Barriers to uptake of PrEP across the continuum among transgender women: A global scoping review

Abstract

Background Although preexposure prophylaxis (PrEP) has demonstrated high efficacy for HIV prevention, rates of PrEP uptake remain low among the transgender population, especially in transgender women (TGW). We conducted this scoping review to assess and characterize barriers to PrEP use along the PrEP care continuum among TGW. Methods We conducted this scoping review by searching studies in Embase, PubMed, Scopus, and Web of Science. Eligibility criteria included: reporting a PrEP related quantitative result among TGW; peer-reviewed and published in English between 2010-2021. Results Globally, high willingness (80%) to use PrEP was found, yet uptake and adherence (35.4%) were low. TGW experiencing hardship, including poverty, incarceration, and substance use, were associated with higher odds of PrEP awareness but lower odds of PrEP use. Structural and social barriers such as stigma, medical mistrust, and perceived racism can be important barriers for PrEP continuation. High social cohesion and hormone replacement therapy were associated with greater odds of awareness. In addition, our study confirmed prior research showing that PrEP does not lower feminizing hormone levels in TGW. Conclusions Significant demographic factors among TGW that are associated with PrEP engagement. It is imperative to focus on TGW as a population with independent needs, requiring specific PrEP care guidelines and tailored resource allocation, that fully considers individual-, provider-, and community/structural-level barriers and facilitators. The present review also indicates that combining PrEP care with GAHT or broader gender-affirmation care may facilitate PrEP use.

Barriers and facilitators to HIV pre-exposure prophylaxis uptake among transgender women in Colombia: A qualitative analysis using the COM-B model

“…In this sample, these interactions took the form of exerted violence, low access to material resources [e.g., income, employment, and education], and discriminatory experiences when accessing healthcare. The context of sex work seems to be the intersection where all these negative forces combine and the effects are dual and paradoxical: on one hand, the perception of high risk of HIV acquisition seems to favour PrEP uptake, but on the other hand, the negative experiences are detrimental for PrEP access, adherence, and persistence [ 21 ].…”

“…Negative interactions with health services and their providers were also common narratives from the participants, which are comparable with other contexts, and would likely discourage PrEP uptake and adherence [ 21 ]. The experiences reported by TGW in our study prompt us to infer that sexual health education that is inclusive of gender diversity is lacking for Colombian healthcare providers.…”

“…As depicted in Table 1 , studies with TGW demonstrated the relevance of various factors on PrEP use that can be mapped in the COM-B. Factors related to the capability domain include HIV prevention knowledge, and skills; factors related to opportunity dimensions include societal influences, resources, interactions with healthcare systems, family, and peers, and HIV stigma; and motivational factors include beliefs, intentions, concerns, mental health states, and habits [ 8 , 9 , 20 , 21 ]. The COM-B relies on the delineation of explanatory factors that influence a particular behaviour on multiple levels [i.e., individual, interpersonal, and contextual], which helps us to identify barriers and facilitators, and a structured framework for intervention design [Objective 1].…”

HIV pre‐exposure prophylaxis programme preferences among sexually active HIV‐negative transgender and gender diverse adults in the United States: a conjoint analysis

“…However, prior research with trans participants across other fields of research may inform this work. Recent quantitative studies have found that anti‐trans stigma, the dearth of trans‐inclusive sexual health programmes and medical mistreatment pose significant barriers to PrEP‐related care [2, 10, 15, 20–24]. Qualitative studies have aligned with these findings and further described how structural factors such as anti‐trans discrimination and disenfranchisement (e.g.…”

“…In light of these recommendations, tailored implementation strategies to achieve equitable PrEP delivery for trans populations are needed [3,13]. Regrettably, implementation studies rarely enrol trans participants in numbers sufficient to yield reliable estimates-transfeminine participants are often subsumed into study cohorts comprised predominantly of cisgender sexual minority men, while transmasculine and nonbinary individuals are rarely enrolled at all [13][14][15][16][17][18] Limited inclusion of trans participants in implementation research will hinder efforts to develop strategies that are salient and relevant to trans individuals who might otherwise benefit from PrEP due to their current sexual practices or personalized HIV prevention needs and preferences [3,13,15,19]. However, prior research with trans participants across other fields of research may inform this work.…”