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      Sexual healthcare and at-home STI test collection: attitudes and preferences of transgender women in the Southeastern United States

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          Abstract

          Background

          HIV and sexually transmitted infections (STIs) disproportionally affect transgender women in the United States, particularly in the Southeast where rates of HIV and bacterial STIs are especially high. Despite the high HIV/STI burden among transgender women, their engagement in sexual healthcare services, including HIV/STI testing, is low. Understanding reasons for this disconnect is essential in developing HIV/STI prevention efforts for this population, especially in the Southeastern US, where access to affirming sexual healthcare providers and resources is limited. We aimed to perform an exploratory qualitative study to describe the attitudes and preferences of transgender women living in Alabama with regards to sexual healthcare and at-home STI test collection.

          Methods

          Transgender women ≥18 years old residing in Alabama were invited to participate in virtual individual in-depth interviews via Zoom. The interview guide explored participant experiences engaging with sexual healthcare services as well as preferences related to extragenital (i.e., rectal, pharyngeal) and at-home STI testing for gonorrhea and chlamydia. A trained qualitative researcher coded transcripts after each interview and iteratively amended the interview guide as themes emerged. Data were coded and thematically analyzed using NVivo qualitative software.

          Results

          Between June 2021-April 2022, 22 transgender women were screened and 14 eligible women enrolled. Eight participants were white (57%), and six were black (43%). Five participants (36%) were living with HIV and engaged with HIV care services. Interview themes included preference for sexual healthcare environments specializing in LGBTQ+ care, enthusiasm toward at-home STI testing, an emphasis on affirming patient-provider interactions in sexual healthcare settings, a preference for sexual healthcare providers involved in STI testing who were not cisgender men, and gender dysphoria around sexual health discussions and testing.

          Conclusion

          Transgender women in the Southeastern US prioritize affirming provider-patient interactions, however resources in the region are limited. Participants were enthusiastic about at-home STI testing options, which have the potential to mitigate gender dysphoria. Further investigation into development of remote sexual healthcare services for transgender women should be performed.

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          Most cited references24

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          Sexually Transmitted Infections Treatment Guidelines, 2021

          These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis ; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium ; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.
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            Research Design : Qualitative, Quantitative, and Mixed Methods Approaches

            <p>This best-selling text pioneered the comparison of qualitative, quantitative, and mixed methods research design. For all three approaches, John W. Creswell and new co-author J. David Creswell include a preliminary consideration of philosophical assumptions, key elements of the research process, a review of the literature, an assessment of the use of theory in research applications, and reflections about the importance of writing and ethics in scholarly inquiry. <br> <br> The Fifth Edition includes more coverage of: epistemological and ontological positioning in relation to the research question and chosen methodology; case study, PAR, visual and online methods in qualitative research; qualitative and quantitative data analysis software; and in quantitative methods more on power analysis to determine sample size, and more coverage of experimental and survey designs; and updated with the latest thinking and research in mixed methods.<br> <br> </p>
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              Estimating the Prevalence of HIV and Sexual Behaviors Among the US Transgender Population: A Systematic Review and Meta-Analysis, 2006–2017

              Background. Transgender women (transwomen) in the United States have been shown to have high HIV risk with Black and Hispanic transwomen being particularly vulnerable. Growing research on transgender men (transmen) also shows increased HIV risk and burden, although not as much is known for this transgender population.Objectives. This systematic review estimates the prevalence of self-reported and laboratory-confirmed HIV infection, reported sexual and injection behaviors, and contextual factors associated with HIV risk of transgender persons living in the United States.Search Methods. We searched the HIV Prevention Research Synthesis database and MEDLINE, EMBASE, PsycINFO, CINAHL, and Sociological Abstracts databases from January 2006 to March 2017 and January 2006 to May 2017, respectively. Additional hand searches were conducted in December 2017 to obtain studies not found in the literature searches.Selection Criteria. Eligible reports were published US-based studies that included transgender persons and reported HIV status.Data collection and analysis. Data were double-coded and quality assessed. We used random-effects models employing the DerSimonian-Laird method to calculate overall prevalence of HIV infection, risk behaviors, and contextual factors for transwomen, transmen, and race/ethnicity subgroups.Main Results. We reviewed 88 studies, the majority of which were cross-sectional surveys. Overall laboratory-confirmed estimated prevalence of HIV infection was 9.2% (95% confidence interval [CI] = 6.0%, 13.7%; κ = 24). Among transwomen and transmen, HIV infection prevalence estimates were 14.1% (95% CI = 8.7%, 22.2%; κ = 13) and 3.2% (95% CI = 1.4%, 7.1%; κ = 8), respectively. Self-reported HIV infection was 16.1% (95% CI = 12.0%, 21.2%; κ = 44), 21.0% (95% CI = 15.9%, 27.2%; κ = 30), and 1.2% (95% CI = 0.4%, 3.1%; κ = 7) for overall, transwomen, and transmen, respectively. HIV infection estimates were highest among Blacks (44.2%; 95% CI = 23.2%, 67.5%; κ = 4). Overall, participation in sex work was 31.0% (95% CI = 23.9%, 39.0%; κ = 39). Transwomen (37.9%; 95% CI = 29.0%, 47.7%; κ = 29) reported higher participation in sex work than transmen (13.1%; 95% CI = 6.6%, 24.3%; κ = 10; P = .001). Most outcomes indicated high heterogeneity in the overall and subgroup analyses.Conclusions. The availability of more data allowed us to calculate estimates separately for transwomen and transmen. HIV prevalence estimates for US transwomen were lower than previous estimates, but estimates for HIV prevalence and participation in sex work were higher when compared with transmen. Evidence gaps remain for transmen and the syndemic relationship of HIV, risky behaviors, and contextual factors specific to the transgender experience.Public Health Implications. This study highlights gender disparities for HIV and risky sexual behavior, as well as evidence gaps that exist for transmen. Tailored programs and services for the transgender population need to be developed to encourage use of and access to HIV prevention services.
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                Author and article information

                Contributors
                Journal
                Front Public Health
                Front Public Health
                Front. Public Health
                Frontiers in Public Health
                Frontiers Media S.A.
                2296-2565
                31 May 2023
                2023
                : 11
                : 1187206
                Affiliations
                [1] 1Division of Infectious Diseases, University of Alabama at Birmingham , Birmingham, AL, United States
                [2] 2Department of Biostatistics, UAB School of Public Health , Birmingham, AL, United States
                [3] 3School of Medicine, University of Alabama at Birmingham , Birmingham, AL, United States
                [4] 4Rollins School of Public Health, Emory University , Atlanta, GA, United States
                Author notes

                Edited by: Christopher Williams, State University of New York, United States

                Reviewed by: Ashley Lacombe-Duncan, University of Michigan, United States; Christine Khosropour, University of Washington, United States

                *Correspondence: Olivia T. Van Gerwen oliviavangerwen@ 123456uabmc.edu
                Article
                10.3389/fpubh.2023.1187206
                10264611
                40814e78-26a3-4345-a3d0-1c8723e1ce1e
                Copyright © 2023 Van Gerwen, Austin, Bethune, Sullivan and Muzny.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 15 March 2023
                : 12 May 2023
                Page count
                Figures: 1, Tables: 1, Equations: 0, References: 26, Pages: 8, Words: 6619
                Funding
                This work was supported by the UAB Center for AIDS Research [P30 AI027767-32 to OV]. OV was also currently funded by the 2022–2023 University of Alabama at Birmingham Department of Medicine Frommeyer Fellowship in Investigative Medicine.
                Categories
                Public Health
                Original Research
                Custom metadata
                Infectious Diseases: Epidemiology and Prevention

                at-home testing,qualitative research,sexually transmitted infections,transgender,sexual health

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