Barriers and Facilitators to PrEP Initiation and Adherence Among Transgender and Gender Non-Binary Individuals in Southern California

Abstract

While transgender and gender non-binary (trans/nb) individuals are disproportionately affected by HIV, pre-exposure prophylaxis (PrEP) uptake remains low in this underserved population. We conducted four focus groups with 37 trans/nb individuals in San Diego and Los Angeles to assess barriers and facilitators of PrEP usage. Transcripts were coded for qualitative themes. Although overall PrEP awareness was high, participants reported limited knowledge and misinformation about PrEP. Barriers to PrEP use included: structural access (e.g., discrimination from health care providers, lack of trans-inclusive services, financial barriers), mental health struggles limiting ability to access PrEP, and concerns about potential side effects, drug-drug interactions with hormone therapy, and lack of other STI protection. Facilitators of PrEP usage included: increased PrEP availability, prior experience taking daily medications, and motivation to have active and healthy lives without fear of contracting HIV. Addressing both structural and psychosocial/behavioral factors in trans-affirming health care environments is crucial to designing inclusive, effective PrEP interventions.

A Scoping Review Investigating Relationships between Depression, Anxiety, and the PrEP Care Continuum in the United States

“…Although depressive symptoms have been identified as barriers to PrEP care [ 49 , 50 ], this review suggests that depressive symptoms alone do not stymie PrEP uptake [ 56 , 58 ]. Indeed, cross-sectional analyses have found depressive symptoms to be positively associated with PrEP use [ 33 , 61 , 62 ].…”

“…A study conducted in southern CA with 30 TGW found that mental health concerns were identified as barriers to PrEP care [ 48 ]. Similarly, another study conducted in southern CA with 37 individuals, the majority of whom were transgender, identified that mental disorder symptoms made PrEP access difficult [ 49 ]. Similarly, in a study of 25 PrEP users in San Francisco, CA, one participant identified depression-related and HIV-related stigma as a barrier to seeking care [ 50 ].…”

“…One qualitative study using a focus groups of 37 predominantly transgender individuals in southern CA identified mental health concerns, including anxiety, to be a barrier to PrEP care access. Participants reported these mental health concerns making it difficult to access both PrEP care and other important health care services [ 49 ].…”

Randomized Trial of Individualized Texting for Adherence Building (iTAB) Plus Motivational Interviewing for PrEP Adherence in Transgender Individuals: The iM-PrEPT Study

“…Our qualitative work found that barriers to PrEP in transgender individuals are multifactorial and include competing health conditions (mental health and substance use), social conditions (housing insecurity and transportation), concerns over interactions with hormones, stigma of taking PrEP, negative health care experiences, and mistrust of providers. 22,23 It is unclear why the intervention was effective for transgender women but not transgender men or nonbinary individuals. Among sex identities, transgender women had the lowest adequate adherence within the iTAB control arm, suggesting they were less adherent than transgender men and nonbinary individuals to begin with.…”

Paying for PrEP: A qualitative study of cost factors that impact pre-exposure prophylaxis uptake in the US.

“…22,23 Even when the medication is covered by insurance, other medical expenses, including copayments, deductibles, and lab costs, may be burdensome, 24 especially among Black and Hispanic/Latino GBMSM. 22,23 The amount of routine out-of-pocket costs that participants were willing to pay varied, and some who were not currently taking PrEP predicted that basic life expenses would prevent them from affording PrEP. Under these circumstances, some questioned the value of a prophylactic medication when there are behavioral alternatives such as condoms or abstinence.…”