Structural and Psychosocial Syndemic Conditions and Condomless Anal Intercourse Among Transgender Women — National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019–2020

Abstract

Psychosocial and structural syndemic conditions, including polydrug use and experiencing homelessness, frequently co-occur and might jointly increase HIV risk. Limited studies have assessed racial and ethnic differences in exposure to syndemic conditions and behaviors associated with HIV transmission among transgender women. This report examines the relation between syndemic conditions and condomless anal intercourse (CAI) among transgender women in seven urban areas in the United States to develop HIV prevention interventions for transgender women. During 2019–2020, transgender women in seven urban areas were recruited using respondent-driven sampling for a biobehavioral survey. Reported syndemic conditions (psychosocial: polydrug use, sexual violence, and psychological distress; structural: homelessness, incarceration, and exchange sex) were summed to create a syndemic score. Using modified Poisson regression to account for RDS, the study assessed whether the strength of the association between syndemic score and CAI differed by race and ethnicity. To assess additive interaction, the relative excess prevalence owing to interaction (REPI) and 95% CIs for selected pairs of syndemic conditions on CAI prevalence stratified by race and ethnicity were estimated. Of 1,348 transgender women (Black = 546, White = 176, and Hispanic = 626), 55% reported CAI; and 24% reported ≥3 syndemic conditions. Reporting additional syndemic conditions was associated with CAI for White, Hispanic, and Black participants. The association was significantly stronger for White than Black and Hispanic participants. Limited significant superadditive interactions were found, although the majority were between structural syndemic conditions. Racial and ethnic differences in REPI estimates were observed. Reporting more syndemic conditions was associated with increased CAI across racial and ethnic groups, demonstrating that HIV prevention efforts for transgender women should address structural and psychosocial syndemic conditions. Results differed by race and ethnicity, indicating that syndemic-focused interventions for transgender women should be tailored to racial and ethnic groups.

Enhanced Cohort Methods for HIV Research and Epidemiology (ENCORE): Protocol for a Nationwide Hybrid Cohort for Transgender Women in the United States

“…Findings from the National HIV Behavioral Surveillance indicated that among transgender women, more syndemic conditions were associated with increased condomless anal intercourse across racial and ethnic groups, and the prevalence of different syndemic conditions varied by racial and ethnic group with excess burden among Black and Latina transgender women. [30] Cross-sectional research has also demonstrated the co-occurring and deleterious interactions of syndemic conditions with HIV vulnerability and with adherence to antiretrovirals for HIV prevention and care. [31,32] Alongside risks, it is vital to identify health-promoting factors and resiliencies that may be leveraged for interventions, including gender affirmation, community involvement, and social support.…”

MMWR Supplement on National HIV Behavioral Surveillance Among Transgender Women—Seven Urban Areas, United States, 2019-2020

“…5 Repeated experiences of social marginalization and the constant struggle to meet basic needs exact a mental health toll that exacerbates the challenges experienced by transgender women in the United States. Among NHBS-Trans participants, 26% of transgender women had experienced psychological distress during the previous 30 days, 6 and 18% had seriously considered suicide during the previous 12 months. 2 Of transgender women, 22% did not currently have any health care provider with whom they felt comfortable discussing gender identity, and 13% reported having never, at any point in their lives, had a health care provider with whom they had been comfortable discussing their gender identity.…”