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Viral suppression with antiretroviral therapy (ART) is a critical component of UNAIDS objectives to end the HIV epidemic. Youth living with HIV (YLH) have worse viral suppression rates than adults. The aim of this study was to identify risk factors for viral non-suppression among YLH in Nigeria. A secondary analysis of enrollment data from the iCARE Nigeria study, collected April-October 2021 for 541 YLH comprised demographic, psychosocial, behavioral, clinical variables, and viral load quantification. Viral non-suppression was defined as viral load ≥ 200 copies/mL. Generalized linear models using Akaike information criterion for selection of indicator variables in a stepwise approach were used to determine the risk factors for viral non-suppression. The final analytic sample was 491 and the proportion of non-suppressed participants at baseline was 40%. In the final model, substance use (other than alcohol, tobacco and/or cannabis) (aOR = 3.20 [95% CI: 1.05, 10.34]), missed medication doses (aOR = 1.09 [95% CI: 1.04, 1.15]), and a higher number of self-reported medication barriers (e.g., forgot, busy, change in routine) (aOR = 1.08 [95% CI: 1.00, 1.16]) were associated with a higher likelihood of viral non-suppression. Being prescribed a first-line regimen (aOR = 0.28 [95% CI: 0.17, 0.44]), disclosure to at least one brother (aOR = 0.64 [95% CI: 0.42, 0.97]), and higher treatment outcome expectancies (e.g., taking medication will improve health) (aOR = 0.81 [95% CI: 0.66, 0.98]), were all associated with a lower likelihood of viral non-suppression. Viral non-suppression among YLH in Nigeria is associated with psychosocial and behavioral factors, including missed doses, medication barriers, treatment outcome expectancies, and disclosure, that are potential targets for intervention to achieve ART goals., Competing Interests: Declarations. Conflict of Interest: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.) more...

The HIV incidence rate continues to increase among youth, especially among young men who have sex with men (YMSM) and young transgender women (YTW). To date, behavioral intention has often been viewed as the likelihood of engaging in prevention behaviors and emphasized as a key antecedent for condom use, disclosure of serostatus, and PrEP use among people living with HIV. In addition, individuals with different sociodemographic factors may have varying degrees of HIV prevention intention, which is a critical knowledge needed to identify facilitators and barriers to HIV prevention intention. This is a secondary data analysis of baseline data from a randomized controlled trial (RCT) (N = 488). This study aimed to identify distinct, latent classes of HIV prevention intention among youth vulnerable to HIV acquisition and to understand the sociodemographic and contextual factors associated with each latent class. Latent class analysis was conducted to identify meaningful latent classes of youths based on HIV prevention intention. Class 1: "High condomless sex, low serosorting, low PrEP intention," Class 2: "High condomless sex, high serosorting, low PrEP intention," Class 3: "Moderate condom use, serosorting, low PrEP intention," and Class 4: "Moderate condom use, high serosorting, moderate PrEP intention" were identified. Significant differences were found in age, sexual orientation, level of education, current employment status, annual household income, housing/living arrangement, and relationship status. Overall, YMSM and YTW without a recent history of HIV testing or PrEP use may have particularly low intentions for HIV prevention, and therefore may be at higher risk for HIV infection., Competing Interests: Declarations. Conflic of Interest: The authors declare that there is no conflict of interest., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.) more...

Effective recruitment strategies are pivotal for informatics-based intervention trials success, particularly for people living with HIV (PLWH), where engagement can be challenging. Although informatics interventions are recognized for improving health outcomes, the effectiveness of their recruitment strategies remains unclear. We investigated the application of a social marketing framework in navigating the nuances of recruitment for informatics-based intervention trials for PLWH by examining participant experiences and perceptions. We used qualitative descriptive methodology to conduct semi-structured interviews with 90 research participants from four informatics-based intervention trials. Directed inductive and deductive content analyses were guided by Howcutt et al.'s social marketing framework on applying the decision-making process to research recruitment. The majority were male (86.7%), living in the Northeast United States (56%), and identified as Black (32%) or White (32%). Most participants (60%) completed the interview remotely. Sixteen subthemes emerged from five themes: motivation, perception, attitude formation, integration, and learning. Findings from our interview data suggest that concepts from Howcutt et al.'s framework informed participants' decisions to participate in an informatics-based intervention trial. We found that the participants' perceptions of trust in the research process were integral to the participants across the four trials. However, the recruitment approach and communication medium preferences varied between older and younger age groups. Social marketing framework can provide insight into improving the research recruitment process. Future work should delve into the complex interplay between the type of informatics-based interventions, trust in the research process, and communication preferences, and how these factors collectively influence participants' willingness to engage., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.) more...

Young men who have sex with men (YMSM) in Nigeria are ten times more likely to be living with HIV-1 than other young men. Due to stigma and criminalization of same-sex sexual behavior, YMSM sexual networks are likely to overlap with those of the general population, leading to a generalized HIV-1 epidemic. Due to limited research on social/sexual network dynamics related to HIV-1 in Nigeria, our study focused on YMSM and sought to assess the feasibility and acceptability of collecting social and sexual network data in Network Canvas from individuals newly diagnosed with HIV-1 in Ibadan, Nigeria. The Network Canvas software was piloted at three sites in Ibadan, Nigeria to collect social/sexual network data from 151 individuals newly diagnosed with HIV-1. Our study sample included 37.7% YMSM; participants reported a mean of 2.6 social alters and 2.6 sexual alters. From the 151 egos and 634 alters, 85 potential unique individuals (194 total) were identified; 65 egos/alters were collapsed into 25 unique individuals. Our success collecting network data from individuals newly diagnosed with HIV-1 in Ibadan demonstrates clear feasibility and acceptability of the approach and the use of Network Canvas to capture and manage these data., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.) more...

Adolescents and sexual minority men (SMM) are high priority groups in the United Nations' 2021 - 2016 goals for HIV prevention and viral load suppression. Interventions aimed at optimizing HIV prevention, testing and viral load suppression for adolescents must also attend to the intersectional realities influencing key sub-populations of SMM. Consequently, there is not a robust evidence-base to guide researchers and program partners on optimal approaches to implementing interventions with adolescent SMM. Using a multiple case study design, we integrated the Implementation Research Logic Model with components of the Consolidated Framework for Implementation Research and applied it as a framework for a comparative description of ten HIV related interventions implemented across five countries (Ghana, Kenya, Nigeria, Tanzania and United States). Using self-reported qualitative survey data of project principal investigators, we identified 17 of the most influential implementation determinants as well as a range of 17 strategies that were used in 90 instances to support intervention implementation. We highlight lessons learned in the implementation research process and provide recommendations for researchers considering future HIV implementation science studies with adolescent SMM., (© 2022. The Author(s).) more...

Adolescents and young adults (AYA) in low to middle income countries (LMIC) have poorer outcomes along each step in the HIV continuum of prevention and care compared to younger children or older adults. The use of mHealth technology provides a potentially promising implementation strategy for interventions to remedy these disparities. We therefore conducted a systematic review of the English literature and conference proceedings from January 1, 2000 to April 1, 2021 evaluating mHealth interventions targeting AYA along each step of the HIV continuum of care in LMIC. We identified 27 mHealth interventions across the HIV continuum, with no interventions addressing transition from pediatric to adult care. The majority of studies were single arm, uncontrolled or underpowered, with few randomized trials resulting in mixed and inconclusive outcomes. mHealth interventions have potential to remedy disparities along the HIV continuum of care for AYA in LMIC but larger, powered randomized trials are needed., (© 2022. The Author(s).) more...

The COVID-19 pandemic has disrupted sexual health services among those most vulnerable to HIV acquisition, such as adolescent men who have sex with men (AMSM). We sought to characterize the changes in sexual-risk behaviors, HIV and other STI testing, and pre-exposure prophylaxis (PrEP) use among a longitudinal cohort of AMSM aged 13 to 18 years before and during the COVID-19 pandemic. We observed a significant decline in HIV testing and a marginal decrease in other STI testing since the pandemic began in March 2020. Outreach efforts and innovative remote delivery of sexual health services are needed to support access to healthcare services among AMSM as the pandemic persists., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.) more...

A large proportion of HIV infections among men who have sex with men occur within primary partnerships, however, there is a lack of research focused on serodiscordant male couples. We used baseline data collected as part of Project Stronger Together-a randomized controlled trial to improve treatment outcomes among 155 serodiscordant male couples. We described engagement in HIV care/prevention using the HIV treatment cascade and PrEP care continuum. Among partners living with HIV, 86.5% were linked to care, 77.4% retained in care, 81.3% prescribed ART, 60.7% adherent, and 67.7%virally suppressed. Among HIV-negative partners, 62.6% were willing to take PrEP, 48.4% had ever taken PrEP, and 26.5% were adherent to PrEP. Black partners living with HIV had lower odds of being virally suppressed compared to White partners. Our findings provide evidence to suggest designing programs to address the racial disparities in viral suppression, addressing barriers to HIV prevention/treatment, and improving PrEP education., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.) more...

Engagement in HIV care and a high level of antiretroviral therapy (ART) adherence for people living with HIV is crucial to treatment success and can minimize the population burden of the disease. Despite this, there is a critical gap in HIV prevention science around the development of interventions for serodiscordant male couples. This paper reports on the results of a randomized controlled trial to assess the efficacy of Stronger Together, a dyadic counseling intervention aimed at increasing engagement in and optimizing HIV care among serodiscordant male couples in Atlanta, GA, Boston, MA, and Chicago, IL. Between 2014 and 2017, 159 male serodiscordant couples (total N = 318) in Atlanta, GA, Boston, MA, and Chicago, IL were enrolled and equally randomized to either the Stronger Together intervention arm (a three-session dyadic intervention involving HIV testing and adherence counseling) or a standard of care (SOC) control arm. Couples completed individual study assessments via an audio computer assisted self-interviewing (ACASI) system at baseline, 6, 12 and 18 months. Primary outcomes included being prescribed and currently taking ART, and fewer missed doses of ART in the past 30 days; because the trial was not powered to examine viral suppression, we examined this as an exploratory outcome. Longitudinal data analysis was by an intention-to-treat approach. Participants ages ranged from 18 to 69 (mean = 35.9), and are predominantly white (77.5%), and college educated (68.4% earned a college degree or higher). Participants randomized to the Stronger Together arm had a significantly greater odds of being prescribed and currently taking ART over time than those in the SOC arm (at 12 months OR 2.75, 95%CI 1.35-4.67, p-value 0.020, and at 18 months OR 2.91, 95%CI 1.61-4.88, p-value 0.013). Similarly, those in the Stronger Together arm had a significantly lower odds of missing a dose of ART in the past 30 days over time compared to those in the SOC arm (at 12 months OR 0.28, 95%CI 0.09-0.81, p-value 0.019, and at 18 months OR 0.25, 95%CI 0.07-0.82, p-value 0.023). Among male couples in serodiscordant relationships, the Stronger Together intervention resulted in significantly improved HIV treatment outcomes at both 12 and 18 months of follow-up. This trial is the first to date to demonstrate evidence of efficacy for a dyadic counseling intervention and has the potential to fill a critical gap in secondary HIV prevention interventions for serodiscordant male couples. more...

The TransLife Care (TLC) project was developed to address the structural factors that act as barriers to HIV care among transgender women of color. The purpose of this study was to evaluate the feasibility and initial efficacy of the TLC project; primary HIV care outcomes included linkage to HIV care, engagement in care, retention in care, use of ART and viral suppression among N = 120 participants. In multivariable analysis, receipt of the intervention (versus none), was associated with any HIV care visit (aOR 2.05; 95% CI 1.25-3.37; p = 0.005), more total HIV care visits (aRR 1.45; 95% CI 1.09-1.94; p = 0.011), being retained in care (aOR 1.58; 95% CI 1.03-2.44; p = 0.038), and having a viral load test done (aOR 1.95; 95% CI 1.23-3.09; p = 0.004). We conclude that a structural intervention, designed and delivered by the focus population, that directly addresses social determinants, is feasible and efficacious to promote HIV care engagement among transgender women of color. more...

Because of stigmatization of and discrimination against lesbian, gay, bisexual, transgender, and other sexual and gender minority (SGM) people in East Africa, there is paucity of SGM-focused sexual health research. Technology-based outreach efforts may represent a feasible way to reach and engage this population. They also may be a way to deliver important yet sensitive sexual health information in a stigma-free, anonymous atmosphere. We explored the feasibility of recruiting and surveying East African SGM adults online, and examined their interest in technology-based sexual health programming. Over a 14-month period, 2451 respondents were surveyed. They were, on average, 26.7 years of age. Fifty-four percent identified as lesbian, gay, and/or bisexual (LGB); a similar percentage (49%) reported having sex with a same-sex partner. Sixteen percent identified as gender minority (i.e. transgender or non-binary); and 29% were assigned female at birth. Almost half (48%) of SGM adults expressed interest in an SGM-focused healthy sexuality program delivered online. Enthusiasm also was noted for email (43%) and text messaging (41%). Compared to face-to-face settings, technology-based settings were more commonly  appraised  as the safest mode through which one could engage in sexual health programming. People who had a same sex partner and those who identified as sexual minority were especially likely to want to engage in technology-based programs. Interest in technology-based programming was similar for adults across gender identities, sex assigned at birth, and age however. Findings suggest that technology may be an underutilized opportunity to reach and engage SGM East Africans in a safe and private manner. Given levels of acceptability indicated by SGM adults across age, sex assigned at birth, and gender and sexual identities in this study, it seems possible that technology-based sexual health and HIV prevention and intervention programs could have the potential to be transformative in East Africa. more...

Transgender women are disproportionately affected by HIV and experiences of social adversity that may interfere with engagement in care and viral suppression. We used latent class analysis to examine patterns of social adversity and their impact on HIV care continuum outcomes in an urban sample of transgender women of color. Participants (n = 224) were median age 29 and 86% non-Hispanic Black. Lack of resources, unemployment, and housing instability were reported by over 50%, and 41% reported history of incarceration. Latent class analysis identified 2 distinct classes representing higher and lower levels of social adversity. In latent class regression, membership in the higher social adversity class was associated with statistically significantly lower odds of viral suppression and HIV care engagement in univariate analysis; when adjusted for age, race, and recruitment site the association remained statistically significant for viral suppression (aOR 0.38, 95% CI 0.18-0.79; chi-square = 6.681, d.f. = 1, p = 0.010), though not for HIV care engagement. Our findings highlight the impact of socio-structural barriers on engagement in the HIV care continuum among transgender women. more...

Sexual agreements are an important HIV risk reduction strategy enacted by men in male-male partnerships. Greater levels of relationship quality have been associated with sexual agreement formation and adherence. However, current evidence supporting the associations between relationship quality and sexual agreements for male dyads is based primarily on the responses of just one partner. Understanding that relationship quality and decisions about sexual agreements are inherently influenced by both partners, the present analysis uses dyadic-level data to examine the sexual agreements among 199 HIV serodiscordant and seroconcordant male dyads (n = 398 individuals). Specifically, the analysis examines measures of love, trust, and conflict style as they relate to (1) the type of agreement established, (2) concordance in agreement reporting, (3) satisfaction with the agreement, and (4) broken agreements. A discrepancy in love between partners was associated with the type of agreement established, whether they reported the same agreement type, and whether one of the partners reported a broken agreement, but it was not associated with either partner's satisfaction with the agreement. A discrepancy in trust was associated with agreement concordance and agreement breaks, but it was not associated with the type of agreement established or satisfaction with the agreement. Lastly, a discrepancy in conflict style was associated with each of the agreement outcomes. Future research and intervention efforts should focus on understanding the behavioral and communication skills necessary for couples to make successful sexual agreements. more...

Emtricitabine/tenofovir disoproxil fumarate as pre-exposure prophylaxis (PrEP) can prevent HIV infection among at-risk individuals, including young transgender women (YTW). We used baseline data from 230 HIV-uninfected YTW (ages 16-29 years) who were enrolled in Project LifeSkills during 2012-2015. We examined factors associated with perceived acceptability of PrEP use (mean score = 23.4, range 10.0-30.0). Participants were largely transgender women of color (67%) and had a mean age of 23 years (SD = 3.5). In an adjusted multiple linear regression model, PrEP interest (β = 3.7, 95% CI 2.2-5.2) and having a medical provider who meets their health needs (β = 2.9, 95% CI 1.3-4.4) was associated with higher PrEP acceptability scores, whereas younger age (21-25 vs 26-29 years) (β = -2.0, 95% CI - 3.6 to - 0.4) and reporting transactional sex in the past 4 months (β = - 1.5, 95% CI - 3.0 to - 0.1) was associated with lower PrEP acceptability scores (all p values < 0.05). Enhancing PrEP-related interventions by addressing the unique barriers to uptake among YTW of younger age or those with history of transactional sex could bolster PrEP acceptability for this population. more...

Pre-exposure prophylaxis (PrEP) is efficacious to prevent HIV infection, however, uptake among young men who have sex with men (YMSM) is relatively low. The purpose of this study was to describe PrEP use and related factors in a representative sample of YMSM in two cities, Chicago and Houston. YMSM, ages 16-29, were recruited via respondent-driven sampling (RDS) from 2014 to 2016. Correlates of PrEP uptake were assessed in weighted multivariable logistic regression models. A total of 12.2% of participants (of 394) reported ever taking PrEP; Black YMSM had the lowest rates of uptake (4.7%) and Whites the highest (29.5%). In a multivariable regression model, having an HIV positive sex partner, reporting recent group sex, peer network size, and city (Chicago) were significantly and positively associated with use of PrEP, while Black race was negatively associated with it. Given evidence of racial/ethnic disparities in PrEP uptake in this study, further research is needed to identify potential mechanisms of action and points of intervention. more...

Young men who have sex with men continue to be highly affected by HIV. To improve understanding of the role that multiple co-occurring health issues (i.e., syndemics) play in HIV acquisition, sophisticated modeling methods are needed. The purpose of this study was to use structural equation modeling to understand the structure of the syndemic and to test its longitudinal association with condomless anal sex. Data are from a longitudinal study of 450 YMSM. A primary syndemic component comprised of substance use, violence, and internalizing mental health factors significantly predicted the number of condomless anal sex partners in the full sample. Analyses exploring associations by race/ethnicity found a significant association among White YMSM, but not among Black or Latino YMSM. Higher-order factor modeling suggests these psychosocial factors form a syndemic in all racial/ethnic groups, but the syndemic, as conceptualized here, may be less relevant to racial/ethnic minority YMSM., Competing Interests: Brian Mustanski declares that he has no conflict of interest. Gregory Phillips declares that he has no conflict of interest. Daniel Ryan declares that he has no conflict of interest. Gregory Swann declares that he has no conflict of interest. Lisa Kuhns declares that she has no conflict of interest. Rob Garofalo declares that he has no conflict of interest. more...

Transgender women are at high risk of HIV infection, with younger transgender women (YTW) particularly vulnerable. Pre-Exposure Prophylaxis (PrEP) has shown efficacy in reducing HIV acquisition, but little is known about PrEP indication or initiation among YTW. Baseline data from 180 YTW age 18-29 years enrolled in Project LifeSkills, an on-going HIV prevention intervention for YTW, were analyzed to examine factors associated with PrEP indication. The sample (mean age = 23.4, SD = 3.2) was comprised largely of women of color (69 %) and of low socioeconomic status (71 % unemployed). Overall, 62 % met criteria for PrEP indication, but only 5 % reported ever taking PrEP. Factors associated with increased odds of PrEP indication were: PrEP interest (aOR 3.24; 95 % CI 1.44, 7.33), number of recent anal sex partners (aOR 1.23; 95 % CI 1.04, 1.46), and lower collective self-esteem scores (aOR 0.67; 95 % CI 0.47, 0.94). Despite high levels of PrEP indication, there remain low levels of PrEP awareness and uptake among YTW. more...

HIV-positive adolescents and young adults often experience suboptimal medication adherence, yet few interventions to improve adherence in this group have shown evidence of efficacy. We conducted a randomized trial of a two-way, personalized daily text messaging intervention to improve adherence to antiretroviral therapy (ART) among N = 105 poorly adherent HIV-positive adolescents and young adults, ages 16-29. Adherence to ART was assessed via self-reported visual analogue scale (VAS; 0-100 %) at 3 and 6-months for mean adherence level and proportion ≥90 % adherent. The average effect estimate over the 6-month intervention period was significant for ≥90 % adherence (OR = 2.12, 95 % CI 1.01-4.45, p < .05) and maintained at 12-months (6 months post-intervention). Satisfaction scores for the intervention were very high. These results suggest both feasibility and initial efficacy of this approach. Given study limitations, additional testing of this intervention as part of a larger clinical trial with objective and/or clinical outcome measures of adherence is warranted. more...

Young men who have sex with men (YMSM) are disproportionately infected with HIV/AIDS and there are few prevention programs with published efficacy for this population. This study evaluated the feasibility, acceptability, and preliminary efficacy of an online, interactive, and highly engaging HIV prevention program called Keep It Up! The intervention was designed to be delivered to diverse YMSM upon receiving an HIV negative text result, with the goal for them to "Keep It Up" and stay negative. In a randomized clinical trial, the intervention was compared to an online didactic HIV knowledge condition. The study sample included 102 sexually active YMSM. Participants reported completing online modules in settings that were private and not distracting. Mixed methods data showed intervention participants felt the program was valuable and acceptable. Compared to the control condition, participants in the intervention arm had a 44 % lower rate of unprotected anal sex acts at the 12-week follow-up (p < 0.05). more...

Youth living with HIV/AIDS (YLH) face unique challenges to optimal adherence to antiretroviral therapy (ART). Accurate, real-time methods to assess adherence are needed to facilitate early intervention and promote viral suppression. The purpose of this study was to assess the feasibility and validity of interactive text message response (ITR) as a measure of adherence to ART among YLH. This study was part of a larger pilot text message reminder intervention conducted at a US community-based, LGBT-focused health center providing clinical services to YLH. Eligibility criteria for this pilot study included HIV-positive serostatus, aged 14-29, use of personal cell phone, English-speaking, and on ART with demonstrated adherence difficulties. During the 24-week study period, participants received personalized daily short message system reminders with a follow-up message 1 hour later asking whether they took medication and directing a response via return text message. To determine whether or not ITR would be a feasible, valid measure of adherence, we calculated the proportion of positive responses indicating medication had been taken divided by the total number of messages requesting a response and compared this response rate to a self-reported adherence measure, the visual analogue scale (VAS). Participants (n = 25) were on average 23 years old, largely male (92%), Black (60%) and behaviorally infected (84%). Over the course of the intervention, study participants responded to prompts via text to indicate whether or not they had taken their medication approximately 61% of the time. The overall mean ITR adherence rate (i.e., positive responses) was 57.4% (SD = 28.5%). ITR and VAS measures were moderately, positively correlated (r = 0.52, p < 0.05) during the first 6 weeks of the study period. ITR adherence rates were significantly higher on weekdays versus weekends (p < 0.05). This pilot study showed both moderate responsiveness of individuals to daily ITR and a moderate correlation of ITR adherence rates with a reliable measure during the first 6 weeks of the study, suggesting that this method, with additional effort and improvements, may be a helpful tool to identify and respond to adherence patterns in real-time. more...

Pre-exposure prophylaxis (PrEP) is a new strategy for reducing the risk of HIV infection; however, questions about the likelihood of use remain. As part of an ongoing longitudinal study of YMSM, interest in PrEP use under various conditions of side-effects, dosing, and effectiveness were assessed. Participants aged 16-20 living in Chicago and the surrounding areas were recruited beginning December 2009, using a modified form of respondent driven sampling. A cross-sectional sample of 171 HIV negative YMSM interviewed approximately 6 months after initial enrollment was analyzed. This sample was somewhat interested in adopting PrEP as an HIV prevention strategy, particularly if the dosing and side-effects burden was low and the perceived benefits were high. PrEP interest was unrelated with drug use and number of sexual partners, but negatively correlated with number of unprotected anal sex acts. The scale was positively associated with intentions for use in specific risk situations. more...

This study examined the HIV risk behaviors and life experiences of 151 transgender female youth, ages 15-24, in Los Angeles and Chicago. Descriptive analyses and logistic regression modeling were used to identify life factors associated with ever having engaged in sex work. Sixty-seven percent of participants had ever engaged in sex work and 19% self-reported being HIV positive. Many factors were significantly associated with sex work for this sample population. A final multivariate logistic regression model found that lower education status, homelessness, use of street drugs, and perceived social support remained significantly associated with sex work when controlling for other factors. Findings highlight the complex HIV risk environment and suggest a need for sex work initiation research for transgender female youth. HIV prevention efforts for this population need to include broad-based approaches that take into account individual, social, and community-level factors relevant to the lives of transgender female youth. more...