Suchergebnisse

Social workers have been critical in the response to HIV from its inception, in HIV prevention, support, and advocacy for stigmatized populations including gay, bisexual, and other men who have sex with men (GBM). Recently, social workers have been tasked with working in an era of increasingly biomedicalized HIV prevention, including pre-exposure prophylaxis (PrEP), a safe and highly effective new prevention technology. However, disparities in PrEP access due to structural barriers, including lack of health insurance coverage, and complex decision-making pathways and processes of engagement present substantial challenges for PrEP implementation. Ensuring equitable access to resources and supporting informed decision making are paramount to social work values, yet scant published literature has considered PrEP social work intervention. This article draws on qualitative data from 29 GBM respondents to highlight gaps in PrEP decision-making support and access that may be amenable to social work intervention. Authors describe opportunities for individual, interpersonal, organizational, and structural social work interventions to address multilevel gaps in PrEP implementation. Findings illuminate the complexity of individual experiences and social discourses regarding PrEP and their impact on GBM and raise important issues for social workers to consider in working with GBM clients, service providers, and administrators.

AbstractIntroductionNotwithstanding the efficacy of oral pre‐exposure prophylaxis (PrEP) in clinical trials, a number of obstacles exist to achieving population‐level impact among gay, bisexual and other men who have sex with men (GBM). However, few studies have explored the subjective experiences of GBM PrEP users and non‐users in the community, outside of clinical trials. The objectives of this study were to explore GBM's experiences of considering, accessing and using (or not using) PrEP, and to understand emerging sexual health, social and community issues among GBM in the PrEP era.MethodsFrom October 2015 to March 2016, we purposively sampled PrEP‐naïve and PrEP‐experienced GBM from community organizations and health centres in Toronto, Canada. In‐depth, 45‐ to 90‐minute semi‐structured interviews explored PrEP perspectives and decision‐making, access, initiation, use over time, sexual practices and psychosocial considerations. Interviews were recorded, transcribed verbatim, uploaded into NVIVO, reviewed using thematic analysis and then contrasted with the PrEP cascade.ResultsParticipants included PrEP users (n = 15) and non‐users (n = 14) (mean age = 36.7 years; SD = 8.2), largely gay‐identified (86.2%), cisgender male (89.7%) and white (79.3%). Themes indicate not only correspondences, but also limitations of the PrEP cascade by complicating a user/non‐user binary and challenging the unilateral presupposition that HIV risk perception leads to PrEP acceptance. Findings further call into question assumptions of a linear stage progression and retention in care as a universal endpoint, instead revealing alternate trajectories of seasonal or intermittent PrEP use and, for some, an end goal of terminating PrEP. GBM's narratives also revealed potent psychological/affective experiences of untethering sex from HIV anxiety; multifaceted PrEP stigma; and challenges to sexual norms and practices that complicate existing behavioural prevention strategies and sexual and social relationships.ConclusionsAn expanded PrEP cascade should consider alternate trajectories of use based on dynamic relationships and behavioural risks that may call for seasonal or intermittent use; systemic barriers in access to and sustaining PrEP; and multiple end goals including PrEP maintenance and discontinuation. Incorporating GBM's lived experiences, evolving preferences, and psychosocial and community‐level challenges into PrEP implementation models, rather than a circumscribed biomedical approach, may more effectively support HIV prevention and GBM's broader sexual and psychological health.

AbstractIntroductionTransgender (trans) and nonbinary people (TNB) are disproportionately impacted by HIV. HIV testing is critical to engage TNB people in HIV prevention and care. Yet, scant literature has examined social and structural factors associated with HIV testing among TNB people of diverse genders and in geographies with potentially lower trans acceptance. We: (1) characterized the prevalence of never having been tested for HIV; and (2) identified associated factors, among TNB people in Michigan, United States.MethodsData were from a community‐based participatory cross‐sectional survey (n = 539 sexually experienced TNB people). The prevalence of never having had an HIV test was reported overall and compared across socio‐demographic, clinical, social and structural factors using bivariable and multivariable logistic regression analyses.Results and discussionApproximately one‐quarter (26.2%) of participants had never had an HIV test (20.8% transfeminine; 30.0% transmasculine; 17.8% nonbinary assigned male at‐birth; and 32.0% nonbinary assigned female at‐birth). In a multivariable socio‐demographic model, older age (adjusted odds ratio [aOR] for 1‐year increase: 0.93, 95% CI: 0.90, 0.96, p<0.001) and Black/African American race (vs. White) (aOR: 0.28, 95% CI: 0.09, 0.86, p<0.05) were associated with increased odds of HIV testing (aORs for never testing). In separate multivariable models controlling for socio‐demographics, ever experiencing sexual violence (aOR: 0.38, 95% CI: 0.21, 0.67, p<0.001), not accessed sexual/reproductive healthcare in the past 12 months (aOR: 4.46, 95% CI: 2.68, 7.43, p<0.001) and reporting a very/somewhat inclusive primary care provider (PCP) (aOR: 0.29, 95% CI: 0.17, 0.49, p<0.001) were associated with HIV testing (aORs for never testing).ConclusionsFindings contribute to scant literature about gender‐based differences in HIV testing inclusive of transmasculine and nonbinary people. Lack of statistically significant gender differences suggests that broad TNB interventions may be warranted. These could include training healthcare providers in trans‐inclusive practices with sexual violence survivors and PCPs in trans‐inclusive HIV prevention and care. Findings showing Black participants were less likely to have never had an HIV test suggest the promise of culturally tailored services, though further investigation is needed. Findings identify social and structural factors associated with HIV testing and can inform multi‐level interventions to increase TNB person's HIV testing.

AbstractIntroduction: Young men who have sex with men (MSM) in Jamaica have the highest HIV prevalence in the Caribbean. There is little information about HIV among transgender women in Jamaica, who are also overrepresented in the Caribbean epidemic. HIV‐related stigma is a barrier to HIV testing among Jamaica's general population, yet little is known of MSM and transgender women's HIV testing experiences in Jamaica. We explored perceived barriers and facilitators to HIV testing among young MSM and transgender women in Kingston, Jamaica.Methods: We implemented a community‐based research project in collaboration with HIV and lesbian, gay, bisexual and transgender (LGBT) agencies in Kingston. We held two focus groups, one with young (aged 18–30 years) transgender women (n = 8) and one with young MSM (n = 10). We conducted 53 in‐depth individual semi‐structured interviews focused on HIV testing experiences with young MSM (n = 20), transgender women (n = 20), and community‐based key informants (n = 13). We conducted thematic analysis to identify, analyze, and report themes.Results: Participant narratives revealed social‐ecological barriers and facilitators to HIV testing. Barriers included healthcare provider mistreatment, confidentiality breaches, and HIV‐related stigma: these spanned interpersonal, community and structural levels. Healthcare provider discrimination and judgment in HIV testing provision presented barriers to accessing HIV services (e.g. treatment), and resulted in participants hiding their sexual orientation and/or gender identity. Confidentiality concerns included: clinic physical arrangements that segregated HIV testing from other health services, fear that healthcare providers would publicly disclose their status, and concerns at LGBT‐friendly clinics that peers would discover they were getting tested. HIV‐related stigma contributed to fear of testing HIV‐positive; this intersected with the stigma of HIV as a "gay" disease. Participants also anticipated healthcare provider mistreatment if they tested HIV positive. Participants identified individual (belief in benefits of knowing one's HIV status), social (social support) and structural (accessible testing) factors that can increase HIV testing uptake.Conclusions: Findings suggest the need for policy and practice changes to enhance confidentiality and reduce discrimination in Jamaica. Interventions to challenge HIV‐related and LGBT stigma in community and healthcare settings can enhance access to the HIV prevention cascade among MSM and transgender youth in Jamaica.

AbstractIntroduction: Transgender women are disproportionately impacted by HIV. Transgender women involved in sex work may experience exacerbated violence, social exclusion, and HIV vulnerabilities, in comparison with non‐sex work‐involved transgender women. Scant research has investigated sex work among transgender women in the Caribbean, including Jamaica, where transgender women report pervasive violence. The study objective was to examine factors associated with sex work involvement among transgender women in Jamaica.Methods: In 2015, we implemented a cross‐sectional survey using modified peer‐driven recruitment with transgender women in Kingston and Ocho Rios, Jamaica, in collaboration with a local community‐based AIDS service organization. We conducted multivariable logistic regression analyses to identify factors associated with paid sex and transactional sex. Exchanging oral, anal or vaginal sex for money only was categorized as paid sex. Exchanging sex for survival needs (food, accommodation, transportation), drugs or alcohol, or for money along with survival needs and/or drugs/alcohol, was categorized as transactional sex.Results: Among 137 transgender women (mean age: 24.0 [SD: 4.5]), two‐thirds reported living in the Kingston area. Overall, 25.2% reported being HIV‐positive. Approximately half (n = 71; 51.82%) reported any sex work involvement, this included sex in exchange for: money (n = 64; 47.06%); survival needs (n = 27; 19.85%); and drugs/alcohol (n = 6; 4.41%). In multivariable analyses, paid sex and transactional sex were both associated with: intrapersonal (depression), interpersonal (lower social support, forced sex, childhood sexual abuse, intimate partner violence, multiple partners/polyamory), and structural (transgender stigma, unemployment) factors. Participants reporting transactional sex also reported increased odds of incarceration perceived to be due to transgender identity, forced sex, homelessness, and lower resilience, in comparison with participants reporting no sex work involvement.Conclusions: Findings reveal high HIV infection rates among transgender women in Jamaica. Sex work‐involved participants experience social and structural drivers of HIV, including violence, stigma, and unemployment. Transgender women involved in transactional sex also experience high rates of incarceration, forced sex and homelessness in comparison with non‐sex workers. Taken together, these findings suggest that social ecological factors elevate HIV exposure among sex work‐involved transgender women in Jamaica. Findings can inform interventions to advance human rights and HIV prevention and care cascades with transgender women in Jamaica.