Faculty Bibliography

Transgender people have a gender identity that differs from their sex assigned at birth. For many transgender individuals accessing gender affirming hormone therapy (GAHT) is an important and medically necessary step in their gender transition. Both feminizing and masculinizing regimens are safe when used within established hormone protocols and are associated with significant improvements in mental health outcomes, including reduction in depression, anxiety and gender dysphoria. Clinicians should be aware of the current best practice guidelines for initiating and maintaining patients on GAHT.

We report 2 cases of neovaginal Chlamydia trachomatis infection in transgender women who underwent penile-inversion vaginoplasty procedures with integrated peritoneum and urethral grafts. These tissue types may have facilitated C. trachomatis infection. Medical providers should implement neovaginal screening for bacterial sexually transmitted infections in transgender patients at risk for infection.

BACKGROUND:In the United States, transgender women (TW) are disproportionately burdened by HIV infection. Cohort studies are needed to evaluate factors driving HIV acquisition among TW over time. These will require implementation strategies that are acceptable to the TW community and feasible to implement. OBJECTIVE:This study aims to investigate the rate and correlates of HIV acquisition and other health outcomes among TW in eastern and southern United States. METHODS:LITE is a multisite prospective cohort in 6 eastern and southern US cities, which will be followed across 24 months of technology-enhanced biobehavioral follow-up. Adult TW, regardless of HIV status, are recruited via convenience sampling (eg, peer referrals, social media, and dating apps). Participants are enrolled in a baseline study visit, complete a sociobehavioral survey, and test for HIV and sexually transmitted infections. Participants who are not living with HIV at baseline are offered enrollment into the cohort (N=1100); follow-up assessments occur quarterly. RESULTS:Cohort assembly was informed by synchronous Web-based focus group discussions with TW (n=41) and by continuing engagement with community advisory board members from each site. Enrollment launched in March 2018. The study is underway in the Atlanta; Baltimore; Boston; Miami; New York City; and Washington, DC, metro areas. As of March 2019, 795 TW completed a baseline visit (mean age 35 years). The majority of the participants are racial/ethnic minorities, with 45% of the TW identifying as black and 28% of the TW identifying as Hispanic/Latinx. More than one-quarter (28%) of the TW are living with HIV infection (laboratory-confirmed). Online recruitment methods support engagement with TW, although peer referral and referral through trusted health facilities and organizations remain most effective. CONCLUSIONS:This study is responsive to increasing research interest in technology-enhanced methods for cohort research, particularly for hard-to-reach populations. Importantly, the diversity of literacy, technology use, and overall socioeconomic situations in this sample of TW highlights the need to leverage technology to permit a flexible, adaptive methodology that enhances engagement of potential participants living in marginalized contexts while still ensuring rigorous and sound study design. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)/UNASSIGNED:DERR1-10.2196/14704.

Objectives/UNASSIGNED:Our study team adapted the MyPEEPS (Male Youth Pursuing Empowerment, Education, and Prevention around Sexuality) curriculum, an evidence-based human immunodeficiency virus (HIV) prevention intervention, from a face-to-face, group-based intervention to an individual-level mobile responsive web-based intervention to improve HIV risk behaviors in very young men, aged 13-18 years. Materials and methods/UNASSIGNED:In adapting the MyPEEPS intervention to mobile app, we used a series of methodologies, including expert panel reviews, weekly team meetings with the software development company, and conducted in-depth interviews with very young men. Following the iterative process, we conducted a 6-week pre-post feasibility pilot trial with 40 young men in Birmingham, AL; Chicago, IL; New York City, NY; and Seattle, WA. Primary outcomes of interest were uptake of the app, accessibility and satisfaction. Results/UNASSIGNED:Across all 4 sites, 62.5% (25/40) of participants completed all modules in the app in an average of 28.85 (SD 21.69) days. Participants who did not attend to the follow-up visit did not complete any of the app modules. Overall participants reported that the app was easy to use, useful and has the potential to improve their sexual health knowledge and behavior and awareness in risky contexts. Participants also highly rated the app, information and interface quality of the app. Discussion/UNASSIGNED:Lessons learned from the pilot included the need for reminder systems and providing anticipatory guidance about Internet connectivity when using the app. These changes will be incorporated into study procedures for our multisite trial. Conclusion/UNASSIGNED:Overall, participants found the app to be highly usable and have the potential to positively improve their sexual risk behavior.

Increasing PrEP adoption for eligible individuals is critical, but limited research has examined individual-level factors that might be amenable to educational or behavioral intervention. Using data from a PrEP demonstration project conducted at a community health center, we examined differences in behavioral and psychosocial factors between patients offered PrEP who chose to accept it and those who declined. In a multivariable model, the odds of accepting PrEP were higher among those with an HIV-positive main partner, greater risk behavior in the past 3 months, and higher HIV risk perception. PrEP adoption was positively associated with PrEP adherence self-efficacy and negatively associated with perceived sensitivity to medicines. These psychological variables were associated with measures of PrEP- and HIV-related stigma. In the multivariable model, there were no differences in PrEP adoption by demographic factors or socioeconomic status. Data suggest that patients' decisions about PrEP uptake may be impacted not only by objective and subjective HIV risk, but also by psychological variables such as stigma beliefs, medication beliefs, and self-efficacy.

Sexually-acquired HCV infections among HIV-uninfected men who have sex with men (MSM) have been rare. With the introduction of pre-exposure prophylaxis (PrEP) against HIV, we hypothesized that these infections would increase. Between 2013 and 2018 we diagnosed 15 likely sexually-acquired HCV infections among 14 MSM using PrEP. Most (87%) were asymptomatic, detected by routine ALT or HCV monitoring. Half reported increasing sex partners and drug use after starting PrEP; 5 reported injection of methamphetamine. Interventions are needed to prevent sexually-acquired HCV infections by MSM using PrEP. CDC guidelines for monitoring during PrEP should include regular ALT and HCV testing.

Purpose: To explore the experiences of transgender and gender nonbinary (TGNB) medical students and physicians in the United States. Methods: The authors conducted a 79-item online survey using Likert-type and open-ended questions to assess the experiences of TGNB-identified U.S. medical students and physicians. Variables included demographic data, disclosure of TGNB status, exposure to transphobia, and descriptions of educational and professional experiences. Recruitment was conducted using snowball sampling through Lesbian, Gay, Bisexual, Transgender, Queer professional groups, list-servs, and social media. The survey was open from June 2017 through November 2017. Results: Respondents included 21 students and 15 physicians (10 transgender women, 10 transgender men, and 16 nonbinary participants). Half (50%; 18) of the participants and 60% (9) of physicians had not disclosed their TGNB identity to their medical school or residency program, respectively. Respondents faced barriers on the basis of gender identity/expression when applying to medical school (22%; 11) and residency (43%; 6). More than three-quarters (78%; 28) of participants censored speech and/or mannerisms half of the time or more at work/school to avoid unintentional disclosure of their TGNB status. More than two-thirds (69%; 25) heard derogatory comments about TGNB individuals at medical school, in residency, or in practice, while 33% (12) witnessed discriminatory care of a TGNB patient. Conclusion: TGNB medical students and physicians faced significant barriers during medical training, including having to hide their identities and witnessing anti-TGNB stigma and discrimination. This study, the first to exclusively assess experiences of TGNB medical students and physicians, reveals that significant disparities still exist on the basis of gender identity.