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Table 1.  

Characteristic No. (%)
Transgender women Severe food insecurity§ Nights homeless Has usual source of care Comfort with a health care provider when discussing gender-related issues
365 30–364 <30 None
Age group, yrs
18–29 496 (30.9) 244 (49.2) 49 (9.9) 135 (27.2) 57 (11.7) 247 (49.8) 374 (75.4) 357 (72.0)
30–39 461 (28.7) 186 (40.4) 48 (10.4) 105 (22.8) 44 (9.5) 258 (56.0) 372 (80.7) 344 (74.6)
40–49 307 (19.1) 113 (36.8) 23 (7.5) 57 (18.8) 23 (7.5) 192 (62.5) 270 (88.0) 254 (82.7)
≥50 343 (21.3) 94 (27.4) 32 (9.3) 41 (12.0) 15 (4.4) 238 (69.4) 308 (89.8) 295 (86.0)
Race and ethnicity**
Black, non-Hispanic 569 (35.4) 221 (38.8) 63 (11.1) 124 (21.8) 51 (9.0) 321 (56.4) 469 (82.4) 452 (79.4)
Hispanic or Latina†† 643 (40.0) 275 (42.8) 49 (7.6) 122 (19.0) 61 (9.5) 396 (61.6) 532 (82.7) 481 (74.8)
White, non-Hispanic 180 (11.2) 81 (45.0) 25 (13.9) 39 (21.7) 13 (7.2) 98 (54.4) 150 (83.3) 148 (82.2)
Multiple, non-Hispanic 124 (7.7) 44 (35.5) 8 (6.5) 39 (31.5) 9 (7.3) 60 (48.4) 105 (84.7) 107 (86.3)
Other,§§ non-Hispanic 89 (5.5) 15 (16.9) 6 (6.7) 13 (14.6) 6 (6.7) 60 (67.4) 66 (74.2) 61 (68.5)
Gender identity¶¶
Woman 509 (31.7) 199 (39.1) 57 (11.2) 118 (23.1) 37 (7.3) 287 (56.4) 431 (84.7) 407 (80.0)
Man 6 (0.4) —*** 5 (83.3)
Transgender woman 1,404 (87.3) 558 (39.7) 131 (9.3) 295 (21.0) 126 (9.0) 817 (58.2) 1,144 (81.5) 1,084 (77.2)
Transgender man 11 (0.7) 7 (63.6) 9 (81.8) 6 (54.6)
A gender not listed here 94 (5.9) 40 (42.6) 12 (12.8) 24 (25.5) 7 (7.5) 46 (48.9) 74 (78.7) 64 (68.1)
Currently has health insurance
Yes 1,337 (83.2) 512 (38.3) 120 (9.0) 281 (21.0) 104 (7.8) 794 (59.4) 1,178 (88.1) 1,127 (84.3)
No 270 (16.8) 124 (45.9) 32 (11.9) 56 (20.7) 36 (13.3) 142 (52.6) 146 (54.1) 124 (45.9)
Unmet need for health care during the past 12 months
Yes 323 (20.1) 186 (57.6) 37 (11.5) 97 (30.0) 36 (11.2) 147 (45.5) 238 (73.7) 224 (69.4)
No 1,285 (79.9) 451 (35.1) 115 (9.0) 241 (18.8) 104 (8.1) 789 (61.4) 1,087 (84.6) 1,027 (79.9)
Self-reported HIV status†††
HIV–positive 615 (38.3) 229 (37.2) 60 (9.8) 139 (22.6) 50 (8.1) 350 (56.9) 546 (88.8) 537 (87.3)
HIV–negative or unknown 991 (61.6) 407 (41.1) 92 (9.3) 199 (20.1) 89 (9.0) 585 (59.0) 778 (78.5) 714 (72.1)
Education
Less than high school 347 (21.6) 168 (48.4) 35 (10.1) 75 (21.6) 33 (9.5) 192 (55.3) 283 (81.6) 268 (77.2)
High school diploma or equivalent 596 (37.1) 247 (41.4) 64 (10.7) 136 (22.8) 61 (10.2) 326 (54.7) 480 (80.5) 447 (75.0)
Some college or technical degree 486 (30.2) 181 (37.2) 40 (8.2) 105 (21.6) 33 (6.8) 290 (59.7) 416 (85.6) 395 (81.3)
College degree or more 177 (11.0) 39 (22.0) 13 (7.3) 21 (11.9) 12 (6.8) 128 (72.3) 144 (81.4) 140 (79.1)
Annual household income, USD
40,000–74,999 173 (10.8) 25 (14.5) 9 (5.2) 13 (7.5) 145 (83.8) 145 (81.8) 140 (80.9)
20,000–39,999 274 (17.0) 78 (28.5) 22 (8.0) 42 (15.3) 20 (7.3) 186 (67.9) 228 (83.2) 218 (79.6)
10,000–19,999 435 (27.1) 155 (35.6) 29 (6.7) 83 (19.1) 30 (6.9) 274 (63.0) 372 (85.5) 358 (82.3)
≤9,999 711 (44.2) 373 (52.5) 94 (13.2) 201 (28.3) 76 (10.7) 324 (45.6) 571 (80.3) 523 (73.6)
Urban area
Atlanta, Georgia 132 (8.2) 55 (41.7) 12 (9.1) 37 (28.0) 18 (13.6) 62 (47.0) 88 (66.7) 87 (65.9)
Los Angeles, California 504 (31.3) 224 (44.4) 50 (9.9) 136 (27.0) 43 (8.5) 270 (53.6) 420 (83.3) 374 (74.2)
New Orleans, Louisiana 165 (10.3) 77 (46.7) 12 (7.0) 35 (21.2) 11 (6.7) 106 (64.2) 143 (86.7) 136 (82.4)
New York, New York 279 (17.4) 114 (40.9) 21 (7.5) 46 (16.5) 27 (9.7) 181 (64.9) 245 (87.8) 222 (79.6)
Philadelphia, Pennsylvania 220 (13.7) 61 (27.7) 13 (5.9) 35 (15.9) 19 (8.6) 151 (68.6) 174 (79.1) 200 (90.9)
San Francisco, California 198 (12.3) 77 (38.9) 39 (19.7) 37 (18.7) 15 (7.6) 80 (40.4) 179 (90.4) 160 (80.8)
Seattle, Washington 110 (6.8) 29 (26.4) 5 (4.6) 12 (10.9) 7 (6.4) 86 (78.2) 76 (69.1) 72 (65.5)
Total 1,608 (100) 637 (39.6) 152 (9.5) 338 (21.0) 140 (8.7) 936 (58.2) 1,325 (82.4) 1,251 (77.8)

Table 1. Structural and health care factors among transgender women (N = 1,608)* — National HIV Behavioral Surveillance System, seven U.S. urban areas, 2019–2020

Abbreviation: USD = U.S. dollars.
*Numbers might not sum to totals because of missing data.
Homelessness was defined as having lived on the street, in a shelter, in a single room occupancy hotel, or in a car during the past 12 months.
§Severe food insecurity was defined as not eating for a whole day because there wasn't enough money for food at some point during the past 12 months.
Usual source of care was defined as having a place to go when sick or in need of health advice other than a hospital emergency department.
**Because of racial and ethnic disparities in HIV prevalence, recruitment was focused on Black or African American and Hispanic or Latina transgender women.
††Hispanic or Latina transgender women might be of any race.
§§Includes persons who indicated Asian, American Indian or Alaska Native, or Native Hawaiian or other Pacific Islander race.
¶¶Participants were asked to report their current gender identities from the following response options: woman, man, transgender woman, transgender man, or a gender not listed here. All eligible participants reported a gender identity of "woman" or "transgender woman;" however, participants were able to select more than one response option. Gender identities are not mutually exclusive.
***Dashes indicate suppression because of small cell size (<5).
†††Participants who reported having a previous positive HIV test result were defined as self-reported HIV–positive.

Table 2.  

Characteristic No. of transgender women Viral suppression Current antiretroviral use
No. (%) aPR (95% CI) p-value No. (%) aPR (95% CI) p-value
Annual household income, USD
40,000–74,999 51 45 (88.2) 1.12 (1.00–1.25) 0.043 48 (94.1) 1.06 (0.99–1.15) 0.107
20,000–39,999 94 83 (88.3) 1.18 (1.09–1.27) <0.001 88 (93.6) 1.07 (1.01–1.14) 0.023
10,000–19,999 177 129 (72.9) 0.96 (0.87–1.05) 0.365 165 (93.2) 1.08 (1.02–1.14) 0.012
≤9,999 290 209 (72.1) Ref 249 (85.9) Ref
Education
Less than high school 144 108 (75.0) Ref 130 (90.3) Ref
High school diploma or equivalent 236 171 (72.5) 1.02 (0.92–1.12) 0.735 210 (89.0) 1.00 (0.95–1.05) 0.967
Some college or technical degree 196 155 (79.1) 1.08 (0.98–1.19) 0.127 177 (90.3) 1.02 (0.95–1.08) 0.606
College degree or more 39 33 (84.6) 1.18 (1.03–1.34) 0.013 34 (87.2) 0.98 (0.88–1.08) 0.661
Experienced homelessness§
Yes 265 179 (67.6) 0.88 (0.81–0.96) 0.003 226 (85.3) 0.91 (0.88–0.96) <0.001
No 350 288 (82.3) Ref 325 (92.9) Ref
No. of nights homeless§
365 60 33 (55.0) 0.75 (0.58–0.96) 0.025 47 (78.3) 0.84 (0.76–0.93) 0.001
30–364 139 97 (69.8) 0.91 (0.83–1.00) 0.048 119 (85.6) 0.92 (0.87–0.98) 0.011
<30 50 39 (78.0) 1.02 (0.88–1.18) 0.804 47 (94.0) 0.99 (0.91–1.08) 0.799
None 350 288 (82.3) Ref 325 (92.9) Ref
Severe food insecurity
Yes 229 150 (65.5) 0.84 (0.76–0.92) <0.001 193 (84.3) 0.92 (0.87–0.96) 0.001
No 386 317 (82.1) Ref 328 (92.7) Ref
Currently has health insurance
Yes 560 435 (77.7) 1.14 (0.96–1.35) 0.133 507 (90.5) 1.16 (1.03–1.30) 0.016
No 54 32 (59.3) Ref 43 (79.6) Ref
Unmet need for health care during the past 12 months
Yes 90 58 (64.4) 0.89 (0.81–0.99) 0.027 74 (82.2) 0.90 (0.84–0.97) 0.008
No 525 409 (77.9) Ref 477 (90.9) Ref
Has usual source of care**
Yes 546 420 (76.9) 1.07 (0.94–1.22) 0.323 496 (90.8) 1.16 (1.03–1.32) 0.015
No 69 47 (68.1) Ref 55 (79.7) Ref
Comfort with a health care provider††
Yes 537 423 (78.8) 1.17 (1.04–1.32) 0.007 490 (91.2) 1.16 (1.05–1.29) 0.004
No 78 44 (56.4) Ref 61 (78.2) Ref
Total 615 467 (75.9) 551 (89.6)

Table 2. HIV treatment among transgender women living with a positive HIV test result — National HIV Behavioral Surveillance System, seven U.S. urban areas,* 2019–2020

Abbreviations: aPR = adjusted prevalence ratio; Ref = referent group; USD = U.S. dollars.
*The seven urban areas include Atlanta, Georgia; Los Angeles, California; New Orleans, Louisiana; New York, New York; Philadelphia, Pennsylvania; San Francisco, California; and Seattle, Washington.
Adjusted for age, race and ethnicity, city, and network size and clustered on urban areas and recruitment chains.
§Homelessness was defined as having lived on the street, in a shelter, in a single room occupancy hotel, or in a car during the past 12 months.
Severe food insecurity was defined as not eating for a whole day because there was not enough money for food at some point during the past 12 months.
**Usual source of care was defined as having a place to go when sick or in need of health advice other than a hospital emergency department.
††Comfort with a health care provider was defined as having a health care provider with whom the participant is comfortable discussing gender-related health issues.

Table 3.  

Characteristic No. of transgender women HIV test in the past 12 months PrEP use in the past 12 months
No. (%) aPR (95% CI) p-value No. (%) aPR (95% CI) p-value
Annual household income, USD
40,000–74,999 122 93 (76.2) 0.93 (0.85–1.01) 0.099 23 (18.8) 0.73 (0.53–0.99) 0.043
20,000–39,999 180 136 (75.6) 0.90 (0.82–0.98) 0.022 55 (30.6) 1.09 (0.90–1.32) 0.377
10,000–19,999 258 214 (82.9) 0.99 (0.94–1.04) 0.640 96 (37.2) 1.45 (1.22–1.74) <0.001
≤9,999 421 358 (85.0) Ref 113 (26.8) Ref
Education
Less than high school 203 173 (85.2) Ref 51 (25.1) Ref
High school diploma or equivalent 360 283 (78.6) 0.93 (0.86–1.01) 0.067 110 (30.6) 1.26 (1.02–1.56) 0.033
Some college or technical degree 290 244 (84.1) 1.00 (0.94–1.07) 0.944 91 (31.4) 1.27 (0.97–1.66) 0.087
College degree or more 138 106 (76.8) 0.95 (0.85–1.06) 0.379 36 (26.1) 1.06 (0.81–1.40) 0.662
Experienced homelessness§
Yes 406 349 (86.0) 1.10 (0.99–1.21) 0.076 126 (31.0) 1.08 (0.93–1.25) 0.332
No 586 458 (78.2) Ref 162 (27.6) Ref
No. of nights homeless§
365 92 73 (79.3) 1.03 (0.90–1.17) 0.663 24 (26.1) 0.98 (0.70–1.38) 0.899
30–364 199 176 (88.4) 1.12 (1.00–1.25) 0.059 62 (31.2) 1.05 (0.84–1.32) 0.654
<30 90 78 (86.7) 1.10 (0.99–1.21) 0.073 29 (32.2) 1.09 (0.83–1.43) 0.525
None 586 458 (78.2) Ref 162 (27.6) Ref
Severe food insecurity
Yes 408 342 (83.8) 1.02 (0.96–1.10) 0.495 137 (33.6) 1.23 (1.03–1.47) 0.024
No 582 463 (79.5) Ref 149 (25.6) Ref
Currently has health insurance
Yes 777 638 (82.1) 1.06 (0.98–1.16) 0.155 240 (30.9) 1.54 (1.26–1.88) <0.001
No 216 170 (78.7) Ref 48 (22.2) Ref
Unmet need for health care during the past 12 months
Yes 233 190 (81.6) 0.99 (0.93–1.05) 0.792 60 (25.7) 0.82 (0.68–1.00) 0.050
No 760 618 (81.3) Ref 228 (30.0) Ref
Has usual source of care**
Yes 779 650 (83.4) 1.16 (1.08–1.23) <0.001 261 (33.5) 2.54 (1.86–3.45) <0.001
No 210 154 (73.3) Ref 26 (12.4)
Comfort with a health care provider††
Yes 714 601 (84.2) 1.12 (1.04–1.21) 0.004 240 (33.6) 1.79 (1.43–2.24) <0.001
No 274 206 (75.2) Ref 48 (17.5) Ref
Total 991 786 (82.3) 288 (29.0)

Table 3. HIV prevention services among transgender women without known HIV infection — National HIV Behavioral Surveillance System, seven U.S. urban areas,* 2019–2020

Abbreviations: aPR = adjusted prevalence ratio; PrEP = preexposure prophylaxis; Ref = referent group; USD = U.S. dollars.
*The seven urban areas include Atlanta, Georgia; Los Angeles, California; New Orleans, Louisiana; New York, New York; Philadelphia, Pennsylvania; San Francisco, California; and Seattle, Washington.
Adjusted for age, race and ethnicity, city, and network size and clustered on urban areas and recruitment chains.
§Homelessness was defined as having lived on the street, in a shelter, in a single room occupancy hotel, or in a car during the past 12 months.
Severe food insecurity was defined as not eating for a whole day because there was not enough money for food at some point during the past 12 months.
**Usual source of care was defined as having a place to go when sick or in need of health advice other than a hospital emergency department.
††Comfort with a health care provider was defined as having a health care provider with whom the participant is comfortable discussing gender-related health issues.

CME / ABIM MOC / CE

Factors Associated With Use of HIV Prevention and Health Care Among Transgender Women — Seven Urban Areas, 2019–2020

  • Authors: Kathryn Lee, MPH; Lindsay Trujillo, MPH; Evelyn Olansky, MPH; Taylor Robbins, MPH; Christine Agnew Brune, PhD; Elana Morris, MPH; Teresa Finlayson, PhD; Dafna Kanny, PhD; Cyprian Wejnert, PhD
  • CME / ABIM MOC / CE Released: 9/26/2022
  • THIS ACTIVITY HAS EXPIRED FOR CREDIT
  • Valid for credit through: 9/26/2023, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for public health officials, women's health clinicians, infectious disease clinicians, internists, nurses, pharmacists, and other clinicians who treat and manage transgender women with or at risk for HIV.

The goal of this activity is for learners to be better able to describe HIV test results and factors associated with HIV prevention and health care use among transgender women, based on a study of 1,608 transgender women who participated in the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance in 7 US urban areas.

Upon completion of this activity, participants will:

  • Assess the association of socioeconomic status and health care accessibility with health care use and outcomes among transgender women who reported a positive HIV test result, based on a study of National HIV Behavioral Surveillance data during 2019 to 2020
  • Evaluate the association of socioeconomic status and health care accessibility with HIV prevention among transgender women who did not report a positive HIV test result, based on a study of National HIV Behavioral Surveillance data during 2019 to 2020
  • Determine the clinical and public health implications of factors associated with HIV-related health outcomes and health care use among transgender women, based on a study of National HIV Behavioral Surveillance data during 2019 to 2020


Faculty

  • Kathryn Lee, MPH

    Division of HIV Prevention
    National Center for HIV, Viral Hepatitis, STD, and TB Prevention
    Centers for Disease Control and Prevention
    Atlanta, Georgia

    Disclosures

    Kathryn Lee, MPH, has no relevant financial relationships.

  • Lindsay Trujillo, MPH

    Social & Scientific Systems, Inc.
    Atlanta, Georgia 

    Disclosures

    Lindsay Trujillo, MPH, has no relevant financial relationships.

  • Evelyn Olansky, MPH

    Social & Scientific Systems, Inc.
    Atlanta, Georgia 

    Disclosures

    Evelyn Olansky, MPH, has no relevant financial relationships.

  • Taylor Robbins, MPH

    Division of HIV Prevention
    National Center for HIV, Viral Hepatitis, STD, and TB Prevention
    Centers for Disease Control and Prevention
    Atlanta, Georgia

    Disclosures

    Taylor Robbins, MPH, has no relevant financial relationships.

  • Christine Agnew Brune, PhD

    Division of HIV Prevention
    National Center for HIV, Viral Hepatitis, STD, and TB Prevention
    Centers for Disease Control and Prevention
    Atlanta, Georgia

    Disclosures

    Christine Agnew Brune, PhD, has no relevant financial relationships.

  • Elana Morris, MPH

    Division of HIV Prevention
    National Center for HIV, Viral Hepatitis, STD, and TB Prevention
    Centers for Disease Control and Prevention
    Atlanta, Georgia

    Disclosures

    Elana Morris, MPH, has no relevant financial relationships.

  • Teresa Finlayson, PhD

    Division of HIV Prevention
    National Center for HIV, Viral Hepatitis, STD, and TB Prevention
    Centers for Disease Control and Prevention
    Atlanta, Georgia

    Disclosures

    Teresa Finlayson, PhD, has no relevant financial relationships.

  • Dafna Kanny, PhD

    Division of HIV Prevention
    National Center for HIV, Viral Hepatitis, STD, and TB Prevention
    Centers for Disease Control and Prevention
    Atlanta, Georgia

    Disclosures

    Dafna Kanny, PhD, has no relevant financial relationships.

  • Cyprian Wejnert, PhD

    Division of HIV Prevention
    National Center for HIV, Viral Hepatitis, STD, and TB Prevention
    Centers for Disease Control and Prevention
    Atlanta, Georgia

    Disclosures

    Cyprian Wejnert, PhD, has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has the following relevant financial relationships:
    Formerly owned stocks in: AbbVie

Editor/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has no relevant financial relationships.


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CME / ABIM MOC / CE

Factors Associated With Use of HIV Prevention and Health Care Among Transgender Women — Seven Urban Areas, 2019–2020

Authors: Kathryn Lee, MPH; Lindsay Trujillo, MPH; Evelyn Olansky, MPH; Taylor Robbins, MPH; Christine Agnew Brune, PhD; Elana Morris, MPH; Teresa Finlayson, PhD; Dafna Kanny, PhD; Cyprian Wejnert, PhDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED FOR CREDIT

CME / ABIM MOC / CE Released: 9/26/2022

Valid for credit through: 9/26/2023, 11:59 PM EST

processing....

Introduction

Transgender women* are disproportionately affected by HIV. Among 1,608 transgender women who participated in CDC's National HIV Behavioral Surveillance (NHBS) during 2019–2020, 42% received a positive HIV test result.[1] This report provides results from seven U.S. urban areas where the 2019–2020 NHBS questionnaire was administered. Thirty-eight percent of participants reported having previously received a positive test result for HIV. Detrimental socioeconomic factors, including low income (44%), homelessness (39%), and severe food insecurity in the past 12 months (40%), were common and associated with lower receipt of HIV prevention and treatment services. Having a usual health care source or a provider with whom the participant was comfortable discussing gender-related health issues was associated with improved HIV prevention and treatment outcomes, including HIV testing, preexposure prophylaxis (PrEP) use, and viral suppression. These findings illustrate the benefit of gender-affirming approaches used by health care providers,[2] and highlight the challenging socioeconomic conditions faced by many transgender women. Ensuring access to gender-affirming health care approaches and addressing the socioeconomic challenges of many transgender women could improve access to and use of HIV prevention and care in this population and will help achieve the goals of the Ending the HIV Epidemic in the United States initiative.[3]

Initiated in 2003, NHBS conducts biobehavioral surveillance among persons at high risk for HIV infection. During June 2019–February 2020, NHBS surveyed 1,608 transgender women in seven U.S. urban areas using respondent-driven sampling. Eligible participants§ completed an interviewer-administered questionnaire and were offered an HIV test. The questionnaire included measures of gender identity, income, health insurance, housing,** food insecurity,†† HIV status, viral suppression (if HIV-positive), comfort with their health care provider in discussing gender-related health issues (hereafter referred to as comfort with a provider), unmet need for health care,§§ and usual source of health care. Because of racial and ethnic disparities in HIV prevalence, recruitment was focused on Black or African American and Hispanic or Latina transgender women as initial sampling recruits. Incentives were provided for completion of the interview and HIV test. Adjusted prevalence ratios (aPRs) and 95% CIs for prevention and treatment outcomes, by self-reported HIV status, were estimated using log-linked Poisson regression models with generalized estimating equations clustered on recruitment chain and urban area; models were adjusted for age, race and ethnicity, and urban area. Analyses were conducted using SAS software (version 9.4; SAS Institute). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.¶¶

Data from 1,608 transgender women were included in this analysis (Table 1). Thirty-eight percent reported having previously received a positive HIV test result.*** Forty-four percent earned <$10,000 annually. During the past 12 months 39% experienced homelessness, and 40% experienced severe food insecurity. Nearly one third (31%) of participants were interviewed in Los Angeles. By urban area, reports of homelessness ranged from 22% to 59%, and reports of recent severe food insecurity ranged from 28% to 47%. Comfort with a provider varied by urban area from 66% to 91%.

Socioeconomic status and health care accessibility were associated with health outcomes (Table 2). Among participants who reported a previous positive test result for HIV, self-reported viral suppression was less common among participants who reported experiencing homelessness during the past 12 months (aPR = 0.88; p = 0.003), and the likelihood of viral suppression decreased as the number of nights of homelessness increased. Severe food insecurity (aPR = 0.84; p<0.001) and unmet need for health care (aPR = 0.89; p = 0.027) were also less common among participants who reported viral suppression. Comfort with a provider (aPR = 1.17; p = 0.007) was more common among participants who reported viral suppression. Similar associations were found for current use of antiretroviral medication. Having a usual source of health care was also associated with current use of antiretroviral medication (aPR = 1.16; p = 0.015).

Among participants who did not report a previous positive test result for HIV, testing for HIV during the past 12 months was more likely among those who reported having a usual source of health care (aPR = 1.16; p<0.001) and comfort with a provider (aPR = 1.12; p = 0.004) (Table 3). PrEP use was more common among participants who reported having health insurance (aPR = 1.54; p<0.001), a usual source of health care (aPR = 2.54; p<0.001), and comfort with a provider (aPR = 1.79; p<0.001), and less likely among participants who reported an unmet need for health care (aPR = 0.82; p = 0.050). PrEP use was also more common among participants who had experienced severe food insecurity than those who had not (aPR = 1.23; p = 0.024).

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* Persons who were assigned male sex at birth and who currently identify as women or transgender women.
† Respondent-driven sampling is a methodology similar to snowball sampling and is often used when trying to sample hard-to-reach populations. The method relies on multiple waves of peer-to-peer recruitment to achieve the desired sample size. https://www.jstor.org/stable/10.1525/sp.2002.49.1.11?seq=1
§ Eligible persons were those who were aged ≥18 years, had current residence in a participating urban area, had not previously participated in the current survey cycle, had ability to complete the survey in either English or Spanish, provided informed consent, and reported a gender identity of woman or transgender woman and were assigned male sex or intersex at birth.
¶ Participants were asked to report their current gender identity from the following response options: woman, man, transgender woman, transgender man, or a gender not listed here. Participants were able to select more than one response option.
** Participants were asked if they had experienced homelessness during the past 12 months, including living on the street, in a shelter, in a single room occupancy hotel, or in a car. They were also asked to provide the number of nights during the past 12 months that they experienced homelessness.
†† Severe food insecurity was defined as having not eaten for a whole day because
there was not enough money for food at some point during the past 12 months.
§§ Having an unmet need for care was defined as a “time when you needed medical care but didn’t get it because you couldn’t afford it” during the past 12 months.
¶¶ 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
*** Among participants, 38% self-reported living with HIV during the interview and were asked questions related to HIV treatment. During postinterview HIV testing, an additional 4% of participants received a positive HIV test result, for a total of 42% of participants who received a positive HIV test result (https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html). Those who did not report living with HIV during the interview were not asked about HIV treatment.