Improved PrEP Awareness and Use among Trans Women in San Francisco, California

Transgender women face a serious risk of HIV infection. Despite this, there is limited knowledge and use of Pre-exposure prophylaxis (PrEP). We measured the continuity of prevention across services in the PrEP cascade and correlates of PrEP use among trans women in San Francisco enrolled in the 2019/20 National HIV Behavioral Surveillance Study. Knowledge and use of PrEP among trans women in San Francisco increased in recent years; almost all (94.0%) had heard about PrEP, 64.7% had discussed PrEP with a healthcare provider, and 44.8% had taken PrEP in the past 12 months. PrEP use was associated with participation in a PrEP demonstration project (aOR = 31.44, p = 0.001) and condomless receptive anal intercourse (aOR = 3.63, p = 0.024). Injection drug use was negatively associated (aOR = 0.19, p = 0.014). Efforts are needed to combat the gender-based stigma and discrimination faced by trans women, which can result in avoidance and mistrust of the medical system.

Ending the HIV epidemic using National HIV Behavioral Surveillance (NHBS): Recommendations based on DC model

Introduction Social network strategies have been used by health departments to identify undiagnosed cases of HIV. Heterosexual cycle (HET4) of National HIV Behavioral Surveillance (NHBS) is a social network strategy implemented in jurisdictions. The main objectives of this research are to 1) evaluate the utility of the NHBS HET cycle data for network analysis; 2) to apply statistical analysis in support of previous HIV research, as well as to develop new research results focused on demographic variables and prevention/intervention with respect to heterosexual HIV risk; and 3) to employ NHBS data to inform policy with respect to the EHE plan. Method We used data from the 2016 NHBS HET4 (DC). A total of 747 surveys were collected. We used the free social-network analysis package, GEPHI, for all network visualization using adjacency matrix representation. We additionally conducted logistic regression analysis to examine the association of selected variables with HIV status in three models representing 1) demographic and economic effects, 2) behavioral effects, and 3) prevention-intervention effects. Results The results showed 3% were tested positive. Seed 1 initiated the largest networks with 426 nodes (15 positives); seed 4 with 273 nodes (6 positives). Seed 3 had 35 nodes (2 positives). All 23 HIV diagnoses were recruited from 4 zip-codes across DC. The risk of testing positive was higher among people high-school dropouts (Relative Risk (RR) (25.645); 95 CI% 5.699, 115.987), unemployed ((4.267); 1.295, 14.064), returning citizens ((14.319); 4.593, 44.645). We also found in the final model higher association of pre-exposure prophylaxis (PrEP) awareness among those tested negative ((4.783); 1.042, 21.944) and HIV intervention in the past 12 months with those tested positive ((17.887); 2.350,136.135). Conclusion The network visualization was used to address the primary aim of the analysis-evaluate the success of the implementation of the NHBS as a social network strategy to find new diagnoses. NHBS remains one of the strongest behavioral supplements for DC’s HIV planning activities. As part of the evaluation process our analysis helps to understand the impact of demographic, behavioral, and prevention efforts on peoples’ HIV status. We strongly recommend other jurisdictions use network visualizations to evaluate the efficacy in reaching hidden populations.

Following Tanya’s Lead: The Mirage and Hope of Social Medicine Research

Entrenched structural inequalities raise challenging questions of how socially-oriented research initiatives are likely to improve health for marginalised people. The recent inclusion of transgender women in the National HIV Behavioral Surveillance (NHBS), an ongoing initiative funded by the Centers for Disease Control and Prevention (CDC) to study the HIV epidemic in the US, is designed to redress the exclusion of transgender people from past HIV research and to confront the disproportionate burden of HIV on transgender women through the production of specific knowledge about HIV risk factors in this population. The hope is that such research will ameliorate the burden of HIV among transgender women. Building on a decade-long ethnographic engagement with transgender activists and health practitioners, I delve into tensions between the health research that sustains this horizon of hope and what I call the ‘mirage’ of social medicine research. My interlocutors call out this mirage of scientific optimism in which ‘all the answers are already known’, suggesting that health research oriented towards social justice simply begets more research. Nonetheless, my interlocutors engaged with me, a physician-anthropologist trainee, in order to insist on the ethical necessity of including transgender people in health research even as they exposed the limits of such inclusion and, more broadly, the limits of medicine’s power to redress social injustice. We should follow their lead, embracing neither futility and hopelessness nor the mirage of medical salvation, in order to build collaborative relationships in the service of a more caring social medicine.

Health Care Coverage and Preexposure Prophylaxis (PrEP) Use Among Men Who Have Sex With Men Living in 22 US Cities With Medicaid Expansion, 2017

Objectives. To compare health care coverage and utilization between men who have sex with men (MSM) in Medicaid expansion versus nonexpansion states. Methods. We used cross-sectional weighted data from the National HIV Behavioral Surveillance system, which used venue-based methods to interview and test MSM in 22 US cities from June through December, 2017 (n = 8857). We compared MSM in Medicaid expansion versus nonexpansion states by using the Rao-Scott χ2 test stratified by HIV status. We used multivariable logistic regression to model the relationship between Medicaid expansion, coverage, and preexposure prophylaxis (PrEP) use. Results. MSM in expansion states were more likely to have insurance (87.9% vs 71.6%), have Medicaid (21.3% vs 3.8%), discuss PrEP with a provider (58.8% vs 44.3%), or use PrEP (31.1% vs 17.5%). Conclusions. Medicaid expansion is associated with higher coverage and care, including PrEP. Public Health Implications. States may consider expanding Medicaid to help end the HIV epidemic. (Am J Public Health. Published online ahead of print January 21, 2021: e1–e9. https://doi.org/10.2105/AJPH.2020.306035 )

Serious Mental Illness Among Young People Who Inject Drugs: An Assessment of Injection Risks and Healthcare Use

Background Data on behavioral correlates of mental illness among young people who inject drugs (PWID) are limited. We examine injection risks and healthcare use among young PWID with probable serious mental illness (PSMI). Methods People who inject drugs were recruited and interviewed in 20 US cities for 2015 National HIV Behavioral Surveillance. Probable serious mental illness was assessed using the Kessler-6 screening scale. Bivariate analyses using log-linked Poisson regression with generalized estimating equations adjusted for design covariates were conducted to examine associations between PSMI and behaviors among PWID ages 18–29 years. Results Of 1769 young PWID, 45% had PSMI. Compared to those without PSMI, PWID with PSMI were more likely to report injecting more than once a day, receptive syringe sharing, sharing of other injection equipment, and unmet needs for medical care and substance use disorder (SUD) treatment. Those with PSMI were less likely to use syringe services programs than those without PSMI. Conclusions Approximately half of young PWID had PSMI. People who inject drugs with PSMI engaged in high-risk injection behaviors and encountered barriers to healthcare. Human immunodeficiency virus prevention programs such as Syringe Services Programs (SSPs) could benefit from screening for mental illness among young PWID and strong linkage to healthcare, including mental health and SUD treatment.