Theodorus G. M. Sandfort

Stigma toward anal sex hinders HIV prevention by limiting equitable access to sexual health services. To mitigate this hindrance, we developed a clinician- and community-informed package of anti-stigma implementation strategies using the Behaviour Change Wheel and its Capability, Opportunity, Motivation, Behaviour (COM-B) Model. The package, “Partnering to Enhance Anal Health Communication and HIV-related Evidence-based Services” (PEACHES 1.0), combined training strategies with quality improvement (QI) strategies. We implemented a pilot evaluation of PEACHES 1.0 among HIV workers in the Southern USA and assessed pre/post-shifts in participants’ self-reported proximal outcomes (mechanisms of action like knowledge, comfort, skills) and their frequency of anal sex-specific health promotion. In two clinics that received organization-specific QI meetings, we also assessed patient uptake of anal sex-related HIV services based on aggregated medical record data. We conducted paired t -tests on longitudinal survey responses, thematic analysis of longitudinal in-depth interviews and open-ended survey responses, and non-statistical comparison of rates for patient uptake of services. Post-PEACHES, HIV workers reported 8% to 54% improvements (all p < .01) in proximal outcomes like knowledge, comfort, and skills. Frequency of self-reported anal health promotion increased 15% to 25% ( p < .01). Clinics that received QI sessions differed in their QI engagement and had diverging patient uptake of services. Clinic A, with greater QI engagement, saw a 60% increase in anorectal STI screening, and a 28% increase in new PrEP prescriptions; Clinic B, with less engagement, saw 17% and 18% decreases, respectively. Qualitative findings indicated that the QI strategies—placing pleasure-inclusive visual cues linked to a website of informational resources in the clinic environment and clinic-specific QI meetings—enabled workers to destigmatize discussions about anal sex within HIV services. Future research should standardize elements of QI, and evaluate scalability with fidelity as well as the potential impact on client outcomes in a fully-powered hybrid implementation-effectiveness trial.

Understanding adolescents’ health care preferences is of critical importance to support optimal use. School-Based Health Centers (SBHCs) are an important setting for adolescents to seek care, yet little is known about their perceptions of and preference for SBHC services. The purpose of this study was to test whether health literacy and greater trust in SBHC providers predicted a preference for receiving health care services at an SBHC. In addition, we tested whether this preference was associated with three categories of reasons for using or not using these services (accessibility, confidentiality, and trust). We conducted a cross-sectional survey in a sample of students at 15 New York City (NYC) high schools with onsite health care services. We assessed health literacy (knowledge of sexually transmitted infections [STIs], awareness of health care rights, health literacy, and communication efficacy) and level of trust in the SBHC and reasons why students would and would not use the SBHC, as well as their preference for receiving specific health care services at the SBHC. In total, 1,382 of 1,601 students who participated met inclusion criteria for this analysis. Multivariable models showed that a stronger preference for receiving services at an SBHC was (1) predicted by greater trust in SBHC providers and higher health literacy and (2) independently predicted by greater perceived accessibility, confidentiality, as well as trust in SBHC services. Our findings show a need for increased outreach efforts within school settings with an SBHC to enhance students’ awareness of the SBHC’s comprehensive services.

Background: An overview of existing research on HIV testing among transgender and other gender-diverse (TGD) populations in the United States, critical for developing effective future interventions and research, is missing. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis, 3 databases (CINAHL, PubMed/Medline, PsycINFO) were searched for studies reporting in English on HIV testing behavior that focused on or included TGD persons, published in the past decade (February 2, 2013 to February 2, 2023). Twenty-six studies were included and extracted using Covidence. Results: Four themes regarding HIV testing among TGD persons were identified: prevalence of HIV testing compared with cisgender persons, testing frequency and associated factors among TGD persons, barriers and facilitators to HIV testing experienced by TGD persons, and testing modalities. TGD persons seemed more likely to have been tested for HIV than cisgender persons, but less frequent than cisgender men who have sex with men. Barriers to testing included availability, confidentiality concerns, and negative interactions with providers. Social support and gender-affirming care were seen as facilitators. Self-testing, although not common, was acceptable and preferred when available. The conceptualizations and operationalizations of the term transgender varied markedly across studies. Conclusions: Our understanding of HIV testing practices in TGD populations is limited and shows serious gaps. Research on repeat testing is needed to enhance HIV prevention and care among TGD populations. Future research might benefit from theory-driven approaches and from involving TGD persons in the design and implementation of studies to ensure relevance and efficacy.

Research linking substance use with HIV risk behaviors and antiretroviral therapy adherence is typically based on self-reported data. However, studies in high-income countries show that men who have sex with men (MSM) often underreport substance use when compared to objective biological testing. Such comparisons have not been conducted among MSM in sub-Saharan Africa. We compared self-reported and objectively measured substance use among MSM participating in HPTN 075, a multi-site observational cohort study conducted in Kenya, Malawi, and South Africa. Urine samples ( n = 734) from 382 participants were tested for the alcohol metabolite ethyl glucuronide and 43 other substances. These tests detect alcohol use in the prior 48–72 h and other substances up to 7 days earlier, depending on the drug. Of the 734 samples, 159 (21.7%) tested positive for ethyl glucuronide. Self-reported alcohol use was available for 97.5% of these cases and confirmed in 141 (91.0%) of them. Sixty samples (8.2%) tested positive for at least one of the 43 other substances. Self-report data were available for 95.0% of those, but use was acknowledged in only 19 (33.3%) cases. These findings suggest that alcohol use is generally reported accurately, while drug use is substantially underreported—likely due to legal prohibitions and social stigma. Incorporating objective substance testing alongside self-reports is recommended to improve the accuracy of substance use measurement in behavioral and clinical HIV research, especially in contexts where stigma or criminalization may inhibit disclosure.

Purpose: This study evaluated the reliability of assessing transgender status in African populations using questions about current gender identification and sex assigned at birth. Methods: Data were obtained from the HIV Prevention Trials Network 075, a study designed to assess the feasibility of recruiting and retaining 400 men who have sex with men (MSM) in a 1-year prospective cohort study in Kenya, Malawi, and South Africa and conducted from 2015 to 2017. We compared responses of 401 participants to questions about gender identity obtained at the screening and enrollment visits and, for a subset of participants, in open interviews 6-9 months after enrollment. Results: One hundred and eleven of the 401 persons reported to identify as female or transgender at either the screening visit and/or the enrollment visit. Of those 111 persons, 42 (37.8%) switched between the two assessment moments from male to female or transgender, or vice versa. Furthermore, most transgender women were sexually attracted to men and identified as gay. In the follow-up interview with a subset of participants, almost all persons categorized as transgender identified as MSM. Conclusion: Categorizing persons as transgender based on self-identified gender and sex assigned at birth has limited reliability in African populations. Possible explanations for the observed inconsistencies in the responses to gender-related questions are discussed. For future studies, an understanding is needed of what specific words and labels such as gender, female, or transgender mean to study participants.

Background: Research on condom failure among African men who have sex with men (MSM) is rare; therefore, we sought to identify multilevel correlates of condom failure. Methods: Using logistic regression, we identified the associations of various participant, partnership, and sexual interaction characteristics with condom slippage and breakage among African MSM participating in HIV Prevention Trials Network (HPTN) 075, a 1-year, multinational, prospective cohort study (2015–2017). Results: Of 401 participants, 387 (96.5%) reported at least one sexual interaction in which condoms were used. Condom slippage was reported in 194 (10.2%) of the 1908 sexual interactions reported by participants and breakage in 223 (11.7%) interactions. Both slippage and breakage were reported less frequently by participants in ongoing intimate relationships compared with those who were not (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.29–0.95; OR, 0.57; 95% CI, 0.34–0.93). Slippage and breakage occurred more frequently when sex happened under the influence of substances (OR, 1.67; 95% CI, 1.13–2.46; OR, 2.08; 95% CI, 1.48–2.93) or when sex was forced (OR, 3.18; 95% CI, 1.68–6.02; OR, 2.39; 95% CI, 1.41–4.04). Having experienced homophobia was also associated with slippage and breakage (OR, 1.32; 95% CI, 1.04–1.68; OR, 1.35; 95% CI, 1.10–1.65). Conclusions: Ongoing condom failures suggest the importance of continued condom education of African MSM, addressing circumstances that promote or hinder optimal use, and increasing their control in sexual interactions. Experienced homophobia might as a distal factor also contribute to condom failure.

Transgender people disproportionately experience high rates of violence across multiple contexts throughout the life course compared to cisgender individuals. Among the cisgender population, child sexual abuse (CSA) is associated with multiple forms of victimization; however, these associations have not been examined among transgender adults. This study evaluated whether transgender adults who have experienced CSA were more likely to report specific forms of victimization and cumulative experiences across types of violence (i.e., more than one type of maltreatment). We conducted a cross-sectional secondary analysis of data from a national probability sample ( N = 274) of transgender adults (U.S. Transgender Population Health Survey, 2016–2018). CSA was measured using the child sexual abuse subsection of the survey’s implementation of the Center for Disease Control’s Behavioral Risk Factor Surveillance System Adverse Childhood Sexual Experience module. Adult experiences of victimization were measured using six questions that assessed experiences of criminal victimization, harassment, and threats. Nearly half (45%) of participants reported having experienced CSA. The majority (85%) of transgender respondents reported having experienced at least one type of adult victimization, with 40% reporting four or more types of victimization (i.e., cumulative victimization). Compared to transgender adults who had never experienced CSA, transgender adults who had experienced CSA victimization were significantly more likely to have experienced individual types of physical and verbal abuse, as well as cumulative experiences of victimization. Results of this study indicate that transgender survivors of CSA, like cisgender persons, are at increased risk for specific types of victimization and cumulative experiences of victimization as adults.

Improving HIV outcomes for men who have sex with men (MSM) in sub-Saharan Africa requires addressing gaps in the HIV treatment cascade. This study examined these gaps among 71 treatment-naive MSM with HIV in the HIV Prevention Trials Network 075, a 1-year prospective biobehavioral cohort study (2015–2017) across four sub-Saharan African sites. Following a positive diagnosis, 86% of participants sought HIV care. Reasons for not having sought care or delays included a lack of perceived health issues and practical challenges. Most participants (80%) who engaged in care were prescribed antiretroviral therapy (ART). Although self-reported adherence was high, over one-third of those prescribed ART had no detectable antiretroviral drugs (ARVs) at the study’s conclusion. ARV detection was significantly associated with study site, higher income, and experienced homophobia. The highest adherence rates were observed at the site offering direct, integrated treatment, underscoring the potential of “one-stop shop” services to mitigate intra-, interpersonal, and structural barriers. Despite a supportive study environment, gaps remain in linking MSM and transfeminine individuals to sustained HIV care and ART adherence. Given the urgency of addressing HIV among these populations, targeted interventions that promote engagement in care and adherence to treatment are critical.

This study explored sexual orientation and gender identity as predictors of health literacy among adolescents attending New York City (NYC) public high schools. Many studies have demonstrated disparities in sexual health among sexual and gender minority (SGM) adolescents. However, little is known about their health literacy. Health literacy, defined as the capacity to acquire, understand, appraise, and apply health information, especially in health decision-making, is a known predictor of health. Data came from a quantitative cross-sectional survey ( N = 1,438) collected at 15 high schools in the Bronx, NYC. Four aspects of health literacy were explored: (1) knowledge of sexually transmitted infections (STIs), (2) knowledge of sexual health rights in New York State, (3) health access literacy and self-efficacy, and (4) health communication. Linear regression analysis was used to test predictors of health literacy. Contrary to our hypothesis, SGM adolescents did not score significantly lower on the health literacy variables compared with cisgender heterosexual adolescents. SGM adolescents scored significantly higher on knowledge of STIs and knowledge of health rights compared with cisgender heterosexual young men. Adolescents who were questioning their sexual identity scored significantly lower compared with both SGM and cisgender heterosexual adolescents on all four health literacy scales. Interventions are needed to ensure that in-school curricula are inclusive and address health literacy among questioning adolescents and cisgender heterosexual young men. Addressing the health needs of questioning adolescents is particularly important because adolescence is a critical time of decision-making around sexuality and health.