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Background: Information is lacking on the relative effectiveness and cost effectiveness--in a primary-care setting--of leukotriene receptor antagonists (LTRAs) as an alternative to inhaled corticosteroids (ICS) for initial asthma controller therapy.Objective: To compare the cost effectiveness of LTRAs versus ICS for patients initiating asthma controller therapy.Methods: An economic evaluation was conducted alongside a 2-year, pragmatic, randomized controlled trial set in 53 primary-care practices in the UK. Patients aged 12-80 years with asthma and symptoms requiring regular anti-inflammatory therapy (n = 326) were randomly assigned to LTRAs (n = 162) or ICS (n = 164). The main outcome measures were the incremental costs per point improvement in the Mini Asthma Quality of Life Questionnaire, per point improvement in the Asthma Control Questionnaire and per QALY gained from the UK NHS and societal perspectives.Results: Over 2 years, resource use was similar between the two treatment groups, but the cost to society per patient was significantly higher for the LTRA group, at pounds sterling 711 versus pounds sterling 433 for the ICS group (adjusted difference pounds sterling 204; 95% CI 74, 308) [year 2005 values]. Cost differences were driven primarily by differences in prescription drug costs, particularly study drug costs. There was a nonsignificant (imputed, adjusted) difference between treatment groups, favouring ICS, in QALYs gained at 2 years of -0.073 (95% CI -0.143, 0.010). Therapy with LTRAs was, on average, a dominated strategy, and, at a threshold for willingness to pay of pounds sterling 30,000 per QALY gained, the probability of LTRAs being cost effective compared with ICS was approximately 3% from both societal and NHS perspectives.Conclusions: There is a very low probability of LTRAs being cost effective in the UK, at 2005 values, compared with ICS for initial asthma controller therapy.Trial Registration: UK National Research Register N0547145240; Controlled Clinical Trials ISRCTN99132811. [ABSTRACT FROM AUTHOR]

Background: Information is lacking on the relative effectiveness and cost effectiveness--in a real-life primary-care setting--of leukotriene receptor antagonists (LTRAs) and long-acting beta2 adrenergic receptor agonists (beta2 agonists) as add-on therapy for patients whose asthma symptoms are not controlled on low-dose inhaled corticosteroids (ICS).Objective: To estimate the cost effectiveness of LTRAs compared with long-acting beta2 agonists as add-on therapy for patients whose asthma symptoms are not controlled on low-dose ICS.Methods: An economic evaluation was conducted alongside a 2-year, pragmatic, randomized controlled trial set in 53 primary-care practices in the UK. Patients aged 12-80 years with asthma insufficiently controlled with ICS (n = 361) were randomly assigned to add-on LTRAs (n = 176) or long-acting beta2 agonists (n = 185). The main outcome measures were the incremental cost per point improvement in the Mini Asthma Quality of Life Questionnaire (MiniAQLQ), per point improvement in the Asthma Control Questionnaire (ACQ) and per QALY gained from perspectives of the UK NHS and society.Results: Over 2 years, the societal cost per patient receiving LTRAs was pounds sterling 1157 versus pounds sterling 952 for long-acting beta2 agonists, a (significant, adjusted) increase of pounds sterling 214 (95% CI 2, 411) [year 2005 values]. Patients receiving LTRAs experienced a non-significant incremental gain of 0.009 QALYs (95% CI -0.077, 0.103). The incremental cost per QALY gained from the societal (NHS) perspective was pounds sterling 22,589 (pounds sterling 11,919). Uncertainty around this point estimate suggested that, given a maximum willingness to pay of pounds sterling 30,000 per QALY gained, the probability that LTRAs are a cost-effective alternative to long-acting beta2 agonists as add-on therapy was approximately 52% from both societal and NHS perspectives.Conclusions: On balance, these results marginally favour the repositioning of LTRAs as a cost-effective alternative to long-acting beta2 agonists as add-on therapy to ICS for asthma. However, there is much uncertainty surrounding the incremental cost effectiveness because of similarity of clinical benefit and broad confidence intervals for differences in healthcare costs.Trial Registration: UK National Research Register N0547145240; Controlled Clinical Trials ISRCTN99132811. [ABSTRACT FROM AUTHOR]

Nucleotide-binding domain and leucine-rich repeat containing receptors (NLRs) are intracellular proteins mainly involved in pathogen recognition, inflammatory responses, and cell death. Until recently, the function of the family member NLR caspase recruitment domain (CARD) containing 5 (NLRC5) has been a matter of debate. It is now clear that NLRC5 acts as a transcriptional regulator of the major-histocompatibility complex (MHC) class I. In this review we detail the development of our understanding of NLRC5 function, discussing both the accepted and the controversial aspects of NLRC5 activity. We give insight into the molecular mechanisms, and the potential implications, of NLRC5 function in health and disease.

Background: Drug overdose deaths increased by 50 % between 2017 and 2021 in San Francisco. Little is known about non-fatal overdose, which heralds future risk for morbidity and overdose death. We assessed non-fatal overdose, access to drug treatment, and overdose prevention service utilization among people who inject drugs (PWID) in San Francisco in 2022., Methods: Data were from the National HIV Behavioral Surveillance (NHBS), a cross-sectional survey among PWID recruited by respondent-driven sampling from June-December 2022. Participants self-reported their experience of overall overdose. Logistic regression analysis identified factors associated with non-fatal overdose., Results: Of 521 PWID, 120 (23.0 %) experienced non-fatal overdose; 207 (39.7 %) frequently injected methamphetamine and 175 (33.6 %) frequently injected heroin in the past 12 months. PWID who experienced non-fatal overdose were more likely to reside in the low-income neighborhoods (25.9 % vs. other neighborhoods 16.8 %, p = 0.022) in the past 12 months. Less than half (43.7 %) of PWID who experienced non-fatal overdose received overdose treatment. Compared to those who did not try to access treatment, adjusted odds of non-fatal overdose was 1.89 times higher among PWID who attempted to access drug treatment but were unable to (p = 0.035, 95 % CI 1.05-3.43); and 1.86 times higher among PWID who attempted to obtain medications to treat drug use but were unable to in the past 12 months (p = 0.049, 95 % CI: 1.00-3.43)., Conclusions: Non-fatal overdose was highly prevalent among PWID, including those who frequently inject stimulants. Public health surveillance will need to be vigilant in monitoring stimulant use and tracking fentanyl contamination in non-opioid drugs. PWID who were most engaged in harm reduction practices were also the most likely to experience non-fatal overdose. Expansion of substance use and overdose treatment, naloxone, fentanyl test strips, and safe drug use education are needed to reduce risk of overdose deaths among PWID., Competing Interests: Declaration of competing interest The authors have no conflicts of interest including financial or non-financial., (Copyright © 2024. Published by Elsevier B.V.)

Background: Transgender women (hereafter "trans women") face social marginalization, stigma, and discrimination and experience a high burden of HIV. More recently, trans women have been identified as having a high risk for hepatitis C (HCV) infection. The interaction between these two diseases and the risks for HIV/HCV co-infection among trans women are understudied., Objective: To characterize epidemiological, behavioral, and socio-structural interactions between HIV and HCV infections among trans women., Methods: This cross-sectional study examined data from a community-based survey of trans women in San Francisco recruited through respondent-driven sampling (RDS) in 2019/2020. Face-to-face interviews collected data on demographics, medical history, drug injection practices, sexual behavior, and socio-structural factors (e.g., poverty, housing insecurity, incarceration, social support). HIV and HCV antibodies were detected using oral fluid rapid tests and prior diagnosis and treatment were collected by self-report. Blood specimens were collected to confirm antibodies using ELISA. Multinomial logistic regression analysis characterized factors associated with HIV infection alone, HCV infection alone, and HIV/HCV co-infection compared to neither infection., Results: Among 201 trans women recruited, HIV prevalence was 42.3%; HCV infection by history or current seroprevalence was 28.9%; evidence for both HIV and HCV infection was present for 18.9%. Two-thirds of trans women (67.2%) had been incarcerated; 30.8% had ever injected drugs. History of injection drug use and receiving emotional support from family were factors found in common for HIV infection, HCV infection, and HIV/HCV co-infection compared to no infection. Having a sexual partner who injects drugs was associated with HIV infection alone. Not lacking care due to cost and older age were associated with co-infection. Older age was also associated with HCV infection. Of trans women with HIV infection, 91.8% had accessed HIV care, whereas only 62% with HCV had accessed some form of care., Conclusions: Our study found high levels of HIV, HCV, and HIV/HCV co-infection among trans women in San Francisco. We found common associations between HIV and HCV through injection practices and emotional support, but having a sexual partner who injects drugs was not associated with HCV infection alone or co-infection. We note a substantial gap in the treatment of HCV for trans women, including those in HIV care, that needs to be urgently addressed., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Chiu 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.)

Background: Young adult (18-30 years) people who inject drugs (PWID) face high hepatitis C virus (HCV) prevalence. In San Francisco, where >60% of PWID lack stable housing, barriers hinder HCV treatment access. We assessed progress towards the World Health Organization's (WHO) HCV elimination goal of an 80% reduction in incidence over 2015-2030, focusing on young (YPWID) and unstably housed PWID in San Francisco., Methods: We developed a dynamic HCV transmission model among PWID, parameterized and calibrated using bio-behavioural survey datasets from San Francisco. This included 2018 estimates for the antibody-prevalence among PWID (77%) and care cascade estimates for HCV for YPWID (72% aware of their status and 33% ever initiating treatment). Based on programmatic data, we assumed a 53.8% reduction in testing and 40.7% decrease in treatment from 2020 due to the COVID-19 pandemic, which partially rebounded from April 2021 with testing rates then being 31.1% lower than pre-pandemic rates and treatment numbers being 19.5% lower. We simulated different scenarios of how services changed after the pandemic to project whether elimination goals would be met., Results: Continuing post-pandemic rates of testing and treatment, the model projects an 83.3% (95% credibility interval [95% CrI]:60.6-96.9%) decrease in incidence among PWID over 2015-2030 to 1.5/100pyrs (95% CrI:0.3-4.4) in 2030. The probability of achieving the elimination goal by 2030 is 62.0%. Among YPWID and unstably housed PWID, the probability of achieving the elimination goal by 2030 is 54.8 and 67.6%, respectively. Importantly, further increasing testing and treatment rates to pre-pandemic levels by 2025 only results in a small increase in the probability (67.5%) of the elimination goal being achieved among all PWID by 2030, while increased coverage of medication for opioid use disorder among YPWID and/or housing interventions results in the probability of achieving elimination increasing to over 75%., Conclusion: The COVID-19 pandemic impeded progress toward achieving HCV elimination. Our findings indicate that existing partial rebounds in HCV testing and treatment may achieve the elimination goal by 2030, with an additional scale-up of interventions aimed at YPWID or unstably housed PWID ensuring San Francisco is likely to achieve elimination by 2030., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: P.V. received an unrestricted research grant from Gilead that is not related to this study. M.D.M .received investigator sponsored research (ISR) funding from Gilead Sciences for research not related to this study. S.N.F. acknowledges consulting support from Gilead Sciences and from End Hep C SF; neither are related to this study. All other authors have no competing interests to report. For the purpose of open access, the author has applied a Creative Commons Attribution (CC BY) license to any Author Accepted Manuscript version arising., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: The transition to the "test-and-treat" policy in Nepal in 2017, coupled with the rapid initiation of antiretroviral therapy (ART) in 2020, necessitates an in-depth understanding of factors influencing ART initiation and retention. This study investigates these factors from the perspectives of healthcare providers, families/communities, and people living with HIV (PLHIV)., Methods: Employing a qualitative design, in-depth interviews were conducted with 24 ART clients and 26 healthcare providers across different provinces of Nepal. A comprehensive interview guide facilitated the exploration of experiences and perceptions. Interviews were transcribed verbatim, and thematic analysis was applied to distill key insights. Guided by a socio-ecological model, interviews were analyzed to identify the barriers and facilitators to ART initiation and continuation at the individual, family/community, and health system levels., Results: Facilitators and barriers were identified at three levels. Individual-level facilitators included fear of death, perceived health benefits, knowledge about HIV/ART, confidentiality, and financial support. Barriers encompassed concerns about lifelong medication, side effects, denial of HIV status, fear of disclosure, and financial constraints. At the family/community level, support from family and community health workers facilitated ART adherence, while social stigma and discrimination posed barriers. The health system's role was dual; the provision of free treatment, a client tracking system and a robust drug supply chain were facilitators, whereas logistical challenges and service accessibility during the COVID-19 pandemic were notable barriers., Conclusions: This study highlights the various factors that influence ART initiation and retention in Nepal during the test-and-treat era. Tailored interventions should focus on increasing awareness about HIV and ART, strengthening healthcare systems, ensuring availability of medications, and providing accessible treatment during service disruptions. Furthermore, these interventions should encourage supportive environments at the individual, community, and healthcare system levels. Taking this holistic approach is essential for effectively implementing ART and achieving long-term health outcomes in light of changing public health policies., (© 2024. The Author(s).)

Tumour-host immune interactions lead to complex changes in the tumour microenvironment (TME), impacting progression, metastasis and response to therapy. While it is clear that cancer cells can have the capacity to alter immune landscapes, our understanding of this process is incomplete. Herein we show that endocytic trafficking at the plasma membrane, mediated by the small GTPase ARF6, enables melanoma cells to impose an immunosuppressive TME that accelerates tumour development. This ARF6-dependent TME is vulnerable to immune checkpoint blockade therapy (ICB) but in murine melanoma, loss of Arf6 causes resistance to ICB. Likewise, downregulation of ARF6 in patient tumours correlates with inferior overall survival after ICB. Mechanistically, these phenotypes are at least partially explained by ARF6-dependent recycling, which controls plasma membrane density of the interferon-gamma receptor. Collectively, our findings reveal the importance of endomembrane trafficking in outfitting tumour cells with the ability to shape their immune microenvironment and respond to immunotherapy., (© 2024. The Author(s).)

HIV disproportionately affects Black/African Americans (AA), while PrEP is under-utilized by Black/AA, women, and people who inject drugs (PWID). In San Francisco, California's National HIV Behavioral Surveillance among PWID in 2022, Black/AA women were the least likely to be tested for HIV among all groups by sex and race/ethnicity and the least likely to be aware of PrEP among women. Yet, Black/AA women were no less likely to see a healthcare provider in the last year. Data suggest that providers' failure to discuss and address HIV risk with Black/AA female PWID is a major barrier to accessing effective care and prevention. El VIH afecta de manera desproporcionada a Black/afroamericanos (AA), mientras que la PrEP está infrautilizada por los Black/AA, las mujeres y las personas que se inyectan drogas (PWID). En la National HIV Behavioral Surveillance de PWID de San Francisco, California en 2022, las mujeres Black/AA eran las que menos probabilidades tenían de someterse a la prueba del VIH entre todos los grupos por sexo y raza/etnia y las que menos probabilidades tenían de conocer la PrEP entre las mujeres. Sin embargo, las mujeres Black/AA no tenían menos probabilidades de acudir a un profesional sanitario en el último año. Los datos sugieren que el hecho de que los proveedores no hablen ni aborden el riesgo de VIH con las PWID de raza Black/AA es un obstáculo importante para acceder a una atención y prevención eficaces., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Young gay, bisexual, and other men who have sex with men (YMSM) in Latin America experience disproportionately high rates of HIV. While new case numbers have stabilised in other demographics, the incidence of HIV in this particular group continues to rise. We estimated the prevalence of HIV and sexually transmitted infections (STI) and identified correlates of new HIV diagnoses among YMSM in Brazil., Methods: Conectad@s was a respondent-driven sampling-based study to recruit and engage YMSM in HIV prevention and treatment services in Rio de Janeiro, Brazil (November 2021-October 2022). Eligibility criteria were age 18-24 years and self-identification as MSM (cis/trans) or non-binary person who have sex with men. Participants underwent HIV/STI testing and completed a socio-behavioural questionnaire. We described baseline characteristics by HIV status and used logistic regression models to identify correlates of new HIV diagnoses. Trial ID: DERR1-10.2196/34885., Findings: Among 409 participants, 370 (90.5%) self-identified as cisgender men, nine (2.2%) transgender men, and 30 (7.3%) non-binary. Median age was 21 years (IQR: 20-23), with 80 (19.6%) aged 18-19 years. Most self-identified as Black or Pardo (70.6%); 109 (26.7%) never tested for HIV. HIV prevalence was 9.8%; 50% (n = 20/40) were newly diagnosed with HIV. Only nine participants ever used PrEP and three were currently using it. Overall, 133 (32.5%) reported sexual violence in their lifetime and 102 (24.9%) reported a suicide attempt. Prevalence of active syphilis, chlamydia, and gonorrhoea were 14.4%, 15.9%, and 14.7%, respectively. New HIV diagnoses were positively associated with engaging in high-risk behaviour (aOR 4.88 [95% CI: 1.88-13.40]) and anxiety (aOR 2.67 [95% CI: 1.01-7.70]), and negatively associated with ever disclosing sexual orientation (aOR 0.19 [95% CI: 0.04-0.92]) and HIV knowledge (aOR 0.77 [95% CI: 0.59-1.01])., Interpretation: High prevalence of HIV coupled with a high proportion of new HIV diagnoses underscore a potentially growing HIV epidemic among YMSM in Brazil., Funding: National Institutes of Health (NIH), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and Ministry of Health of Brazil., Competing Interests: All authors declare no competing interests., (© 2024 The Authors.)

Introduction: Little is known about differences in HIV risk for trans women by partner gender, particularly with respect to social determinants and partner-level circumstances that affect behavior. We examined differences in demographic, social determinants, and HIV-related risk behaviors for trans women with cis men and trans women sexual partners., Materials and Methods: Data are from a cross-sectional survey of trans women and their sexual partners conducted between April 2020 and January 2021. Interviews were held remotely during shelter-in-place due to Covid-19 via videoconference. Analysis characterizedassociations between HIV risk and protective behaviors comparing trans women with cisgender men partners to trans women with non-cisgender sexual partners., Results: A total of 336 sexual partners were identified from 156 trans women. Trans women with cis men partners had significantly less education and employment and more incarceration and recidivism than trans women with trans women partners. Trans women and their cisgender men partners had shared experiences of unstable housing, incarceration, and HIV. Trans women with cisgender men partners reported significantly more sex exchange partners, receptive condomless sex, receptive or insertive condomless sex while using substances, and HIV infection compared to trans women with trans women partners., Conclusions: Trans women with cisgender men sexual partners faced higher HIV risk than trans women with trans women sexual partners. These risks may be related to the social and economic drivers that both trans women and their cis men partners faced, including barriers to education and employment, along with incarceration and recidivism. Interventions focused on economic stability, workforce development and post incarceration re-entry support for housing and employment for trans women with cis men partners and the cisgender men partners as well may have the most impact on reducing HIV risk and incidence., Competing Interests: Competing interests: All authors declare no competing interests.

We aimed to estimate the proportions of childhood parental neglect, abuse, and rejection and to evaluate the co-occurrence of these experiences among transgender women in Rio de Janeiro, Brazil. This was a cross-sectional study with a convenience sample enrolled between July 2019 and March 2020, using an adapted version of the Childhood Trauma Questionnaire. Proportions and corresponding confidence intervals (CI) were calculated. Kendall correlation with Tau-b estimator was used in the bivariate analyses. We gathered data from 139 participants. The most prevalent types of childhood traumas were emotional abuse (60.43%, 95% CI [51.79, 68.62]), physical abuse (57.55%, 95% CI [48.90, 65.89]) and sexual abuse (44.60%, 95% CI [36.18, 53.27]). Severe to extreme physical and emotional abuse occurred among 40.29% (95% CI [32.06, 48.93]) and 5.75% (95% CI [2.51, 11.02]) of participants, respectively. The proportion of parental rejection (eviction) was 32.37% (95% CI [25.04, 40.69]) and occurred with the other forms of abuse, except sexual abuse. Multiple types of childhood abuse, neglect, and parental rejection were observed among transgender women in our sample. The harmful effects of childhood abuse on the mental and physical health of people in the transgender population are of concern, particularly considering the cumulative effect produced by the co-occurrence of such events and their harmful lifetime effects. It is urgently necessary to debate and formulate public policies to ensure the right to gender expression from childhood., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Clinical trials provide evidence that pre-exposure prophylaxis (PrEP) prevents HIV acquisition including through sharing of injection equipment among people who inject drugs (PWID). However, uptake among many populations at risk for HIV has been slow, particularly among PWID. We examined data from the National HIV Behavioral Surveillance (NHBS) from San Francisco in 2022 to measure PrEP uptake and identify factors associated with PrEP awareness among PWID. Of 479 PWID with HIV-negative or unknown HIV status, 54.9% were aware of PrEP, 5.9% had discussed PrEP with a healthcare provider, and 1.5% had used PrEP in the past year. Lack of PrEP awareness was associated with being age 50 years and older (adjusted odds ratio [aOR] 0.40, 95% CI 0.27-0.60), being men who have sex with women (vs. men who have sex with men, aOR 0.47, 95% CI 0.24-0.92), having a disability (aOR 0.58, 95% CI 0.35-0.95), using heroin as their most frequently injected drug (aOR 0.51, 95% CI, 0.34-0.78), not having tested for HIV, HCV, or an STD in the past year (aOR 0.43, 95% CI 0.28-0.64), and not having access to new sterile needles in the past year (aOR 0.28, 95%CI 0.08-1.00). We found negligible change in the awareness and uptake of PrEP among PWID since previously measured in NHBS in 2018. Low PrEP use among PWID may be addressed by increasing provider discussion of PrEP with their PWID patients and clients during routine care, expanding testing for injection-related infections among PWID, and integrating PrEP access into harm reduction programs., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Articular cartilage exhibits site-specific tissue inhomogeneity, for which the tissue properties may continuously vary across the articular surface. To facilitate practical applications such as studying site-specific cartilage degeneration, the inhomogeneity may be approximated with several distinct region-wise variations, with one set of tissue properties for one region. A clustering method was previously developed to partition such regions using cartilage indentation-relaxation and thickness mapping instead of simply using surface geometry. In the present study, a quantitative parameter based on streaming potential measurement was introduced as an additional feature to assess the applicability of the methodology with independent datasets. Experimental data were collected from 24 sets of femoral condyles, extracted from fresh porcine stifle joints, through streaming potential mapping, automated indentation, and needle penetration tests. K-means clustering and Elbow method were used to find optimal region partitions. Consistent with previous findings, three regions were suggested for either lateral or medial condyle regardless of left or right joint. The region shapes were approximately triangular or trapezoidal, which was similar to what was found previously. Streaming potentials were confirmed to be region-dependent, but not significantly different among joints. The cartilage was significantly thicker in the medial than lateral condyles. The region areas were consistent among joints, and comparable to that found in a previous study. The present study demonstrated the capability of region partitioning methods with different variables, which may facilitate new applications whenever site-specific tissue properties must be considered., Competing Interests: Declaration of competing 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 © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Many adolescents and young adults (AYAs; 10-24 years old) are excluded from HIV research because of social, ethical, and legal challenges with informed consent, resulting in limited AYA-focused data. We use a participatory approach to identify strategies for improving AYA consent processes in HIV research in low- and middle-income countries (LMICs)., Methods: We conducted a digital crowdsourcing open call for ideas to improve AYA consent to HIV research in LMICs. Crowdsourcing involves engaging a group of people in problem-solving, then sharing emergent solutions. Submissions were evaluated by 3 independent judges using predefined criteria, with exceptional strategies receiving prizes. Demographic data were collected, and textual data were qualitatively analyzed for emergent themes in barriers and facilitators for improving AYA consent in HIV research, guided by a socioecological model., Results: We received 110 strategies total; 65 were eligible for evaluation, 25 of which were identified as finalists. Fifty-eight participants from 10 LMICs submitted the 65 eligible submissions, of which 30 (52%) were 18 to 24 years old. Thematic analysis identified 10 barriers to AYA consent, including HIV stigma, limited education, and legal/regulatory barriers. Strategies for improving AYA consent processes revealed 7 potential facilitators: enhancing AYA engagement in research, involving parents/guardians, improving education/awareness, improving institutional practices/policy, making research participation more AYA-friendly, enhancing engagement of other key communities of interest, and empowering AYA., Conclusions: Diverse communities of interest in LMICs developed compelling strategies to enhance informed consent that may improve AYA inclusion in HIV research. These data will be used to develop practical guidance on improving AYA consent processes., Competing Interests: Conflict of Interest and Sources of Funding: The authors declare no conflict of interest exists: This work was supported by The Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant number 4UH3HD096929-03). K. M. T. is supported by the National Institute of Allergy and Infectious Diseases (grant number: T32AI007001)., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Strengthening exercise improves symptoms in knee osteoarthritis (OA), but it remains unclear if biomechanical mechanisms contribute to this improvement. Muscle capacity utilization, which reflects the proportion of maximum capacity required to complete tasks, may provide insight into how strengthening exercise improves clinical outcomes in painful knee OA., Purpose: The purpose of this secondary analysis was to determine if a 12-week strengthening intervention reduced muscle capacity utilization during walking, squat and lunge tasks in females with painful knee OA., Methods: Data from 28 females (age 59.6 ± 6.2 years old; body mass index 29.1 ± 4.7 kg/m 2 ) with clinical knee OA were included. Participants completed a strengthening intervention 3 times per week for 12 weeks. Knee extensor isometric torque was measured on a commercial dynamometer; peak values from three exertions were averaged. Peak KFM was extracted and averaged from five walking trials. Mean KFM was extracted and averaged from three trials for each of static lunges and squats. Muscle capacity utilization was the ratio of mean peak KFM to peak extensor torque for walking; and mean KFM to peak extensor torque for squats and lunges. Paired t-tests determined differences between peak extensor torque, peak KFM and muscle capacity utilization from pre to post intervention (p < 0.05)., Results & Significance: Peak extensor torque increased at follow up (p = 0.02). Peak KFM during walking decreased (p = 0.005). Muscle capacity utilization during walking (p = 0.008) and squat (p = 0.002) decreased. Mean KFM and muscle capacity utilization during lunge remained unchanged from pre to post intervention. The reduction in muscle capacity utilization at follow up indicates the strengthening intervention produced a decrease in proportion of the maximal capacity a participant used to complete walking and squat tasks. Strengthening both increases maximal muscle capacity and decreases the net moment required during daily tasks in knee OA., Competing Interests: Declaration of Competing Interest Confirm that there are no financial and personal relationships with other people or organizations that could inappropriately influence (bias) this work and therefore, there is not any conflict of interest associated with this publication to be declared., (Copyright © 2024. Published by Elsevier B.V.)

Background: Substance use and mental distress are known barriers to HIV care engagement among trans women. Less is known about access and utilization of mental health and substance use care among trans women and the relationship between unmet behavioral health needs and HIV viral suppression. We examined the relationship between mental health and substance use on HIV viral load among trans women living with HIV. We also examined the relationship between mental health and substance use services needs with HIV care engagement and having a detectable viral load by comparing engagement in care cascades., Methods: Data are from a 2022 baseline assessment for an intervention with trans women living with HIV (n = 42) in San Francisco. Chi-Squared or Fisher's exact tests were conducted to determine associations between HIV viral load, mental health, and substance use. We also examine characteristics associated with each step in the HIV, mental health, and substance use care cascades., Results: Most participants were trans women of color (85.7%), 40 years of age or older (80.9%), with low income (88.1%), and almost half were unstably housed (47.6%). Of the 32 participants who screened positive for depression, anxiety and/or psychological distress, 56.3% were referred for mental health services in the past 12 months. Of those who were referred, 44.4% received mental health services. Of the 26 participants who screened positive for a substance use disorder, 34.6% were referred to substance use services in the past 12 months. Of those referred, 33.3% received substance use services in the past 3 months. Latina trans women had a low referral rate to meet their mental health needs (50%) and only 16.7% of African American/Black trans women who screened positive for a substance use disorder were referred for services, while trans women of other race/ethnicities had high referral and services utilization. No significant results were found between HIV viral load and screening positive for a mental health disorder. Methamphetamine use was statistically associated with having a detectable HIV viral load (p = 0.049)., Conclusions: We identified significant unmet mental health and substance use services needs and noted racial/ethnic disparities in the context of high HIV care engagement among trans women living with HIV. We also found that methamphetamine use was a barrier to having an undetectable viral load for trans women living with HIV. To finally end the HIV epidemic, integration of behavioral health screening, linkage, and support are needed in HIV care services for populations most impacted by HIV, especially trans women., Trial Registration: NCT, NCT 21-34,978. Registered January 19, 2022., (© 2024. The Author(s).)

Introduction: Young transgender women (trans women) experience poor health in part due to discrimination. Factors that promote resilience may help young trans women positively adapt to discrimination, resulting in attenuation of poor health outcomes. While religion is sometimes a source of stigma and transphobia, qualitative studies have identified religiosity as an important resilience resource for young trans women. The goals of this study were to quantitatively measure religiosity and resilience among young trans women and to assess whether they are associated., Methods: From 2012-2013, 300 young trans women between the ages of 16-24 years were enrolled in a longitudinal study; we examined the cross-sectional baseline data on demographics, religiosity, and resilience. Bivariate and multivariable logistic regression analysis examined the correlation between demographics (age, gender, race/ethnicity, education, income) and religiosity among young trans women. Additionally, bivariate and multivariable logistic regression analysis examined the association between religiosity and resilience among young trans women, controlling for age, gender, race/ethnicity, education, and income., Results: Participants who reported high religiosity had significantly greater odds (aOR 1.78, 95% CI 1.05-3.01, p = .03) of reporting high resilience compared to those reporting low religiosity. Black/African American participants had significantly higher odds (aOR 6.16, 95% CI 2.34-16.20, p = < .001) of reporting high religiosity compared to those who identified as White., Conclusion: Religiosity may be an important resilience resource for young trans women. Gender affirming religious and spiritual interventions may promote resilience among some young trans women., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Wang 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.)

Objective: Defining a clinician's ability to perceptually identify mass from voice will inform the feasibility, design priorities, and performance standards for tools developed to screen for laryngeal mass from voice. This study defined clinician ability of and examined the impact of expertise on screening for laryngeal mass from voice., Study Design: Task comparison study between experts and nonexperts rating voices for the probability of a laryngeal mass., Setting: Online, remote., Methods: Experts (voice-focused speech-language pathologists and otolaryngologists) and nonexperts (general medicine providers) rated 5-s/i/voice samples (with pathology defined by laryngoscopy) for the probability of laryngeal mass via an online survey. The intraclass correlation coefficient (ICC) estimated interrater and intrarater reliability. Diagnostic performance metrics were calculated. A linear mixed effects model examined the impact of expertise and pathology on ratings., Results: Forty clinicians (21 experts and 19 nonexperts) evaluated 344 voice samples. Experts outperformed nonexperts, with a higher area under the curve (70% vs 61%), sensitivity (49% vs 36%), and specificity (83% vs 77%) (all comparisons p < .05). Interrater reliability was fair for experts and poor for nonexperts (ICC: 0.48 vs 0.34), while intrarater reliability was excellent and good, respectively (ICC: 0.9 and 0.6). The main effects of expertise and underlying pathology were significant in the linear model (p < .001)., Conclusion: Clinicians demonstrate inadequate performance screening for laryngeal mass from voice to use auditory perception for dysphonia triage. Experts' superior performance indicates that there is acoustic information in a voice that may be utilized to detect laryngeal mass based on voice., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Climate change and habitat loss are recognized as important drivers of shifts in wildlife species' geographic distributions. While often considered independently, there is considerable overlap between these drivers, and understanding how they contribute to range shifts can predict future species assemblages and inform effective management. Our objective was to evaluate the impacts of habitat, climatic, and anthropogenic effects on the distributions of climate-sensitive vertebrates along a southern range boundary in Northern Michigan, USA. We combined multiple sources of occurrence data, including harvest and citizen-science data, then used hierarchical Bayesian spatial models to determine habitat and climatic associations for four climate-sensitive vertebrate species (American marten [ Martes americana ], snowshoe hare [ Lepus americanus ], ruffed grouse [ Bonasa umbellus ] and moose [ Alces alces ]). We used total basal area of at-risk forest types to represent habitat, and temperature and winter habitat indices to represent climate. Marten associated with upland spruce-fir and lowland riparian forest types, hares with lowland conifer and aspen-birch, grouse with lowland riparian hardwoods, and moose with upland spruce-fir. Species differed in climatic drivers with hares positively associated with cooler annual temperatures, moose with cooler summer temperatures and grouse with colder winter temperatures. Contrary to expectations, temperature variables outperformed winter habitat indices. Model performance varied greatly among species, as did predicted distributions along the southern edge of the Northwoods region. As multiple species were associated with lowland riparian and upland spruce-fir habitats, these results provide potential for efficient prioritization of habitat management. Both direct and indirect effects from climate change are likely to impact the distribution of climate-sensitive species in the future and the use of multiple data types and sources in the modelling of species distributions can result in more accurate predictions resulting in improved management at policy-relevant scales., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. Ecology and Evolution published by John Wiley & Sons Ltd.)

Purpose: The purpose of our study was to examine the effects of mental distress (depression, anxiety, and post-traumatic stress disorder [PTSD]), incarceration, and hate crime on stimulant use (methamphetamine, crack, and cocaine) among transgender women. Methods: We conducted a secondary analysis of longitudinal data collected from 2016 to 2018 with 429 transgender women in the San Francisco Bay Area. Generalized estimating equation log-binomial regressions were used to calculate relative risks of stimulant use associated with mental distress, incarceration, and hate crime. Results: At baseline, transgender women experienced transphobic hate crime (46.4%), incarceration (53.0%), mental distress (69.2%), and stimulant use (28.4%). Transgender women who used stimulants reported lower education (45.1%, χ 2  = 14.3, p  = 0.001) and significantly more had been incarcerated (62.3%, χ 2  = 5.9, p  = 0.015), and reported diagnoses of depression (67.8%, χ 2  = 6.1, p  = 0.014), anxiety (62.8%, χ 2  = 4.3, p  = 0.039), and PTSD (43.8%, χ 2  = 6.7, p  = 0.010). Longitudinal multivariate analysis found that depression (adjusted relative risk [aRR] = 1.46, 95% confidence interval [CI] 1.09-1.95), anxiety (aRR = 1.42, 95% CI = 1.05-1.93), and PTSD (aRR = 1.38, 95% CI = 1.02-1.87) were associated with methamphetamine use but not with crack or cocaine use. Incarceration was associated with methamphetamine use and crack use, whereas experiencing hate crime was associated with crack use. Conclusions: Mental distress, incarceration, and hate crime were key exposures of stimulant use among transgender women. Intervention targets for reducing stimulant use should consider working upstream by addressing underlying stressors impacting mental health for transgender women, including laws to protect transgender women from hate crime and to reduce their disproportionate representation in the criminal justice system.

Purpose: Sex work is a common form of work among young trans women (YTW)., Methods: Using an occupational health frame, we measured associations between demographics, sex work, and vocational outcomes in 18-month visit data from the SHINE study ( n =263, San Francisco)., Results: Overall, 41.8% reported lifetime sex work, primarily escorting/paid sex. Motivations included "better pay" and "can't get a job due to gender discrimination." Occupational injuries included anxiety (53.6%) and depression (50%), with significantly higher relative risk for YTW doing multiple types of sex work. Criminalization experiences (i.e., incarceration, arrests, and police interaction) were common., Conclusion: Results echo calls for sex worker-affirming mental health care for YTW., Competing Interests: No competing financial interests exist., (© Marla Renee Fisher et al., 2023; Published by Mary Ann Liebert, Inc.)

Stigma towards trans women in Nepal creates individual and system-level risks for HIV. A critical protective factor is access to HIV prevention. Research is needed to determine the impact of stigma on HIV testing among trans women in Nepal. We conducted a secondary analysis of data collected using respondent driven sampling in 2019 on HIV risk among trans women in Nepal. Data analysis was restricted to trans women who were HIV negative at testing through the parent study. Descriptive statistics, tests for bivariable associations between HIV testing and stigma variables, and binomial Poisson regression were conducted to examine HIV testing outcomes. There were 173 participants who tested negative for HIV in our sample. The majority were under age 35 (59%) and most had a grade school education or less (64.7%). No trans women were homeless and most rented a room (70.5%) or owned their home (19.7%). The majority were currently sex workers (57.8%). Almost all HIV-negative trans women had ever been tested for HIV (90.8%), but only 53.5% in the last 3 months. The most frequently cited reason for not having been tested was thinking they were at low risk for HIV (40.9%) and being afraid of receiving a positive test result (22.7%). HIV and anti-trans stigma were high across most measures, including that almost all (94.2%) believed that most people in Nepal would discriminate against people with HIV. And most participants thought trans women were not accepted in Nepali Society (65.9%). Most participants also reported high social support (70.5%). Social cohesion among participants varied, with most experiencing medium (41.6%) or high (33.5%) social cohesion. Just over half had high social participation (55.5%). Participants who reported current sex work had lower prevalence of not testing for HIV in the last 3 months (prevalence ratio, PR = 0.54, 95% confidence interval, 95%CI = 0.32-0.92, p = 0.02). Every one-unit increase in social cohesion was associated with 1.05 times the prevalence of not testing for HIV in the last 3 months (95%CI = 1.01-1.09, p-value = 0.02). Trans women who did sex work were more likely to be HIV tested while those who were more socially connected to peers were less likely to have recently been tested for HIV. HIV stigma may result in fear of social rejection from peers if one tests positive. Interventions that focus on addressing stigma within trans women's social networks and strategies to mitigate HIV stigma in society may result in increased frequency of HIV testing among trans women in Nepal., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Wilson 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.)

The potential of MRI to predict cartilage mechanical properties across an entire cartilage surface in an ex vivo model would enable novel perspectives in modeling cartilage tolerance and predicting disease progression. The purpose of this study was to integrate MR imaging with full-surface indentation mapping to determine the relationship between femoral cartilage thickness and T2 relaxation change following loading, and cartilage mechanical properties in an ex vivo porcine stifle model. Matched-pairs of stifle joints from the same pig were randomized into either 1) an imaging protocol where stifles were imaged at baseline and after 35 min of static axial loading; and 2) full surface mapping of the instantaneous modulus (IM) and an electromechanical property named quantitative parameter (QP). The femur and femoral cartilage were segmented from baseline and post-intervention scans, then meshes were generated. Coordinate locations of the indentation mapping points were rigidly registered to the femur. Multiple linear regressions were performed at each voxel testing the relationship between cartilage outcomes (thickness change, T2 change) and mechanical properties (IM, QP) after accounting for covariates. Statistical Parametric Mapping was used to determine significance of clusters. No significant clusters were identified; however, this integrative method shows promise for future work in ex vivo modeling by identifying spatial relationships among variables., Competing Interests: Declaration of competing 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 © 2023 Elsevier Ltd. All rights reserved.)

Competing Interests: SO is a shareholder and employee of AstraZeneca. KT was supported by awards from the Transdisciplinary Research Initiatives Fund at the Environment and Sustainability Institute and the Wellcome Trust Translational Research Exchange at Exeter (TREE), both at the University of Exeter (Exeter, UK). Online workshops were organised with support from the Continuing Professional Development Team at the University of Exeter, funded by the National Institute of Health and Social Care School for Public Health (University of Exeter) and the Dr Edouard Delcroix Prize in Oceans and Human Health, awarded to Prof Lora Fleming. The infographic in the figure was commissioned to Dr Will Stahl-Timmins (blog.willstahl.com), and jointly funded by TREE and a Natural Environment Research Council-funded Knowledge Exchange Fellowship awarded to Prof Will Gaze (reference NE/V019279/1).

Background: The novel coronavirus (COVID-19) is negatively impacting vulnerable and marginalized communities. Growing research among sexual and gender minority communities shows increased COVID-19 risk and burden due to underlying social structure factors, however, not as much is known about the impact on trans women. Our team gathered data on COVID-19 risk, self-reported prevalence, and testing behaviors as part of an ongoing study of trans women's HIV risk and partnerships to fill this gap in data., Methods: This is a secondary analysis of data from The Partners Study, a study of HIV risk and transmission among trans women and their sexual partners in the San Francisco Bay Area. We collected COVID-19-related data from 87 trans women from July 2020 to January 2021. Participants were asked whether they were tested for COVID-19, had symptoms, or tested positive for the virus between March 2020 to the time they were screened to participate for a survey interview., Results: The majority of trans women did not report experiencing COVID-19 symptoms (85.05%, n =74/87) since March 2020. More than half had been tested for COVID-19 (68.9%, n =60/87). Overall, we found a COVID-19 prevalence of 8.33% ( n =5/60) among those who received a COVID-19 test., Public Health Implications: The COVID-19 prevalence among trans women in our sample was higher than in other gender groups in San Francisco, suggesting that trans women may be disproportionately impacted by this disease. More research is needed to determine the impact of COVID-19 on trans women, and to develop strategies to increase testing and vaccinations among vulnerable communities preventing onward spread., Competing Interests: No competing financial interests exist., (Copyright 2022, Mary Ann Liebert, Inc., publishers.)

This study characterized the prevalence of transphobic adverse childhood experiences (ACEs) among young trans women (YTW) and assessed its relationship with poor mental health and sexual risk. A survey was administered between 2012 and 2014 to 300 YTW aged 16-24 living in the San Francisco Bay Area. Transphobic childhood verbal abuse, physical abuse, and high transphobic childhood adversity were endemic, and we found strong associations with depression, posttraumatic stress disorder, and any and receptive anal intercourse. ACEs may be critical social determinants of mental and sexual health for YTW and validated measures to screen for ACEs are needed, along with interventions that provide gender-affirmative support for parents., Competing Interests: No competing financial interests exist., (Copyright 2022, Mary Ann Liebert, Inc., publishers.)

Background: Trans women face tremendous social inequities as well as disproportionate rates of HIV and substance use, yet disaggregated substance use data specific to trans women remain limited., Methods: We conducted a secondary analysis of baseline data from the Trans*National Study (2016-2017) surveying trans women in the San Francisco Bay Area (n = 629). Multivariable logistic regression was used to analyze socio-demographic and environmental correlates of substance use, and bivariate associations between substance use and HIV-associated outcomes are presented alongside prevalence data., Results: Over half (52.9%) reported using substances in the prior year, most frequently marijuana, methamphetamine, and crack/cocaine. Those with unmet gender-affirming health care needs, lack of insurance, or a history of experiencing racial violence, transphobic violence, adult housing instability, or extreme poverty had higher odds of substance use. Sex work and condomless anal sex were also independently associated with substance use., Conclusions: Among this sample of trans women, substance use and substance use concurrent with sex were highly prevalent, and associated with a number of socioeconomic and health care needs. These findings corroborate the need for holistic and intersectional efforts to reduce substance use and HIV risk., (© 2022. The Author(s).)

Background: Trans women have high HIV prevalence and lag behind 90-90-90 targets for HIV care. In San Francisco in 2017, 96% of trans women were aware of their status, 75% were on antiretroviral therapy, 88% had viral suppression. Initiatives to address gaps include peer navigators, free gender-affirming surgery, and housing. Our study updates HIV prevalence and engagement in care among trans women., Methods: Cross-sectional community-based survey of trans women living in San Francisco sampled by respondent-driven sampling, 7/2019-2/2020 ( N = 201). Eligibility was: self-identified trans women or other gender and assigned male at birth; living in San Francisco; English/Spanish-speaking; and 18 years or older., Results: HIV prevalence was 42.3% (95%CI 35.4.-49.4) and associated with having a partner who injected drugs (adjusted odds ratio [AOR] 3.30, 95%CI 1.58-6.90), ever injected drugs (AOR 2.28, 95%CI 1.06-4.89), cost not a barrier to healthcare (AOR 2.63, 95%CI 1.02-6.67), emotional support from family (AOR 2.85, 95%CI 1.43-5.65), and Black/African-American (AOR 2.59, 95%CI 1.16-5.79). Of trans women with HIV, 92.9% were previously diagnosed, 89.9% were on ART, 91.5% reported viral suppression., Conclusions: Trans women met 90-90-90 targets in 2020, at 93-90-92 . Interventions need to reach Black/African-American trans women, trans women who inject drugs, and partners of trans women.

Background: Little is known about the barriers to mental health and substance use services for trans women living with HIV. We conducted a qualitative study with trans women living with HIV and providers to explore barriers to mental health and substance use services in San Francisco., Methods: We conducted focus group discussions and key informant interviews with a total of 15 medical, mental health, substance use, and social service providers and trans women living with HIV. We identified, analyzed, and reported themes using thematic analysis and derived themes directly from the data., Results: Our study participants identified two main themes and three subthemes. One main theme is that trans women and providers have lost trust in the system due to (a) lack of a linkage system between referrals and services, (b) structural barriers such as service location, language capacity, clinic hours, and (c) constant changes in services available. Another main theme is anti-trans and mental health stigma., Conclusions: Interventions to coordinate linkage from medical to mental health and substance use (MHSU) services are urgently needed to facilitate the utilization of MHSU services. Other interventions to improve quality monitoring and system improvement, and to address multiple stigmas broadly in society are needed to improve unmet MHSU service needs among trans women living with HIV in San Francisco., (© 2022. The Author(s).)

Background: The HIV epidemic has revealed considerable disparities in health among sexual and gender minorities of color within the Unites States, disproportionately affecting cisgender men who have sex with men (MSM) and trans women. Social inequities further disadvantage those with intersectional identities through homophobia, antitrans discrimination, and racism, shaping not only those at risk for HIV infection but also HIV prevention and care outcomes. Digital interventions have great potential to address barriers and improve HIV care among cisgender MSM and trans women; however, efficacy of digital HIV care interventions vary and need further examination., Objective: This study assessed the 12-month efficacy of a 6-month digital HIV care navigation intervention among young people living with HIV in San Francisco, California. We examined dose-response relationships among intervention exposure (eg, text messaging), viral suppression, and mental health. Health electronic navigation (eNav) is a 6-month, text message-based, digital HIV care navigation intervention, in which young people living with HIV are connected to their own HIV care navigator through text messaging to improve engagement in HIV primary care., Methods: This study had a single-arm, prospective, pre-post design. Eligibility criteria for the study included the following: identifying as cisgender MSM or trans women, being between the ages of 18 and 34 years, being newly diagnosed with HIV, or not being engaged or retained in HIV care or having a detectable viral load. We assessed and analyzed sociodemographics, intervention exposure, and HIV care and mental health outcome data for participants who completed the 6-month Health eNav intervention. We assessed all outcomes using generalized estimating equations to account for within-subjects correlation, and marginal effects of texting engagement on all outcomes were calculated over the entire 12-month study period. Finally, we specified an interaction between texting engagement and time to evaluate the effects of texting engagement on outcomes., Results: Over the entire 12-month period, this study shows that every one-text increase in engagement was associated with an increased odds of undetectable viral load (adjusted odds ratio 1.01, 95% CI 1.00-1.02; P=.03). Mean negative mental health experiences decreased significantly at 12 months compared to baseline for every one-text increase in engagement (coefficient on interaction term 0.97, 95% CI 0.96-0.99; P<.01)., Conclusions: Digital care navigation interventions including Health eNav may be a critical component in the health delivery service system as the digital safety net for those whose social vulnerability is exacerbated in times of crisis, disasters, or global pandemics owing to multiple social inequities. We found that increased engagement in a digital HIV care navigation intervention helped improve viral suppression and mental health-intersecting comorbid conditions-6 months after the intervention concluded. Digital care navigation may be a promising, effective, sustainable, and scalable intervention., International Registered Report Identifier (irrid): RR2-10.2196/16406., (©Sean Arayasirikul, Caitlin M Turner, Dillon Trujillo, Jarett Maycott, Erin C Wilson. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 18.07.2022.)

Purpose: Few studies have examined the importance of improving the sexual health delivery system beyond HIV among trans women. We assessed survey data from the National HIV Behavioral Surveillance Transgender Woman (NHBS-Trans) Study in San Francisco to characterize the utilization of sexual health services among HIV-negative trans women and to explore opportunities to improve sexual health services for trans women., Methods: Trans women were recruited through respondent-driven sampling from July 2019 to February 2020. The analytic sample was restricted to 116 HIV-negative trans women. We identified trends in data using chi-squared tests to assess significance between sexual risk behavior and the use of preventative sexual health services and built logistic regression models to assess the relationships between sexual risk behaviors and sexually transmitted infection (STI) testing., Results: The majority of sample was trans women of color with most identifying as Latinx (42.2%). Over half were low income (56%), and majority had been homeless in past 12 months (62.9%). The prevalence of condomless receptive anal sex was 52.6% with about two-thirds (62.1%) recently having an STI test. Participants who engaged in recent condomless receptive anal sex had more than fivefold greater odds of having a recent STI test compared to their counterparts who did not (adjusted odds ratio [aOR] 5.60, 95% confidence interval [CI] 1.83-17.11; p =0.003). We also found age- and education-related disparities in STI testing., Conclusion: This study characterized the utilization of sexual health services among HIV-negative trans women and identified important disparities in STI testing. We discuss opportunities to strengthen sexual health care delivery systems., Competing Interests: No competing financial interests exist., (Copyright 2022, Mary Ann Liebert, Inc., publishers.)

Despite high HIV prevalence, the reasons trans women acquire HIV are not well understood. Trans women are often mis-classified or aggregated with men who have sex with men (MSM) in epidemiologic studies and HIV surveillance data. Trans women enrolled in the 2019/2020 National HIV Behavioral Surveillance Study in San Francisco were asked an open-ended question about how they were infected with HIV. The most common responses were "Sex with a straight cisgender man partner when the respondent identified as a trans woman" (43.0%); "Sexual assault" (13.9%); "Injection drug use (IDU)" (10.1%); "IDU or sexual contact" (7.6%) and "Sex with a partner who injected drugs" (7.6%). Sex with a cisgender man partner prior to identifying as a trans women (MSM contact) was not mentioned by any respondent. HIV prevention strategies targeting MSM will fail to reach trans women and many of their cisgender men partners., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: To measure the prevalence and correlates of intimate partner, physical, and sexual violence experienced by trans women. Materials and Methods: A National HIV Behavioral Surveillance (NHBS) Study of 201 trans women was conducted in San Francisco from July 2019 to February 2020 using respondent-driven sampling. Prevalence ratio tests were used to test differences in the prevalence of violence by demographic characteristics including housing status. Results: Among 201 trans women interviewed, 26.9% were currently homeless. In the past year, 59.7% had been homeless, 34.3% changed housing, 60.7% had a housing situation other than renting or owning. Experiences of violence were common: 36.8% experienced any form of violence, including sexual (16.9%), intimate partner (14.9%), and other physical (25.4%) in the past year. Experiences of violence were significantly associated with multiple measures of housing insecurity. Younger age, being misgendered, and substance use were also associated with experiences of violence. Conclusions: Trans women face dual crises in housing and violence. Affordable, subsidized, and safe housing has the potential to reduce the exposure and vulnerability to violence faced by trans women.

Background: To determine if improvements in social determinants of health for trans women and decreases in transphobic discrimination and violence occurred over three study periods during which extensive local programs were implemented to specifically address longstanding inequities suffered by the transgender community., Methods: Interviewer-administered surveys from repeated cross-sectional Transwomen Empowered to Advance Community Health (TEACH) studies in 2010, 2013 and 2016-2017 in San Francisco collected experiences with transphobia violence and discrimination. Respondent-driven sampling was used to obtain a sample of participants who identified as a trans woman., Results: Violence due to gender identity was prevalent; in each study period, verbal abuse or harassment was reported by over 83% of participants, and physical abuse or harassment was reported by over 56%. Adverse social determinants of health including homelessness, living below the poverty limit, methamphetamine use, depression, PTSD, and anxiety all significantly increased from 2010 to 2016. When testing for trends, housing discrimination and physical violence were both more likely in 2016-2017 compared to the two earlier study periods. Housing discrimination (aOR 1.41, 95% CI 1.00-1.98) and physical violence due to gender identity/presentation (aOR 1.39, 95% CI 1.00-1.92) both significantly increased from 2010 to 2016., Conclusion: Our findings are particularly alarming during a period when significant public health resources and community-based initiatives specifically for trans women were implemented and could have reasonably led us to expect improvements. Despite these efforts, physical violence and housing discrimination among trans women worsened during the study periods. To ensure future improvements, research and interventions need to shift the focus and burden from trans people to cisgender people who are the perpetuators of anti-trans sentiment, stigma, discrimination and victimization., (© 2022. The Author(s).)

Transgender women experience violence and discrimination that lead to stress responses and contribute to poor mental health. In this analysis of baseline data from Transcendendo , a trans-specific open cohort in Rio de Janeiro, Brazil, we hypothesized that the experience of discrimination and violence would be associated with depressive symptoms and that resilience could mitigate this association. Results showed that prior experiences with discrimination and sexual and physical violence were associated with depressive symptoms, while resilience was inversely associated with depressive symptoms. Resilience did not moderate nor mediate the strong effects of discrimination and violence on depressive symptoms in adjusted models., Competing Interests: No competing financial interests exist., (© Paula M. Luz et al. 2022; Published by Mary Ann Liebert, Inc.)

Transgender women face a serious risk of HIV infection. Despite this, there is limited knowledge and use of Pre-exposure prophylaxis (PrEP). We measured the continuity of prevention across services in the PrEP cascade and correlates of PrEP use among trans women in San Francisco enrolled in the 2019/20 National HIV Behavioral Surveillance Study. Knowledge and use of PrEP among trans women in San Francisco increased in recent years; almost all (94.0%) had heard about PrEP, 64.7% had discussed PrEP with a healthcare provider, and 44.8% had taken PrEP in the past 12 months. PrEP use was associated with participation in a PrEP demonstration project (aOR = 31.44, p = 0.001) and condomless receptive anal intercourse (aOR = 3.63, p = 0.024). Injection drug use was negatively associated (aOR = 0.19, p = 0.014). Efforts are needed to combat the gender-based stigma and discrimination faced by trans women, which can result in avoidance and mistrust of the medical system., (© 2021. The Author(s).)

Background: In many parts of the world, including Brazil, uptake for biomedical interventions has been insufficient to reverse the HIV epidemic among key populations at high risk for HIV, including men who have sex with men. Young MSM (YMSM), particularly Black YMSM, have high HIV incidence, low viral suppression, and low preexposure prophylaxis (PrEP) uptake and adherence. Therefore, novel approaches to increase the HIV biomedical interventions uptake by YMSM are urgently needed., Objective: We describe the Conectad@s Project, which aims to: (1) estimate the prevalence and incidence of HIV and other sexually transmitted infections, the onset of sexual risk behavior, and barriers to biomedical interventions among YMSM aged 18 to 24 years in Rio de Janeiro, Brazil; and (2) conduct a technology-based adherence intervention study to promote a rapid linkage of YMSM to HIV care or prevention, and support and sustain adherence., Methods: A cross-sectional survey will be conducted with 400 YMSM recruited using respondent-driven sampling (RDS) adapted for social media-based sampling, preceded by a formative phase. HIV and sexually transmitted infections testing will be conducted, including early HIV infection biomarker detection. Behavioral, partnership, network, and structural measures will be collected through structured questionnaires. All individuals recruited for the survey will have access to HIV risk assessment, antiretroviral therapy (ART), PrEP, prevention counseling, and a technology-based adherence intervention. Those who accept the adherence intervention will receive weekly text messages via a social networking app (WhatsApp) for 24 weeks, with follow-up data collected over 48 weeks., Results: The Conectad@s project has been approved by our local institutional review board (#CAAE 26086719.0.0000.4262) in accordance with all applicable regulations. Questionnaires for the RDS survey and intervention were developed and tested in 2020, formative interviews were conducted in January and February 2021 to guide the development of the RDS, and enrollment is planned to begin in early 2022., Conclusions: The Conectad@s Project is a vanguard study that, for the first time, will apply digital RDS to sample and recruit YMSM in Brazil and rapidly connect them to ART, PrEP, or prevention counseling through a technology-based adherence intervention. RDS will allow us to estimate HIV prevalence among YMSM and measure HIV infection biomarkers in the context of the onset of risky behavior. The data will lay the groundwork to adapt and implement HIV prevention strategies, identify barriers to the earliest HIV infection diagnosis, immediate ART or PrEP initiation, and detect new clusters of HIV transmission., International Registered Report Identifier (irrid): DERR1-10.2196/34885., (©Thiago Silva Torres, Emilia Moreira Jalil, Lara Esteves Coelho, Daniel Rodrigues Barros Bezerra, Cristina Moreira Jalil, Brenda Hoagland, Sandra Wagner Cardoso, Sean Arayasirikul, Valdilea Gonçalves Veloso, Erin C Wilson, Willi McFarland, Beatriz Grinsztejn. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 13.01.2022.)

Background: Falls in care home residents are common, unpleasant, costly and difficult to prevent., Objectives: The objectives were to evaluate the clinical effectiveness and cost-effectiveness of the Guide to Action for falls prevention in Care Homes (GtACH) programme., Design: A multicentre, cluster, parallel, 1 : 1 randomised controlled trial with embedded process evaluation and economic evaluation. Care homes were randomised on a 1 : 1 basis to the GtACH programme or usual care using a secure web-based randomisation service. Research assistants, participating residents and staff informants were blind to allocation at recruitment; research assistants were blind to allocation at follow-up. NHS Digital data were extracted blindly., Setting: Older people's care homes from 10 UK sites., Participants: Older care home residents., Intervention: The GtACH programme, which includes care home staff training, systematic use of a multidomain decision support tool and implementation of falls prevention actions, compared to usual falls prevention care., Outcomes: The primary trial outcome was the rate of falls per participating resident occurring during the 90-day period between 91 and 180 days post randomisation. The primary outcome for the cost-effectiveness analysis was the cost per fall averted, and the primary outcome for the cost-utility analysis was the incremental cost per quality adjusted life-year. Secondary outcomes included the rate of falls over days 0-90 and 181-360 post randomisation, activity levels, dependency and fractures. The number of falls per resident was compared between arms using a negative binomial regression model (generalised estimating equation)., Results: A total of 84 care homes were randomised: 39 to the GtACH arm and 45 to the control arm. A total of 1657 residents consented and provided baseline measures (mean age 85 years, 32% men). GtACH programme training was delivered to 1051 staff (71% of eligible staff) over 146 group sessions. Primary outcome data were available for 630 GtACH participants and 712 control participants. The primary outcome result showed an unadjusted incidence rate ratio of 0.57 (95% CI 0.45 to 0.71; p  < 0.01) in favour of the GtACH programme. Falls rates were lower in the GtACH arm in the period 0-90 days. There were no other differences between arms in the secondary outcomes. Care home staff valued the training, systematic strategies and specialist peer support, but the incorporation of the GtACH programme documentation into routine care home practice was limited. No adverse events were recorded. The incremental cost was £20,889.42 per Dementia Specific Quality of Life-based quality-adjusted life-year and £4543.69 per quality-adjusted life-year based on the EuroQol-5 dimensions, five-level version. The mean number of falls was 1.889 (standard deviation 3.662) in the GtACH arm and 2.747 (standard deviation 7.414) in the control arm. Therefore, 0.858 falls were averted. The base-case incremental cost per fall averted was £190.62., Conclusion: The GtACH programme significantly reduced the falls rate in the study care homes without restricting residents' activity levels or increasing their dependency, and was cost-effective at current thresholds in the NHS., Future Work: Future work should include a broad implementation programme, focusing on scale and sustainability of the GtACH programme., Limitations: A key limitation was the fact that care home staff were not blinded, although risk was small because of the UK statutory requirement to record falls in care homes., Trial Registration: This trial is registered as ISRCTN34353836., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 26, No. 9. See the NIHR Journals Library website for further project information.

Background: Pre-exposure prophylaxis (PrEP) uptake among trans people to date has been low. Recommendations implemented in San Francisco to offer PrEP with feminizing hormones have not led to improvement of PrEP uptake in trans communities. New delivery models may be needed. The aim of this study was to examine whether a PrEP-only clinic was more likely to serve trans people at highest risk of HIV than trans-affirming primary care clinics., Methods: Participants were recruited between 2017 and 2019 as part of a PrEP demonstration project in the San Francisco Bay Area. Survey data including sociodemographics, HIV-related risk behavior, barriers to PrEP, and self-reported PrEP adherence were collected at baseline, 3 months, and 6 months for all participants. Bivariable Poisson regression models were used to examine differences between participants in the primary care clinics and PrEP-only clinic delivered to participants., Results: Baseline survey data were collected from 153 participants. Those with a higher number of sexual partners were significantly more likely to use the PrEP-only clinic rather than the primary care clinics. Participants with higher perceived HIV risk and those who engaged in sex work were also more likely to use the PrEP-only clinic compared with the primary care clinic. Medical mistrust was higher at baseline among participants of the PrEP-only clinic. PrEP adherence was not significantly different by delivery model. Few participants identified PrEP barriers, such as interactions with feminizing hormones, to be determinants of PrEP uptake., Conclusions: A PrEP-only delivery model could improve PrEP uptake and may better meet the needs of trans people who could most benefit from PrEP., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: Many adolescents and young adults (AYA) have unmet HIV prevention needs. We describe the Prevention and Treatment through a Comprehensive Care Continuum for HIV-affected Adolescents in Resource Constrained Settings (PATC3H) consortium organization, transition milestones, and youth engagement strategies. The PATC3H consortium focuses on reducing HIV incidence and related health disparities among AYA., Design and Methods: Organizational data were obtained from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and supplemented with a brief survey completed by study principal investigators. Transition from the initial phase (years 1 and 2) to the subsequent phase (years 3 and 5) was contingent on meeting prespecified milestones. We reviewed the structure and function of the research consortium, identified shared elements of transition milestones, and examined common youth engagement strategies., Results: The PATC3H consortium supports eight research studies through a milestone transition mechanism. The consortium includes AYA HIV research studies in seven countries - Brazil, Kenya, Mozambique, Nigeria, South Africa, Uganda, and Zambia. The NIH request for applications required transition milestones that included early consultation with stakeholders. The transition milestones required by NIH for the eight studies included early consultation with health and policy stakeholders, pilot intervention data, and commitment from national government stakeholders. All studies provided multiple pathways for AYA engagement, including AYA advisory boards and youth-led research studies., Conclusion: Data suggest that requiring milestones to transition to the final phase may have facilitated health and policy stakeholder engagement and enhanced formative assessment of regulatory protocols. These data have implications for designing engaged research studies in low and middle-income countries., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Trans women have been shown to experience disproportionately poor outcomes in physical and mental health. Although it is common to talk about the violence against trans people, little is still known about mental health outcomes and experiences of suicidality among trans women, particularly in developing countries. This study aims to investigate risk factors and associations with mental health, suicide ideation and suicide attempts among trans women in the largest metropolitan area in Brazil., Methods: Trans women living in São Paulo were recruited between May 2017 and July 2019 using the long-chain peer referral method Respondent-Driven Sampling. Multivariate regression models were used to investigate the associations with K10 score classification (logistic) and suicidal ideation/suicide attempt (ordinal logistic)., Results: A total of 763 trans women were included in the study. Over one quarter (26.5%) of trans women had been diagnosed with anxiety in the past, and close to one in five (19.1%) trans women had received a diagnosis of depression. More than two in five (41.9%) trans women had moderate to severe psychological distress. More than half of all participating trans women reported having previously either experienced suicidal ideation or attempted to take their own lives (25.0 and 31.2% respectively). In multivariate regression, moderate to severe psychological distress was associated with homelessness, income, current sex work, use of stimulant drugs, history of physical abuse, depression diagnosis and access to mental health treatment. Suicidal ideation and suicide attempts were associated with race/skin color, living arrangements, marital status, current sex work, history of sexual violence, depression and PTSD diagnoses, access to mental health treatment and psychological distress., Conclusions: This study showed that there is a significant association between mental health conditions, lack of treatment for these conditions and suicidality among trans gender women. Findings point to the need for a structural transformation in Brazil that enables a reduction in the social inequality and violence that impact the mental health of trans women. A number of recommendations to achieve this are provided., (© 2021. The Author(s).)

Background: Trans women face disproportionate burden of adverse health outcomes, including mental health issues. Very little is known about suicidal behavior among trans women in low- and middle-income settings, such as Brazil. We aimed to estimate the prevalence of lifetime suicidal behavior and to identify its associated factors among Brazilian trans women., Methods: This was a cross-sectional study conducted among 345 trans women living in Rio de Janeiro, Brazil. We examined the prevalence of suicidal behavior (ideation and suicide attempt) and its associated factors using stepwise backward Poisson regression analysis with robust variance., Results: Suicidal ideation was present among 47.25% of participants, and the prevalence of lifetime suicide attempt was 27.25%. Trans women with prior physical violence perpetrated by a family member had significantly higher prevalence of suicidal ideation (adjusted prevalence ratios [aPR]1.37), whereas those who reported sex work had lower prevalence ratio of suicidal ideation (aPR 0.76). Suicide attempt was significantly associated with living alone (aPR 1.48), physical violence by a casual partner (aPR 1.92), and sexual violence by a family member (aPR 1.69). Depression was significantly associated with both outcomes (aPR 1.90 for suicidal ideation and aPR 2.21 for suicide attempt)., Conclusion: Suicidal behavior prevalence rates among Brazilian trans women were alarming and directly linked to violence and poor mental health. Effective mental health and public health policies addressing violence against trans women are urgently needed to prevent suicidal behavior among this highly vulnerable population., Competing Interests: The authors have declared that no competing interests exist.

Young men who have sex with men (YMSM) under 25 years old are among the few populations with increasing numbers of new HIV infections in parts of the world where HIV incidence is declining overall. In this systematic review, we synthesize the literature on HIV prevalence among MSM in Latin America and the Caribbean focusing on YMSM. Results were stratified according to study population sampling method used (probability and non-probability based). Forty-seven studies from 17 countries were published in the last 10 years. Among studies using probability-based sampling method (N = 21), HIV prevalence among MSM ranged from 1.2 to 32.6%. HIV prevalence tended to increase over time in studies sampling at different time points. HIV prevalence among YMSM exceeded 5.0% in more than a half of studies (51%; N = 22/43). Our review corroborates the high and potentially rising incidence of HIV among YMSM and characterizes the region's greatest challenge to ending the epidemic., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

Hepatitis C infections continue to rise among marginalized communities, including among transgender people. Efforts to eliminate hepatitis C from San Francisco require successful identification of active HCV infections among transgender women and subsequent treatment of infection. This secondary analysis of the National HIV Behavioral Surveillance Transgender Women (NHBS-Trans) Study aims to identify areas of improvement in the hepatitis C care cascade and associated barriers that preclude successful treatment. One hundred and eighty (89.6%) trans women reported being previously screened for HCV, 47 (26.1%) reported being diagnosed with HCV, twenty-eight of the 47 (59.6%) who reported HCV diagnosis also reported that they received HCV treatment, with and 24 of the 28 (85.7%) reported completing their treatment. Overall, we detected HCV antibodies among 23.9% of participants and detected HCV RNA among 6.0%. This suggests that despite improvements in screening for HCV, active cases may not be successfully treated. Efforts to reduce barriers to HCV care should be prioritized, with heightened consideration for trans-specific needs., (© 2021 John Wiley & Sons Ltd.)

Background: Transgender women worldwide have the highest prevalence of HIV and the lowest access to prevention among groups at risk of HIV. However, few longitudinal studies have directly measured HIV incidence and identified predictors of HIV acquisition among transgender women., Setting: São Paulo, Latin America's largest city., Methods: We conducted a longitudinal study among transgender women in São Paulo. Participants were recruited by a long-chain peer referral process from May 2017 to July 2019. Those aged 18 years and older and who were HIV-negative at baseline were retested every 6 months up to 18 months. HIV incidence was calculated by dividing the number of seroconversions by the person-years (PYs) of follow-up; 95% confidence intervals (CIs) were constructed assuming a Poisson distribution. Conditional maximum likelihood ratios assessed differences in HIV incidence by risk factors., Results: A racially/ethnically diverse sample of 545 HIV-negative transgender women was enrolled. In 485.5 PYs of follow-up, 13 seroconversions were observed, yielding an incidence of 2.68 per 100 PYs (95% CI: 1.43 to 4.58). HIV incidence was significantly higher among transgender women aged 18-24 years (rate ratio 3.85, 95% CI: 1.24 to 12.93) and among those who engaged in sex work in the preceding month (rate ratio 5.90, 95% CI: 1.71 to 26.62)., Conclusions: HIV transmission continues at a high rate among transgender women in Brazil. Factors such as young age, lower level of education, and limited employment opportunities may lead to dependence on sex work that in turn increases HIV risk. Transgender-friendly prevention services, particularly programs delivering pre-exposure prophylaxis, are urgently needed., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)