High risk and low uptake of pre‐exposure prophylaxis to prevent HIV acquisition in a national online sample of transgender men who have sex with men in the United States

Abstract

Introduction Trans masculine people who have sex with cisgender (“cis”) men (“trans MSM”) may be at‐risk for HIV infection when they have cis MSM partners or share needles for hormone or recreational drug injection. Limited data are available characterizing indications and uptake of pre‐exposure prophylaxis (PrEP) in trans MSM. The aim of this study was to assess PrEP indication and uptake as a means of primary HIV prevention for adult trans MSM in the U.S. Methods Between November and December 2017, a national convenience sample of trans MSM in the U.S. (n = 857) was recruited using participatory methodologies and completed an online survey of demographics, HIV risk, PrEP, behavioural and psychosocial factors. Self‐reported receptive anal sex or frontal/vaginal sex (with or without a condom) with a cis male sex partner in past six months was an eligibility criterion. A multivariable logistic regression procedure was used to model PrEP indications (yes/no) per an interpretation of U.S. Centers of Disease Control and Prevention recommendations among those without HIV (n = 843). Results The diverse sample was 4.9% Black; 22.1% Latinx ethnicity; 28.4% non‐binary gender identity; 32.6% gay‐identified; 82.7% on testosterone. Overall, 84.1% had heard of PrEP. Of these, 33.3% reported lifetime PrEP use (21.8% current and 11.5% past). Based on HIV behavioural risk profiles in the last six months, 55.2% of respondents had indications for PrEP. In a multivariable model, factors associated with PrEP indication included where met sex partners, not having sex exclusively with cismen, higher perceived HIV risk, greater number of partners and high cis male partner stigma (all p < 0.05). Discussion The majority of trans MSM in this sample had a PrEP indication. Stigma was associated with risk for HIV acquisition and represents a critical target for HIV biobehavioural prevention interventions for trans MSM, who appear to be underutilizing PrEP. Conclusions Results from this study support the full inclusion of trans MSM in HIV biobehavioural prevention efforts. Public health interventions and programmes are needed to reach trans MSM that attend to general MSM risk factors as well as to vulnerabilities specific to trans MSM, including the context of stigma from cis male sexual partners.

Eliciting Preferences for HIV Prevention Technologies: A Systematic Review

“…This is despite the fact that transgender women who have sex with men have a 49 times higher odds of living with HIV than other adults of reproductive age, globally [ 121 ]. No studies reported including transgender MSM, another at-risk, but largely invisible, group [ 122 , 123 ], nor other gender-diverse identities (i.e., non-binary people).…”

Barriers to the Wider Use of Pre-exposure Prophylaxis in the United States: A Narrative Review

“…84.1% of participants had heard of PrEP [160] Race/ ethnicity c,d Survey of a Northern California consortium of individuals with recently acquired HIV (N = 122), the majority of whom were MSM (84%) and of minority racial/ethnic background (64%) A lack of PrEP awareness was noted in 69% of Black participants [161] Survey of Black individuals in the USA (N = 855)…”

“…PrEP awareness among TGW was 4.7% [ 155 ] Survey of substance-using Black MSM and TGW in New York City ( N = 1673) b Only 18.2% of participants were aware of PrEP [ 156 ] Gender a,b Survey of women visiting safety net family planning clinics in Atlanta ( N = 500), of whom 47% were aged ≤ 28 years, 69% Black, and 12% Hispanic Only 19% of participants knew about PrEP before their visit [ 157 ] Assessment of women enrolled in an HIV study at Southern US sites ( N = 225), the majority of whom were Black (83%) Of the 72 participants who were PrEP-eligible, only 11% had previously heard of PrEP [ 158 ] Focus groups and interview of HIV-negative cis women visiting an STI clinic or emergency department in Chicago ( N = 370), the majority of whom were Black (83%) d Only 30% of participants had heard of PrEP before the survey. The only factor associated with hearing about PrEP was knowing someone on PrEP [ 159 ] Cross-sectional survey of HIV-negative cis women involved in the criminal justice system ( N = 125) Only 25% of participants were aware of PrEP [ 37 ] Survey of individuals attending family planning and sexual health clinics in Arizona, the majority of whom were women (65%) Women had lower prior awareness of PrEP than men [ 19 ] Survey of TGM who have sex with cis men ( N = 857) 84.1% of participants had heard of PrEP [ 160 ] Race/ethnicity c,d Survey of a Northern California consortium of individuals with recently acquired HIV ( N = 122), the majority of whom were MSM (84%) and of minority racial/ethnic background (64%) A lack of PrEP awareness was noted in 69% of Black participants [ 161 ] Survey of Black individuals in the USA ( N = 855) …”

HIV Testing and PrEP Use in a National Probability Sample of Sexually Active Transgender People in the United States

“…A recent online survey of 857 transmasculine individuals who have sex with men found that of those who were HIV-negative, 52.5% met PrEP indications and 33.3% reported lifetime PrEP use (21.8% current and 11.5% past). 11 In another recent study, of 439 transmasculine individuals who were eligible for PrEP, only 11% had received a PrEP prescription. 12 …”