Service utilization and HIV outcomes among transgender women receiving Ryan White Part A services in New York City

Jacinthe A Thomas; Mary K Irvine; Qiang Xia; Graham A Harriman

doi:10.1371/journal.pone.0253444

. 2021 Jul 1;16(7):e0253444. doi: 10.1371/journal.pone.0253444

Service utilization and HIV outcomes among transgender women receiving Ryan White Part A services in New York City

Jacinthe A Thomas ^1,^*, Mary K Irvine ¹, Qiang Xia ¹, Graham A Harriman ¹

Editor: Kwasi Torpey²

PMCID: PMC8248705 PMID: 34197479

Abstract

Background

Prior research has found evidence of gender disparities in U.S. HIV healthcare access and outcomes. In order to assess potential disparities in our client population, we compared demographics, service needs, service utilization, and HIV care continuum outcomes between transgender women, cisgender women, and cisgender men receiving New York City (NYC) Ryan White Part A (RWPA) services.

Methods

The analysis included HIV-positive clients with an intake assessment between January 2016 and December 2017 in an NYC RWPA services program. We examined four service need areas: food and nutrition, harm reduction, mental health, and housing. Among clients with the documented need, we ascertained whether they received RWPA services targeting that need. To compare HIV outcomes between groups, we applied five metrics: engagement in care, consistent engagement in care, antiretroviral therapy (ART) use, point-in-time viral suppression, and durable viral suppression.

Results

All four service needs were more prevalent among transgender women (N = 455) than among cisgender clients. Except in the area of food and nutrition services, timely (12-month) receipt of RWPA services to meet a specific assessed need was not significantly more or less common in any one of the three client groups examined. Compared to cisgender women and cisgender men, a lower proportion of transgender women were durably virally suppressed (39% versus 52% or 50%, respectively, p-value < 0.001).

Conclusions

Compared with cisgender women and cisgender men, transgender women more often presented with basic (food/housing) and behavioral-health service needs. In all three groups (with no consistent between-group differences), assessed needs were not typically met with the directly corresponding RWPA service category. Targeting those needs with RWPA outreach and services may support the National HIV/AIDS Strategy 2020 goal of reducing health disparities, and specifically the objective of increasing (to ≥90%) the percentage of transgender women in HIV medical care who are virally suppressed.

Introduction

The federal Ryan White HIV/AIDS Program (RWHAP) has been a critical safety net for people living with HIV (PLWH) for the past thirty years [1]. The program funds medical and supportive services for individuals without sufficient alternative resources to manage HIV disease. RWHAP services are designed to support engagement in HIV medical care and address psychosocial or structural barriers to viral suppression (reduction of HIV-1 viral load [VL] in plasma to levels below the detection limit of common HIV RNA tests used by healthcare providers). More than half of all U.S. PLWH are RWHAP clients [2]. In 2018, 87% of RWHAP clients were virally suppressed, exceeding the national viral suppression average of 63% [3]. However, while RWHAP services appear to have a positive effect on treatment outcomes [4, 5], significant inequities exist among clients [6], particularly by gender identity. Overall, in 2018, transgender women in RWHAP experienced lower retention in care and viral suppression (78% retention and 81% suppression) than cisgender women in RWHAP (83% retention and 87% suppression); these outcome disparities were observed in each housing status category (unstably housed, temporarily housed, and stably housed) [3]. Prior research in the U.S. has shown that transgender women, compared with other PLWH, face barriers to engagement in care and antiretroviral treatment (ART) adherence due to negative experiences with healthcare providers [7, 8].

Multiple New York City (NYC) reports have also shown evidence of gender disparities in HIV outcomes. A citywide study based on HIV surveillance data found that transgender women had lower viral suppression than men who have sex with men (MSM) in the first 12 months after HIV diagnosis [9]. Similarly, a more recent analysis highlighted significant differences in viral suppression among transgender women, cisgender women, and MSM receiving Ryan White Part A (RWPA) services [10]. In addition, NYC Health Department data from a 2014 client satisfaction survey showed that transgender women respondents were less likely to be “very satisfied” with their RWPA services or the way they were treated overall, compared to cisgender women respondents [10]. Transgender women surveyed were also significantly less likely than cisgender women to "agree" or "strongly agree" with statements indicating that they were treated with respect and that all staff were nice to them. In the same survey, qualitative feedback from transgender women clients highlighted unmet service needs for food and housing [10].

While very few studies have examined care continuum outcomes among transgender women compared with cisgender women and men enrolled in RWHAP [11], no published studies have compared transgender and cisgender RWHAP clients on both service utilization and care continuum outcomes. For the current analysis, we examined differences between transgender women, cisgender women, and cisgender men in NYC RWPA with regard to: 1) demographics and service utilization; 2) four areas of service need: food and nutrition, harm reduction, mental health, and housing services, and the extent to which those needs were met with directly related NYC RWPA supportive services; and 3) HIV outcomes along the care continuum, including engagement in care, ART use, point-in-time viral suppression and durable viral suppression. Assessing and understanding unmet service needs and HIV outcome disparities experienced by transgender NYC RWPA clients can inform the development of strategies to intervene and ultimately to advance gender equity in HIV care continuum outcomes.

Materials and methods

Inclusion criteria

The analysis included HIV-positive clients with at least one complete NYC RWPA assessment, from January 2016 to December 2017, in a contract for medical or non-medical case management, mental health or supportive counseling, food and nutrition, harm reduction, housing, legal, and/or health education/risk reduction services. These NYC RWPA service categories were selected because they focus on HIV-diagnosed individuals, share a core set of assessment questions relevant to service needs, and follow clients beyond the initial linkage to care. New York State (NYS) eligible metropolitan area (EMA) RWPA clients in these service categories are assessed upon enrollment in order to identify specific needs for services and devise a plan to address them. They are also reassessed approximately every six months thereafter while they remain enrolled, allowing for the identification of persistent and emerging needs, to guide client-centered service planning and coordination.

Data sources

Data on enrollments, demographics, and receipt of RWPA services, as well as assessments, were drawn from the Electronic System for HIV/AIDS Reporting and Evaluation (eSHARE), a secure, Web-based reporting system for HIV services contracts. NYC client-level RWPA data are routinely matched against data from the NYC HIV Surveillance Registry (the “Registry”) using a deterministic matching process, which has been described elsewhere [12]. For the current analysis, provider-reported programmatic data in eSHARE were merged with the Registry to link individual RWPA client records with complete NYC laboratory (VL and CD4) test records. Electronically captured, named reporting of all HIV-related laboratory tests, including positive diagnostic tests and viral nucleotide sequences, has been mandatory in NYS since 2005 [13].

Ethics

Participant consent did not apply for this retrospective analysis, which utilized secondary data reported to the NYC Health Department as required under NYS law or under contractual agreements with RWPA-funded agencies. The HIV surveillance and RWPA programmatic data sets were fully de-identified prior to analysis. Only authorized Health Department analysts trained in HIV confidentiality and data security protocols have access to these data sets. This analysis met the definition of public health surveillance and was designated as not human subjects research by the NYC Health Department institutional review board (IRB).

Demographic measures

Using information from eSHARE, we defined transgender women as clients having either self-identified gender reported as “transgender woman or girl” or self-identified gender reported as “woman or girl” and sex assigned at birth reported as “male.” Cisgender women clients were defined as having self-identified gender reported as “woman or girl” and sex assigned at birth reported as “female.” Similarly, we used self-identified gender (reported as “man or boy”) and sex assigned at birth (reported as “male”) to classify cisgender men. Transgender men and non-binary individuals were not included as separate groups because of their small numbers (<35 and <5, respectively) in the client cohort available for analysis. eSHARE also captures age, race and ethnicity, country of birth, educational attainment, employment status, and primary language. Race and ethnicity were combined into a single race/ethnicity variable, for which clients who identified as having Hispanic ethnicity were categorized as "Hispanic/Latinx" regardless of reported race, and non-Hispanic/Latinx clients reporting only one race (Black or White) were categorized as that race, while a relatively small number of non-Hispanic/Latinx clients reporting Asian race, more than one race, or “Other” race were included in a combined "Asian/Other/Mixed race" category, and non-Hispanic/Latinx clients with entirely missing race data were included in the "Unknown" category. We combined race and ethnicity into a single variable in part because data on race were disproportionately missing among clients for whom Hispanic ethnicity was reported. Educational attainment was categorized as “below high school” and “at or above high school/general educational development (GED)” (for completion of high school or any amount of higher education). Employment status, which is based on five mutually exclusive levels, was categorized as “employed” (for full-time or part-time employment); “unemployed” (for unemployed or unpaid volunteer/peer worker status); and “out of workforce” (for student, retired or homemaker status).

Service need and utilization measures

RWPA clients can be enrolled in more than one program or service category at a time. To determine service category utilization, we checked for receipt of any service between January 1, 2016 and December 31, 2017 in the service categories included in this analysis (i.e. medical or non-medical case management, mental health or supportive counseling, food and nutrition, harm reduction, housing, legal and/or health education/risk reduction services). Using data from assessments that were completed between January 1, 2016 and December 31, 2017, we defined need according to the following criteria. Food and nutrition need was defined as food insufficiency (FI) or income ≤130% of Federal Poverty Level (FPL), based on the eligibility cutoff in NYS for the Supplemental Nutritional Assistance Program (SNAP) [14]. FI status was assessed based on responses to the following questions, collected in only some of the service categories included in the analysis: 1) “In the past three months, how often has it happened that there was not enough money for food in the household?” 2) “Which of the following best describes your situation in terms of food you eat?” and 3) “In the last 30 days, did you go a whole day without anything at all to eat (because you did not have adequate access to food)?” Clients were classified as having FI if they reported (1) “once in a while,” “fairly often,” or “very often” not having enough money for food in the past 3 months; (2) “sometimes” or “often” not having enough to eat; or (3) going for a whole day without anything at all to eat in the past 30 days. Harm reduction need was defined as use of cocaine/crack, heroin, crystal methamphetamine, or prescription drugs to get high in the past three months. Mental health need was defined as a mental component summary score of ≤37.0 on the 12-item Short Form survey [15]. Housing need was defined as unstable housing, which includes homelessness and transitional/temporary housing situations.

We chose to analyze these four areas of need because they each have a parallel RWPA service category that is funded within the NYS EMA. While some other service categories funded locally are designed to respond to a wider range of needs or barriers to care/treatment engagement (e.g., non-medical or medical case management), others (e.g., oral healthcare) address needs that have not been directly assessed in eSHARE or could be considered universal. Among transgender women, cisgender women and cisgender men with evidence of a need at intake assessment between January 1, 2016 and December 31, 2017, we ascertained whether they received NYC RWPA services targeting that need within 12 months after the first assessment indicating that need.

HIV outcome measures

HIV outcomes were derived from HIV-related laboratory test information from the Registry. We used five metrics: 1) engagement in care, defined as having at least one HIV-related (VL or CD4) laboratory test within 12 months after the last service received between January 1, 2016 and December 31, 2017 (observation period); 2) consistent engagement in care, defined as having at least two HIV-related (VL or CD4) laboratory tests, at least two months apart, within 12 months after the last service received in the observation period; 3) ART use, defined as having a current ART prescription in the observation period; 4) point-in-time viral suppression, defined as having a value <200 copies/mL on the latest VL test result within 12 months after the last service received in the observation period; and 5) durable viral suppression, defined as having at least two VL test results at least 2 months apart within 12 months after the last service received in the observation period, and having values <200 copies/mL on all VL results in that 12-month follow-up period. Clients without a VL test in that timeframe were classified as virally unsuppressed.

Data analysis

All analyses were performed in SAS version 9.4. Overall differences in service utilization and HIV outcomes between the three groups were first assessed using the χ2 test or the Fisher’s exact test (where appropriate). Where initial tests showed any significant gender disparity, post-hoc tests were used for pairwise comparisons. Poisson regression models were used to estimate adjusted prevalence ratios of HIV care continuum outcomes for transgender women and cisgender men compared to cisgender women, controlling for age, race/ethnicity, and country of birth [16]. We selected these variables as covariates based on a causal model using a directed acyclic graph [17].

Results

Clients eligible for the overall analysis included 455 transgender women (3%), 4,906 cisgender women (33%), and 9,699 cisgender men (64%). The demographic characteristics of the three groups are listed in Table 1. In all three gender groups, most clients were Black or Hispanic, U.S.-born, primarily English speaking, and unemployed. There were differences between the three groups on all demographic characteristics. Compared to cisgender women and cisgender men, transgender women were more likely to be younger (21% versus 7% and 10%) and Hispanic/Latinx (43% versus 32% and 38%). A higher proportion of transgender women were unemployed (75%) and reported Spanish as their primary language (24%), compared to the two other groups. Transgender women were more likely to be born outside of the U.S. (28%) and to have education at or above the high school/GED level (60%) compared to cisgender women (24% and 50%), but cisgender men were more likely than transgender women to have that higher level of educational attainment (66%).

Table 1. Demographic characteristics of HIV-positive Ryan White Part A clients served and assessed between January 1, 2016 and December 31, 2017.

Characteristics	Transgender Women (N = 455)		Cisgender Women (N = 4906)		Cisgender Men (N = 9699)
Characteristics	N	%	N	%	N	%
Age group (years)
Under 30	94	21	355	7	975	10
30-49	255	56	1654	34	3735	39
50 or older	106	23	2897	59	4989	51
Race and ethnicity
Black	217	48	2992	61	4574	47
Hispanic/Latinx	197	43	1563	32	3653	38
White	21	5	220	4	1073	11
Asian/Other/Mixed race	18	4	97	2	352	4
Unknown	2	<1	34	<1	47	<1
Country of birth
U.S./U.S. territories	321	71	3604	73	6666	69
Outside of the U.S.	126	28	1187	24	2766	29
Unknown	8	2	115	2	267	3
Educational attainment
Below high school	165	36	2244	46	2859	29
At or above high school/GED	271	60	2462	50	6406	66
Unknown	19	4	200	4	434	4
Employment status
Employed	48	11	564	12	1596	16
Unemployed	340	75	3468	71	6650	69
Out of workforce	57	13	792	16	1248	13
Unknown	10	2	82	2	205	2
Primary language
English	328	72	3794	77	7250	75
Spanish	111	24	784	16	1972	20
Other	11	2	314	6	432	4
Unknown	5	1	14	<1	45	<1

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GED, general educational development; HIV, human immunodeficiency virus.

Percentages may not add to 100% within a client subgroup, because of rounding.

Transgender women were significantly more likely to receive harm reduction services (24% versus 14% for both cisgender women and cisgender men) and housing assistance (23% versus 9% and 11% for cisgender women and cisgender men, respectively) (Table 2). However, compared to cisgender men, a significantly lower proportion of transgender women received food and nutrition services (23% versus 31%). Transgender women were also less likely to receive legal services (17% versus 25% and 24% for cisgender women and cisgender men, respectively) (Table 2).

Table 2. Ryan White Part A service category utilization by gender, 2016-2017.

Service Category	TW (N = 455)	CW (N = 4906)	CM (N = 9699)	Overall	TW vs. CW		TW vs. CM		CW vs. CM
Service Category	N (%)	N (%)	N (%)	P-value*	Chi-square	P-value	Chi-square	P-value	Chi-square	P-value
Case Management	194 (43)	2021 (41)	3983 (41)	0.7995	—	—	—	—	—	—
Harm Reduction	111 (24)	704 (14)	1400 (14)	<.001	35.08	<.001	37.10	<.001	0.02	0.8905
Housing	106 (23)	423 (9)	1084 (11)	<.001	105.15	<.001	66.97	<.001	22.60	<.001
Food and Nutrition	104 (23)	1324 (27)	2998 (31)	<.001	3.46	0.0628	11.91	<.001	23.56	<.001
Mental Health	94 (21)	1122 (23)	1753 (18)	<.001	1.13	0.2873	2.01	0.1566	47.96	<.001
Legal	77 (17)	1234 (25)	2361 (24)	<.001	13.78	<.001	11.9	<.001	1.16	0.2822
Health Education/Risk Reduction	44 (10)	429 (9)	844 (9)	0.7746	—	—	—	—	—	—

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TW, transgender women; CW, cisgender women; CM, cisgender men.

*P-value is based on the chi-square/Fisher’s exact test as applicable.

Dashes signify that pairwise comparisons were not conducted when no significant main effect was found.

Significant p-values are bolded.

Compared to cisgender women and cisgender men, significantly higher proportions of transgender women had an apparent need for support in the areas of housing (52% versus 24% and 35%, respectively), harm reduction (23% versus 12% and18%, respectively), and food and nutrition (95% versus 92% and 88%, respectively) (Table 3). Transgender women also had a higher apparent need for mental health services, as compared with cisgender men (24% versus 20%). A smaller proportion of transgender women with food and nutrition service needs received those services in the following 12 months (23%), compared to cisgender women (28%) and cisgender men (33%) with the same need (Table 4). Otherwise, timely (12-month) receipt of RWPA services to meet a specific assessed need was not significantly more or less common in any one of the three client groups examined.

Table 3. Ryan White Part A service category need by gender.

Service Area	TW (N = 455)	CW (N = 4906)	CM (N = 9699)	Overall	TW vs. CW		TW vs. CM		CW vs. CM
	Had Need	Had Need	Had Need	P-value*	Chi-square	P-value	Chi-square	P-value	Chi-square	P-value
	N (%)	N (%)	N (%)	P-value*	Chi-square	P-value	Chi-square	P-value	Chi-square	P-value
Food/Nutrition	431 (95)	4514 (92)	8528 (88)	<.001	6.04	0.014	40.63	<.001	64.68	<.001
Harm Reduction	105 (23)	600 (12)	1737 (18)	<.001	45.87	<.001	8.24	0.0041	75.17	<.001
Mental Health	107 (24)	1100 (22)	1922 (20)	<.001	0.29	0.5906	3.87	0.049	13.59	<.001
Housing	238 (52)	1167 (24)	3419 (35)	<.001	233.7	<.001	71.01	<.001	183.66	<.001

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TW, transgender women; CW, cisgender women; CM, cisgender men.

*P-value is based on the chi-square/Fisher’s exact test as applicable.

Significant p-values are bolded.

Table 4. Ryan White Part A service category utilization by gender among those with assessed need – within 12 months after the assessment indicating the need.

Service Area	TW		CW		CM		Overall	TW vs. CW		TW vs. CM		CW vs. CM
	Had need	Had service	Had Need	Had service	Had Need	Had service	P-value*	Chi-square	P-value	Chi-square	P-value	Chi-square	P-value
	N(%)	N (%)	N (%)	N (%)	N (%)	N (%)	P-value*	Chi-square	P-value	Chi-square	P-value	Chi-square	P-value
Food/Nutrition	431 (95)	99 (23)	4514 (92)	1246 (28)	8528 (88)	2785 (33)	<.001	4.04	0.0445	15.43	<.001	34.36	<.001
Harm Reduction	105 (23)	71 (68)	600 (12)	348 (58)	1737 (18)	1080 (62)	0.0788	—	—	—	—	—	—
Mental Health	107 (24)	47 (44)	1100 (22)	506 (46)	1922 (20)	811 (42)	0.1273	—	—	—	—	—	—
Housing	238 (52)	150 (63)	1167 (24)	671 (58)	3419 (35)	2045 (60)	0.1931	—	—	—	—	—	—

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TW, transgender women; CW, cisgender women; CM, cisgender men.

*P-value is based on the chi-square/Fisher’s exact test as applicable.

Had service: Among those with a need.

Dashes signify that pairwise comparisons were not conducted when no significant main effect was found.

Significant p-values are bolded.

Of the five care continuum metrics that we examined (Tables 5 and 6), only the durable viral suppression measure was substantially and significantly different between transgender women and the other two groups. There were significant overall gender differences in the unadjusted analyses for consistent engagement in care and ART prescription status, but pairwise comparisons showed no significant disadvantage for transgender women relative to cisgender women or to cisgender men (Table 5). Compared to cisgender women and cisgender men, a lower proportion of transgender women clients had durable viral suppression (39% versus 52% or 50%, respectively, p-value < 0.001). The adjusted prevalence ratio (aPR) shows that transgender women were less likely to have durable viral suppression than cisgender women (aPR: 0.80, 95% CI: 0.69-0.94), after controlling for age, race/ethnicity, and country of birth (Table 6).

Table 5. HIV outcomes among Ryan White Part A clients by gender, based on HIV surveillance.

Service Category	TW (N = 455)	CW (N = 4906)	CM (N = 9699)	Overall	TW vs. CW		TW vs. CM		CW vs. CM
Service Category	N (%)	N (%)	N (%)	P-value*	Chi-square	P-value	Chi-square	P-value	Chi-square	P-value
Engagement in care	453 (99.6)	4892 (99.7)	9650 (99.5)	0.16	—	—	—	—	—	—
Consistent engagement in care	447 (98.2)	4856 (99.0)	9548 (98.4)	0.0253	1.36	0.2443	0.10	0.7490	7.96	0.0048
ART prescription	420 (92.3)	4484 (91.4)	8803 (90.8)	0.0404	2.47	0.1159	0.74	0.3892	5.20	0.0226
Viral suppression	347 (73.3)	3956 (80.6)	7781 (80.2)	0.0811	—	—	—	—	—	—
Durable viral suppression	175 (38.5)	2562 (52.2)	4830 (49.8)	<.001	25.26	<.001	18.43	<.001	7.77	0.0053

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TW, transgender women; CW, cisgender women; CM, cisgender men; ART, antiretroviral therapy; HIV, human immunodeficiency virus.

*P-value is based on the chi-square/Fisher’s exact test as applicable.

Dashes signify that pairwise comparisons were not conducted when no significant main effect was found.

Significant p-values are bolded.

Table 6. Adjusted prevalence ratios of HIV care outcomes among Ryan White Part A clients, based on HIV surveillance.

	Cisgender women Reference	Cisgender men (95% CI)	Transgender women (95% CI)
Engagement in care	1.00	1.00 (0.96, 1.03)	1.00 (0.91, 1.10)
Consistent engagement in care	1.00	1.00 (0.96, 1.03)	0.99 (0.90, 1.10)
ART prescription	1.00	0.99 (0.95, 1.03)	0.99 (0.89, 1.09)
Viral suppression	1.00	0.98 (0.94, 1.02)	0.97 (0.87, 1.09)
Durable viral suppression	1.00	0.92 (0.88, 0.97)	0.80 (0.69, 0.94)

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ART, antiretroviral therapy; CI, confidence interval; HIV, human immunodeficiency virus.

Prevalence ratios were adjusted for age, race/ethnicity, and country of birth.

Discussion

Our analysis compared demographics, service needs and utilization, and HIV care continuum outcomes for transgender women, cisgender women, and cisgender men enrolled in NYC RWPA programs. Transgender women, compared to cisgender women and cisgender men in our sample, tended to be younger and more often Hispanic/Latinx, primarily Spanish-speaking, and unemployed.

We found significant differences in service category utilization for the three groups, with a lower use of food and nutrition services among transgender women (relative to cisgender men) and a lower use of legal services (relative to cisgender men and to cisgender women). Transgender women in NYC RWPA were more likely than cisgender women and cisgender men to have a documented need for food and nutrition, harm reduction, or housing assistance. Furthermore, compared to cisgender men, transgender women were more likely to have documented need for mental health services. The high prevalence of basic and behavioral-health needs among transgender women may correspond to structural inequities and barriers faced by this population, including gender-related stigma and discrimination and racial/ethnic and linguistic discrimination, which could diminish economic opportunity and negatively impact health [18]. Transgender women, however, were just as likely as cisgender women and cisgender men to receive RWPA services to address their harm reduction, housing, and/or mental health needs.

The observed lower use of food and nutrition services among transgender women with assessed need may have to do in part with our definition of need for food and nutrition services, which for many clients was based on the FPL measure alone, since FI questions are not collected from all service categories in NYC RWPA. Because transgender women tend to experience high rates of poverty [18, 19], they may have been classified as having a need for food and nutrition based on their income even if they were not experiencing FI. In addition, some food and nutrition services, especially home delivery of meals, are more focused on people with disabilities or chronic illnesses other than HIV, including PLWH who are older or homebound. Relative to the overall NYC RWPA client population, transgender women clients are younger and might not be as frequently perceived as needing home delivery of meals.

Our results on service needs are consistent with those of Mizuno et al.’s analysis of data from the Medical Monitoring Project (MMP) [20], showing a higher proportion of transgender women having a need for supportive services, as compared to non-transgender persons. These findings suggest the urgency of closing gaps in services for transgender women living with HIV, since unmet basic/material and behavioral health-related needs have been repeatedly demonstrated to negatively impact HIV treatment outcomes [21–23].

In bivariate analyses, we found overall significant differences between transgender women and cisgender women or cisgender men with regards to consistent engagement in care. Although a slightly higher proportion of transgender women were prescribed ART, this favorable outcome was not translated into an advantage for short-term or durable viral suppression. Transgender women were less likely to be virally suppressed or durably virally suppressed, although only the latter result reached statistical significance. This is consistent with previous findings showing gender disparities in viral suppression [11, 20, 24]. These disparities may be due in part to the expression of gender-related bias in negative interactions with providers, stigma, and mistreatment in service settings [7, 8, 10]. Our findings may also reflect the particular challenge of maintaining daily adherence to ART over time in the face of persistent barriers to treatment, as compared with achieving shorter-term or lower-threshold outcomes like twice-yearly medical visits, ART initiation, or even point-in-time viral suppression [25].

Existing research highlights some potential ways in which service utilization may be related to HIV care continuum outcomes. For example, a previous study among NYC RWPA clients enrolled in a medical case management program known as Care Coordination has shown that persistent challenges such as low mental health functioning, hard drug use, or unstable housing function as barriers to desired outcomes, but the resolution of these barriers tends to be associated with greater improvement in care engagement and/or viral suppression [26]. This finding reinforces the importance of addressing unmet psychosocial and structural needs as a way to optimize viral suppression. In addition, given the immense influence of stable housing on HIV outcomes [27, 28] and the disproportionate housing instability among transgender women in NYC RWPA, efforts to better meet housing needs will be important to advancing gender equity in viral suppression.

Our analysis has several limitations. First, ascertainment of gender identity from program reporting can be subject to error; however, we trained and provided guidance to NYC RWPA service providers on how to collect these data via client self-report. Second, the definitions that we used for the four areas of need are limited in sensitivity and specificity. The standardized assessment tools used for routine RWPA reporting are not designed to function as comprehensive screening tools, particularly with regard to complex conditions such as mental health or substance use disorders. Third, we only account for receipt of services during the 12-month observation period after the assessment indicating the need, so some clients who did not receive the targeted RWPA service during the observation period may still have had that need met at a later point. In addition, given that RWPA services are used in NYC to fill gaps in services available through other payers, many of the needs identified by RWPA providers and clients may ultimately be addressed through linkages to (or independent client utilization of) non-RWPA support services, such as those available through Medicaid, SNAP, other Parts (B, C or D) of the RWHAP and/or Housing Opportunities for Persons with AIDS (HOPWA), including the NYC HIV/AIDS Services Administration (HASA). However, even in prior analyses based on integrated RWPA and HOPWA housing service data, which substantially improved ascertainment of housing assistance, assessed housing need was still not consistently met with a RWPA or HOPWA housing service among transgender women [29].

Conclusions

In all four need areas we could measure across multiple programs, transgender women in NYC RWPA more often presented with service needs than cisgender clients, although service need for mental health was not significantly different when compared to cisgender women, specifically. For all three groups of clients, we found that assessed needs were not consistently met with the corresponding RWPA support service within a 12-month period, and there were no consistent differences between groups in rates of receipt of services, though transgender women were significantly less likely to receive food/nutrition services to address apparent need in that area. Future studies should pursue greater integration of services data across major public payers and data sources (e.g., Medicaid, other parts of Ryan White, SNAP), to better isolate unmet service needs. Simultaneous efforts to strengthen outreach, promote gender-affirming service delivery and increase engagement of transgender women in RWPA programs addressing basic survival and behavioral health needs can support the National HIV/AIDS Strategy 2020 goal of reducing health disparities, and specifically the objective of increasing (to ≥90%) the percentage of transgender women in HIV medical care who are virally suppressed [30].

Acknowledgments

The authors are indebted to: Kristina Rodriguez, Melanie Lawrence and Scott Spiegler for their contribution through their involvement with the Care and Treatment Race to Justice Transgender Women of Color Workgroup; Anisha Gandhi, Matthew Feldman and Kent Sepkowitz for their helpful critiques of initial drafts; and NYC Ryan White Part A service providers for their dedication to the delivery of services.

Data Availability

Due to legal restrictions (under New York Public Health Law Article 21, Title III) and the confidential nature of HIV surveillance data in New York, public health authorities in New York City cannot release individual-level data on reported HIV cases for purposes other than ensuring appropriate HIV care. This restriction applies even to de-identified patient-level datasets. However, NYC DOHMH staff are available to assist external researchers who may have further specific data questions or uses. An email can be sent to hivreport@health.nyc.gov with questions or requests for additional information, which will be answered promptly by NYC DOHMH staff.

Funding Statement

This work was supported through a grant from the Health Resources and Services Administration [H89HA00015] to the New York City Department of Health and Mental Hygiene. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0253444.r001

Decision Letter 0

Ethan Morgan

10 Dec 2020

PONE-D-20-32483

Service utilization and HIV outcomes among transgender women receiving Ryan White Part A services in New York City

PLOS ONE

Dear Dr. Thomas,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

My own comments are as Reviewer 2 below, however, I agree with the other reviewer's comments as well. Please consider each carefully and incorporate as you see fit. I look forward to receiving your revisions in due course.

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Ethan Morgan

Academic Editor

PLOS ONE

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Reviewer #1: This paper compares the service needs, service utilization, and HIV outcomes of people living with HIV receiving Ryan White services across sex/gender identity. The data are taken from assessments part of the Ryan White program. The authors found that transgender women had higher service needs than cisgender women and men. They also found that transgender women were less likely to use food and nutrition services, and that they were less likely to be durably virally suppressed.

This is a well-presented manuscript that could make an important contribution to our understanding of HIV outcome disparities based on sex/gender. The use of program data (with a large sample) that includes actual measurements of HIV outcomes is strong (compared to, for instance, a study that would be based on a convenience sample or self-reports). Though I see a lot of potential in this manuscript, I have several reservations with the analysis that I believe warrant a major revision before I can recommend for publication.

1. It doesn’t seem like the authors conducted post-hoc tests to assess differences between their three groups of interest (trans women, ciswomen, and cismen) although they report the results as if they did. The chi-square test only assesses whether two variables are significantly associated, but it doesn’t tell which of the subgroups differ significantly from one another. For example, if percentages for group a, b, and c are 16, 20, and 24% respectively, it is possible that group b is not significantly different from either group a or c, and that the only significant difference is between a and c. In this case, we could report that group a was significantly less like to XXX than group c, but not different from group b. To obtain such details, typically a post-hoc z test with p values corrected with the Bonferroni method is used (which is only a matter a checking a few extra boxes for SPSS). The authors should add a column to their tables reporting which group differences were significant (e.g., a<b,c a="" or="">

2. As per guidelines for the journal (which are the standard for most journals), please report test statistics in the tables (i.e., chi-square) and p values to no less than <.001. https://journals.plos.org/plosone/s/submission-guidelines

3. I’m not fully convinced by how the authors defined and operationalized “need.” For instance, “harm reduction need” was defined as “recent” substance use (page 8; also please define “recent”). Is it fair to conclude that anyone who has recently used certain substances has a need for harm reduction? In any case, I think it would be better to report the variable as what it actually measured, that is, substance use. In this case, it would be more accurate to report that X% of participants used substances recently and only Y% of them had accessed harm-reduction services.

4. The definition of “food and nutrition need” also seemed problematic, although the authors recognized that in the Discussion (page 13). I don’t know that it’s accurate to say that everyone under a certain income level has food and nutrition needs. If the authors have a strong rationale for doing so, they should explain it. Otherwise, they may reconsider their operationalization of “need.”

5. The results report on service “need” and utilization, and then on HIV outcomes; however, there is no connection between the two areas (services and HIV outcomes). In the discussion, the authors explain that poorer HIV outcomes among trans women might be due to less service utilization. Why wasn’t service need or utilization included as a potential predictor of HIV outcomes?

6. Looking at HIV outcomes, the authors did multivariable analyses controlling for age, race/ethnicity, and country of birth. However, there is no mention of bivariate tests to determine which control variables to include. It would be appropriate to report what tests were done to establish why these three control variables were selected. The results of bivariate analyses could be reported as supplemental material, if space is a concern.

7. In table 5, because the confidence interval for durable viral suppression includes 1, I don’t think it’s appropriate to report as statistically significant. It seems like trans women were not significantly different from cis men with regards to durable viral suppression. However, cis women were significantly more likely to present durable viral suppression than cis men (probably compared to trans women as well). Why were cis men chosen as the reference group? In any case, this result and associated conclusions should be revisited.

8. On page 7, line 143, “Employment status was categorized as “employed” (for full-time or part-time employment); “unemployed” (for unemployed or unpaid volunteer/peer worker status); and “out of workforce” (for student, retired or homemaker status).” In which category was put a student who is also employed?

9. Page 12, line 223, the authors mention the “ART use measures”. Which ones of the variables are referred to as being about ART use? ART prescription and viral suppression don’t clearly measure use of medication (which sounds more like adherence).

10. Were there participants who did not fit in the three sex/gender categories examined, for instance transgender men or nonbinary individuals? If so, please explain the decision to exclude from the analysis and how many were excluded.</b,c>

Reviewer #2: In summary, this is a very well-conducted paper on HIV disparities among transgender women. The study is very well done and easy to read and follow. Only a very few minor suggestions below. Really, awesome job!

1. In the introduction, I found myself wondering whether there were also disparities by race/ethnicity? This isn’t key to the article so don’t feel the need to add it, but a sentence may just help set the context more.

2. Are participants compensated for their time at all? I don’t think so since these are services under RWPA activities but it may make sense to state this clearly. Up to the authors.

3. Table 1 is missing p-values or, at a minimum, any indication of significance. Please add these.

4. Second and third paragraphs of results are missing any mention of these results being from Tables 2 and 3.

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Reviewer #1: No

Reviewer #2: No

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PLoS One. 2021 Jul 1;16(7):e0253444. doi: 10.1371/journal.pone.0253444.r002

Author response to Decision Letter 0

22 Jan 2021

January 22, 2021

Dear Dr. Morgan,

My co-authors and I are pleased at the opportunity to revise and resubmit our manuscript entitled ‘Service utilization and HIV outcomes among transgender women receiving Ryan White Part A services in New York City’ (PONE-S-20-38897).

We are grateful for your constructive comments and suggestions on our manuscript. We have carefully considered all the comments, and respond to each critical point below, in blue, noting where revisions have been made to the manuscript. We explained why no participant consents were required for this retrospective analysis, updated Tables 2 and 3 to reflect the p-values according to PLOS ONE’s style requirements, and included the new results using cisgender women instead of cisgender men as the reference group in Table 5.

We have uploaded both a clean and a tracked version of the revised manuscript.

Responses to reviewers’ comments

1. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

Response: No participant consents were required for this retrospective analysis, which utilized secondary data that have been reported to the NYC Health Department by our Ryan White Part A (RWPA)-funded service provider agencies and by HIV medical care providers and laboratories, as mandated by NYS laws. Both the RWPA and surveillance data sets that were used were fully de-identified prior to analysis. Only designated staff members who have undergone confidentiality training have access to these data sets. All designated staff members are expected to adhere to the Department of Health data security and confidentiality protocols. This analysis plan was reviewed by the NYC Department of Health IRB and was categorized as public health surveillance, not human subjects research. As a result, no informed consent requirement applies.

2. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

Response: Due to legal restrictions (under New York Public Health Law Article 21, Title III) and the confidential nature of HIV surveillance data in New York, public health authorities in New York City cannot release individual-level data on reported HIV cases for purposes other than ensuring appropriate HIV care. This restriction applies even to de-identified patient-level datasets. However, NYC DOHMH staff are available to assist external researchers who may have further specific data questions or uses. An email can be sent to hivreport@health.nyc.gov with questions or requests for additional information, which will be answered promptly by NYC DOHMH staff.

Review Comments to the Author

Response: Recently, experts have recommended moving away from statistical testing to estimation (Amrhein V, Greenland S, McShane B. Retire statistical significance. Nature 2019;567:305-307.; Greenland S, Senn SJ, Rothman KJ, et al. Statistical tests, P values, confidence intervals and power: a guide to misinterpretations. Eur J Epidemiol 2016;31:337-350.; Wasserstein R, Lazar NA. The ASA statement on p-values: context, process, and purpose. Am Stat 2016;70:129-133.). Following their recommendations, we draw our conclusions of differences across groups based on the effect size, i.e., prevalence ratios, and confidence intervals, not the overall p-values or the p-values from pairwise comparisons with Bonferroni adjustment. We present the overall p-value as a statistical summary of the compatibility between the observed data and what we would expect to see if there were no differences.

Response: In the revised manuscript, we have updated Tables 2 and 3 according to the PLOS ONE guidelines, which state the following on p-values: “Report exact p-values for all values greater than or equal to 0.001. P-values less than 0.001 may be expressed as p < 0.001, or as exponentials in studies of genetic associations.”

Response: The definition that we applied matches the eligibility criteria for RWPA Harm Reduction programs. We recognize that it is not a perfect measure for assessing individual need for substance use-related services. Given that we cannot obtain a more nuanced assessment of problem substance use from routine RWPA provider reporting, we treated ‘hard drug’ use (defined as use of cocaine/crack, heroin, crystal meth, or prescription drugs to get high in the past 3 months) as a proxy for need, leveraging existing data. We have replaced the term ‘recent’ in the revised manuscript, in favor of specifying the 3-month timeframe (line 166, page 8). We limited the measure of need to focus on hard drugs because of their association with dependency or other harms to health and safety. We did not include all substance use (e.g., marijuana use or alcohol use), out of recognition that some substances may be used recreationally with moderation, such that reporting some use does not indicate a need for services to reduce use or reduce the harms from use. Furthermore, based on prior analyses in NYC RWPA programs, hard drug use has been found to be associated with worse health outcomes (Feldman MB, Kepler KL, Irvine MK, Thomas JA. Associations between drug use patterns and viral load suppression among HIV-positive individuals who use support services in New York City. Drug and Alcohol Dependence. 2019; 197:15-21.). As mentioned in the paper, there are some limitations related to the substance use data available for analysis. In the RWPA program, substance use is assessed via self-report, and therefore the data can be subject to social desirability bias, which would result in the under-ascertainment of drug use.

Response: For clients who were not assessed for food and nutrition need, we based the definition on the national cutoff for SNAP eligibility (130% of the Federal Poverty Level), due to the prevalence of food insufficiency among low-income individuals affected by HIV (Pellowski JA, Kalichman SC, Matthews KA, et al. A pandemic of the poor: social disadvantage and the U.S. HIV epidemic. Am Psychol. 2013;68:197–209.). While we agree that not all clients with that income level have food and nutrition service need, given the cost of living in NYC, people at or below that income level in NYC are likely to experience food insufficiency. In addition, households with incomes below 185% of the poverty threshold (34.3% of all U.S. households) have been found to have higher rates of food insufficiency than the national average, regardless of HIV status (Coleman-Jensen A, Nord M, Singh A. Household Food Security in the United States in 2012, ERR-155, Washington, DC: U.S. Department of Agriculture, Economic Research Service; 2013.).

Response: We cannot make that conclusion based on the analyses that were performed for this manuscript. It would have required analyses beyond the scope of this paper, such as looking at doses of services received and change in the outcomes over time (following initiation of services), in order to understand the relationship between service utilization and health outcomes. Also, the RWPA services on which we have data are not the only relevant services a client may be receiving. For example, services funded by Medicaid, Medicare, the Veteran's Administration, and other funding streams outside of RWPA were not available for our analysis. Therefore, we didn’t look at service need or utilization as a potential predictor of HIV outcomes. However, in the discussion, we suggested a potential link between service utilization and outcomes based on the literature, and not based on the specific analyses presented in the paper.

Response: We selected age, race/ethnicity, and country of birth as covariates using a directed acyclic graph, by following guidance for authors from editors of respiratory, sleep, and critical care journals (Lederer D, Bell S, Branson R, et al. Control of confounding and reporting of results in causal inference studies. Guidance for authors from editors of respiratory, sleep, and critical journals. Ann Am Thorac Soc 2019;16:22-28.). A previous study has found that bivariable analysis may not be appropriate to screen risk factors to be included in multivariable analysis (Sun G, Shook TL, Kay GL. Inappropriate use of bivariable analysis to screen risk factors for use in multivariable analysis. J Clin Epidemiol 1996;49:907-916.).

Response: We agree that cisgender women should be the reference group. We have included the new results using cisgender women as the reference group in Table 5 and updated the manuscript where applicable. The new Table 5 shows that, compared with cisgender women, transgender women were 20% (aPR = 0.80; 95% CI: 0.69, 0.94) less likely to have durable viral suppression, and the confidence interval does not contain 1.

Response: All clients reporting any form of paid employment, including students, were categorized as employed. We have clarified the language in the revised manuscript (line 143, page 7) to indicate that the levels of employment, collected during assessment, are mutually exclusive.

Response: We are referring to ART prescription, derived from the question ‘Is the client currently prescribed ART?’. We have changed the wording/labeling in the revised paper accordingly to match to what is being collected from RWPA enrollees.

Response: We used two variables, sex assigned at birth and gender, to define the three groups. There were 31 transgender men and 3 non-binary individuals who met the overall eligibility criteria but were excluded from the analysis. Transgender men and non-binary individuals were not included as separate groups because of their small numbers in the client cohort available for analysis.

Reviewer #2:

Response: This is a great point. However, we did not expect to detect conventional disparities by race/ethnicity, mainly because the overwhelming majority of clients in the NYC RWPA program and in this particular cohort identify as Black and Latinx. For example, overall, 13,196 RWPA clients (88%) and 414 transgender women (91%) included in this analysis were Black or Latinx.

2. Are participants compensated for their time at all? I don’t think so since these are services under RWPA activities but it may make sense to state this clearly. Up to the authors.

Response: No, they are not compensated. There was no time requirement for inclusion in the analysis, since we used existing data sets produced as part of routine reporting on HIV services and HIV laboratory monitoring.

3. Table 1 is missing p-values or, at a minimum, any indication of significance. Please add these.

Response: We understand p-values as measures for inferential purposes, not descriptive ones. Therefore, we did not include p-values in Table 1, but did include them in other tables when we compared outcomes across groups. (Turkiewicz A, Luta G, Hughes HV. Statistical mistakes and how to avoid them -- lessons learned from the reproducibility crisis. Osteoarthritis Cartilage 2018;26:1409e1411.). We will add the p-values to Table 1, if it is a PLOS ONE requirement.

4. Second and third paragraphs of results are missing any mention of these results being from Tables 2 and 3.

Response: In the revised manuscript, we have indicated in those paragraphs which results are from Tables 2 and 3.

Sincerely,

Jacinthe Thomas (for the authors)

Senior Research Analyst, Care & Treatment Research & Evaluation Unit

Bureau of HIV, New York City Department of Health & Mental Hygiene

Phone: (917) 648-2898

E-mail: jthomas1@health.nyc.gov

Attachment

Submitted filename: Response_to_Reviewers.doc

Click here for additional data file.^{(170.5KB, doc)}

PLoS One. doi: 10.1371/journal.pone.0253444.r003

Decision Letter 1

Kwasi Torpey

5 May 2021

PONE-D-20-32483R1

Service utilization and HIV outcomes among transgender women receiving Ryan White Part A services in New York City

PLOS ONE

Dear Dr Thomas,

The authors should address and incorporate #2 and 3 from Reviewer 1.

Please submit your revised manuscript by 10th May 2021. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Professor Kwasi Torpey, MD PhD MPH

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

The revised manuscript titled "Service utilization and HIV outcomes among transgender women receiving Ryan White

Part A services in New York City" was reviewed in response to reviewers' comments. Most of the comments were satisfactorily addressed. However, there were a few comments that the authors provide a rationale citing relevant literature to support their approach. However, I strongly recommend the authors to address #2 and 3 raised by Reviewer 1 pasted below

2. In their response, the authors mention their justification for the covariates they have included in their regression models. This explanation should be included in the manuscript.

3. Though justified, the exclusion of a small number of transgender men and nonbinary individuals from the analytic sample should be mentioned in the manuscript.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Partly

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #1: The authors did a minor revision of their manuscript; some of my concerns from the initial submission remain.

1. To my comment asking for subgroup comparisons, the authors offered resources warning against common misuse of statistical significance. I carefully looked through these resources and do not believe the authors of this manuscript have followed their recommendations. In their responses, the authors say these experts recommend “moving away from statistical testing,” but I understand these articles to be warning us against misinterpretations of statistical significance.

For example, at lines 213–216 of their manuscript, the authors state “Compared to cisgender women and cisgender men, significantly higher proportions of transgender women had an apparent need for support in the areas of housing (52% versus 24% and 35%, respectively), mental health (24% versus 22% and 20%, respectively), or harm reduction (23% versus 12% and 18%, respectively) (Table 3).” Here, the authors rely on the statistically significant p value to report that transgender women had “significantly” higher need in the area of mental health. However, if the authors did not simply rely p values to make conclusions—as they indicate in their responses—they would remark that the proportion of transgender women and cisgender women with mental health needs were not highly different (24% and 22%) instead of relying on the statistical test to claim a “significant” difference. What is more, as I pointed in my initial review, there is no evidence that these two proportions are statistically different because there were no subgroup comparisons. As such, the authors seem to be drawing conclusions based on p values (and incorrect ones). Although I provide only one example, most of the results of the paper are reported similarly and the abstract and discussion rely on subgroup comparisons that are not well supported.

If the authors wish to move away from statistical testing, they should not rely on those tests to make statements of difference. However, if I understood the resources provided correctly, statistical tests should still be done (and done correctly), but researchers should provide more nuanced discussions and conclusions of the results that do not simply make a dichotomy between what is significant and not.

2. In their response, the authors mention their justification for the covariates they have included in their regression models. This explanation should be included in the manuscript.

3. Though justified, the exclusion of a small number of transgender men and nonbinary individuals from the analytic sample should be mentioned in the manuscript.

4. I believe the author guidelines also require including test statistics (chi-square value), not only p values (for Tables 2 and 3).

Reviewer #2: I have no additional comments, all of my previous concerns have now been adequately addressed. Thank you!

**********

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Reviewer #1: No

Reviewer #2: No

PLoS One. 2021 Jul 1;16(7):e0253444. doi: 10.1371/journal.pone.0253444.r004

Author response to Decision Letter 1

28 May 2021

May 28, 2021

Dear Dr. Torpey,

We appreciate your consideration of our revised manuscript entitled ‘Service utilization and HIV outcomes among transgender women receiving Ryan White Part A services in New York City’ (PONE-S-20-38897). Thank you for extending the resubmission deadline.

We are grateful for the opportunity to fully address one major concern from the prior review on the test that was used to assess differences between the groups. We have conducted the suggested statistical tests and updated Tables 2, 3, and 4 to add chi-square values and p-values from pairwise comparisons, and split Table 3 in two to avoid having too much information in one table. We have responded to each of the comments below, in blue, noting where revisions have been made to the manuscript.

We are encouraged to see that Reviewer #2 felt the revised version of the

manuscript had addressed all concerns included in the prior review. We have uploaded both a clean and a tracked version of the revised manuscript.

Responses to comments from Reviewer #1

Response: We agree with the reviewer’s comment. In order to mention significant differences between the subgroups, we must rely on post-hoc tests and p-values from pairwise comparisons for such an assessment. Therefore, we have included the chi-square values and p-values in Table 2, 3, 4, and 5 and updated the manuscript where applicable.

2. In their response, the authors mention their justification for the covariates they have included in their regression models. This explanation should be included in the manuscript.

Response: In the revised manuscript, we have added a sentence to indicate how we decided on those three covariates.

3. Though justified, the exclusion of a small number of transgender men and nonbinary individuals from the analytic sample should be mentioned in the manuscript.

Response: In the revised manuscript, we have indicated that transgender men and nonbinary individuals were excluded from the analysis due to their small numbers.

4. I believe the author guidelines also require including test statistics (chi-square value), not only p values (for Tables 2 and 3).

Response: In the revised manuscript, we have updated Tables 2, 3, and 4 and added both the chi-square values and p-values from pairwise comparisons.

5. Thank you for including your ethics statement in your Response to Reviewers: "No participant consents were required for this retrospective analysis, which utilized secondary data that have been reported to the NYC Health Department by our Ryan White Part A (RWPA)-funded service provider agencies and by HIV medical care providers and laboratories, as mandated by NYS laws. Both the RWPA and surveillance data sets that were used were fully de-identified prior to analysis. Only designated staff members who have undergone confidentiality training have access to these data sets. All designated staff members are expected to adhere to the Department of Health data security and confidentiality protocols. This analysis plan was reviewed by the NYC Department of Health IRB and was categorized as public health surveillance, not human subjects research. As a result, no informed consent requirement applies.".

To help ensure that the wording of your manuscript is suitable for publication, would you please also add this statement at the beginning of the Methods section of your manuscript file.

Response: To comply with the submission guidelines, we have expanded the Ethics language into a full paragraph in the revised manuscript and added further subheadings in the Methods section to ensure that the focus of each Methods sub-section was clearly introduced.

Sincerely,

Jacinthe Thomas (for the authors)

Senior Research Analyst, Care & Treatment Research & Evaluation Unit

Bureau of HIV, New York City Department of Health & Mental Hygiene

Phone: (917) 648-2898

E-mail: jthomas1@health.nyc.gov

Attachment

Submitted filename: Response_to_Reviewers.doc

Click here for additional data file.^{(170.5KB, doc)}

PLoS One. doi: 10.1371/journal.pone.0253444.r005

Decision Letter 2

Kwasi Torpey

7 Jun 2021

Service utilization and HIV outcomes among transgender women receiving Ryan White Part A services in New York City

PONE-D-20-32483R2

Dear Dr. Thomas,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Professor Kwasi Torpey, MD PhD MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Outstanding issues addressed

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0253444.r006

Acceptance letter

Kwasi Torpey

23 Jun 2021

PONE-D-20-32483R2

Service utilization and HIV outcomes among transgender women receiving Ryan White Part A services in New York City

Dear Dr. Thomas:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Kwasi Torpey

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Attachment

Submitted filename: Response_to_Reviewers.doc

Click here for additional data file.^{(170.5KB, doc)}

Attachment

Submitted filename: Response_to_Reviewers.doc

Click here for additional data file.^{(170.5KB, doc)}

Data Availability Statement

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PERMALINK

Service utilization and HIV outcomes among transgender women receiving Ryan White Part A services in New York City

Jacinthe A Thomas

Mary K Irvine

Qiang Xia

Graham A Harriman

Roles

Abstract

Background

Methods

Results

Conclusions

Introduction

Materials and methods

Inclusion criteria

Data sources

Ethics

Demographic measures

Service need and utilization measures

HIV outcome measures

Data analysis

Results

Table 1. Demographic characteristics of HIV-positive Ryan White Part A clients served and assessed between January 1, 2016 and December 31, 2017.

Table 2. Ryan White Part A service category utilization by gender, 2016-2017.

Table 3. Ryan White Part A service category need by gender.

Table 4. Ryan White Part A service category utilization by gender among those with assessed need – within 12 months after the assessment indicating the need.

Table 5. HIV outcomes among Ryan White Part A clients by gender, based on HIV surveillance.

Table 6. Adjusted prevalence ratios of HIV care outcomes among Ryan White Part A clients, based on HIV surveillance.

Discussion

Conclusions

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Ethan Morgan

Roles

Author response to Decision Letter 0

Decision Letter 1

Kwasi Torpey

Roles

Author response to Decision Letter 1

Decision Letter 2

Kwasi Torpey

Roles

Acceptance letter

Kwasi Torpey

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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