BACKGROUND: The healthcare transition (HCT) from pediatric to adult HIV care can be disruptive to HIV care engagement and viral suppression for youth living with HIV (YLH).

METHODS: We performed qualitative interviews with 20 YLH who experienced HCT and with 20 multidisciplinary pediatric and adult HIV clinicians to assess and rank barriers and facilitators to HCT and obtain their perspectives on strategies to improve the HCT process. We used the Exploration Preparation Implementation Sustainment Framework to guide this qualitative inquiry.

RESULTS: The most impactful barriers identified by YLH and clinicians focused on issues affecting the patient-clinician relationship, including building trust, and accessibility of clinicians. Both groups reported that having to leave the pediatric team was a significant barrier (ranked #1 for clinicians and #2 for YLH). The most impactful facilitator included having a social worker or case manager to navigate the HCT (listed #1 by clinicians and #2 by YLH); case managers were also identified as the individual most suited to support HCT. While YLH reported difficulty building trust with their new clinician as their #1 barrier, they also ranked the trust they ultimately built with a new clinician as their #1 facilitator. Factors reported to bridge pediatric and adult care included providing a warm handoff, medical record transfer, developing relationships between pediatric clinics and a network of youth-friendly adult clinics, and having the pediatric case manager attend the first adult appointment. Longer new patient visits, increased health communication between YLH and clinicians and sharing vetted clinician profiles with YLH were identified as innovative strategies.

CONCLUSION: In this multi-disciplinary contextual inquiry, we have identified several determinants that may be targeted to improve HCT for YLH.

BACKGROUND: Clinical decision support (CDS) is a promising intervention for improving uptake of HIV testing and pre-exposure prophylaxis (PrEP). However, little is known regarding provider perspectives on acceptability, appropriateness, and feasibility of CDS for HIV prevention in pediatric primary care, a key implementation setting.

METHODS: This was a cross-sectional multiple methods study utilizing surveys and in-depth interviews with pediatricians to assess acceptability, appropriateness, and feasibility of CDS for HIV prevention, as well as to identify contextual barriers and facilitators to CDS. Qualitative analysis utilized work domain analysis and a deductive coding approach grounded in the Consolidated Framework of Implementation Research. Quantitative and qualitative data were merged to develop an Implementation Research Logic Model to conceptualize implementation determinants, strategies, mechanisms, and outcomes of potential CDS use.

RESULTS: Participants (n = 26) were primarily white (92%), female (88%), and physicians (73%). Using CDS to improve HIV testing and PrEP delivery was perceived as highly acceptable (median score 5), IQR [4-5]), appropriate (5, IQR [4-5]), and feasible (4, IQR [3.75-4.75]) using a 5-point Likert scale. Providers identified confidentiality and time constraints as two key barriers to HIV prevention care spanning every workflow step. With respect to desired CDS features, providers sought interventions that were integrated into the primary care workflow, standardized to promote universal testing yet adaptable to the level of a patient's HIV risk, and addressed providers' knowledge gaps and bolstered self-efficacy in providing HIV prevention services.

CONCLUSIONS: This multiple methods study indicates that clinical decision support in the pediatric primary care setting may be an acceptable, feasible, and appropriate intervention for improving the reach and equitable delivery of HIV screening and PrEP services. Design considerations for CDS in this setting should include deploying CDS interventions early in the visit workflow and prioritizing standardized but flexible designs.

HIV prevalence and engagement in sexual behaviors associated with HIV transmission are high among transgender people of color. Per intersectionality, this disproportionate burden may be related to both interpersonal and structural racism and transphobia. The goal of this study was to estimate the association between interpersonal and structural discrimination and sexual behaviors among transgender and gender diverse (TGD) U.S. young adults. We used logit models with robust standard errors to estimate the individual and combined association between interpersonal and structural racism and transphobia and sexual behaviors in a national online sample of TGD young adults of color (TYAOC) aged 18-30 years (N = 228). Racism was measured at the interpersonal and structural level using the Everyday Discrimination Scale and State Racism Index, respectively. Transphobia was measured at the interpersonal and structural level using the Gender Minority Stress Scale and the Gender Identity Tally, respectively. We found that interpersonal racism was associated with transactional sex, and interpersonal transphobia was associated with alcohol/drug consumption prior to sex and transactional sex among TYAOC. We also found evidence of a strong joint association of interpersonal and structural racism and transphobia with alcohol/drug consumption prior to sex (OR 3.85, 95% CI 2.12, 7.01) and transactional sex (OR 3.54, 95% CI 0.99, 12.59) among TYAOC. Racism and transphobia have a compounding impact on sexual behaviors among TYAOC. Targeted interventions that reduce discrimination at both the interpersonal and structural level may help reduce the HIV burden in this marginalized population.

BACKGROUND: Engaging adolescents and young adults (AYAs) who are at elevated risk for HIV acquisition or who are living with HIV in health care has posed a major challenge in HIV prevention and care efforts. Mobile health (mHealth) interventions are a popular and accessible strategy to support AYA engagement despite barriers to care present along the HIV care continuum. Even with progress in the field of mHealth research, expert recommendations for the process of designing, evaluating, and implementing HIV-related mHealth interventions are underdeveloped.

OBJECTIVE: The aim of this study was to compile expert recommendations on the development, evaluation, and implementation of AYA-focused HIV prevention and care mHealth interventions.

METHODS: Experts from adolescent mHealth HIV research networks and investigators of recently funded HIV mHealth projects and programs were identified and invited to complete a series of electronic surveys related to the design, implementation, and evaluation of HIV-related mHealth interventions. A modified Delphi method was used to ask experts to score 35 survey items on a 4-point Likert scale from not important to very important and encouraged experts to leave additional comments in textboxes. Responses were reviewed by the researchers, a team of 4 HIV mHealth intervention experts. The average importance ratings from survey responses were calculated and then categorized as retained (high importance), flagged (mid-level importance), or dropped (no/low importance). Additionally, thematic analysis of expert comments helped modify survey items for the next survey round. An evaluation of the level of agreement among experts on the most important items followed each round until consensus was reached.

RESULTS: Of the 35 invited experts, 23 completed the first survey representing a variety of roles within a research team. Following two rounds of Delphi surveys, experts scored 24 of the 28 (86%) survey items included in round two as important to very important. The final consensus items included 24 recommendations related to the mHealth intervention design process (n=15), evaluation (n=2), and implementation (n=7). The 3 survey items with the highest average scores focused on the design process, specifically, (1) the creation of a diverse team including researchers, app software developers, and youth representation; (2) the importance of AYA-focused content; and (3) the value of an iterative process. Additionally, experts highlighted the importance of establishing the best ways to collect data and the types of data for collection during the evaluation process as well as constructing a plan for participant technology disruption when implementing an mHealth intervention.

CONCLUSIONS: The modified Delphi method was a useful tool to convene experts to determine recommendations for AYA-focused HIV prevention and care mHealth interventions. These recommendations can inform future mHealth interventions. To ensure the acceptability, feasibility, and efficacy of these AYA HIV prevention interventions, the focus must be on the specific needs of AYAs by including representation of AYAs in the process, including consistent and relevant content, ensuring appropriate data is collected, and considering technology and health accessibility barriers.

CONTEXT: Studies on cardiometabolic health in transgender and gender diverse youth (TGDY) are limited to small cohorts.

OBJECTIVE: To determine the odds of cardiometabolic-related diagnoses in TGDY compared to matched controls in a cross-sectional analysis, using a large, multisite database (PEDSnet).

DESIGN: Electronic health record data (2009-2019) were used to determine odds of cardiometabolic-related outcomes based on diagnosis, anthropometric and laboratory data using logistic regression among TGDY youth vs. controls. The association of gender affirming hormone therapy (GAHT) with these outcomes was examined separately among TGDY.

SETTING: Six PEDSnet sites.

PATIENTS OR OTHER PARTICIPANTS: TGDY (n=4,172) were extracted from PEDSnet and propensity-score matched on 8 variables to controls (n=16,648).

INTERVENTION(S): N/A.

MAIN OUTCOME MEASURE(S): Odds of having cardiometabolic-related diagnoses among TGDY compared to matched controls, and among TGDY prescribed GAHT compared to those not prescribed GAHT.

RESULTS: In adjusted analyses, TGDY had higher odds of overweight/obesity (1.2 [95% confidence interval 1.1-1.3]) than controls. TGDY with a testosterone prescription alone or in combination with a gonadotropin releasing hormone agonist (GnRHa) had higher odds of dyslipidemia (1.7 [1.3-2.3], 3.7 [2.1-6.7], respectively) and liver dysfunction (1.5 [1.1-1.9], 2.5 [1.4-4.3]) than TGDY not prescribed GAHT. TGDY with a testosterone prescription alone had higher odds of overweight/obesity (1.8 [1.5-2.1]) and hypertension (1.6 [1.2-2.2]) than those not prescribed testosterone. Estradiol and GnRHa alone were not associated with greater odds of cardiometabolic-related diagnoses.

CONCLUSIONS: TGDY have increased odds of overweight/obesity compared to matched controls. Screening and tailored weight management, sensitive to the needs of TGDY, are needed.

<p>Since May 2021, numerous state legislatures in the United States have introduced bills to restrict the participation of transgender and gender diverse (trans) youth in gender-segregated sports in a manner consistent with their gender identity. The purpose of this study was to understand how medical providers of pediatric gender-affirming care for trans youth view these legislative efforts and how they believe these bills will affect their practice and patients. In March 2021, we recruited participants using listservs known to be frequented by providers of gender-affirming medical care to complete a survey about bills that restrict trans youths' participation in sex-segregated sports. Eligible participants were over the age of 18, currently worked as a physician, nurse practitioner, or physician's assistant, and provided gender-affirming care to trans youth under the age of 18 in the United States. We analyzed the responses of 103 providers from all 50 states and the District of Columbia. Most participants identified as White (77%), cisgender women (70%), and specialized in pediatric care (52%). The most salient theme, described by nearly all participants, was that legislation banning trans youth from sports participation would lead to worsening discrimination and stigmatization. Other themes included worsening mental and physical health of trans youth, forced changes to clinical practice, politicization of trans youth, and efforts required to stop these bills. Providers of gender-affirming care in this study overwhelmingly opposed legislation that bans trans youth from sports participation citing the severe consequences to the well-being of trans youth. More research is needed to examine stakeholder's opinions regarding legislation that does not ban but otherwise restricts sports participation by trans youth.</p>

<p><strong>PURPOSE: </strong>While some adolescents celebrate menstruation as a rite of passage, others seek discretion due to stigma. Many youth have used Twitter to combat stigma and raise awareness about other culturally taboo topics, but previous work has not explored youth conversations regarding menstruation. This study aims to assess whether Twitter can provide useful insights into how youth perceive menstruation.</p>

<p><strong>METHODS: </strong>The team searched 162,316,839 tweets of 71,443 users of the age range 13-25&nbsp;years in the Health Language Processing Twitter Youth Cohort for tweets that matched menstruation-related keywords: a pad, my pad, my period, her period, your period, tampon, diva cup, menstruate, that time of the month. Twelve codes emerged using a grounded theory approach and were sorted into three themes.</p>

<p><strong>RESULTS: </strong>Analysis was conducted on 10,000 tweets. Three themes emerged, including menstrual health, menstrual stigma, and menstrual positivity. Tweets related to menstrual health included physical complications, sexual/reproductive health, health education, and LGBTQ health. Tweets that addressed menstrual stigma included inconvenience/limitations, shame/stereotypes, religion/alternate perceptions, access/affordability, and self-depreciation/harm. Tweets related to menstrual positivity included awareness/community, strength/resilience, and environment/sustainability.</p>

<p><strong>DISCUSSION: </strong>This study provides insights into youth perceptions about menstruation. There was overwhelming emphasis placed on the negative expectations and shame around menstruation. A significant minority of tweets were directly or indirectly related to advocacy or education, which supports the potential use of Twitter as a platform to improve public health messaging, transform health outcomes, and promote equity among youth who menstruate.</p>

<p>This study aims to describe health inequities experienced by transgender Hispanic (TH) individuals in the United States. This retrospective case-control study used the Behavioral Risk Factor Surveillance System (BRFSS) data from 2014 to 2018. Propensity score matching and logistic and negative binomial regression were used to compare TH survey respondents with other relevant populations across the following outcomes: health care access, health risk factors, self-reported chronic conditions, and perceived health status. Relative to transgender White (TW) respondents, TH respondents (=414) were less likely to report having health insurance (odds ratio [OR]: 0.35, &lt;0.001), a regular provider (OR=0.40, &lt;0.001), and were more likely to report cost barriers to care (OR=1.85, &lt;0.001) and HIV risk factors (OR=2.41, &lt;0.001). Similar results were found when comparing outcomes with cisgender White respondents. TH respondents reported fewer days of poor health (rate ratio [RR]=0.67, &lt;0.001), activity limited days (RR=0.64, =0.011), and were less likely to report depression (OR=0.44, &lt;0.001) than TW respondents. Relative to cisgender Hispanic (CH) respondents, TH respondents experienced more cost barriers (OR=1.56, =0.003), higher HIV risk (OR=3.38, &lt;0.001), and more activity limited days (RR=2.93, &lt;0.001). Our results demonstrate that TH individuals may be less likely to have access to health care and have poorer health-related quality-of-life when compared with either CH or TW individuals. It is vital that additional research further elucidate the challenges faced by this multiply marginalized population including racism and transphobia. Further health care solutions should be responsive to the unique challenges of the TH population at the individual and institutional level.</p>

<p><strong>BACKGROUND: </strong>Data regarding the acceptability, feasibility, and quality of telehealth among adolescents and young adults (AYA) and their parents and caregivers (caregivers) are lacking.</p>

<p><strong>OBJECTIVE: </strong>The aim of this study was to assess the noninferiority of telehealth versus in-person visits by comparing acceptability with respect to efficiency, effectiveness, equity, patient-centeredness, and confidentiality.</p>

<p><strong>METHODS: </strong>Cross-sectional web-based surveys were sent to caregivers and AYA following video visits within an Adolescent Medicine subspecialty clinic in May-July 2020. Proportions of AYA and caregivers who rated telehealth as noninferior were compared using chi-squared tests. Feasibility was assessed via items measuring technical difficulties. Deductive thematic analysis using the Institute of Medicine dimensions of health care quality was used to code open-ended question responses.</p>

<p><strong>RESULTS: </strong>Survey response rates were 20.5% (55/268) for AYA and 21.8% (123/563) for caregivers. The majority of the respondents were White cisgender females. Most AYA and caregivers rated telehealth as noninferior to in-person visits with respect to confidentiality, communication, medication management, and mental health care. A higher proportion of AYA compared to caregivers found telehealth inferior with respect to confidentiality (11/51, 22% vs 3/118, 2.5%, P&lt;.001). One-quarter (14/55) of the AYA patients and 31.7% (39/123) of the caregivers reported technical difficulties. The dominant themes in the qualitative data included advantages of telehealth for efficiency and equity of health care delivery. However, respondents' concerns included reduced safety and effectiveness of care, particularly for patients with eating disorders, owing to lack of hands-on examinations, collection of vital signs, and laboratory testing.</p>

<p><strong>CONCLUSIONS: </strong>Telehealth was highly acceptable among AYA and caregivers. Future optimization should include improving privacy, ameliorating technical difficulties, and standardizing at-home methods of obtaining patient data to assure patient safety.</p>