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Background: Transgender and nonbinary populations are disproportionately affected by HIV and face barriers to accessing HIV-related services. Pre-exposure prophylaxis (PrEP) may benefit those at risk of HIV acquisition. However, PrEP awareness and uptake, along with potential barriers and facilitators, have not been investigated among transgender and nonbinary individuals living in Canada., Setting: This study analyzed data from 1965 participants of the 2019 Trans PULSE Canada survey, a national convenience sampling survey of transgender and nonbinary individuals in Canada., Methods: Data were analyzed to estimate levels of PrEP awareness and uptake and to identify predictors of PrEP awareness among the study population. Prevalence ratios estimated from block-wise modified Poisson regression models were used to assess predictors of PrEP awareness., Results: PrEP awareness, lifetime PrEP use, and current PrEP use were estimated to be 71.0%, 2.2%, and 0.9%, respectively, among the full sample, and 82.3%, 7.3%, and 3.8% among those with indications for PrEP use. Respondents who were aged 45 years or older, transfeminine, Indigenous, living in Atlantic Canada or Quebec, and had high school education or less were significantly less likely to be aware of PrEP. Lifetime sex work, past-year HIV/STI testing, being single or in a nonmonogamous relationship, and higher levels of emotional social support were positively associated with PrEP awareness., Conclusions: There is a need to improve PrEP awareness and particularly uptake among transgender and nonbinary individuals in Canada. This study revealed inequities in PrEP awareness within this population, which may serve as targets for future public health initiatives., Competing Interests: A. I. Scheim received honoraria from ViiV Healthcare. The remaining authors have no conflicts of interest to disclose., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: Trans and non-binary (TNB) immigrants, refugees, and newcomers (IRN) face intersecting challenges and barriers, including stigma and persecution in countries of origin, and others unique to the Canadian resettlement process. The present study aimed to investigate factors that are associated with having a primary healthcare provider among TNB IRN., Design: Trans PULSE Canada was a community-based, national study of health and wellbeing among 2,873 TNB people residing in Canada, aged 14 and older, who were recruited using a multi-mode convenience sampling approach.. The survey asked questions about identity, community, service access, health - and IRN were asked questions specific to immigration/settlement., Results: Of the 313 IRN participants who completed the full survey version (age M = 34.1, SE =0.75), 76.4 % had a primary healthcare provider. TNB IRN largely reported being Canadian citizens (59.8 %), gender non-binary or similar (46.9 %), currently living in Ontario (35.5 %), and having immigrated from the United States (32.1 %). Chi-square analyses revealed that having a primary healthcare provider was associated with age, gender identity, citizenship status, region of origin, current location in Canada, length of time since immigrating to Canada, status in gender affirming medical care, and having extended health insurance. With modified Poisson regression, we found that TNB IRN who were non-permanent residents, originating from European, African, and Oceania regions, or living in Quebec and the Prairie provinces were less likely to have a primary healthcare provider., Conclusion: Results may inform settlement organizations of the unique needs and barriers of TNB IRN. Schools and LGBTQ+ organizations may better serve this population - especially those originating from highlighted regions, who live in Quebec or the Prairie provinces, and/or are non-permanent residents - by offering programs that connect them to primary healthcare providers who are competent in cross-cultural trans health., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Greta Bauer reports financial support was provided by Canadian Institutes of Health Research. Monica Ghabrial receives financial support from the Canadian Institutes of Health Research Fellowship. The other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Anti-gender campaigns in the United States and globally have promoted policies and legislation that significantly limit bodily autonomy for women, transgender, and nonbinary people. This attack on the human rights of women and gender-diverse communities not only reflects implicit and explicit bias but also detrimentally impacts population health and well-being. We outline the domestic and global rise of anti-gender campaigns and their deep historical connections to broader forms of discrimination and inequality to argue that there is an ethical, democratic, and scientific imperative to more critically center and contextualize gender in health research. While the inclusion of gender as a complex concept in research design, implementation, and dissemination is important, we emphasize that gender inequities must be understood as inextricable from other systems of discrimination and exclusion. To that end, this commentary outlines two actions: for researchers to advance critical approaches to gender as part of a broader landscape of discrimination, and for the US National Institutes of Health to integrate both sex and gender into funded research., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Health administrative data can be used to improve the health of people who inject drugs by informing public health surveillance and program planning, monitoring, and evaluation. However, methodological gaps in the use of these data persist due to challenges in accurately identifying injection drug use (IDU) at the population level. In this study, we validated case-ascertainment algorithms for identifying people who inject drugs using health administrative data in Ontario, Canada., Study Design and Setting: Data from cohorts of people with recent (past 12 months) IDU, including those participating in community-based research studies or seeking drug treatment, were linked to health administrative data in Ontario from 1992 to 2020. We assessed the validity of algorithms to identify IDU over varying look-back periods (ie, all years of data [1992 onwards] or within the past 1-5 years), including inpatient and outpatient physician billing claims for drug use, emergency department (ED) visits or hospitalizations for drug use or injection-related infections, and opioid agonist treatment (OAT)., Results: Algorithms were validated using data from 15,241 people with recent IDU (918 in community cohorts and 14,323 seeking drug treatment). An algorithm consisting of ≥1 physician visit, ED visit, or hospitalization for drug use, or OAT record could effectively identify IDU history (91.6% sensitivity and 94.2% specificity) and recent IDU (using 3-year look back: 80.4% sensitivity, 99% specificity) among community cohorts. Algorithms were generally more sensitive among people who inject drugs seeking drug treatment., Conclusion: Validated algorithms using health administrative data performed well in identifying people who inject drugs. Despite their high sensitivity and specificity, the positive predictive value of these algorithms will vary depending on the underlying prevalence of IDU in the population in which they are applied., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr Jordan Feld has received research support from AbbVie Inc and Gilead Sciences for matters unrelated to the current study. Dr Eric Benchimol has acted as a consultant for McKesson Canada, the Dairy Farmers of Ontario and the Canadian Agency for Drugs and Technology in Health (CADTH) for matters unrelated to the topic of this research or to this study. Dr Sofia Bartlett has consulted, participated in advisory boards, and spoken for AbbVie Inc., Gilead Sciences Canada, Inc. and Cepheid Inc. for matters unrelated to the current study, and no personal payments were accepted. Dr Naveed Janjua has participated in advisory boards and has spoken for AbbVie and Gilead, for matters unrelated to the current study. All other coauthors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2024. Published by Elsevier Inc. All rights reserved.)

To build a just, equitable, and diverse academy, scientists and institutions must address systemic barriers that sex and gender minorities face. This Commentary summarizes (1) critical context informing the contemporary oppression of transgender people, (2) how this shapes extant research on sex and gender, and (3) actions to build an inclusive and rigorous academy for all., Competing Interests: Declaration of interests A.I.S. received consulting fees from the World Health Organization to conduct systematic reviews on transgender health., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Objectives: Transgender and gender diverse (trans) health research has grown rapidly, highlighting the need to characterize the scientific evidence base. We conducted a systematic review of peer-reviewed research on disease burden and correlates in trans adolescents and adults over a 20-month period to identify knowledge gaps and assess methodological characteristics including measurement of gender identity, community engagement, and study quality., Data Sources, Eligibility Criteria, and Synthesis Methods: We searched seven databases using terms related to (a) transgender populations and (b) health or disease. Eligible studies were in English, French, or Spanish and reported original quantitative data on mental health or substance use conditions, infectious diseases, or non-communicable conditions in at least 25 trans individuals aged 15+. Quality assessment was performed in duplicate on a 10% sample of articles and findings were summarized using narrative synthesis., Results: The 328 included studies were conducted in 45 countries, with most from North America (54%) and limited research from South Asia (3%), Sub-Saharan Africa (3%), and the Middle East and North Africa (2%). Most studies used cross-sectional designs (73%) and convenience sampling (65%). Only 30% of studies reported any form of community engagement. Mental health and substance use disorders were the most studied area (77% of studies) and non-communicable conditions the least (16%). Available data indicated that trans populations experience high disease burden with considerable heterogeneity within and across settings. Of 39 articles assessed for quality, 80% were rated as fair, 18% as poor, and 3% as good quality., Conclusions and Implications: Geographic, gender-specific, and topical gaps remain in trans health, but we found more research from African countries, with transmasculine people, and on non-communicable conditions than previous syntheses. Areas for growth in trans health research include community engagement, non-binary health, chronic and age-related conditions, and health determinants., Registration: PROSPERO CRD42021234043., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Scheim et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: Due to structural transphobia, trans and nonbinary (TNB) individuals were particularly vulnerable to the negative effects of social isolation and financial instability resulting from COVID-19. The present study examined the effect of change in finances and access to TNB peer gatherings on anxiety and depression during the COVID-19 pandemic. Methods: Participants were 18 years and older (mean = 30) and completed prepandemic baseline (Fall 2019) and pandemic follow-up (Fall 2020) surveys. Multivariable regressions examined associations between mental health and change in (1) finances and (2) access to TNB peer gatherings (in person or online). Results: Of 780 participants, 50% reported that the COVID-19 pandemic had a negative impact on personal income and 58.3% reported negative impact on access to TNB peer gatherings. Depression and anxiety symptoms increased from prepandemic to follow-up, and most participants were above measurement cutoffs for clinical levels at both time points. Change in finances and access to TNB peer gatherings interacted with prepandemic depression scores to predict depression symptoms during the COVID-19 pandemic. For participants with high prepandemic depression scores, financial stability predicted pandemic depression scores comparable to that predicted by negative financial change. No interaction was found between these variables when predicting anxiety symptoms during the COVID-19 pandemic. Conclusion: Findings underscore the influence of inequality and prepandemic mental health when considering the impact of COVID-19 on wellbeing. Results suggest need for multifaceted programs and services, including financial support and meaningful TNB community engagement, to address barriers to health equity posed by systematic gender oppression.

Background: Transmasculine people are at risk for HIV; yet few HIV prevention interventions have been developed for this population. We adapted an existing HIV prevention smartphone app for cisgender men who have sex with men to meet the sexual health needs of transmasculine people., Objective: This study aims to assess the acceptability of the adapted app, Transpire, among transmasculine people living in Atlanta, Georgia, and Washington, DC, via in-depth interviews of participants in a pilot feasibility trial., Methods: Participants used the Transpire app for 3 months as part of a pilot study of the app. Eligible participants were aged 18-34 years. There were no eligibility criteria with respect to race and ethnicity, and most participants were non-Hispanic White. At the end of the follow-up, participants were invited to participate in web-based in-depth interviews to discuss their experiences using the app and feedback on design and content. Interviews were transcribed and coded using a constant comparative approach. Three main themes were identified: sexual behavior, app experiences and feedback, and pre-exposure prophylaxis., Results: Overall, participants found the app acceptable and thought that it would be a useful tool for themselves and their peers. Participants reported appreciating having a comprehensive information source available to them on their phones and reported learning more about HIV, sexually transmitted infections, and pre-exposure prophylaxis via the app. They also reported appreciating the inclusive language that was used throughout the app. Although the app included some resources on mental health and substance use, participants reported that they would have appreciated more resources and information in these areas as well as more comprehensive information about other health concerns, including hormone therapy. Representative quotes are presented for each of the identified themes., Conclusions: There is a desire to have greater access to reliable sexual health information among transmasculine people. Mobile apps like Transpire are an acceptable intervention to increase access to this information and other resources. More evidence is needed, however, from more racially and ethnically diverse samples of transmasculine people., (©Jeb Jones, Gareth Butler, Meaghan Woody, Amanda D Castel, Paige Kulie, Martha Sheets, Ayden I Scheim, Sari L Reisner, Rachel Valencia, Minglun Wang, Joanne D Stekler, Patrick S Sullivan, Rob Stephenson. Originally published in JMIR Formative Research (https://formative.jmir.org), 21.09.2023.)

In the United States, a context of multiple marginalization shapes sexual health disparities experienced by transgender women. Using data from 396 transgender women with negative or unknown HIV status, we performed exploratory factor analysis on responses to gender identity and sexual behavior stigma items and regressed sexual health outcomes on extracted factors via modified Poisson regression with robust variance estimation. Overall, 97.2% of participants endorsed ≥ 1 gender identity stigma; 67.2% endorsed ≥ 1 sexual behavior stigma; and 66.9% endorsed ≥ 1 of each. Extracted factors included gender-identity social stigma, reflecting experiences related to family, fearfulness in public, and verbal harassment (α = 0.68); gender-identity institutional stigma/violence, reflecting experiences related to healthcare, police interactions, and interpersonal violence (α = 0.73); and global sexual behavior stigma, reflecting experiences related to family, friends, and healthcare, as well as police interactions, fearfulness in public, verbal harassment, and interpersonal violence (α = 0.83). Gender-identity social stigma was significantly, positively associated with testing for HIV and testing for sexually transmitted infections. Gender-identity institutional stigma/violence and global sexual behavior stigma were both significantly, positively associated with condomless anal sex, sex work, testing for HIV, testing for sexually transmitted infections, and use of HIV pre-exposure prophylaxis. Stigma-mitigation remains critical to improve quality of life and sexual health for transgender women in the United States., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Transgender and non-binary people (TGNB) have a higher rate of heavy episodic drinking than cisgender people; however, extant knowledge about predictors of hazardous alcohol drinking (HAD) among different TGNB groups is limited. This study examined predictors of HAD in a national sample of TGNB people in Canada., Methods: Logistic regression models were fit to examine the effects of 1) minority stressors and 2) stress-buffering factors on the likelihood of HAD, stratified by gender, among 2324 TGNB individuals from the Trans PULSE Canada survey, a cross-sectional survey conducted in 2019 among trans and non-binary people aged 14+ in Canada., Results: Almost 17% of participants reported past-year HAD. Lifetime day-to-day and lifetime major discrimination were associated with higher odds of HAD in the full sample [(AOR=1.37, 95% CI: 1.30, 1.44) and (AOR=1.69, 95% CI: 1.55, 1.86) respectively], and across all gender groups. Social support was associated with lower odds of HAD in trans men, non-binary people assigned female at birth (NB-AFAB), and non-binary people assigned male at birth (NB-AMAB) groups, but with higher odds of HAD in the trans women group. Misgendering was associated with lower odds of HAD in trans men and NB-AFAB, but higher odds of HAD in trans women and NB-AMAB. Mixed effects of gender distress, gender positivity, and gender-affirming medical care were also reported across groups., Conclusion: The study provided a more detailed understanding of the predictors of HAD across four TGNB groups. Public health interventions should focus on structural discrimination and social support for TGNB people., Competing Interests: Declaration of Competing Interest No conflict declared., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: State-level variation in how restrictive policies affect health care access for transgender populations has not been widely studied. Therefore, we assessed the association between structural stigma and four measures of individual health care access among transgender people in the United States, and the extent to which structural stigma explains state-level variability., Methods: Data were drawn from the 2015-2019 Behavioral Risk Factor Surveillance System and the Human Rights Campaign's State Equality Index. We calculated weighted proportions and conducted multilevel logistic regression of individual heterogeneity and discriminatory accuracy., Results: An increase in the structural stigma score by one standard deviation was associated with lower odds of health care coverage (OR = 0.80; 95% CI: 0.66, 0.96) after adjusting for individual-level confounders. Approximately 11% of the total variance for insurance coverage was attributable to the state level; however, only 18% of state-level variability was explained by structural stigma. Adding Medicaid expansion attenuated the structural stigma-insurance association and explained 22% of state-level variation in health insurance. For the remaining outcomes (usual source of care, routine medical check-up, and cost-related barriers), we found neither meaningful associations nor considerable between-state variability., Conclusions: Our findings support the importance of Medicaid expansion and transgender-inclusive antidiscrimination protections to enhance health care insurance coverage. From a measurement perspective, however, additional research is needed to develop and validate measures of transgender-specific structural stigma to guide future policy interventions.

Despite the availability of publicly funded hepatitis C (HCV) treatment in Canada, treatment gaps persist, particularly among people who inject drugs. We estimate correlates of HCV care cascade engagement (testing, diagnosis, and treatment) among people who inject drugs in Toronto, Canada and examine the effect of accessing differing supervised consumption service (SCS) models on self-reported HCV testing and treatment. This is a cross-sectional baseline analysis of 701 people who inject drugs surveyed in the Toronto, Ontario integrated Supervised Injection Services (OiSIS-Toronto) study between November 2018 and March 2020. We examine correlates of self-reported HCV care cascade outcomes including SCS model, demographic, socio-structural, drug use, and harm reduction characteristics. Overall, 647 participants (92%) reported ever receiving HCV testing, of whom 336 (52%) had been diagnosed with HCV. Among participants who reported ever being diagnosed with HCV, 281 (84%) reported chronic HCV, of whom 130 (46%) reported HCV treatment uptake and 151 (54%) remained untreated. Compared to those with no SCS use, participants who had ever injected at an integrated SCS model with co-located HCV care had greater prevalence of both ever receiving HCV testing (adjusted prevalence ratio [aPR]: 1.12, 95% confidence interval [CI]: 1.02-1.24) and ever receiving HCV treatment (aPR: 1.67, 95% CI: 1.04-2.69). Over half of participants diagnosed with chronic HCV reported remaining untreated. Our findings suggest that integrated SCS models with co-located HCV care represent key strategies for linkage to HCV care, but that more is needed to support scale-up., (© 2022 John Wiley & Sons Ltd.)

Background: Studies show higher rates of sexually transmitted infections (STIs) among transgender (trans) and non-binary (TNB) persons compared with the general population. Scant studies have examined non-HIV STI testing (henceforth referred to as STI testing); fewer inclusive of trans men and non-binary persons. We characterised the prevalence of STI testing and time since last STI test and gender-based differences in these outcomes among TNB persons., Methods: Data were analysed from a 2018 community-based participatory cross-sectional survey (n =528). Prevalence of lifetime STI testing history and time since last STI test were reported overall and compared across genders (trans men, trans women, non-binary assigned female at-birth, non-binary assigned male at-birth) using Chi-squared, then bivariable and multivariable logistic regression analyses to compare lifetime STI testing history (ever vs never) across sociodemographic and health care characteristics., Results: Most (n =425; 80.5%) participants reported having ever had an STI test; over half (59.8%) ever tested had tested within the past year. Bivariate analyses showed no significant gender differences in lifetime STI testing history (P =0.298) or time since last STI test (P =0.118). In a multivariable model, higher age, reporting multiple committed partners (vs single/divorced), known HIV status, and ever receiving information about pre-exposure prophylaxis (PrEP) were positively associated with ever having had an STI test, whereas Latinx race/ethnicity (vs white) was negatively associated., Conclusions: Findings showed high rates of lifetime STI testing and recent testing, with no gender-based differences. Never testing rates were concerning considering screening recommendations. Broad based (non-gender specific) TNB-focused interventions may be warranted to increase uptake.

Background: Virtual health care use has dramatically increased in response to the COVID-19 pandemic, raising the question of its potential role after the pandemic. For transgender (trans) and nonbinary (TNB) people, virtual care is promising because it may expand access to appropriate health care providers. However, emerging research indicates potential disparities in virtual care access related to sociodemographic, health, and social factors. There is a paucity of research on the factors affecting patient preferences for virtual versus in-person care, particularly in TNB communities., Objective: This study aimed to identify the sociodemographic, health, and social factors associated with postpandemic virtual care preferences in TNB communities., Methods: The 2020 Trans PULSE Canada COVID survey examined the health, social, and economic impacts of the COVID-19 pandemic among 820 TNB participants who previously completed the prepandemic 2019 Trans PULSE Canada survey (n=2783). Data were weighted to the demographics of the 2019 sample. Chi-square tests were used to compare postpandemic preferences for virtual versus in-person care across sociodemographic, health, and social characteristics. Participants provided open-text responses explaining their preferences, which were used to contextualize quantitative findings., Results: Among 812 participants who indicated whether they would prefer virtual or in-person care after the pandemic, a weighted 32.7% (n=275) would prefer virtual care and 67.3% (n=537) would prefer in-person care. Preference for in-person over virtual care was associated with being in the 14-19 (49/56, weighted 85.0%), 50-64 (51/62, weighted 80.0%), and ≥65 (9/10, weighted 90.7%) age groups (χ 2 5 =19.0; P=.002). Preference for virtual over in-person care was associated with having a chronic health condition (125/317, weighted 37.7% versus 150/495, weighted 29.9%; χ 2 1 =4.7; P=.03) and having probable anxiety (229/645, weighted 34.7% versus 46/167, weighted 25.7%; χ 2 1 =4.3; P=.04). Among participants with romantic partners, preferences varied based on the partner's level of support for gender identity or expression (χ 2 3 =13.3; P=.004). Participants with moderately supportive partners were more likely than participants with very supportive partners to prefer in-person care (36/43, weighted 85.1% versus 275/445, weighted 62.3%). Care preferences did not vary significantly based on the indicators of socioeconomic status. Open-text responses showed that multiple factors often interacted to influence participant preferences, and that some factors, such as having a chronic condition, simultaneously led some participants to prefer virtual care and others to prefer in-person care., Conclusions: TNB people may have differential interest in virtual care based on factors including age, chronic and mental health conditions, and gender-unsupportive home environments. Future research examining virtual care preferences would benefit from mixed methods intersectional approaches across these factors, to explore complexity in the barriers and facilitators of virtual care access and quality. These observed differences support flexibility with options to choose between in-person and virtual health care to meet TNB patients' specific health needs., (©Jose M Navarro, Ayden I Scheim, Greta R Bauer. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 26.10.2022.)

Long-acting injectable pre-exposure prophylaxis (LAI-PrEP) was recently approved for HIV prevention as an alternative to daily oral PrEP. We explored preferences and attitudes toward LAI-PrEP among Black, Hispanic/Latino, and White gay, bisexual, and other men who have sex with men (GBM) using focus groups ( n = 13) and in-depth interviews ( n = 17). Participants expressed differing levels of interest in LAI-PrEP. While important benefits of LAI-PrEP included convenience, provider-facilitated PrEP discussion, and expansion of PrEP options, participants raised concerns about treatment efficacy and side effects, discomfort with needles/injections, cost, and frequency of clinic visits. Our findings highlight ongoing challenges with accessing HIV-prevention tools and provide guidance for developing strategies to enhance LAI-PrEP uptake among GBM.

Introduction: Transgender (trans) and nonbinary people (TNB) are disproportionately impacted by HIV. HIV testing is critical to engage TNB people in HIV prevention and care. Yet, scant literature has examined social and structural factors associated with HIV testing among TNB people of diverse genders and in geographies with potentially lower trans acceptance. We: (1) characterized the prevalence of never having been tested for HIV; and (2) identified associated factors, among TNB people in Michigan, United States., Methods: Data were from a community-based participatory cross-sectional survey (n = 539 sexually experienced TNB people). The prevalence of never having had an HIV test was reported overall and compared across socio-demographic, clinical, social and structural factors using bivariable and multivariable logistic regression analyses., Results and Discussion: Approximately one-quarter (26.2%) of participants had never had an HIV test (20.8% transfeminine; 30.0% transmasculine; 17.8% nonbinary assigned male at-birth; and 32.0% nonbinary assigned female at-birth). In a multivariable socio-demographic model, older age (adjusted odds ratio [aOR] for 1-year increase: 0.93, 95% CI: 0.90, 0.96, p<0.001) and Black/African American race (vs. White) (aOR: 0.28, 95% CI: 0.09, 0.86, p<0.05) were associated with increased odds of HIV testing (aORs for never testing). In separate multivariable models controlling for socio-demographics, ever experiencing sexual violence (aOR: 0.38, 95% CI: 0.21, 0.67, p<0.001), not accessed sexual/reproductive healthcare in the past 12 months (aOR: 4.46, 95% CI: 2.68, 7.43, p<0.001) and reporting a very/somewhat inclusive primary care provider (PCP) (aOR: 0.29, 95% CI: 0.17, 0.49, p<0.001) were associated with HIV testing (aORs for never testing)., Conclusions: Findings contribute to scant literature about gender-based differences in HIV testing inclusive of transmasculine and nonbinary people. Lack of statistically significant gender differences suggests that broad TNB interventions may be warranted. These could include training healthcare providers in trans-inclusive practices with sexual violence survivors and PCPs in trans-inclusive HIV prevention and care. Findings showing Black participants were less likely to have never had an HIV test suggest the promise of culturally tailored services, though further investigation is needed. Findings identify social and structural factors associated with HIV testing and can inform multi-level interventions to increase TNB person's HIV testing., (© 2022 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person., Competing Interests: Conflict of interests were reviewed as part of the selection process for committee members and at the end of the process before publication. No conflicts of interest were deemed significant or consequential., (© 2022 The Author(s). Published with license by Taylor & Francis Group, LLC.)

Background: Emerging international evidence indicates the COVID-19 pandemic has exacerbated socioeconomic and health challenges faced by transgender (trans) and non-binary populations globally. This qualitative study is among the first to characterize impacts of the pandemic on these groups in Canada., Methods: Drawing on data from the Trans PULSE Canada survey (N = 820), we used thematic analysis to examine the free-form responses of 697 participants to one open-ended question on impacts of the pandemic. We first organized responses into descriptive themes, and then used this preliminary analytical process to construct more refined, higher order themes that provided a rich account of the pandemic's impacts., Results: Our results are organized into five themes that highlight the pandemic's impacts on trans and non-binary populations in Canada. These include: (1) reduced access to both gender-affirming and other healthcare, (2) heightened financial, employment, and housing precarity, (3) strained social networks in an era of physical distancing and virtual communication, (4) an intensification of safety concerns, and (5) changes in experiences of gender affirmation., Conclusion: Our findings highlight the pandemic's systemic impacts on the lives of trans and non-binary people in domains such as healthcare, employment, and housing, and on the social networks of these groups, many of which reflect an exacerbation of pre-existing inequities. Based on our analysis, we recommend that public health researchers, policymakers, and practitioners attend to the structural impacts of the pandemic on these groups as primary sites of inquiry and intervention., (© 2022. The Author(s).)

Research on transmasculine people's health is scant globally, including in India. We explored transmasculine people's experiences in affirming their gender in family and social spaces, and how those experiences impact mental health. In 2019, we conducted four focus groups ( n  = 17 participants) and 10 in-depth interviews with transmasculine people in Mumbai and Chennai. Data analyses were guided by minority stress theory and the gender affirmation model. Within family, the pressure to conform to assigned gender roles and gender policing usually began in adolescence and increased over time. Some participants left parental homes due to violence. In educational settings, participants described the enforcement of gender-normative dress codes, lack of faculty support, and bullying victimisation, which led some to quit schooling. In the workplace, experiences varied depending on whether participants were visibly trans or had an incongruence between their identity documents and gender identity. Everyday discrimination experiences in diverse settings contributed to psychological distress. Amidst these challenges, participants reported resilience strategies, including self-acceptance, connecting with peers, strategic (non)disclosure, and circumventing gendered restrictions on dress and behaviour. Interventions at social-structural, institutional, family and individual levels are needed to reduce stigma and discrimination faced by transmasculine people in India and to promote their mental health.

Background: In March 2020, following a provincial COVID-19 emergency declaration, modifications to opioid agonist treatment (OAT) were introduced in Ontario, Canada to promote treatment access amid the pandemic and ongoing opioid overdose crisis. Modifications included federal exemptions to facilitate OAT prescription re-fills, extensions, and deliveries and interim treatment guidance emphasizing take-home (non-observed) doses and reduced urine drug screening for OAT patients., Methods: We conducted an interrupted time series study using health administrative data from September 17 th , 2019-September 21 st , 2020, on 359 people who inject drugs with suspected opioid use disorder in Toronto, Ontario. We used segmented regression analyses to evaluate the joint effects of the provincial COVID-19 emergency declaration, federal OAT exemptions, and interim treatment guidance-all implemented between March 17 th -23 rd , 2020-on the weekly proportion of participants enrolled in OAT (i.e., ≥1 day(s) covered with methadone or buprenorphine/naloxone), with an opioid-related overdose (based on emergency department visits and hospitalizations), and who died (all-cause), and the weekly proportion of OAT-enrolled participants receiving take-home doses (i.e., ≥1 day(s) covered) and undergoing urine drug screening., Results: Post-implementation, the interventions were associated with immediate absolute changes in OAT enrollment (+1.95%; 95% CI=0.04%-3.85%), receipt of take-home doses (+18.3%; 95% CI=13.2%-23.4%), and urine drug screening (-22.4%; 95% CI=[-26.9%]-[-17.9%]) and a gradual absolute increase of 0.56% in urine drug screening week-to-week (95% CI=0.27%-0.86%) beyond the pre-implementation trend. At 26 weeks post-implementation, OAT enrollment and urine drug screening approached pre-implementation levels whereas the increase in take-home doses was largely sustained (+15.0%; 95% CI=4.33%-25.6%). No post-implementation increases in opioid-related overdoses were observed. Death was not modelled (low event frequency)., Conclusion: Changes to OAT provision following provincial COVID-19 restrictions were associated with an immediate and sustained increase in take-home dose coverage among OAT-enrolled participants, without corresponding increases in opioid-related overdoses among all participants., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

HIV pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV; however, PrEP use among transgender individuals remains low. We conducted a systematic review to identify barriers and facilitators to PrEP uptake, adherence, and persistence among transgender individuals in the United States. We conducted a literature search in PubMed and CINAHL databases in March 2021 and followed PRISMA guidelines. Studies were eligible if they were published in a peer-reviewed journal and reported interest, uptake, adherence, and/or persistence of PrEP use among transgender individuals. Articles that did not disaggregate results for transgender participants were excluded. Data from included articles were coded using content analysis and narratively synthesized using a framework matrix. We screened 254 unique articles published after US Food and Drug Administration approval of PrEP, and 33 articles were included in the review. Five themes were identified in the literature, including (1) PrEP concentrations were lower among individuals taking feminizing hormones, but the difference did not appear clinically significant; (2) concerns regarding interactions between gender-affirming hormone therapy and PrEP remain a large barrier; (3) PrEP initiation may facilitate increased self-advocacy and self-acceptance; (4) lack of trust in medical institutions impacts PrEP uptake; and (5) social networks have a significant influence on PrEP knowledge, interest, and adherence. Additional research is needed involving transgender men and nonbinary persons, and efforts to improve PrEP persistence among the transgender community are needed. Training health care providers to provide inclusive and affirming care is perhaps one of the strongest areas for intervention to increase PrEP uptake and persistence.

Researchers are increasingly recognizing the importance of studying and addressing intersectional stigma within the field of HIV. Yet, researchers have, arguably, struggled to operationalize intersectional stigma. To ensure that future research and methodological innovation is guided by frameworks from which this area of inquiry has arisen, we propose a series of core elements for future HIV-related intersectional stigma research. These core elements include multidimensional, multilevel, multidirectional, and action-oriented methods that sharpen focus on, and aim to transform, interlocking and reinforcing systems of oppression. We further identify opportunities for advancing HIV-related intersectional stigma research, including reducing barriers to and strengthening investments in resources, building capacity to engage in research and implementation of interventions, and creating meaningful pathways for HIV-related intersectional stigma research to produce structural change. Ultimately, the expected payoff for incorporating these core elements is a body of HIV-related intersectional stigma research that is both better aligned with the transformative potential of intersectionality and better positioned to achieve the goals of Ending the HIV Epidemic in the United States and globally. ( Am J Public Health . 2022;112(S4):S413-S419. https://doi.org/10.2105/AJPH.2021.306710).

Transgender (trans) and non-binary people experience barriers to culturally competent healthcare and many have reported avoiding care. COVID-19 and related mitigation strategies may have exacerbated avoidance, and poor mental health may be bidirectionally related to avoiding care. This study estimated the prevalence of primary care avoidance during the pandemic in a national sample of trans and non-binary people in Canada with a primary care provider and examined the association between poorer self-rated mental health and avoidance. In Fall 2019, Trans PULSE Canada collected multi-mode survey data from trans and non-binary people. In September to October 2020, 820 participants completed a COVID-19-focused survey. In this cross-sectional analysis, multivariable logistic regression models estimated odds ratios adjusted for confounders and weighted to the 2019 sample. The analysis included 689 individuals with a primary healthcare provider, of whom 61.2% (95% CI: 57.2, 65.2) reported fair or poor mental health and 25.7% (95% CI: 22.3, 29.2) reported care avoidance during the pandemic. The most common reason for avoidance was having a non-urgent health concern (72.7%, 95% CI: 65.9, 79.5). In adjusted analyses, those with fair or poor mental health had higher odds of avoiding primary care as compared to those with good to excellent mental health (adjusted odds ratio [AOR] = 2.37; 95% CI: 1.50, 3.77). This relationship was similar when excluding COVID-related reasons for avoidance (AOR = 2.52; 95% CI: 1.52, 4.17). Expansion of virtual communication may enhance primary care accessibility, and proactively assessing mental health symptoms may facilitate connections to gender-affirming mental health services., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Issues: Non-medical prescription opioid use (NMPOU) contributes substantially to the global burden of morbidity. However, no systematic assessment of the scientific literature on the associations between NMPOU and health outcomes has yet been undertaken., Approach: We undertook a systematic review evaluating health outcomes related to NMPOU based on ICD-10 clinical domains. We searched 13 electronic databases for original research articles until 1 July 2021. We employed an adaptation of the Oxford Centre for Evidence-Based Medicine 'Levels of Evidence' scale to assess study quality., Key Findings: Overall, 182 studies were included. The evidence base was largest on the association between NMPOU and mental and behavioural disorders; 71% (129) studies reported on these outcomes. Less evidence exists on the association of NMPOU with infectious disease outcomes (26; 14%), and on external causes of morbidity and mortality, with 13 (7%) studies assessing its association with intentional self-harm and 1 study assessing its association with assault (<1%)., Implications: A large body of evidence has identified associations between NMPOU and opioid use disorder as well as on fatal and non-fatal overdose. We found equivocal evidence on the association between NMPOU and the acquisition of HIV, hepatitis C and other infectious diseases. We identified weak evidence regarding the potential association between NMPOU and intentional self-harm, suicidal ideation and assault., Discussion and Conclusions: Findings may inform the prevention of harms associated with NMPOU, although higher-quality research is needed to characterise the association between NMPOU and the full spectrum of physical and mental health disorders., (© 2022 Australasian Professional Society on Alcohol and other Drugs.)

Transgender (trans) communities in the USA and globally have long organized for health and social equity but have only recently gained increased visibility within public health. In this review, we synthesize evidence demonstrating that trans adults in the USA are affected by disparities in physical and mental health and in access to health care, relative to cisgender (nontrans) persons. We draw on theory and data to situate these disparities in their social contexts, explicating the roles of gender affirmation, multilevel and intersectional stigmas, and public policies in reproducing or ameliorating trans health disparities. Until recently, trans health disparities were largely made invisible by exclusionary data collection practices. We highlight the importance of, and methodological considerations for, collecting inclusive sex and gender data. Moving forward, we recommend routine collection of gender identity data, an emphasis on intervention research to achieve trans health equity, public policy advocacy, and investment in supporting gender-diverse public health leadership.

Background: Studies of people who inject drugs (PWID) commonly use questionnaires to determine whether participants are currently, or have recently been, on opioid agonist treatment for opioid use disorder. However, these previously unvalidated self-reported treatment measures may be susceptible to inaccurate reporting., Methods: We linked baseline questionnaire data from 521 PWID in the Ontario integrated Supervised Injection Services cohort in Toronto (November 2018-March 2020) with record-level health administrative data. We assessed the validity (sensitivity, specificity, positive and negative predictive value [PPV and NPV]) of self-reported recent (in the past 6 months) and current (as of interview) opioid agonist treatment with methadone or buprenorphine-naloxone relative to prescription dispensation records from a provincial narcotics monitoring system, considered the reference standard., Results: For self-reported recent opioid agonist treatment, sensitivity was 78% (95% CI = 72, 83), specificity was 90% (95% CI = 86, 94), PPV was 90% (95% CI = 85, 93), and NPV was 79% (95% CI = 74, 84). For self-reported current opioid agonist treatment, sensitivity was 84% (95% CI = 78, 90), specificity was 87% (95% CI = 83, 91), PPV was 74% (95% CI = 67, 81), and NPV was 93% (95% CI = 89, 95)., Conclusions: Self-reported opioid agonist treatment measures were fairly accurate among PWID, with some exceptions. Inaccurate recall due to a lengthy lookback window may explain underreporting of recent treatment, whereas social desirability bias may have led to overreporting of current treatment. These validation data could be used in future studies of PWID to adjust for misclassification in similar self-reported treatment measures., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Aims: Drug checking services provide people who use drugs with chemical analysis results of their drug samples while simultaneously monitoring the unregulated drug market. We sought to identify and synthesize literature on the following domains: (a) the influence of drug checking services on the behaviour of people who use drugs; (b) monitoring of drug markets by drug checking services; and (c) outcomes related to models of drug checking services., Methods: Systematic review. A systematic literature search was conducted in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Scopus, Web of Science and Dissertations and Theses Global. Eligible studies were peer-reviewed articles and conference abstracts or grey literature, published in any language since 1990 and including original data on the domains. We assessed risk of bias for quantitative peer-reviewed articles reporting on behaviour or models of drug checking services using National Institutes of Health tools., Results: We screened 2463 titles and abstracts and 156 full texts, with 90 studies meeting inclusion criteria. Most (n = 65, 72.2%) were from Europe and used cross-sectional designs (n = 79, 87.7%). Monitoring of drug markets by drug checking services (n = 63, 70%) was the most reported domain, followed by the influence of drug checking services on behaviour (n = 31, 34.4%), including intent to use, actual use and disposal of the drug, and outcomes related to models of drug checking services (n = 17, 18.9%). The most common outcome measures were detection of unexpected substances (n = 50, 55.6%), expected substances (n = 44, 48.9%), new psychoactive substances (n = 40, 44.4%) and drugs of concern (n = 32, 36.5%) by drug checking services., Conclusions: Drug checking services appear to influence behavioural intentions and the behaviour of people who use drugs, particularly when results from drug checking services are unexpected or drugs of concern. Monitoring of drug markets by drug checking services is well established in Europe, and increasingly in North America. Concerns about drug contents and negative health consequences facilitate the use of drug checking services; lack of concern; trust in drug sellers; lack of accessibility of drug checking services; and legal and privacy concerns are barriers to use., (© 2021 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

This paper presents results of a research priority setting process focused on trans women living with and affected by HIV across Canada. It features data from semi-structured interviews and focus groups conducted with a diverse group of 76 trans women in five urban centers across the country on how they have navigated health and social service programming within their geographic context. The results focus on the structure and types of services. Respondents offered simple, yet creative ways to address barriers to vital services based on their individual and collective experiences. Notably, participants stressed the need for 1) trans-friendly and trans-specific services, 2) integrated health services, and aid in navigating complex, overlapping systems, and 3) comprehensive community-based services. They also suggest employing trans women as care coordinators or case managers in order to foster more trans-friendly environments and empower community members. We identify concrete ways to improve health and social services at the level of service delivery and program design, as well as recommendations for future participatory research. We close with an interrogation of trans people, and trans women living with and affected by HIV in particular, as 'hard to reach' populations., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Gender-affirming hormones have been shown to improve psychological functioning and quality of life among transgender and nonbinary (trans) people, yet, scant research exists regarding whether and why individuals take more or less hormones than prescribed. Drawing on survey data from 379 trans people who were prescribed hormones, we utilized multivariable logistic regression models to identify factors associated with hormone-dosing behaviors and content analysis to examine the reasons for dose modifications. Overall, 24% of trans individuals took more hormones than prescribed and 57% took less. Taking more hormones than prescribed was significantly associated with having the same provider for primary and gender-affirming care and gender-based discrimination. Income and insurance coverage barriers were significantly associated with taking less hormones than prescribed. Differences by gender identity were also observed. Addressing barriers to hormone access and cost could help to ensure safe hormone-dosing behaviors and the achievement trans people's gender-affirmation goals., Competing Interests: Competing interests The authors declare no competing interests.

Background: Previous Canadian studies have identified problems regarding health care access for transgender (trans) and nonbinary people, but all-ages national data have been lacking. This study describes access to care among trans and nonbinary people in Canada, and compares health care access across provinces or regions., Methods: We conducted a bilingual, multimode cross-sectional survey (Trans PULSE Canada) from July 26 to Oct. 1, 2019. We recruited trans and nonbinary people aged 14 years and older using convenience sampling. We assessed 5 outcomes: having a primary care provider, having a primary care provider with whom the respondent was comfortable discussing trans health issues, past-year unmet health care need, medical gender affirmation status, and being on a wait-list to access gender-affirming medical care. Average marginal predictions were estimated from multivariable logistic regression models with multiply imputed data., Results: The survey included 2873 participants, and 2217 surveys were analyzed after exclusions. Of the 2217 trans and nonbinary respondents, most had a primary care provider ( n = 1803; 81.4%, 95% confidence interval [CI] 79.8%-83.0%), with model-predicted probabilities from 52.1% (95% CI 20.2%-84.1%) in the territories to 92.9% (95% CI 83.5%-100.0%) in Newfoundland and Labrador. Of the respondents, 52.3% ( n = 1150; 95% CI 50.3%-54.2%) had a primary care provider with whom they were comfortable discussing trans health issues, and 44.4% ( n = 978; 95% CI 42.3%-46.4%) reported an unmet health care need. Among participants who needed gender-affirming medical treatment ( n = 1627), self-defined treatment completion ranged from an estimated 16.8% (95% CI 0.6%-32.5%) in Newfoundland and Labrador to 59.1% (95% CI 52.5%-65.6%) in Quebec. Of those who needed but had not completed gender-affirming care at the time of the study ( n = 1046), 40.7% ( n = 416; 95% CI 37.8%-43.6%) were on a wait-list, most often for surgery. These outcomes, with the exception of having a provider with whom one is comfortable discussing trans issues, varied significantly by province or region ( p < 0.05)., Interpretation: Participants reported considerable unmet needs or delays in primary, general and gender-affirming care, with significant regional variation. Our results indicate that, despite efforts toward equity in access to care for trans and nonbinary people in Canada, inequities persist., Competing Interests: Competing interests: None declared., (© 2021 CMA Joule Inc. or its licensors.)

Background: Transgender (trans) women face constrained access to gender-affirming HIV prevention and care. This is fueled in part by the convergence of limited trans knowledge and competency with anti-trans and HIV-related stigmas among social and healthcare providers. To advance gender-affirming HIV service delivery we implemented and evaluated 'Transgender Education for Affirmative and Competent HIV and Healthcare (TEACHH)'. This theoretically-informed community-developed intervention aimed to increase providers' gender-affirming HIV prevention and care knowledge and competency and reduce negative attitudes and biases among providers towards trans women living with and/or affected by HIV., Methods: Healthcare and social service providers and providers in-training (e.g., physicians, nurses, social workers) working with trans women living with and/or affected by HIV (n = 78) participated in a non-randomized multi-site pilot study evaluating TEACHH with a pre-post-test design. Pre- and post-intervention surveys assessed participant characteristics, intervention feasibility (e.g., workshop completion rate) and acceptability (e.g., willingness to attend another training). Paired sample t-tests were conducted to assess pre-post intervention differences in perceived competency, attitudes/biases, and knowledge to provide gender-affirming HIV care to trans women living with HIV and trans persons., Results: The intervention was feasible (100% workshop completion) and acceptable (91.9% indicated interest in future gender-affirming HIV care trainings). Post-intervention scores indicated significant improvement in: 1) knowledge, attitudes/biases and perceived competency in gender-affirming HIV care (score mean difference (MD) 8.49 (95% CI of MD: 6.12-10.86, p < 0.001, possible score range: 16-96), and 2) knowledge, attitudes/biases and perceived competency in gender-affirming healthcare (MD = 3.21; 95% CI of MD: 1.90-4.90, p < 0.001, possible score range: 9-63). Greater change in outcome measures from pre- to post-intervention was experienced by those with fewer trans and transfeminine clients served in the past year, in indirect service roles, and having received less prior training., Conclusions: This brief healthcare and social service provider intervention showed promise in improving gender-affirming provider knowledge, perceived competency, and attitudes/biases, particularly among those with less trans and HIV experience. Scale-up of TEACHH may increase access to gender-affirming health services and HIV prevention and care, increase healthcare access, and reduce HIV disparities among trans women., Trial Registration: ClinicalTrials.gov ( NCT04096053 )., (© 2021. The Author(s).)

Purpose: There is a need for ongoing behavioral surveillance of human immunodeficiency virus (HIV)/sexually transmitted infection (STI) risk among transgender women, using assessments adapted to this population. We therefore developed and piloted the Transgender Women's Internet Survey and Testing (TWIST) study, a cross-sectional behavioral survey of transgender women in the United States coupled with remote biospecimen collection and testing. Methods: Participants age 15+ were recruited by using social media advertisements. Participants were eligible to take the survey if they reported male sex at birth, identified as female or as a transgender woman, resided in the United States, and reported ever having oral, vaginal, or anal sex. We examined a number of behavioral indicators by age, county population density, and medical gender affirmation treatment, using multivariable regression modeling. A sample of respondents was invited to receive a home biospecimen collection kit for HIV/STI testing. Results: The 401 participants were mainly non-Hispanic white and younger than 25 years. Self-reported HIV prevalence was 1.3% (5/401), and almost half (47.1%, 189/401) did not know their HIV status. Receiving medical gender affirmation was strongly associated with past-year HIV and STI testing, independent of general health care engagement. Of the 155 participants invited to receive home biospecimen collection kits, 48 (31.0%) consented and of those, 21 (43.8%) returned specimens for testing. Conclusion: This pilot study successfully reached its recruitment target and generated useful behavioral measures from an online sample of transgender women. We anticipate that online recruitment combined with self-collection of biospecimens will serve as an innovative and scalable strategy for ongoing monitoring of HIV/STI behavioral trends among U.S. transgender women., Competing Interests: No competing financial interests exist., (Copyright 2021, Mary Ann Liebert, Inc., publishers.)