clients of a subscription-based telehealth platform, stated acceptability of integrated PrEP/PEP services was high regardless of gender identity or geography. Limited awareness, cost concerns, and the large gap between awareness and utilization require further attention to realize the potential benefits of biomedical HIV prevention integration into telehealth GAC.

Remote biospecimen collection (RBSC), such as home-based HIV testing and self-collection of dried blood spots (DBS) to assess adherence to antiretroviral drug regimens, has become an important tool to support clinical research because it can facilitate participant reach, lower participant burden, and reduce discomfort with attending research visits in clinic spaces. RBSC is common in sexual health clinical intervention trials to assess the impact of an intervention or program on primary and secondary outcomes. However, the products and strategies employed to successfully implement RBSC can vary widely across studies. The purpose of this narrative review is twofold. First, to provide an overview of currently available RBSC products, their attributes, and their suitability for various clinical research applications. Considerations for blood-based and volumetric absorptive microsampling collection products, as well as self-administered sexually transmitted infection testing and other specimen types, are described. Second, RBSC implementation considerations at each stage of the collection process are discussed primarily from the perspective of the authors' collective expertise and experience with RBSC in HIV prevention and treatment clinical research. Successful RBSC product selection and implementation require a multidisciplinary team approach that is participant-centered to achieve high return rates, and ample time should be allotted to address the complexities of the procedures and processes. This review of RBSC product and implementation considerations offers an actionable framework and roadmap when considering incorporation of RBSC into clinical trials research. TRIAL REGISTRATION: N/A.

Purpose: The purpose of this study was to compare the clinical acceptability of testosterone levels, time to treatment, and postinstruction questions/problems between in-person and telehealth injection teaching for adolescents and young adults (AYA) initiating gender-affirming testosterone therapy. Methods: A retrospective cohort study was conducted using electronic medical record data from a large pediatric gender health clinic. Patients who received subcutaneous testosterone prescriptions between March 15, 2018, and March 14, 2022, were included. The study compared patients receiving in-person versus telehealth injection teaching. Data were collected on demographics, testosterone levels at 3 and 6 months, time from prescription to treatment, and post-instruction contacts. Statistical analyses included t -tests, chi-square tests, logistic regression, linear regression, and zero-inflated negative binomial. Results: The study included 278 patients, with 136 (48.9%) receiving in-person teaching and 142 (51.1%) receiving telehealth teaching. There were no significant differences in baseline characteristics between groups. Clinical effectiveness, indicated by testosterone levels at 3 and 6 months, revealed no significant difference between instruction methods ( p = 0.768 and p = 0.350). Time to treatment initiation was comparable (in-person: 15.34 days; telehealth: 18.02 days), with no significant difference in adjusted analysis ( p = 0.204). Post-instruction contacts were slightly higher in the telehealth group (2.87 vs. 2.42, p = 0.040), but injection-related questions were rare and similar between groups ( p = 0.650). Conclusion: Telehealth instruction for testosterone injection is as effective as in-person teaching methods for AYA initiating gender-affirming care. The findings support the continued use of telehealth to enhance access to gender-affirming care, particularly in light of its clinical efficacy and patient acceptability.

Background: Offering contraceptive methods at pharmacies without a prescription is an innovative solution to reduce the incidence of unintended pregnancies among adolescents and young adults (AYA). Pharmacy-prescribed contraception may increase the convenience, simplicity, and affordability of contraceptives. Objective: The aim of this study was to develop, pilot test, and evaluate the acceptability and feasibility of a telemedicine electronic platform app simulating pharmacist prescribing of contraceptives to AYA as well as assess agreement between pharmacist-simulated contraceptive approvals and contraception as prescribed in routine clinic visits. Methods: This study was conducted in two phases: (1) development and usability testing of a prototype app to simulate pharmacists prescribing contraceptives to AYA and (2) pilot testing the app in a simulation for AYA requesting contraception from a pharmacist with pharmacist review and request approval or rejection. Eligibility criteria in both phases included the following: assigned female sex at birth, age 15-21 years, seeking contraceptive services at an academic adolescent medicine clinic, prior history of or intention to have penile-vaginal intercourse in the next 12 months, smartphone ownership, and English language proficiency. Phase 1 (usability) involved a video-recorded “think aloud” interview to share feedback and technical issues while using the app prototype on a smartphone and the completion of sociodemographic, sexual history, and perception of the prototype surveys to further develop the app. Phase 2 (pilot) participants completed phase 1 surveys, tested the updated app in a simulation, and shared their experiences in an audio-recorded interview. Descriptive analyses were conducted for quantitative survey data, and thematic analyses were used for interview transcripts. Results: Of the 22 participants, 10 completed usability testing, with a mean age of 16.9 (SD 1.97) years, and 12 completed pilot testing, with a mean age of 18.25 (SD 1.48) years. Three issues with the prototype were identified during “think aloud” interviews: challenges in comprehension of medical language, prototype glitches, and graphic design suggestions for engagement. Usability testing guided the frontend and backend creation of the platform. Overall, participants agreed or strongly agreed that using an app to receive contraceptives would make it easier for teens to access (n=19, 86%) and make contraceptive use less stigmatizing (n=19, 86%). In addition, participants agreed that receiving contraception prescriptions from a pharmacist without a clinic visit would be safe (n=18, 82%), convenient (n=19, 86%), acceptable (n=18, 82%), and easy (n=18, 82%). Pharmacists and medical providers had 100% agreement on the prescribed contraceptive method for pilot participants. Conclusions: AYA found contraceptive prescription by a pharmacist via an app to be highly acceptable and provided critical feedback to improve the design and delivery of the app. Additionally, pharmacist contraceptive approvals and contraception as prescribed in routine clinic visits were identical.

Although every youth in pediatric/adolescent HIV care will need to transition to adult-oriented care, there are no existing evidence-based interventions to optimize health through this process. Healthcare transition poses a persistent challenge to the health of youth living with HIV, which may result in gaps in care engagement, medication adherence, and viral suppression. Our process evaluation of iTransition, a multilevel mobile health (mHealth) intervention, included iterative interviews with youth, providers, and Transition Champions. These data, along with team meeting notes, highlight the important role the intervention plays in addressing healthcare transition-related challenges, positioning it to fill a critical gap for both youth and providers. It also highlights important individual (e.g., competing priorities of youth and providers), clinical (e.g., electronic health record integration), and contextual (e.g., clinical policies during COVID-19 pandemic) challenges to intervention reach and implementation. More work is needed to refine interventions to support care continuity for youth living with HIV as they transition to adult-oriented care.

Background: Adolescents and young adults account for over 21% of new HIV infections in the U.S. with most new cases among young men. As an important information source for this group, social media can uniquely reveal the perspectives and communicative patterns of this key population. We identified 6,439 young male Twitter users (ages 13–24) in the U.S. using an NLP pipeline with geolocations. From their Twitter timelines, we collected 24,600 HIV-related tweets, among which the most retweeted and favorited tweets (n = 472) were analyzed through a content analysis. Results: Three themes arose in this online viral discourse around HIV among young men: (i) othering, (ii) politics and activism, (iii) risk and wellness. Othering tweets contained stigmatizing jokes and insults alienating individuals who identify as lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, or being elsewhere on the gender and sexuality spectrum (LGBTQIA +), and people with HIV. Politics and activism tweets discussed awareness, stigma, HIV criminalization, violence, LGBTQIA + , and women’s rights. Risk and wellness tweets discussed risk behaviors for sexually transmitted infections (STIs) (e.g., condomless sex, transactional sex, multiple sexual partners), or safer sex and preventive practices (e.g., pre-exposure prophylaxis [PrEP], condom use, achieving undetectable viral load, medication adherence, and STI testing). Conclusion: The social acceptability of high-risk sex behaviors is high among young male Twitter users. Given the double-edged nature of social media—health-promoting (e.g., awareness, health activism) as well as risk-promoting (e.g., risky behavior endorsement, identity attacks)— this population may benefit from targeted health communication intervention. Future HIV prevention efforts should counter the stigma, misinformation, and risk-promoting viral messages prevalent on social media.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Offering contraceptive methods at pharmacies without a prescription is an innovative solution to reduce the incidence of unintended pregnancies among adolescents and young adults (AYA). Pharmacy-prescribed contraception may increase the convenience, simplicity, and affordability of contraceptives. Objective: The aim of this study was to develop, pilot test, and evaluate the acceptability and feasibility of a telemedicine electronic platform app simulating pharmacist prescribing of contraceptives to AYA as well as assess agreement between pharmacist-simulated contraceptive approvals and contraception as prescribed in routine clinic visits. Methods: This study was conducted in two phases: (1) development and usability testing of a prototype app to simulate pharmacists prescribing contraceptives to AYA and (2) pilot testing the app in a simulation for AYA requesting contraception from a pharmacist with pharmacist review and request approval or rejection. Eligibility criteria in both phases included the following: assigned female sex at birth, age 15-21 years, seeking contraceptive services at an academic adolescent medicine clinic, prior history of or intention to have penile-vaginal intercourse in the next 12 months, smartphone ownership, and English language proficiency. Phase 1 (usability) involved a video-recorded “think aloud” interview to share feedback and technical issues while using the app prototype on a smartphone and the completion of sociodemographic, sexual history, and perception of the prototype surveys to further develop the app. Phase 2 (pilot) participants completed phase 1 surveys, tested the updated app in a simulation, and shared their experiences in an audio-recorded interview. Descriptive analyses were conducted for quantitative survey data, and thematic analyses were used for interview transcripts. Results: Of the 22 participants, 10 completed usability testing, with a mean age of 16.9 (SD 1.97) years, and 12 completed pilot testing, with a mean age of 18.25 (SD 1.48) years. Three issues with the prototype were identified during “think aloud” interviews: challenges in comprehension of medical language, prototype glitches, and graphic design suggestions for engagement. Usability testing guided the frontend and backend creation of the platform. Overall, participants agreed or strongly agreed that using an app to receive contraceptives would make it easier for teens to access (n=19, 86%) and make contraceptive use less stigmatizing (n=19, 86%). In addition, participants agreed that receiving contraception prescriptions from a pharmacist without a clinic visit would be safe (n=18, 82%), convenient (n=19, 86%), acceptable (n=18, 82%), and easy (n=18, 82%). Pharmacists and medical providers had 100% agreement on the prescribed contraceptive method for pilot participants. Conclusions: AYA found contraceptive prescription by a pharmacist via an app to be highly acceptable and provided critical feedback to improve the design and delivery of the app. Additionally, pharmacist contraceptive approvals and contraception as prescribed in routine clinic visits were identical.

Context Treatment for transmasculine youth (TMY) can involve testosterone treatment and is sometimes preceded by gonadotropin-releasing hormone agonist (GnRHa) treatment for puberty blockade. GnRHas can increase final height in birth-assigned females with central precocious puberty. Maximizing final adult height (FAH) is an important outcome for many TMY. Objective Our objective was to determine how GnRHa treatment before testosterone impacts FAH. Methods Retrospective cohort study at 5 US transgender health clinics. Participants were 32 TMY treated with GnRHas in early to midpuberty before testosterone (GnRHa + T group) and 62 late/postpubertal TMY treated with testosterone only (T-only group). Results The difference between FAH minus midparental target height (MPTH) was +2.3 ± 5.7 cm and −2.2 ± 5.6 cm in the GnRHa + T and T-only groups, respectively (P < .01). In the GnRHa + T group, FAH was 1.8 ± 3.4 cm greater than predicted adult height (PAH) (P < .05) and FAH vs initial height (IH) z-score was 0.5 ± 1.2 vs 0.16 ± 1.0 (P < .05). After adjusting for patient characteristics, each additional month of GnRHa monotherapy increased FAH by 0.59 cm (95% CI 0.31, 0.9 cm), stage 3 breast development at start of GnRHa was associated with 6.5 cm lower FAH compared with stage 2 (95% CI −10.43, −2.55), and FAH was 7.95 cm greater in the GnRHa + T group than in T-only group (95% CI −10.85, −5.06). Conclusion Treatment with GnRHa in TMY in early puberty before testosterone increases FAH compared with MPTH, PAH, IH, and TMY who only received testosterone in late/postpuberty. TMY considering GnRHas should be counseled that GnRHas may mildly increase their FAH if started early.