Title: Detectable viral load associated with unmet mental health and substance use needs among
trans women living with HIV in San Francisco, California
Version: 1 Date: 27 Oct 2023
Reviewer's report:
This study aimed to examine prevalence of mental health symptoms and substance use among
a sample of trans women connected to public health clinic and also the care cascade related to
HIV, mental health, and substance use. Overall, the manuscript is appropriately concise and is an
important topic. Below you will find some comments that aim to help strengthen the manuscript
and prepare it for publication.
OVERALL
- Authors use the phrase “mental diagnosis” and “mental illness diagnosis”, however, these terms
are outdated, clinically inaccurate, and potentially non-affirming. Wording that is used clinically
includes “mental health diagnoses/disorders/conditions” or “psychiatric diagnoses/disorders”
-Also, the term "mental distress " should be replaced with "psychological distress" - there is
historical discriminatory use of the word "mental"
INTRODUCTION
- Authors state there is “universal access to a range of important health services like HIV
specialty and gender-affirming care” – however, this is not true; extant literature and current
sociopolitical events do not support this statement. For example, many states currently have bans
on trans health care, in some areas public HIV care is inaccessible, and science shows high rates
of discrimination in care (i.e.,  not affirming). The issue with asserting there is universal care
removes some of the onus that needs to be on the system level.
- Authors say “in our city” but the city is not defined
-L97: Authors state “Mental illness and substance use are also associated with poor HIV care
outcomes…” however, I believe authors may mean a more broad “mental health” (vs mental
illness) given that any level of psychological distress (vs. specific diagnoses that fall under
mental illness) is associated with HIV outcomes
- Authors state “less is known about this connection for trans women” (related to mental
health/substance use and HIV) and “Yet no study that we know of examines the relationship
between mental health and HIV outcomes among trans women living with HIV” – both of
these statements appear to be overstated. There is much literature and multiple studies on these
connections among trans women. What is more novel is that examination of the care cascade.
-When discussing aims, authors state "poor HIV viral suppression" - however, authors actually
examine detectability. This is an important distinction clinically given suppression is <200 mL/
copies and detectability depends on the test used - in this case <50.
METHODS
- There is no statement related to informed consent / HIPAA waiver for EMR data
- Authors use the term “alcohol dependence” and “drug dependence” throughout the manuscript.
These terms are outdated and have been removed from the DSM/language in substance use
research. Further, the AUDIT-C and DAST-10 cannot tell us someone has an AUD or SUD, but
rather, just screens for identification of those with potential problematic alcohol and drug use.
Authors use language that uses these measures to identify “alcohol/drug dependence”.
-Similarly, authors use language that the PHQ can “determine whether anxiety and depression
were present”. However, this brief measure can screen for depression and anxiety symptoms
which is an indicator of potential clinically significant symptom level. I understand this may
sound nitpicky, however, it is important to be very clear what these brief measures can and
cannot do from a clinical perspective, especially to not overpathologize trans women. Also,
authors state “normal anxiety or depression”; please edit to not use the word normal, but rather
what authors mean is not clinically significant levels – we don’t want to label anything as normal
because that inherently makes something else abnormal.
-Authors never describe food insecurity in measures.
RESULTS
- Unclear why authors are reporting % for those that consumed alcohol 4 or more times a week –
this is not a clinical indicator of anything nor is not a level used to indicate a problematic pattern
- Eligibility (connected to public health care) makes care cascade results extremely biased – this
should be discussed in limitations.
- What is “older trans women” – not defined in text when used
DISCUSSION
- Overall, the discussion does a wonderful job discussing implications especially acknowledging
the systems- and structural-level. I really enjoyed given authors do not put the responsibility on
trans women themselves .
- One reason not mentioned related to trans women not being connected to care is the historical
organization and provider discriminations faced and also the political policies being put into
place (trans healthcare bans).