Matthew J Mimiaga1,2,3,4, Jaclyn M W Hughto1,2,4, Katie B Biello1,2,4, Christopher M Santostefano1, Lisa M Kuhns5,6, Sari L Reisner4,7,8, Robert Garofalo5,6. 1. Center for Health Equity Research, Brown University, Providence, RI. 2. Departments of Behavioral and Social Sciences and Epidemiology, Brown University, School of Public Health, Providence, RI. 3. Department of Psychiatry and Human Behavior, Brown University Alpert Medical School, Providence, RI. 4. The Fenway Institute, Fenway Health, Boston, MA. 5. Division of Adolescent Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL. 6. Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL. 7. Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA. 8. Department of Epidemiology, Harvard T.H Chan School of Public Health, Boston, MA.
Abstract
BACKGROUND: Worldwide, young transgender women (YTW) contend with exceptionally high risks of HIV infection. Cross-sectional studies have suggested that co-occurring epidemics or "syndemics" of psychosocial problems may accelerate HIV acquisition and transmission through elevated sexual risk behavior among transgender women. We aimed to examine how a syndemic of 7 psychosocial problems potentiates HIV sexual risk behavior among a multicity, longitudinal cohort of sexually active YTW in the United States. METHODS: Between 2012 and 2015, 233 YTW from Boston, MA, and Chicago, IL, completed behavioral surveys at baseline, 4, 8, and 12 months. We used generalized estimating equations to examine the prospective relationship of overlapping psychosocial problems and HIV sexual risk behavior (ie, condomless anal or vaginal sex) among YTW. RESULTS: The prevalence of 7 psychosocial syndemic problems was substantial at baseline and remained high at each time point: 6.4% reported polydrug use in the past 4 months (excluding stimulants); 7.7% reported heavy alcohol use in the past 4 months; 10% reported a history of childhood sexual abuse; 15.9% reported stimulant use in the past 4 months; 41.7% reported experiencing lifetime intimate partner violence; 42.1% reported clinically significant depressive symptoms; and 68.6% reported lifetime transgender-specific victimization. We identified a statistically significant positive "dose-response" relationship between the number of psychosocial syndemic problems and condomless anal or vaginal sex over time. CONCLUSIONS: The accumulation of "syndemic" psychosocial problems predicted HIV sexual risk behavior in a prospective cohort of YTW. Given the high prevalence of psychosocial problems and HIV sexual risk behavior, as well as having the highest HIV incidence among any risk group, the HIV prevention agenda requires a shift toward improved assessment of psychosocial comorbidities and stronger integration with gender-affirming and supportive mental health, violence recovery, and addiction treatment services for this population.
BACKGROUND: Worldwide, young transgender women (YTW) contend with exceptionally high risks of HIV infection. Cross-sectional studies have suggested that co-occurring epidemics or "syndemics" of psychosocial problems may accelerate HIV acquisition and transmission through elevated sexual risk behavior among transgender women. We aimed to examine how a syndemic of 7 psychosocial problems potentiates HIV sexual risk behavior among a multicity, longitudinal cohort of sexually active YTW in the United States. METHODS: Between 2012 and 2015, 233 YTW from Boston, MA, and Chicago, IL, completed behavioral surveys at baseline, 4, 8, and 12 months. We used generalized estimating equations to examine the prospective relationship of overlapping psychosocial problems and HIV sexual risk behavior (ie, condomless anal or vaginal sex) among YTW. RESULTS: The prevalence of 7 psychosocial syndemic problems was substantial at baseline and remained high at each time point: 6.4% reported polydrug use in the past 4 months (excluding stimulants); 7.7% reported heavy alcohol use in the past 4 months; 10% reported a history of childhood sexual abuse; 15.9% reported stimulant use in the past 4 months; 41.7% reported experiencing lifetime intimate partner violence; 42.1% reported clinically significant depressive symptoms; and 68.6% reported lifetime transgender-specific victimization. We identified a statistically significant positive "dose-response" relationship between the number of psychosocial syndemic problems and condomless anal or vaginal sex over time. CONCLUSIONS: The accumulation of "syndemic" psychosocial problems predicted HIV sexual risk behavior in a prospective cohort of YTW. Given the high prevalence of psychosocial problems and HIV sexual risk behavior, as well as having the highest HIV incidence among any risk group, the HIV prevention agenda requires a shift toward improved assessment of psychosocial comorbidities and stronger integration with gender-affirming and supportive mental health, violence recovery, and addiction treatment services for this population.
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