Abstract
Introduction:
Hispanic/Latino men who have sex with men (MSM) and transgender women (TGW) are disproportionately affected by HIV in the U.S. This study evaluated HIV prevention services and outcomes among Hispanic/Latino MSM and TGW in the targeted highly effective interventions to reduce the HIV epidemic (THRIVE) demonstration project and considered lessons learned.
Methods:
The authors described the THRIVE demonstration project services provided to Hispanic/Latino MSM and TGW in 7 U.S. jurisdictions from 2015 to 2020. HIV prevention service outcomes were compared between 1 site with (2,147 total participants) and 6 sites without (1,129 total participants) Hispanic/Latino-oriented pre-exposure prophylaxis clinical services, and Poisson regression was used to estimate the adjusted RR between sites and pre-exposure prophylaxis outcomes. Analyses were conducted from 2021 to 2022.
Results:
The THRIVE demonstration project served 2,898 and 378 Hispanic/Latino MSM and TGW, respectively, with 2,519 MSM (87%) and 320 TGW (85%) receiving ≥1 HIV screening test. Among 2,002 MSM and 178 TGW eligible for pre-exposure prophylaxis, 1,011 (50%) MSM and 98 (55%) TGW received pre-exposure prophylaxis prescriptions, respectively. MSM and TGW were each 2.0 times more likely to be linked to pre-exposure prophylaxis (95% CI=1.4, 2.9 and 95% CI=1.2, 3.6, respectively) and 1.6 and 2.1 times more likely to be prescribed pre-exposure prophylaxis (95% CI=1.1, 2.2 and 95% CI=1.1, 4.1), respectively, at the site providing Hispanic/Latino-oriented pre-exposure prophylaxis clinical services than at other sites and adjusted for age group.
Conclusions:
The THRIVE demonstration project delivered comprehensive HIV prevention services to Hispanic/Latino MSM and TGW. Hispanic/Latino-oriented clinical settings may improve HIV prevention service delivery to persons in Hispanic/Latino communities.
INTRODUCTION
HIV disproportionately impacts Hispanic/Latino gay, bisexual, and other men who have sex with men (collectively referred to as men who have sex with men [MSM]) and transgender women (TGW) in the U.S.1–3 Hispanic/Latino persons experience disparities in the implementation of HIV prevention resources such as pre-exposure prophylaxis (PrEP), a critical component of the Ending the HIV Epidemic in the U.S. (EHE) initiative.4,5 One national survey found that a lower proportion of Hispanic/Latino MSM than of White MSM were aware of PrEP, had discussed PrEP with their healthcare provider, or had used PrEP.6 The survey underscores the most recent national PrEP data from 2021 showing that PrEP coverage was lower for Hispanic/Latino persons (20%) than for White persons (80%).7
Previous research has identified key individual-, network-, healthcare system-, and structural-level barriers to effective PrEP use for Hispanic/Latino persons. These barriers include language, immigration status, stigma, mental health, substance use, distrust of healthcare systems, access to care, and health insurance, among others.4,8–14 To date, few studies have described the impact of culturally tailored interventions to improve PrEP uptake for Hispanic/Latino persons. Those that did primarily adopted peer-led strategies, including PrEP outreach, PrEP navigation, and social network–based interventions.15–18
To address the disproportionate impact of HIV among Black and Hispanic/Latino persons, the Targeted Highly Effective Interventions to Reduce the HIV Epidemic (THRIVE) demonstration project funded 7 U.S. health departments to implement comprehensive, culturally competent HIV prevention and care interventions for Black and Hispanic/Latino MSM and TGW.19 Participating health departments created and led collaboratives, including health departments, community-based organizations (CBOs), behavioral and social service providers, and clinical providers, to implement HIV prevention activities.20 One THRIVE site specifically developed strong partnerships with multiple established Hispanic/Latino-serving community clinics and CBOs that offered Spanish language PrEP navigation and clinical services that were oriented toward Hispanic/Latino persons in terms of language, staff composition, and location (referred to as Hispanic/Latino-oriented PrEP clinical services in the remaining part of this paper). The objectives of this study were to evaluate HIV prevention service use and outcomes among Hispanic/Latino MSM and TGW served in THRIVE and to compare service delivery outcomes for 1 site with partners providing Hispanic/Latino-oriented PrEP clinical services in their collaborative with outcomes for the other sites without such partners.
METHODS
The THRIVE demonstration project was conducted from 2015 to 2020 and has previously been described.19,21–23 Briefly, the 7 funded THRIVE jurisdictions included Birmingham, AL; Baltimore, MD; District of Columbia; New Orleans, LA; Brooklyn, New York City, NY; Philadelphia, PA; and Hampton Roads, Virginia. All jurisdictions served communities with high HIV morbidity or mortality among Black and Hispanic/Latino MSM.19 Jurisdictions collected longitudinal client-level data and reported deidentified data to the Centers for Disease Control and Prevention for program evaluation purposes. The THRIVE evaluation was determined to be nonresearch and exempt from IRB.
Study Sample
A THRIVE client was defined as any person aged ≥18 years who received a THRIVE-funded service. This analysis was restricted to THRIVE clients who self-reported their ethnicity as Hispanic (Hispanic/Latino persons may be of any race), were categorized as MSM or TGW, and were HIV-negative or had an undetermined HIV status at the time of enrollment (referred to as persons without HIV). MSM were defined as persons reporting sex at birth as male, current gender as male, and past or current sex with men; TGW were defined as persons reporting sex at birth as male and current gender as female or transgender woman.
Regarding HIV prevention services provided, all THRIVE jurisdictions implemented HIV prevention programs and activities, including laboratory-based HIV antigen–antibody testing; PrEP; nonoccupational post-exposure prophylaxis (nPEP); and navigation and linkage to HIV prevention and care, behavioral health services, and essential support services.22,23 Each THRIVE collaborative tailored services to the needs of their communities by partnering with CBOs and providers that effectively engaged Black and Hispanic/Latino MSM and TGW. Because THRIVE sites were heterogeneous in size and baseline capacity for HIV prevention service provision, service delivery models and the scope of services provided varied by collaborative partners at all sites.
Although all THRIVE sites strove to provide culturally competent HIV prevention services for both Black and Hispanic/Latino MSM and TGW, 1 site included collaborative partners that provided HIV prevention, PrEP navigation, and PrEP clinical services more comprehensively designed to serve Hispanic/Latino clients in terms of language, staff composition, and location. Specifically, this site partnered with multiple community clinics and CBOs that served primarily Hispanic/Latino clients; developed bilingual health education materials and HIV prevention programs tailored to Hispanic/Latino MSM and TGW; employed staff who were native Spanish speakers and shared similar cultural backgrounds as their clients, including not only administrative staff and navigators but also nurses, clinicians, and behavioral health specialists (rather than using in-person or phone interpreter services during clinical encounters); and were located in areas with high densities of Hispanic/Latino residents. For other THRIVE sites, collaboratives may have included partners that provided outreach materials in Spanish, employed a Spanish-speaking navigator or outreach worker, or offered Spanish-language interpretation services, but those collaboratives were not able to achieve the comprehensive scope of services tailored to Hispanic/Latino clients as the site previously described.
Measures
Age at enrollment was categorized as 18–24, 25–34, 35–44, 45–54, and ≥55 years. HIV prevention services outcomes were defined according to the cross-site project evaluation plan. Clients were screened for PrEP eligibility using a questionnaire on the basis of the Centers for Disease Control and Prevention’s PrEP clinical guidelines.24 The main PrEP outcomes of interest were linkage to PrEP, defined by a person attending an initial appointment with a PrEP provider, and PrEP prescription, defined as the provision of a PrEP prescription by a PrEP provider. PrEP navigation was defined as using a navigator for PrEP regardless of whether linkage to PrEP occurred. Clients were screened for nPEP eligibility by assessing behavioral risk to determine whether an exposure (1) posed a substantial risk of HIV infection and (2) occurred within 72 hours of evaluation; clients meeting both criteria were considered eligible. The main nPEP outcome was prescription of nPEP medication for eligible clients. Regarding unmet needs, clients were screened for behavioral health or essential support service needs (e.g., mental health, substance use, and insurance, among others). Sites developed their own screening tools to assess unmet needs, which relied on clients self-reporting. Unmet need was defined as when a client self-reported a behavioral health or essential support service need, and navigation for unmet needs was defined as using a navigator to address the client’s unmet need regardless of whether linkage to the service occurred.
Statistical Analysis
This study described the number of Hispanic/Latino MSM and TGW without HIV served in THRIVE by site and age at enrollment. For HIV testing, the number of tests performed, the number of clients with ≥1 HIV test, and the number of clients with a positive test were summed. The proportions screened and eligible for nPEP and, among those eligible, the proportion prescribed nPEP were calculated. The proportions screened and eligible for PrEP were calculated. Among PrEP-eligible persons, the proportions referred and linked to a PrEP provider and prescribed PrEP were calculated. Missing results from continuum steps were imputed as received if a client was prescribed PrEP and imputed as not received if a client was not prescribed PrEP or if the PrEP prescription variable was missing. The proportion who received navigation services among PrEP-eligible persons was determined. In addition, the proportions screened for unmet behavioral health and essential support service needs, including mental health, substance use, health insurance, housing, employment assistance, transportation, and educational assistance, were calculated. The proportion with an unmet need among those screened and the proportion who received navigation services among those with unmet needs were calculated.
To protect anonymity for site-to-site comparisons, sites were assigned a random identifier (1–7). Sites were grouped into those with partners in their collaborative who offered Hispanic/Latino-oriented PrEP clinical services (Site 7) and those without such partners (Sites 1–6). The PrEP and nPEP clinical services continua were compared between groups. In addition, the RRs with 95% CIs of the binary outcomes of being linked and prescribed PrEP, comparing sites providing Hispanic/Latino-oriented PrEP clinical services with those that did not, were estimated using Poisson regression models with a sandwich estimator for robust SEs that controlled for age and fit for MSM and TGW THRIVE clients separately. Data were analyzed using SAS 9.4 (SAS Inc, Cary, NC).
RESULTS
From 2015 through 2020, THRIVE enrolled 2,898 Hispanic/Latino MSM and 378 Hispanic/Latina TGW (Table 1).
Table 1.
Characteristics of Hispanic/Latino MSM and TGW Without HIV and HIV Prevention Services Received, THRIVE, 2015–2020
| Characteristics | MSM, n (%) | TGW, n (%) |
|---|---|---|
| Total, N | 2,898 (100) | 378 (100) |
| Age group at enrollment, years | ||
| 18–24 | 574 (20) | 78 (21) |
| 25–34 | 1,331 (46) | 158 (42) |
| 35–44 | 516 (18) | 80 (21) |
| 45–54 | 194 (7) | 22 (6) |
| ≥55 | 78 (3) | 6 (2) |
| Unknown | 205 (7) | 34 (9) |
| THRIVE site | ||
| Site 1 | 57 (2) | 1 (0) |
| Site 2 | 110 (4) | 7 (2) |
| Site 3 | 378 (13) | 23 (6) |
| Site 4 | 236 (8) | 30 (8) |
| Site 5 | 137 (5) | 17 (4) |
| Site 6 | 126 (4) | 7 (2) |
| Site 7 | 1,854 (64) | 293 (78) |
| HIV testing | ||
| Total tests | 8,016 | 1,058 |
| Clients with ≥1 HIV test | 2,519 (87) | 320 (85) |
| Clients with positive test results | 26 (1) | 2 (1) |
| nPEP services | ||
| Screened for nPEPa | 1,040 (36) | 86 (23) |
| Eligible for nPEPb | 131 (13) | 12 (14) |
| Prescribed nPEPc | 69 (53) | 11 (92) |
| PrEP services | ||
| Screened for PrEPa | 2,467 (85) | 213 (56) |
| Eligible for PrEPa | 2,002 (69) | 178 (47) |
| Referred for PrEPd | 1,836 (92) | 155 (87) |
| Linked to PrEP servicesd | 1,456 (73) | 125 (70) |
| Prescribed PrEPd | 1,011 (50) | 98 (55) |
| PrEP navigation services | ||
| Navigation services receivedd | 904 (45) | 75 (42) |
Note: The 7 funded THRIVE jurisdictions included Birmingham, AL; Baltimore, MD; District of Columbia; New Orleans, LA; Brooklyn, New York City, NY; Philadelphia, PA; and Hampton Roads, VA.
Among persons without HIV.
Among persons screened for nPEP.
Among persons eligible for nPEP.
Among persons eligible for PrEP.
MSM, men who have sex with men; nPEP, nonoccupational post-exposure prophylaxis; PrEP, pre-exposure prophylaxis; TGW, transgender women; THRIVE, Targeted Highly Effective Interventions to Reduce the HIV Epidemic.
Most Hispanic/Latino clients were aged <35 years (MSM: 1,905 [66%]; TGW: 236 [62%]). Among MSM, 1,044 (36%) were enrolled at Sites 1–6, and 1,854 (64%) were enrolled at Site 7; among TGW, 85 (22%) were enrolled at Sites 1–6, and 293 (78%) were enrolled at Site 7.
During THRIVE, 8,016 and 1,058 total HIV tests were performed among Hispanic/Latino MSM and TGW, respectively (Table 1). HIV testing identified 26 (1%) MSM and 2 (1%) TGW with newly diagnosed HIV. Regarding nPEP among MSM, 1,040 (36%) were screened for nPEP, and 69 (53% of persons eligible) were prescribed nPEP (Table 1). For TGW, 86 (23%) were screened for nPEP, and 11 (92% of persons eligible) were prescribed nPEP. At Sites 1–6, the proportions of nPEP-eligible persons who were prescribed nPEP were 13% (9 of 71) and 0% (0 of 1) for MSM and TGW, respectively. At Site 7, 100% of eligible MSM (60 of 60) and TGW (11 of 11) were prescribed nPEP.
Table 1 describes PrEP services outcomes, including navigation for Hispanic/Latino MSM and TGW overall. Briefly, among PrEP-eligible MSM, 1,456 (73%) were linked to PrEP services, and 1,011 (50%) were prescribed PrEP; among PrEP-eligible TGW, 125 (70%) were linked to PrEP services, and 98 (55%) were prescribed PrEP.
Figure 1 reports the outcomes for the PrEP continuum for Hispanic/Latino MSM and TGW. Among MSM, the percentages of clients screened for PrEP (Sites 1–6: 96%; Site 7: 79%) and eligible for PrEP (Sites 1–6: 80%; Site 7: 63%) differed by site. The percentages of PrEP-eligible MSM referred for PrEP (Sites 1–6: 88%; Site 7: 94%), linked to PrEP (Sites 1–6: 45%; Site 7: 93%), and prescribed PrEP (Sites 1–6: 37%; Site 7: 60%) were all higher for Site 7 than for Sites 1–6. Among TGW, the percentages of clients screened for PrEP (Sites 1–6: 94%; Site 7: 45%) and eligible for PrEP (Sites 1–6: 81%; Site 7: 37%) differed by site. The percentages of PrEP-eligible TGW referred for PrEP (Sites 1–6: 87%; Site 7: 87%) were similar. The percentages of PrEP-eligible TGW linked to PrEP (Sites 1–6: 43%; Site 7: 87%) and prescribed PrEP (Sites 1–6: 33%; Site 7: 69%) were higher for Site 7.
Figure 1.
HIV PrEP services among Hispanic/Latino (A) MSM and (B) TGW during the THRIVE demonstration project, 2015–2020. Note: The number above each bar represents the number in each subgroup followed by the percentage among the total sample size for the corresponding sites. At Sites 1–6, 1,044 MSM were HIV-negative; at Site 7, 1,854 MSM were HIV-negative. At Sites 1–6, 85 TGW were HIV-negative; at Site 7, 293 TGW were HIV-negative.
MSM, men who have sex with men; PrEP, pre-exposure prophylaxis; TGW, transgender women; THRIVE, Targeted Highly Effective Interventions to Reduce the HIV Epidemic.
The age-adjusted RRs (aRRs) to evaluate the association between study sites offering Hispanic/Latino-oriented PrEP clinical services and PrEP outcomes were estimated in Table 2. Among MSM, there was an increased likelihood of PrEP linkage (aRR=2.0, 95% CI=1.4, 2.9) and prescription (aRR=1.6, 95% CI=1.1, 2.2) for the site that provided Hispanic/Latino-oriented PrEP clinical services. Among TGW, results were similar, with an increased likelihood of PrEP linkage (aRR=2.0, 95% CI=1.2, 3.6) and prescription (aRR=2.1, 95% CI=1.1, 4.1) for the site that provided Hispanic/Latino-oriented PrEP clinical services.
Table 2.
Association of PrEP Services With THRIVE Site for Hispanic/Latino MSM and TGW, THRIVE, 2015–2020
| THRIVE site | Linked to PrEP,a aRR (95% CI)b | Prescribed PrEP,a aRR (95% CI)b |
|---|---|---|
| MSM | ||
| Sites 1–6c | Reference | Reference |
| Site 7c | 2.0 (1.4–2.9) | 1.6 (1.1–2.2) |
| TGW | ||
| Sites 1–6c | Reference | Reference |
| Site 7c | 2.0 (1.2–3.6) | 2.1 (1.1–4.1) |
Among persons eligible for PrEP.
aRR (95% CIs) using Poisson regression.
Adjusted for age group.
aRR, adjusted RR; MSM, men who have sex with men; PrEP, pre-exposure prophylaxis; TGW, transgender women; THRIVE, Targeted Highly Effective Interventions to Reduce the HIV Epidemic.
Table 3 describes unmet behavioral health and essential support services needs for Hispanic/Latino MSM and TGW. Among MSM, unmet needs were highest for health insurance (55%), substance use services (40%), and mental health services (28%). Navigation services were provided for >50% of MSM with an unmet need for every category except for substance use (9%). Among TGW, unmet needs were highest for health insurance (72%), mental health services (63%), and substance use services (52%). Navigation services were provided for >50% of TGW with an unmet need for every category except for substance use (0%).
Table 3.
Unmet Behavioral Health and Essential Support Service Needs Among Hispanic/Latino MSM and TGW, THRIVE, 2015–2020
| Unmet need | Screened for need, n (%) | Persons with unmet need,a n (%) | Navigation provided,b n (%) |
|---|---|---|---|
| MSM (n=2,898) | |||
| Insurance | 1,178 (41) | 648 (55) | 450 (69) |
| Mental Health | 907 (31) | 255 (28) | 182 (71) |
| Substance use | 1,217 (42) | 491 (40) | 45 (9) |
| Employment assistance | 1,063 (37) | 242 (23) | 124 (51) |
| Educational assistance | 1,046 (36) | 143 (14) | 118 (83) |
| Housing | 1,007 (35) | 90 (9) | 73 (81) |
| Transportation | 809 (28) | 62 (8) | 38 (61) |
| TGW (n=378) | |||
| Insurance | 216 (57) | 156 (72) | 143 (92) |
| Mental Health | 142 (38) | 90 (63) | 48 (53) |
| Substance use | 155 (41) | 81 (52) | 0 (0) |
| Employment assistance | 121 (32) | 55 (45) | 31 (56) |
| Educational assistance | 126 (33) | 45 (36) | 29 (64) |
| Housing | 121 (32) | 30 (25) | 23 (77) |
| Transportation | 92 (24) | 19 (21) | 11 (58) |
Among persons who were screened for unmet needs.
Among persons who reported an unmet need.
MSM, men who have sex with men; TGW, transgender women; THRIVE, Targeted Highly Effective Interventions to Reduce the HIV Epidemic.
DISCUSSION
Overall, THRIVE sites achieved higher PrEP coverage rates (MSM, 50%; TGW, 55%) among Hispanic/Latino MSM and TGW than the national average (20%) for Hispanic/Latino persons.7 The largest proportion of PrEP prescriptions among PrEP-eligible clients were at the site with partners who provided Hispanic/Latino-oriented PrEP clinical services. At this site, 60% and 69% of eligible MSM and TGW, respectively, were prescribed PrEP; MSM and TGW were 2 times more likely to be linked to PrEP and 1.6–2.1 times more likely to be prescribed PrEP than at sites without Hispanic/Latino-oriented PrEP clinical services. This level of PrEP coverage exceeded the EHE goal of 50% PrEP coverage by 2025 and approached the PrEP coverage indicator among White persons in the U.S., significantly narrowing the disparity in HIV prevention with PrEP among Hispanic/Latino men.7,25 Similar trends by site were observed for nPEP, with Site 7 prescribing nPEP to a higher percentage of eligible THRIVE clients.
Sites 1–6 screened a higher proportion of Hispanic/Latino MSM and TGW clients for PrEP than Site 7. This evaluation was not able to identify all factors that may have contributed to this difference. However, variations in the implementation of THRIVE services by jurisdiction, especially differences in THRIVE client identification and PrEP screening protocols, likely contributed to this finding. Despite a lower PrEP screening proportion, the key outcome, PrEP prescription coverage, was higher at the site with partners who provided Hispanic/Latino-oriented PrEP clinical services than at sites without those partners.
Hispanic/Latino persons face many barriers to accessing HIV prevention services. The results of THRIVE suggest that a coordinated, comprehensive strategy developed in partnership between health departments, CBOs, behavioral and social service providers, and clinical providers can successfully address barriers to HIV prevention services. Furthermore, offering culturally and linguistically appropriate HIV prevention clinical services may be an important strategy to address barriers and ultimately reduce HIV transmission in the Hispanic/Latino community. Although the literature regarding culturally appropriate interventions to improve PrEP uptake for Hispanic/Latino persons is limited, previous research has shown that these interventions can improve outcomes for other HIV prevention and treatment services.26–28
THRIVE jurisdictions identified many unmet behavioral health and essential support service needs among Hispanic/Latino clients, including health insurance, mental health service, and substance use service needs as the most prevalent. Sites successfully provided navigation services to address many of the needs of Hispanic/Latino clients. These unmet needs represent individual- and structural-level barriers to HIV prevention services, and the high burden of unmet needs across both groups reinforces the value of screening and assisting Hispanic/Latino clients to connect with needed services. However, providing navigation for substance use services was challenging because <10% of MSM and 0% of TGW with unmet needs for substance use services received navigation. Qualitative interviews with THRIVE sites revealed significant challenges in identifying substance use treatment partners in THRIVE jurisdictions (MRT, unpublished observations, 2022). Insufficient substance use treatment services are a national problem. One national survey reported that only 10.3% of U.S. persons who had a substance use disorder in 2019 received substance use treatment that year.29 The shortage is compounded by insufficient training for clinicians to provide evidence-based substance use disorder care and shortages of addiction medicine specialists.30–32 Where substance use disorder treatment services do exist, they are rarely tailored to the needs of sexual and gender minorities, and cost remains a barrier.30,33,34 These unmet needs represent important obstacles to achieving the EHE’s goal to reduce new HIV infections by 90%.5
In THRIVE, Hispanic/Latina TGW had a high burden of unmet needs across all domains. This difference was most pronounced for mental health service needs, where 63% of TGW reported unmet needs compared with 28% for MSM. The high rate of mental health service needs was reflected in a national survey of transgender persons, which found that Hispanic/Latino transgender persons experienced serious psychological distress (45%) or had previously attempted suicide (45%), at rates 9 and 10 times higher than that of the U.S. population, respectively.35 Previous studies have documented high rates of substance use, unemployment, homelessness, and lack of health insurance or access to health care among transgender persons.3,35–38 These barriers, exacerbated by the HIV stigma, racism, and transphobia that underlie them, have led to large disparities in HIV prevalence among Hispanic/Latina TGW compared with that among White TGW. A recent meta-analysis estimated HIV prevalence to be 26% among Hispanic/Latina TGW in the U.S. A survey of TGW in 7 major U.S. cities estimated the prevalence of HIV to be 35% among Hispanic/Latina TGW.2,3 Efforts to provide comprehensive, culturally appropriate HIV prevention services informed by the unique needs of Hispanic/Latina TGW are urgently needed.
Limitations
This analysis had some limitations. First, limited sociodemographic information such as education and income were collected, limiting the assessment of compositional differences in Hispanic/Latino populations across sites and their inclusion as potential confounders in analytic models. Second, the implementation of THRIVE services varied by jurisdiction, including identifying THRIVE clients and screening for PrEP eligibility. This, along with other unmeasured site-related factors, impact the ability to compare services received by clients across sites and may have contributed to differences in the outcomes observed. Therefore, although the results of THRIVE are very encouraging, the authors cannot conclude that providing Hispanic/Latino-oriented clinical services was the cause of the differences in outcomes observed. Third, this study may have underestimated an outcome (e.g., PrEP prescription) if participants received these services from organizations outside of the THRIVE collaborative. The likelihood that THRIVE clients received services outside of the collaboratives may have varied by site, given differences in the composition of the collaboratives and resource availability in participating jurisdictions. Finally, findings from this analysis might not be generalizable to other jurisdictions with different patient populations and number of HIV diagnoses.
CONCLUSIONS
In summary, the THRIVE demonstration project successfully served Hispanic/Latino MSM and TGW by implementing and supporting the use of comprehensive HIV prevention services, including HIV testing, PrEP, and nPEP. The inclusion of collaborative partners that provided Hispanic/Latino-oriented PrEP clinical services was associated with increased receipt of HIV prevention services by Hispanic/Latino MSM and TGW. This study also found that a large proportion of Hispanic/Latino THRIVE clients, especially TGW, had unmet behavioral health and essential support service needs. Implementing comprehensive, Hispanic/Latino-oriented HIV prevention services; behavioral health services; and essential support services that are specifically designed to meet the needs of Hispanic/Latino MSM and TGW communities can support achieving the goals of the EHE initiative and decrease disparities in HIV diagnoses among these populations.
ACKNOWLEDGMENTS
The Targeted Highly Effective Interventions to Reduce the HIV Epidemic project team includes Zoe Edelstein, Stephanie Hubbard, Anthony James, Anne Kimball, Jerris Raiford, William T. Robinson, and Lucila Wood. The authors thank the Targeted Highly Effective Interventions to Reduce the HIV Epidemic demonstration project sites, collaborative partners, and clients served by the demonstration project. KLD was affiliated with the Division of HIV Prevention, Centers for Disease Control and Prevention and the United States Public Health Service when this work occurred.
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The funder had no role in the study or writing and submission of results.
Funding for this demonstration project was provided by the U.S. Department of Health and Human Services Minority HIV/AIDS Fund.
Footnotes
No financial disclosures were reported by the authors of this paper.
CREDIT AUTHOR STATEMENT
Robert A. Bonacci: Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing. Mary R. Tanner: Conceptualization, Formal analysis, Funding acquisition, Methodology, Project administration, Supervision, Writing – review & editing. Weiming Zhu: Data curation, Formal analysis, Methodology, Software, Writing – review & editing. Tameka Hayes: Data curation, Formal analysis, Software, Writing – review & editing. Kenneth L. Dominguez: Conceptualization, Funding acquisition, Methodology, Project administration, Supervision, Writing – review & editing. Kashif Iqbal: Funding acquisition, Project administration, Supervision, Writing – review & editing. Jeffrey Wiener: Data curation, Methodology, Software, Writing – review & editing. Kate Drezner: Investigation, Writing – review & editing. Jacky Jennings: Investigation, Writing – review & editing. Benjamin Tsoi: Investigation, Writing – review & editing. Debbie Wendell: Investigation, Writing – review & editing. Karen Hoover: Funding acquisition, Project administration, Supervision, Writing – review & editing.
REFERENCES
- 1.Centers for Disease Control and Prevention. Estimated HIV incidence and prevalence in the United States, 2015–2019. Atlanta, GA: Centers for Disease Control and Prevention; 2021. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-supplemental-report-vol-26-1.pdf. Published May 2021. Accessed February 17, 2023. [Google Scholar]
- 2.Becasen JS, Denard CL, Mullins MM, Higa DH, Sipe TA. Estimating the prevalence of HIV and sexual behaviors among the U.S. transgender population: a systematic review and meta-analysis, 2006–2017. Am J Public Health. 2019;109(1):e1–e8. 10.2105/AJPH.2018.304727. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Centers for Disease Control and Prevention. HIV infection, risk, prevention, and testing behaviors among transgender women—national HIV behavioral surveillance, 7 U.S. Cities, 2019–2020. Atlanta, GA: Centers for Disease Control and Prevention; 2021. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-27.pdf. Published April 2021. Accessed February 17, 2023. [Google Scholar]
- 4.Bonacci RA, Smith DK, Ojikutu BO. Toward greater pre-exposure prophylaxis equity: increasing provision and uptake for Black and Hispanic/Latino individuals in the U.S. Am J Prev Med. 2021;61(suppl 1):S60–S72 5. 10.1016/j.amepre.2021.05.027. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Fauci AS, Redfield RR, Sigounas G, Weahkee MD, Giroir BP. Ending the HIV Epidemic: a plan for the United States. JAMA. 2019;321 (9):844–845. 10.1001/jama.2019.1343. [DOI] [PubMed] [Google Scholar]
- 6.Kanny D, Jeffries WL 4th, Chapin-Bardales J, et al. Racial/ethnic disparities in HIV preexposure prophylaxis among men who have sex with men - 23 urban areas, 2017. MMWR Morb Mortal Wkly Rep. 2019;68(37):801–806. 10.15585/mmwr.mm6837a2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Core indicators for monitoring the Ending the HIV Epidemic initiative (preliminary data): national HIV Surveillance System data reported through March 2022; and preexposure prophylaxis (PrEP) data reported through December 2021. Centers for Disease Control and Prevention. https://www.cdc.gov/hiv/library/reports/surveillance-data-tables/vol-3-no-2/index.html. Updated August 9, 2022. Accessed December 20, 2022. [Google Scholar]
- 8.Levison JH, Levinson JK, Alegría M. A critical review and commentary on the challenges in engaging HIV-infected Latinos in the continuum of HIV care. AIDS Behav. 2018;22(8):2500–2512. 10.1007/s10461-018-2187-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Horridge DN, Oh TS, Alonzo J, et al. Barriers to HIV testing within a sample of Spanish-speaking Latinx gay, bisexual, and other men who have sex with men: implications for HIV prevention and care. HealthBehav Res. 2019;2(3). 10.4148/2572–1836.1069. 10.4148/2572-1836.1069. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Ogunbajo A, Storholm ED, Ober AJ, et al. Multilevel barriers to HIV PrEP uptake and adherence among Black and Hispanic/Latinx transgender women in Southern California. AIDS Behav. 2021;25(7):2301–2315. 10.1007/s10461-021-03159-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Guilamo-Ramos V, Thimm-Kaiser M, Benzekri A, et al. The invisible U.S. Hispanic/Latino HIV crisis: addressing gaps in the national response. Am J Public Health. 2020;110(1):27–31. 10.2105/AJPH.2019.305309. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Mansergh G, Herbst JH, Holman J, Mimiaga MJ. Association of HIV pre-exposure prophylaxis awareness, preferred Spanish (vs. English) language use, and sociodemographic variables among Hispanic/Latino men who have sex with men. Ann Epidemiol. 2019;31:8–10. 10.1016/j.annepidem.2019.01.003. [DOI] [PubMed] [Google Scholar]
- 13.García M, Harris AL. PrEP awareness and decision-making for Latino MSM in San Antonio, Texas. PLoS One. 2017;12(9):e0184014. 10.1371/journal.pone.0184014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Mayer KH, Agwu A, Malebranche D. Barriers to the wider use of pre-exposure prophylaxis in the United States: a narrative review. Adv Ther. 2020;37(5):1778–1811. 10.1007/s12325-020-01295-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Reback CJ, Clark KA, Runger €D, Fehrenbacher AE. A promising PrEP navigation intervention for transgender women and men who have sex with men experiencing multiple syndemic health disparities. J Community Health. 2019;44(6):1193–1203. 10.1007/s10900-019-00705-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Oral abstracts of the 10th IAS Conference on HIV Science, 21–24 July 2019, Mexico City, Mexico. J Int AIDS Soc. 2019;22(suppl 5):e25327. 10.1002/jia2.25327. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Patel VV, Ginsburg Z, Golub SA, et al. Empowering with PrEP (E-PrEP), a peer-led social media-based intervention to facilitate HIV preexposure prophylaxis adoption among young Black and Latinx gay and bisexual men: protocol for a cluster randomized controlled trial. JMIR Res Protoc. 2018;7(8):e11375. 10.2196/11375. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Blackstock OJ, Platt J, Golub SA, et al. A pilot study to evaluate a novel pre-exposure prophylaxis peer outreach and navigation intervention for women at high risk for HIV infection. AIDS Behav. 2021;25 (5):1411–1422. 10.1007/s10461-020-02979-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.About THRIVE. Centers for Disease Control and Prevention. https://www.cdc.gov/hiv/research/thrive/about.html. Updated August 15, 2022. Accessed December 20, 2022. [Google Scholar]
- 20.Tanner MR, Iqbal K, Dominguez KL, Zhu W, Obi J, Hoover KW. Key factors for successful implementation of HIV prevention services by THRIVE community collaboratives. Public Health Rep. 2022;137 (2):310–316. 10.1177/00333549211005793. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Iqbal K, Dong X, Zhu W, et al. Decreased human immunodeficiency virus diagnosis rates among black and hispanic or latino men who have sex with men in U.S. jurisdictions supported by the THRIVE demonstration project, 2014–2019. Clin Infect Dis. 2023;76(2):307–314. 10.1093/cid/ciac774. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Kimball AA, Zhu W, Tanner MR, et al. The effect of navigation on linkage to a PrEP provider among PrEP-eligible men who have sex with men in a U.S. Demonstration project. AIDS Behav. In press. Online November 22, 2022. 10.1007/s10461-022-03931-y. [DOI] [PubMed] [Google Scholar]
- 23.Tanner MR, Zhu W, Iqbal K, et al. HIV pre-exposure prophylaxis services for Black and Hispanic or Latino gay, bisexual, and other men who have sex with men and transgender women in THRIVE, 2015 –2020. J Acquir Immune Defic Syndr. 2022. In press. Online December 8. 10.1097/QAI.0000000000003138. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 update: a clinical practice guideline. Atlanta, GA: Centers for Disease Control and Prevention; 2018. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prepguidelines-2017.pdf. Published March 2018. Accessed February 17, 2023. [Google Scholar]
- 25.America’s HIV epidemic analysis dashboard (AHEAD). HHS. https://ahead.hiv.gov/. Updated 2021. Accessed December 20, 2022. [Google Scholar]
- 26.Enriquez M, Farnan R, Cheng AL, et al. Impact of a bilingual/bicultural care team on HIV-related health outcomes. J Assoc Nurses AIDS Care. 2008;19(4):295–301. 10.1016/j.jana.2008.04.004. [DOI] [PubMed] [Google Scholar]
- 27.Wilson K, Durantini MR, Albarracín J, Crause C, Albarracín D. Reducing cultural and psychological barriers to Latino enrollment in HIV-prevention counseling: initial data on an enrollment meta-intervention. AIDS Care. 2013;25(7):881–887. 10.1080/09540121.2012.729803. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Rhodes SD, Alonzo J, Mann-Jackson L, et al. A peer navigation intervention to prevent HIV among mixed immigrant status Latinx GBMSM and transgender women in the United States: outcomes, perspectives and implications for PrEP uptake. Health Educ Res. 2020;35 (3):165–178. 10.1093/her/cyaa010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Abuse Substance and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2019 National Survey on Drug Use and Health. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2020. https://www.samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/2019NSDUHFFR1PDFW090120.pdf. Published 2020. Accessed December 20, 2022. [Google Scholar]
- 30.Madras BK, Ahmad NJ, Wen J, Sharfstein JS. Improving access to evidence-based medical treatment for opioid use disorder: strategies to address key barriers within the treatment system. NAM Perspect. 2020;2020 10.31478/202004b. 10.31478/202004b. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.National Academies of Sciences, Engineering, Medicine, Health and Medicine Division, Board on Health Sciences Policy, Committee on Medication-Assisted Treatment for Opioid Use Disorder, Mancher M and Leshner AI, Medications for Opioid Use Disorder Save Lives, 2019, The National Academies Press; Washington, DC. https://nap.nationalacademies.org/catalog/25310/medications-for-opioid-use-disorder-save-lives. Accessed February 17, 2023. [PubMed] [Google Scholar]
- 32.McNeely J, Schatz D, Olfson M, Appleton N, Williams AR. How physician workforce shortages are hampering the response to the opioid crisis. Psychiatr Serv. 2022;73(5):547–554. 10.1176/appi.ps.202000565. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Mereish EH. Substance use and misuse among sexual and gender minority youth. Curr Opin Psychol. 2019;30:123–127. 10.1016/j.copsyc.2019.05.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Ji CG, Cochran B. The availability of sexual and gender minority (SGM) specific substance use services. Subst Use Misuse. 2022;57 (14):2126–2133. 10.1080/10826084.2022.2137812. [DOI] [PubMed] [Google Scholar]
- 35.James SE, Salcedo B. 2015 U.S. Transgender Survey: Report on the Experiences of Latino/a Respondents. Washington, DC and Los Angeles, CA: National Center for Transgender Equality and TransLatin@Coalition; 2017. https://transequality.org/sites/default/files/docs/usts/USTSLatinReport-Nov17.pdf. Published 2017. Accessed December 20, 2022. [Google Scholar]
- 36.Poteat T, Malik M, Scheim A, Elliott A. HIV prevention among transgender populations: knowledge gaps and evidence for action. Curr HIV/AIDS Rep. 2017;14(4):141–152. 10.1007/s11904-017-0360-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Neumann MS, Finlayson TJ, Pitts NL, Keatley J. Comprehensive HIV prevention for transgender persons. Am J Public Health. 2017;107 (2):207–212. 10.2105/AJPH.2016.303509. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.De Santis JP. HIV infection risk factors among male-to-female transgender persons: a review of the literature. J Assoc Nurses AIDS Care. 2009;20(5):362–372. 10.1016/j.jana.2009.06.005. [DOI] [PubMed] [Google Scholar]