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

Abstract

Background: Cross-sectional studies have suggested that co-occurring epidemics or syndemics of psychosocial problems may accelerate HIV acquisition and transmission via elevated sexual risk behavior among transgender women. We aimed to examine how a of seven psychosocial problems potentiates HIV sexual risk behavior among a multicity, longitudinal cohort of sexually active young transgender women (YTW) in the United States. Methods: Between 2012 and 2015, 233 YTW from Boston, MA and Chicago, IL completed behavioral surveys at baseline, 4-, 8-, and 12-months. We used generalized estimating equations to examine the prospective relationship of overlapping psychosocial problems and condomless anal or vaginal sex (CAVS) among YTW. Findings: The prevalence of seven psychosocial problems was substantial at baseline and remained high at each time point: 42.1% clinically significant depressive symptoms; 6.4% polydrug use past 4 months (>3 drugs used, excluding stimulants); 15.9% stimulant use past 4 months; 7.7% heavy alcohol use past 4 month (≥ 4 drinks every day or ≥ 6 drinks on a typical day when drinking); 10% childhood sexual abuse; 41.7% experiencing lifetime intimate partner violence; and 68.6% lifetime transgender specific victimization. We identified a statistically significant positive dose-response relationship between the number of psychosocial problems and CAVS over time (with the greatest adjusted odds ratio among those with 5 or more psychosocial problems; aOR=3.27; 95% confidence interval: 1.14-9.41). Interpretation: The accumulation of syndemic psychosocial problems predicted HIV sexual risk behavior in a prospective cohort of YTW. Given the high prevalence of psychosocial problems and HIV sexual risk behavior, as well as having the highest HIV incidence among any risk group, the HIV prevention agenda requires a shift toward improved assessment of psychosocial comorbidities and stronger integration with mental health and substance abuse treatment services for this population. Funding: R01MH094323 from the National Institute of Mental Health. Declaration of Interest: All authors declare that they have no conflict of interest. Ethical Approval: The study was approved by institutional review boards at Ann & Robert H. Lurie Children’s Hospital and The Fenway Institute, Fenway Health. Written informed consent was obtained for each participant with parental consent waived for minors (aged 16-17 years).