Are Transgender Persons at Higher Risk for HIV Than Other Sexual Minorities? A Comparison of HIV Prevalence and Risks

SUMMARY

Recent studies have shown that transgender people are at high risk for HIV. Few studies, however, have directly compared the HIV risks and sexual health of transgender persons with that of other sexual minority populations. This study used baseline data of intervention studies targeting transgender persons, men who have sex with men, and women who have sex with women and men to compare their HIV risk behavior and sexual health. No significant differences were found between transgender persons and nontransgender men or women in consistent condom use or attitudes toward condom use. Transgender persons were less likely to have multiple partners and more likely to be monogamous than men who have sex with men; no differences were found between transgender persons and the women in this respect. When combining data on condom use, monogamy, and multiple partners, transgender persons did not differ from either nontransgender group in their overall risk for HIV. Transgender persons were less likely than the men or the women to have been tested for HIV. With regard to HIV prevalence, 17% of the men compared to only one transgender person and none of the women reported being HIV-positive. Transgender persons were also less likely than men who have sex with men to use drugs; no differences were found in the use of alcohol. However, with regard to mental health, transgender persons were more likely than the men to have experienced depression and more likely than men or women to have considered or attempted suicide. Finally, transgender persons reported the lowest levels of support from family and peers. Thus, in our sample, transgender persons appear to be at lower risk for HIV but at higher risk for mental health concerns than men who have sex with men. Remarkably few differences were found between transgender persons and women who have sex with women and men-a finding which might reflect the impact of social stigma on sexual health and have implications for the design of future HIV/STI prevention efforts.     

Psychological Sequelae of Avoiding HIV-Serostatus Information

The psychological sequelae of choosing to learn or not to learn one's HIV serostatus were examined in a group of 224 men who had been tested for HIV. Correlates of this avoidance were measured (a) when both groups had been tested and given the opportunity to receive the test results, and (b) after the group that initially chose to avoid HIV-serostatus information had learned their test results (and an equivalent time point for those who had already learned their HIV serostatus). Results indicate that those who kept themselves unaware of their serostatus had AIDS-related worries and concerns significantly higher than individuals aware that they were HIV seronegative and equivalent to individuals aware that they were HIV seropositive, at the first time point. Thus, unaware seronegative men suffered unnecessary worries and concerns. Both HIV-seropositive and HIV-seronegative men who were initially unaware showed a decline in mood disturbance on learning their HIV status. These findings suggest that learning threatening information may be more psychologically beneficial than avoiding it.     

Repeat HIV Testing and HIV Transmission Risk Behaviors Among Sexually Transmitted Infection Clinic Patients

HIV testing and counseling expends considerable HIV prevention resources and offers great opportunities for HIV risk reduction. Individuals who are at risk for HIV and have not been HIV tested are the focus of current targeted testing campaigns and yet persons who are repeatedly tested for HIV often continue engaging in high-risk practices. This study examined HIV testing, risk behaviors, and other medical diagnostic testing practices of men (N = 231) and women (N = 86) attending an inner-city sexually transmitted infections (STI) clinic. Results showed that 75 (23%) participants had not yet been tested for HIV, 45 (14%) had been tested once, and 197 (63%) had been tested two or more times. Patients that had not been tested and those who were repeatedly tested were similar in their risk behaviors; both demonstrated significantly greater risks for HIV than persons tested just once, although repeat testers were more likely to have had a past STI. HIV testing history was minimally associated with other medical testing and health protective practices, such as testicular self-examination, mammography, and having had PAP tests. Results support targeting high-risk untested persons for HIV testing and suggest an urgent need for interventions to reduce risk behaviors among STI clinic patients who repeatedly test for HIV.     

HIV Testing Experience and Risk Behavior Among Sexually Active Black Young Adults: A CBPR-Based Study Using Respondent-Driven Sampling in Durham,North Carolina

African Americans are disproportionately affected by the HIV epidemic inclusive of men who have sex with men, heterosexual men, and women. As part of a community‐based participatory research study we assessed HIV testing experience among sexually active 18–30 year old Black men and women in Durham, NC. Of 508 participants, 173 (74 %) men and 236 (86 %; p = 0.0008) women reported ever being tested. Barriers to testing (e.g., perceived risk and stigma) were the same for men and women, but men fell behind mainly because a primary facilitator of testing—routine screening in clinical settings—was more effective at reaching women. Structural and behavioral risk factors associated with HIV infection were prevalent but did not predict HIV testing experience. Reduced access to health care services for low income Black young adults may exacerbate HIV testing barriers that already exist for men and undermine previous success rates in reaching women.     

Using the Millon Behavioral Medicine Diagnostic (MBMD) to Evaluate the Need for Mental Health Services in Association with Biomarkers of Disease Status Among HIV Positive Men and Women

Psychological distress states have been related to rate of disease progression among HIV-positive individuals. However, the measures that have been used in this research as well as the treatment context of the populations studied are highly variable, making it challenging for clinicians to incorporate such measures into screening batteries. The present study examined the association of two summary scales of the Millon Behavioral Medicine Diagnostic (MBMD; Millon et al., Millon Behavioral Medicine Diagnostic. NCS Assessments, Minneapolis, 2001), with markers of HIV disease status (CD4 and CD8 cell counts, viral load) among an ethnically diverse sample of 147 HIV-positive individuals (52 men who have sex with men, 34 men who have sex with women, and 51 women) who had recently initiated Highly Active Antiretroviral Therapy (HAART). After controlling for age and months since HIV diagnosis, we found that higher scores on the overall MBMD Psych Referral Summary Scale, reflecting a need for mental health treatment, were related to greater HIV viral load but did not relate to CD4 or CD8 cell counts. Subgroup analyses revealed that Psych Referral scores were related to greater HIV viral load only for the men who have sex with men (MSM) subgroup. These results suggest that the MBMD may help in identifying psychosocial characteristics associated with some markers of disease status in persons with HIV and perhaps may also be useful in identifying individual differences in response to treatment and eventual disease outcome.     

The AIDS epidemic in Cuba

The strategy of the Cuban government to control HIV consists of examining the whole adult population and quarantining all seropositive persons in local institutions. Between 1986 and 1990, a total of 8,832,726 HIV tests were done using domestic ELISA and Western blot methods. 497 persons (362 men and 135 women) were found to be HIV-positive. 122 infections were directly attributed to Cuban intervention in Africa. 150 infected men were homosexuals and bisexuals. Infected blood products caused 9 cases, and neonatal transmission produced 3 infections. 63 AIDS cases were reported since December 1989. Compulsory testing would be more acceptable if HIV infected persons would get zidovudine (AZT) for secondary prevention. It is estimated that this policy has prevented 4000 new infections. The violation of human rights by quarantining people with false positive results is real: 23-53 such people are estimate to be quarantined. Tourists are not examined because of the economic need for more revenue from tourism, thus HIV transmission could continue despite quarantines. The cost of testing is high, although health care already made up 12% of the budget in 1989, increasing from 7.8% in 1983. Tracing sexual contacts requires 450 nurses and 200 epidemiologist. The public education campaign about AIDS involved 30 television programs and several hundred radio programs by groups of experts discussing transmission, AZT treatment, and treatment of opportunistic infections. Since 1988, schools have also included AIDS education from the 5th grade on. Condom use is stressed, but machismo often hinders its acceptance. While AIDS is a menace, the rate of syphilis increased from 7.2/100,000 in 1970 to 84.3/100,000 in 1987. Stressing personal responsibility in preventing HIV infection skirts the need for modification of high risk behavior and lulls the public into a false sense of security because of the belief that full protection from AIDS is provided by the quarantine.     

The Sexual Compulsivity Scale: further development and use with HIV-positive persons

We examined the reliability and validity of the Sexual Compulsivity Scale for use in assessing HIV-positive men and women. Measures collected from 287 men and women recruited from the community, the majority of whom were African American and over the age of 30, showed that the Sexual Compulsivity Scale was reliable for men (alpha = .89) and women (alpha = .92). Correlations with measures of sexual behaviors and numbers of sex partners supported the concurrent validity of the Sexual Compulsivity Scale for men and women. Results of discriminant function analyses that included participant age, use of nonalcohol drugs, the Sexual Compulsivity Scale, and scores on measures of trait anxiety, obsessive-compulsiveness, future pessimism, cognitive depression, and borderline personality characteristics showed that sexual compulsivity clearly discriminated between persons with 1 or no sex partners and persons with multiple partners in the past 3 months, for both men and women, suggesting evidence for criterion-related validity. Associations between sexual compulsivity scores and other markers of psychopathology showed different patterns for men and women; sexual compulsivity was associated with indexes of psychopathology in men but not in women. We conclude that the Sexual Compulsivity Scale is reliable and valid in assessing men and women infected with HIV, although sexual compulsivity may present differently between genders in relation to other forms of psychopathology.     

HIV-related stigma among market workers in China.

HIV-related stigma was examined among 209 employees and owners of stalls in 5 markets in an eastern coastal city in China. Of the participants 53% were women and 47% were men; 100% were Han. Ages ranged from 18 to 49 years (M=35, SD=8.1). Half of the participants believed that punishment was an appropriate response toward those living with HIV (50%). Over half (56%) were unwilling to be friends with infected individuals. The majority thought that those living with HIV should be isolated (73%). They agreed that persons living with HIV should not take care of other people's children (85%). Punishing beliefs toward persons living with HIV were related to being male, older, married, less educated, and unwilling to be tested for HIV.     

The Nature and Correlates of Psychological Adjustment in Gay Men with AIDS-Related Conditions1

This study assessed differences in the psychological adjustment of gay men who tested positive for the antibody to the human immunodeficiency virus (HIV). Twenty-one were symptomatic for AIDS, and 27 were asymptomatic. A group of 15 gay men who tested negative for the HIV was included as a comparison group. Men in the three groups were equivalent on demographic variables. Symptomatic men reported more health problems than either asymptomatic or seronegative men. Relative to men who were symptomatic, those who were asymptomatic reported more death anxiety, less optimism, and greater severity of psychological distress, and reported more frequent use of avoidance and distancing as coping strategies. The poor psychological functioning of asymptomatic subjects was attributed to the uncertainty regarding their future health status. Generally, positive psychological well-being of symptomatic and asymptomatic men was related to the infrequent use of avoidance coping strategies and high satisfaction with perceived social support.     

The Influences of Sex and Gender-Role Identity on Moral Cognition and Prosocial Personality Traits

The relations of sex and gender-role identity to moral thought and prosocial personality traits were examined. Two hundred and nine men and women rated the importance of real-life, care-related, justice-related, and mixed (both care- and justice-related) moral dilemmas. Responses on the real-life and mixed dilemmas also were scored for care and justice orientations. Women and feminine persons viewed moral conflicts as more important than did men and masculine people. On the mixed dilemmas, women scored higher than men on care reasoning, whereas men scored higher than women on justice reasoning. Regardless of sex or gender role, relational real-life dilemmas evoked higher importance and care reasoning scores than did nonrelational ones. Women and persons high in femininity showed more empathic concern for other people. Masculine persons scored lower on personal distress, whereas androgynous persons reported more helpful behaviors than did all others.     

The Role of Male Sexual Partners in HIV Infection Among Male-to-Female Transgendered Individuals

SUMMARY

Male-to-female transgendered persons (MtF) in San Francisco have very high HIV prevalence and incidence. To explore possible sources for these high rates of HIV infection, a rapid needs assessment was conducted using two methods: (1) an interviewer-administered, mostly closed-ended survey with the male partners of MtF persons, and (2) focus groups with MtF persons. Five main themes were evident from the findings: (1) male partners of MtF persons are of all ages, races, sexual orientations, and socioeconomic backgrounds; (2) high-risk sex occurs between MtF persons and their male sexual partners, despite a high level of concern about HIV among both the male and MtF study participants; (3) drug use appears to play a role in unsafe sex between MtF and their male partners; (4) male partners of MtF persons may represent a possible bridge for HIV transmission among different populations, given that they reported sex with male and female partners, as well as transgendered partners; and (5) men engaging in receptive anal sex with MtF partners probably occurs more frequently than reported by the male participants, given the comments of MtF study participants. The results indicate a need for creative, community-based HIV prevention strategies that target the male partners of MtF transgendered persons.     

Optimism, coping, psychological distress, and high-risk sexual behavior among men at risk for acquired immunodeficiency syndrome (AIDS).

In a cohort of gay men responding to the threat of acquired immunodeficiency syndrome (AIDS), dispositional optimism was associated with less distress, less avoidant coping, positive attitudes as a coping strategy, and fewer AIDS-related concerns. Men who knew they were seropositive for human immunodeficiency virus (HIV) were significantly more optimistic about not developing AIDS than men who knew they were seronegative for HIV. This AIDS-specific optimism was related to higher perceived control over AIDS and to active coping among seropositive men only and to health behaviors in both serostatus groups. There was no relation of optimism to risk-related sexual behavior. It is concluded that optimism is psychologically adaptive without necessarily compromising health behavior. It is also concluded that it is useful to distinguish between event-based optimistic expectations and dispositional optimism.     

Stigma,Disclosure and Relationship Agency in Black Women’s Sexual Relationships with Behaviorally Bisexual Black Men

The health needs and relationships of Black women partnered with behaviorally bisexual Black men are under addressed in the public health literature. This paper explores the relationship dynamics of Black women’s sexual relationships with behaviorally bisexual Black men. We conducted thirty qualitative interviews with a group of HIV negative and HIV positive women partnered with behaviorally bisexual Black men in the San Francisco Bay Area. Women took part in a one-time qualitative interview that addressed relationships, bisexual partners, sexuality, HIV risk behaviors, and disclosure. Women described experiences of their own and their partner’s experiences of disclosure and sexual stigma, along with structural racism and masculine cultural norms that contribute to men’s non-disclosure of sex with men. The paper identifies the ways in which disclosure and stigma are experienced by a sample of women in relationships with behaviorally bisexual Black male partners, pointing to the ways in which these women demonstrate sexual agency in these relationships. These sexual narratives emphasize the ways in which Black women are at once agentic and also navigate gendered vulnerability in their relationships with bisexual men. These findings of Black women’s sexual agency present a call to develop health interventions resonant with Black women’s relationship experiences and structures of bisexual relationships.     

Psychosocial adjustment along the HIV disease continuum

Abstract

Evidence suggests that certain indices of stage of HIV disease are determinants of psychological distress, although information is lacking on how disease stage impacts on multiple domains of adjustment. The present study aimed: (1) to explore differences among clinical stages of HIV on measures of psychosocial adjustment, and (2) to explore the relationship between indices of psychosocial adjustment to HIV and self-report measures of physical health. Ninety six HIV-infected persons and 33 HIV seronegative comparison group participants were interviewed and completed self-administered scales. Participants were divided into four groups (the independent variable): a comparison group and three HIV groups, representing the three clinical indices of illness stage (asymptomatic, early symptomatic and AIDS). Three subjective health indices included number of HIV-related symptoms, global health rating, and T4 count. The dependent variables included 5 psychosocial adjustment measures. Results indicated that social and instrumental domains of adjustment were significantly associated with both clinical stage and all 3 subjective health indices. Levels of psychological distress were associated with number of physical symptoms and global health rating, but were unrelated to clinical stage and T4 count. Emotional and existential concerns were unrelated to all indices of illness stage.     

Perceived self-efficacy domains as predictors of fear of the unknown and fear of dying among older adults

Using a sample of 167 women and 121 men, aged 65-87, this study tested the hypothesis that self-efficacy beliefs of older persons are significantly stronger predictors of death fears than are demographics, social support, and physical health variables used in earlier predictor models. Standard self-report measures were used to assess all predictor variables, including perceived self-efficacy in 8 different domains. Findings from a series of hierarchical regression analyses that were conducted separately for men and women supported the hypothesis concerning the superiority of self-efficacy variables as predictors of fear of the unknown after death and fear of dying, with spiritual health efficacy and instrumental efficacy being the most potent predictors of death fears for women and men, respectively.     

Effects of Gender, Age, and Education on Assertiveness in a Nigerian Sample

Two hundred fourteen (214) married persons, 101 men and 113 women aged 20–60, with at least high school education, participated in the study which investigated the effects of gender, age, and educational attainment on assertiveness among married persons in Nigeria. The Assertive Behavior Assessment scale (ABAS; Onyeizugbo, 1998 ) was used to measure assertiveness. It was hypothesized that persons with higher educational attainment will report more assertiveness than persons with lower educational attainment. Results supported the hypothesis. In addition, interactions between gender and age, and gender and educational attainment were found. Younger men reported more assertiveness than younger women whereas older women reported more assertiveness than older men. Also, women participants of lower educational attainment reported more assertiveness than their men counterparts whereas men of higher educational attainment reported more assertiveness than their women counterparts. Results of this study suggest that women in Nigeria may become more assertive with age.     

Primary relationships affect the psychological health of homosexual men at risk for AIDS.

Less is known about the effects of primary relationships on psychological health for homosexual men and women than for heterosexual men and women. Given the HIV/AIDS epidemic, the primary relationships of homosexual men are especially important to examine at the present time. Using questionnaire data collected from 259 homosexual men, this study examined the effects of status and quality of relationship on psychological health. Analysis indicated that homosexual men who are in primary relationships experience fewer depressive symptoms and greater well-being than other homosexual men but that being in a relationship does not predict changes in these outcomes over time. Men who report high quality of relationship show improvements over time in psychological health. These findings are discussed in light of the HIV/AIDS epidemic.