Background Substance use is a leading cause of morbidity and mortality that is under-identified in medical practice. Objective The Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) Tool was developed to address the need for a brief screening and assessment instrument that includes all commonly used substances, and fits into clinical workflows. The goal of this study was to assess the performance of the TAPS Tool in primary care patients. Design Multi-site study conducted within the National Drug Abuse Treatment Clinical Trials Network, comparing the TAPS Tool against a reference standard measure. Setting Five adult primary care clinics. Participants 2,000 adult patients were consecutively recruited from clinic waiting areas. Measurements Interviewer- and self-administered versions of the TAPS Tool were compared to the reference standard modified Composite International Diagnostic Interview (CIDI), which measures problem use and substance use disorders (SUD). Results Interviewer- and self-administered versions of the TAPS Tool had similar diagnostic characteristics. For identifying problem use (at a cutoff of 1+), the TAPS Tool had sensitivity 0.93 (95% CI 0.90–0.95) and specificity 0.87 (95% CI 0.85–0.89) for tobacco, and sensitivity 0.74 (95% CI 0.70–0.78), specificity 0.79 (95% CI 0.76–0.81) for alcohol. For problem use of illicit and prescription drugs, sensitivity ranged from 0.82 (95% CI 0.76–0.87) for marijuana to 0.63 (95% CI 0.47–0.78) for sedatives, and specificity was 0.93 or higher. For identifying any SUD, sensitivity was lower, but a score of 2+ greatly increased the likelihood of having a SUD. Limitations Low prevalence of some drug classes led to poor precision in some estimates. Research assistants were not blinded to the participant’s TAPS Tool responses when they administered the CIDI. Conclusions In a diverse population of adult primary care patients, the TAPS Tool detected clinically relevant problem substance use. While it may also detect tobacco, alcohol, and marijuana use disorders, further refinement is needed before the TAPS Tool can be broadly recommended as a screener for SUD.

Background Transgender women (“trans women”), particularly African-American and Latina trans women, have disproportionately high prevalence of HIV in the United States (U.S.). In order to decrease gender dysphoria and overcome discrimination, trans women affirm their gender through social and medical transition, often in contexts of economic hardship and sexual risk. This study qualitatively examined how gender-affirming behaviors enhance or diminish vulnerability to HIV in light of structural and economic barriers to gender transition. Methods We conducted individual interviews with 19 adult trans women in two U.S. cities (Richmond, VA and St. Louis, MO) who reported one or more sexual risk behaviors and recent economic hardship related to employment/income, housing, or food security. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Results The majority (74%) of trans women were racial/ethnic minorities with mean age of 26.3 years. Gender-affirming behaviors varied with 58% of trans women having legally changed their name and gender marker; 79% having initiated hormone therapy; and 11% having not initiated any medical or legal changes. None had undertaken surgical changes. Findings suggested that the process of gender transitioning resulted in both increasing and decreasing HIV risk. The high need for gender affirmation by male sex partners contributed to trans women’s exposure to sexual objectification, sexual risk behaviors, and conflicting interests in HIV prevention messaging. Loss of housing and employment due to transition along with the high costs of transition products and medical visits increased reliance on sex work and created new obstacles in accessing HIV services. Trans women experienced lower HIV risk as they acquired legal and medical transition services, reshaped interactions with sex partners, and received gender-affirming support by others, including health providers, employers, peers, and housing professionals. Sexual abstinence was viewed as a negative consequence of incomplete transition, although characterized as a period of low HIV risk. Conclusions Structural and policy initiatives that promote safe gender transition and economic stability in trans women may play a critical role in reducing HIV in this population. Addressing the harmful pressures for U.S. trans women to conform to perceived feminine stereotypes may also serve an important role.