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J Acquir Immune Defic Syndr. 2019 Feb 25. doi: 10.1097/QAI.0000000000002009. [Epub ahead of print]

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.

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Center for Health Equity Research, Brown University, Providence, RI, USA.
Departments of Behavioral and Social Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, USA.
Department of Psychiatry and Human Behavior, Brown University Alpert Medical School,Providence, RI, USA.
The Fenway Institute, Fenway Health, Boston, MA, USA.
Division of Adolescent Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
Department of Pediatrics, Boston Children's Hospital/Harvard Medical School, Boston, MA, USA.
Department of Epidemiology, Harvard T.H Chan School of Public Health, Boston, MA, USA.



Worldwide, young transgender women (YTW) contend with exceptionally high-risks for HIV infection. 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 syndemic of seven psychosocial problems potentiates HIV sexual risk behavior among a multicity, longitudinal cohort of sexually active YTW in the United States.


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


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


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 as well as stronger integration with gender-affirming and supportive mental health, violence recovery, and addiction treatment services for this population.

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