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Background Knowledge of HIV risk factors and reduction strategies is essential for prevention in key populations such as men who have sex with men (MSM) and transgender women (TGW). We evaluated factors associated with HIV-related knowledge among MSM and TGW and the impact of engagement in care at trusted community health centers in Nigeria. Methods The TRUST/RV368 cohort recruited MSM and TGW in Lagos and Abuja, Nigeria via respondent driven sampling. During study visits every three months, participants underwent structured interviews to collect behavioral data, received HIV education, and were provided free condoms and condom compatible lubricants. Five HIV-related knowledge questions were asked at enrollment and repeated after 9 and 15 months. The mean number of correct responses was calculated for each visit with 95% confidence intervals (CIs). Multivariable Poisson regression was used to calculate adjusted risk ratios and CIs for factors associated with answering more knowledge questions correctly. Results From March 2013 to April 2018, 2122 persons assigned male sex at birth were enrolled, including 234 TGW (11.2%). The mean number of correct responses at enrollment was 2.36 (95% CI: 2.31–2.41) and increased to 2.95 (95% CI: 2.86–3.04) and 3.06 (95% CI: 2.97–3.16) after 9 and 15 months in the study, respectively. Among 534 participants who completed all three HIV-related knowledge assessments, mean number of correct responses rose from 2.70 (95% CI: 2.60–2.80) to 3.02 (95% CI: 2.93–3.13) and then 3.06 (95% CI: 2.96–3.16). Factors associated with increased overall HIV-related knowledge included longer duration of study participation, HIV seropositivity, higher education level, and more frequent internet use. Conclusions There was suboptimal HIV-related knowledge among Nigerian MSM and TGW at that improved modestly with engagement in care. These data demonstrate unmet HIV education needs among Nigerian MSM and TGW and provide insights into modalities that could be used to address these needs.

Public Beliefs about Housing Affordability as a Key Social Determinant of Health and its Impact on Support for Affordable Housing Policy

Recent attention to the interrelationship between racism, socioeconomic status (SES) and health has led to a small, but growing literature of empirical work on the role of structural racism in population health. Area-level racial inequities in SES are an indicator of structural racism, and the associations between structural racism indicators and self-rated health are unknown. Further, because urban-rural differences have been observed in population health and are associated with different manifestations of structural racism, explicating the role of urban-rural classification is warranted. This study examined the associations between racial inequities in SES and self-rated health by county urban-rural classification. Using data from County Health Rankings and American Communities Surveys, black-white ratios of SES were regressed on rates of fair/poor health in U.S. counties. Racial inequities in homeownership were negatively associated with fair/poor health ( β  = −0.87, s.e. = 0.18), but racial inequities in unemployment were positively associated with fair/poor health ( β  = 0.03, s.e. = 0.01). The associations between structural racism and fair/poor health varied by county urban-rural classification. Potential mechanisms include the concentration of resources in racially segregated counties with high racial inequities that lead to better health outcomes, but are associated with extreme black SES disadvantage. Racial inequities in SES are a social justice imperative with implications for population health that can be targeted by urban-rural classification and other social contextual characteristics.

Objective: Cardiometabolic disease is the leading cause of mortality in the United States. Cardiometabolic function during adolescence predicts future cardiometabolic disease, yet few studies have examined early determinants of cardiometabolic function. Informed by evidence of sex differences in the prevalence and severity of cardiometabolic disorders and evidence of sexual dimorphism in the stress response, we examined sex differences in the association between living in poverty and cardiometabolic function during adolescence, a precursor of later cardiometabolic disorders. Methods: We linked data from 10 415 adolescents aged 12-19 in the National Health and Nutrition Examination Survey (1999-2012) with US Census–tract data on area-level poverty (percentage of the population living in poverty, grouped into quartiles). We parameterized cardiometabolic dysfunction by summing the z scores of 6 cardiometabolic biomarkers, grouped into quintiles. Hierarchical ordinal models estimated associations. Results: Compared with residents in low-poverty areas, residents in high-poverty areas had elevated odds of cardiometabolic dysfunction (highest quartile of poverty odds ratio [OR] = 1.27; 95% confidence interval [CI], 1.08-1.50). This association was more pronounced among boys than girls (highest quartile of poverty for boys: OR = 1.36; 95% CI, 1.10-1.70; highest quartile of poverty for girls: OR = 1.17; 95% CI, 0.94-1.47). Conclusion: Our study supports the existence of sex-specific associations. These results highlight the potential for community-based programs, such as housing assistance, to improve population health.

Sexual and gender minority (SGM) youth are more likely to use alcohol than their heterosexual cisgender peers. At the same time, SGM youth experience sexuality- and gender identity-specific stressors known to exacerbate negative health outcomes. Though scholars have established a link between minority stressors (e.g., internalized stigma and victimization) and increased alcohol use for SGM youth as a whole, there is little indication of whether internalized stigma and victimization are more strongly associated with alcohol use for specific groups of SGM youth. A United States sample of 11,811 racially and geographically diverse 13–17 year old SGM youth was used to employ a series of gender-stratified multivariable regression models to examine the association among internalized stigma, victimization, and alcohol-related behaviors, and whether they differed for specific groups of sexual minority youth. Sexual orientation moderated several associations between sexual minority stressors (i.e., victimization and stigma) and youth’s alcohol use (i.e., recent use and heavy episodic drinking) across models stratified by gender (i.e., male, female, and non-binary). For example, bisexual boys had stronger associations between SGM-specific victimization and alcohol use frequency and heavy episodic drinking relative to gay boys; conversely, victimization and alcohol use frequency were more weakly associated among bisexual girls relative to lesbian/gay girls. Pansexual girls showed weaker associations between internalized stigma and alcohol use frequency compared to lesbian/gay girls. This paper demonstrates who among SGM youth are more likely to engage in alcohol-related behaviors as a function of differential forms of SGM-related victimization and stigma. These findings can inform substance use interventions that are tailored to youth of diverse sexual orientations and gender identities.

Adolescent girls and young women (AGYW) in Uganda are at risk of early sexual debut, unwanted pregnancy, violence, and disproportionally high HIV infection rates, driven in part by transactional sex. This paper examines the extent to which AGYW’s participation in transactional sex is perceived to be coerced. We conducted 19 focus group discussions and 44 in-depth interviews using semi-structured tools. Interviews were audio recorded, and transcribed verbatim. Data were analysed using a thematic analysis. While AGYW did not necessarily use the language of coercion, their narratives describe a number of coercive aspects in their relationships. First, coercion by force as a result of “de-toothing” a man (whereby they received money or resources but did not wish to provide sex as “obligated” under the implicit “terms” of the relationships). Second, they described the coercive role that receiving resources played in their decision to have sex in the face of men’s verbal insistence. Finally, they discussed having sex as a result of coercive economic circumstances including poverty, and because of peer pressure to uphold modern lifestyles. Support for income-generation activities, microfinance and social protection programmes may help reduce AGYW’s vulnerability to sexual coercion in transactional sex relationships. Targeting gender norms that contribute to unequal power dynamics and social expectations that obligate AGYW to provide sex in return for resources, critically assessing the meaning of consensual sex, and normative interventions building on parents’ efforts to ascertain the source of their daughters’ resources may also reduce AGYW’s vulnerability to coercion.

Purpose:  Sexual minorities experience signi fi cant health disparities across a variety of mental, behav ioral, and physical health indicators. Yet, an understanding of the etiology and progression of sexual minority health disparities across the lifespan is limited. Methods:  We used the U.S. National Epidemiologic Survey of Alcohol and Related Conditions III to  evaluate the association between sexual minority status and seven past-year health outcomes (alcohol  use disorder, tobacco use disorder, drug use disorder, major depressive episode, generalized anxiety  disorder, sexually transmitted infection, and cardiovascular conditions). To do this, we used unadjusted  and adjusted logistic regression among our study sample (n ¼ 30,999; aged 18 e 65 years) and time- varying effect models to evaluate how sexual orientation differences in these outcomes vary across  adulthood. Results:  Relative to heterosexuals, sexual minorities had elevated odds of past-year alcohol use disorder  and drug use disorder across all ages (18 e 65 years) although the magnitude of the disparity varies by  age. Sexual minorities were also more likely to experience major depressive episode, generalized anxiety  disorder, tobacco use disorder, sexually transmitted infection, and cardiovascular disease, but only at  speci fi c ages. Conclusions:  Sexual minority health disparities vary appreciably across the adult lifespan, thus eluci dating critical periods for focused prevention efforts.

Few societal attitudes and opinions have changed as quickly as those regarding sexual minority people and rights. In the context of dramatic social change, there have been multiple policy changes toward social inclusion and rights for lesbian, gay, and bisexual (LGB) people, and perceptions that the sociocultural context for LGB people—perhaps particularly for youth—has improved. Yet recent evidence from the developmental sciences points to paradoxical findings: in many cases there have been growing rather than shrinking health disparities. The authors suggest that there is a developmental collision between normative adolescent developmental processes and sexual minority youth identities and visibility.

Introduction: Sexual minorities are disproportionately more likely than heterosexuals to suffer from substance use disorders, but relatively little is known about differences in substance use disorders across diverse sexual minority subgroups. There is also limited understanding of how different social stressors account for sexual orientation disparities in substance use disorders. Methods: Using nationally representative data collected in 2012−2013 (n=34,597), differences in past-year DSM-5 alcohol, cannabis, and tobacco use disorders were assessed across 4 sexual orientation groups (heterosexuals and 3 sexual minority subgroups, lesbian/gay-, bisexual-, and heterosexual-identified sexual minorities). This study assessed whether stressful life events mediated substance use disorder disparities between heterosexuals and each sexual minority subgroup, and whether stressful life events and lesbian, gay, and bisexual discrimination events mediated these substance use disorder differences. Analyses were conducted in 2019. Results: For both men and women, substance use disorders and stress experiences varied by sexual identity. For example, compared with heterosexual men, larger proportions of gay and bisexual men had a past-year alcohol use disorder. Among women, all sexual minority subgroups had higher rates of each substance use disorder than heterosexuals. For each substance use disorder, stressful life events mediated disparities between heterosexuals and sexual minority subgroups, except for heterosexual-identified sexual minority men. Both stressful life events and lesbian, gay, and bisexual discrimination mediated substance use disorder differences between sexual minority subgroups, with stronger indirect effects through lesbian, gay, and bisexual discrimination for lesbians/gay men and stronger indirect effects through stressful life events for bisexual adults, generally. Conclusions: Sexual minority subgroups have a greater prevalence of substance use disorders, mediated through both stressful life events and lesbian, gay, and bisexual discrimination. More research is needed to comprehensively assess the processes underlying sexual orientation substance use disparities.