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Longitudinal Analysis of Syndemic Psychosocial Problems Predicting HIV Risk Behavior Among a Multicity Prospective Cohort of Sexually Active Young Transgender Women in the United States

Mimiaga, Matthew J., ScD, MPHa,b,c,d; Hughto, Jaclyn M.W., PhD, MPHa,b,d; Biello, Katie B., PhD, MPHa,b,d; Santostefano, Christopher M., BSN, RNa; Kuhns, Lisa M., PhD, MPHe,f; Reisner, Sari L., ScD, MAd,g,h; Garofalo, Robert, MD, MPHe,f

JAIDS Journal of Acquired Immune Deficiency Syndromes: June 1, 2019 - Volume 81 - Issue 2 - p 184–192
doi: 10.1097/QAI.0000000000002009
Prevention Research

Background: Worldwide, young transgender women (YTW) contend with exceptionally high risks of HIV infection. Cross-sectional studies have suggested that co-occurring epidemics or “syndemics” of psychosocial problems may accelerate HIV acquisition and transmission through elevated sexual risk behavior among transgender women. We aimed to examine how a syndemic of 7 psychosocial problems potentiates HIV sexual risk behavior among a multicity, longitudinal cohort of sexually active YTW in the United States.

Methods: Between 2012 and 2015, 233 YTW from Boston, MA, and Chicago, IL, completed behavioral surveys at baseline, 4, 8, and 12 months. We used generalized estimating equations to examine the prospective relationship of overlapping psychosocial problems and HIV sexual risk behavior (ie, condomless anal or vaginal sex) among YTW.

Results: The prevalence of 7 psychosocial syndemic problems was substantial at baseline and remained high at each time point: 6.4% reported polydrug use in the past 4 months (excluding stimulants); 7.7% reported heavy alcohol use in the past 4 months; 10% reported a history of childhood sexual abuse; 15.9% reported stimulant use in the past 4 months; 41.7% reported experiencing lifetime intimate partner violence; 42.1% reported clinically significant depressive symptoms; and 68.6% reported lifetime transgender-specific victimization. We identified a statistically significant positive “dose–response” relationship between the number of psychosocial syndemic problems and condomless anal or vaginal sex over time.

Conclusions: The accumulation of “syndemic” psychosocial problems predicted HIV sexual risk behavior in a prospective cohort of YTW. Given the high prevalence of psychosocial problems and HIV sexual risk behavior, as well as having the highest HIV incidence among any risk group, the HIV prevention agenda requires a shift toward improved assessment of psychosocial comorbidities and stronger integration with gender-affirming and supportive mental health, violence recovery, and addiction treatment services for this population.

aCenter for Health Equity Research, Brown University, Providence, RI;

bDepartments of Behavioral and Social Sciences and Epidemiology, Brown University, School of Public Health, Providence, RI;

cDepartment of Psychiatry and Human Behavior, Brown University Alpert Medical School, Providence, RI;

dThe Fenway Institute, Fenway Health, Boston, MA;

eDivision of Adolescent Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL;

fDepartment of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL;

gDepartment of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA; and

hDepartment of Epidemiology, Harvard T.H Chan School of Public Health, Boston, MA.

Correspondence to: Matthew J. Mimiaga, ScD, MPH, Center for Health Equity Research, Brown University, 121 South Main Street, Providence, RI 02903 (e-mail:

Supported by award R01MH094323 (R.G. and M.J.M.) from the National Institute of Mental Health of the National Institutes of Health.

Data from Project LifeSkills were presented at the 2016 International AIDS Conference; July 18, 2016; Durban, South Africa.

The authors have no funding or conflicts of interest to disclose.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1975 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all participants included in the study.

Received October 04, 2018

Accepted February 04, 2019

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