Wiewel et al. suggest that misclassification may account for differences between Medical Monitoring Project (MMP) estimates of the proportion of US transgender HIV patients that are transgender men and HIV case surveillance estimates of this proportion among persons living with diagnosed HIV in New York City and California. The risk of misclassification attributable to data entry is reduced by MMP’s electronic data collection, which has programmed logic checks based on responses to questions about sex at birth and gender to prevent errors. Furthermore, in certain sections of the interview, transgender persons are asked interview questions that would not pertain to cisgender persons, providing additional protection against data entry errors. We attribute the differences Wiewel et al. note to the method of measurement used to calculate estimates and substantial differences in populations.

OBJECTIVES: Health systems must rapidly move knowledge into practice to address disparities impacting sexual and gender minority (SGM) patients. This qualitative study explores barriers and facilitators that arose during an initiative to improve care for SGM patients in federally qualified health centres (FQHCs) from the perspectives of FQHC staff. DESIGN: Cross-sectional qualitative content analysis, using a general inductive approach, of secondary data from transcripts of intervention events offered to FQHC staff and semistructured interviews with staff and FQHC leadership during the intervention. SETTING: 10 FQHCs from nine states in the USA. PARTICIPANTS: FQHC quality improvement (QI) and clinical care staff, and leaders at each FQHC. INTERVENTIONS: The transforming care for lesbian, gay, bisexual and transgender people QI initiative combined two evidence-based programmes, Learning Collaborative (LC) and Project Extension for Community Healthcare Outcomes (ECHO), to assist primary care health centres in developing capacity to identify SGM patients, monitor their health and care, and improve disparities. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was identification of barriers and facilitators to implementing initiatives to improve care for SGM patients. The secondary outcome was clarification of how intervention participants used Project ECHO sessions versus LC meetings to obtain information that influenced implementation of the initiative at their FQHC. RESULTS: Barriers and facilitators mapped to two major themes: 'Clinical' (patients' health, wellness, and available treatment) and Health Systems and Institutional Culture (FQHC operations, and customs and social institutions within the FQHCs and in the external environment). Common 'Clinical' inquiries were for assistance with behavioural health, pre-exposure prophylaxis and transgender hormone therapy. Prevalent facilitators included workflow change and staff training, while adapting electronic health records for data collection, decision support and data extraction was the most prevalent barrier. CONCLUSIONS: Project ECHO and LC provided complimentary forums to explore clinical and operational changes needed to improve care for SGM at FQHCs.

Disease intervention specialists (DIS) conduct partner notification for STD and HIV to interrupt the transmission of STD/HIV. In 2016, we collected information from health departments in the United States of America to determine the number of DIS and whether this number was sufficient for STD/HIV prevention. We identified 1610 STD/HIV DIS positions in the USA and 379 DIS supervisory positions. Of DIS positions, 85% were filled indicating potential issues with turnover. Using nationally reportable data from 2016, we found that states with more primary and secondary syphilis cases had more DIS. DIS participated in public health emergencies in 57% of states. Most USA states indicated that the DIS workforce was not sufficient for STD/HIV prevention. Knowledge of information about DIS workload (e.g. number of STD/HIV cases assigned per DIS) would be helpful.

PURPOSE: Lesbian, gay, bisexual, and transgender (LGBT) people experience multiple disparities in access to care and health outcomes. We developed a quality improvement initiative, Transforming Primary Care for LGBT People, to enhance the capacity of federally qualified health centers (FQHCs) to provide culturally affirming care for this population. METHODS: The 1-year intervention blended the models of Practice Improvement Collaboratives and Project ECHO (Extension for Community Health Outcomes) to facilitate learning and translate knowledge into action. FQHC teams received coaching in creating LGBT-inclusive environments, collecting sexual orientation and gender identity (SOGI) data, taking risk-based sexual histories, and screening LGBT people for syphilis, chlamydia and gonorrhea, and HIV. We used a preintervention-postintervention evaluation design. RESULTS: We selected 10 FQHCs serving 441,387 patients in 123 clinical sites in 9 states. The intervention spread from 10 clinicians in 10 clinical sites to 431 clinicians in 79 clinical sites. FQHCs reported increases in culturally affirming practices, including collecting patient pronoun information (42.9% increase) and identifying LGBT patient liaisons (300.0% increase). Postintervention, among 9 FQHCs reporting SOGI data from electronic health records, SOGI documentation increased from 13.5% to 50.8% of patients (276.3% increase). Among 8 FQHCs reporting number of LGBT patients, screening of LGBT patients increased from 22.3% (95% CI, 4.9%-40.0%) to 34.6% (95% CI, 19.4%-48.6%) for syphilis (86.5% increase); from 25.3% (95% CI, 7.6%-43.1%) to 44.1% (95% CI, 30.2%-58.1%) for chlamydia and gonorrhea (109.0% increase); and from 14.8% (95% CI, 3.2%-26.5%) to 30.5% (95% CI, 26.7%-34.3%) for HIV (132.4% increase). CONCLUSIONS: FQHCs participating in this initiative reported improved capacity to provide culturally affirming care and targeted screening for LGBT patients.

OBJECTIVES: To present the first national estimate of the sociodemographic, clinical, and behavioral characteristics of HIV-positive transgender men receiving medical care in the United States. METHODS: This analysis included pooled interview and medical record data from the 2009 to 2014 cycles of the Medical Monitoring Project, which used a 3-stage, probability-proportional-to-size sampling methodology. RESULTS: Transgender men accounted for 0.16% of all adults and 11% of all transgender adults receiving HIV medical care in the United States from 2009 to 2014. Of these HIV-positive transgender men receiving medical care, approximately 47% lived in poverty, 69% had at least 1 unmet ancillary service need, 23% met criteria for depression, 69% were virally suppressed at their last test, and 60% had sustained viral suppression over the previous 12 months. CONCLUSIONS: Although they constitute a small proportion of all HIV-positive patients, more than 1 in 10 transgender HIV-positive patients were transgender men. Many experienced socioeconomic challenges, unmet needs for ancillary services, and suboptimal health outcomes. Attention to the challenges facing HIV-positive transgender men may be necessary to achieve the National HIV/AIDS Strategy goals of decreasing disparities and improving health outcomes among transgender persons. (Am J Public Health. Published online ahead of print November 21, 2017: e1-e3. doi:10.2105/AJPH.2017.304153).

Sexually transmitted diseases (STDs) remain a significant cause of morbidity in the United States. In 2013, 1.4 million cases of chlamydia were reported to the Centers for Disease Control and Prevention (CDC), making it the most commonly reported notifiable disease in the United States.1 With such high case numbers, it is unreasonable to expect state and locally funded STD clinics to care for all patients with STDs. However, dedicated STD clinics often serve as a safety net for uninsured or underinsured individuals and provide higher-quality STD services than general medical/primary care clinics.2 Sexually transmitted disease clinics often provide additional services for free or with sliding scale fees, such as walk in or express visits, onsite diagnostics, and partner services, where clinic staff offer testing and treatment to the partner(s) of the patient.3 Sexually transmitted disease clinics are seen as an important place to receive confidential services.3 Recently, this service model has faced numerous challenges with local STD clinics experiencing budget cutbacks or closing.4 Furthermore, the landscape of healthcare provision in the United States is changing as a result of legislation and is causing a shift in the places where individuals seek care and who pays for it. Large municipalities with significant disease burden have been challenged to find the right balance between state and locally funded STD clinics and other models of STD service provision. Because of budget constraints, high disease burden, and a syphilis outbreak, perhaps nowhere has this struggle been more pronounced than in Detroit, Michigan.

This report summarizes current (as of 2011) guidelines or recommendations published by multiple agencies of the U.S. Department of Health and Human Services (DHHS) for prevention and control of human immunodeficiency virus (HIV) infection, viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB) for persons who use drugs illicitly. It also summarizes existing evidence of effectiveness for practices to support delivery of integrated prevention services. Implementing integrated services for prevention of HIV infection, viral hepatitis, STDs, and TB is intended to provide persons who use drugs illicitly with increased access to services, to improve timeliness of service delivery, and to increase effectiveness of efforts to prevent infectious diseases that share common risk factors, behaviors, and social determinants. This guidance is intended for use by decision makers (e.g., local and federal agencies and leaders and managers of prevention and treatment services), health-care providers, social service providers, and prevention and treatment support groups. Consolidated guidance can strengthen efforts of health-care providers and public health providers to prevent and treat infectious diseases and substance use and mental disorders, use resources efficiently, and improve health-care services and outcomes in persons who use drugs illicitly. An integrated approach to service delivery for persons who use drugs incorporates recommended science-based public health strategies, including 1) prevention and treatment of substance use and mental disorders; 2) outreach programs; 3) risk assessment for illicit use of drugs; 4) risk assessment for infectious diseases; 5) screening, diagnosis, and counseling for infectious diseases; 6) vaccination; 7) prevention of mother-to-child transmission of infectious diseases; 8) interventions for reduction of risk behaviors; 9) partner services and contact follow-up; 10) referrals and linkage to care; 11) medical treatment for infectious diseases; and 12) delivery of integrated prevention services. These strategies are science-based, public health strategies to prevent and treat infectious diseases, substance use disorders, and mental disorders. Treatment of infectious diseases and treatment of substance use and mental disorders contribute to prevention of transmission of infectious diseases. Integrating prevention services can increase access to and timeliness of prevention and treatment.