A study recently published in The Journal of Acquired Immune Deficiency Syndromes indicates that transgender (trans) women in Brazil had low levels of pre-exposure prophylaxis (PrEP) awareness. This was combined with significant proportions being willing to use PrEP as a prevention tool and being eligible for PrEP.
Another recent qualitative study published in Culture, Health and Sexuality provides a contextual frame for these findings as it explores the HIV programming needs of trans women in Brazil. Several social and contextual factors, such as experienced and anticipated trans discrimination and HIV stigma, were linked to an avoidance of prevention and treatment services for both HIV-negative and positive trans women. In addition to biomedical interventions, socio-structural interventions also emerged as crucial for trans women in Brazil.
Globally, trans women are at a disproportionally higher risk of contracting HIV – this is estimated at 49 times higher than other groups. In the South American context, particularly Brazil, trans women have substantially higher rates of HIV prevalence, even when compared to other key populations such as men who have sex with men. It has been estimated that nearly a third of all trans women in Brazil may be infected with HIV, often accessing healthcare testing and treatment services late. This key population has been described as the most at-risk group in the country.
There is a lack of specific HIV prevention aimed at trans women in Brazil. The unique needs of this community raises specific challenges: transphobia and healthcare-related stigma, social and economic marginalisation, as well as issues related to gender-related health care (such as concerns about interactions between HIV medications and hormone therapy).
The first study utilised respondent-driven sampling to recruit trans women for face-to-face interviews which assessed PrEP awareness and willingness. It also estimated how many trans women would be considered eligible for PrEP, based on factors such as not being in a monogamous relationship, having had condomless anal sex or an STI in the past 12 months or an HIV-positive sexual partner in the last three months. The survey was conducted from August 2015 to January 2016 and data was collected from 345 participants. All participants identified as trans women and resided in Rio de Janeiro. Most participants were aged 25-35, with eight years or less of formal education.
Participants were first asked a question to probe for awareness of PrEP; after a brief explanation, they were asked about willingness to take PrEP. Additional questions included concerns about PrEP as well as preferred routes of administration, sexual behaviour, drug and hormone use, experiences of health-related stigma and so forth. HIV and STI testing was carried out with all participants after the survey was conducted.
Of the 345 participants offered HIV testing, 59% were HIV negative, 29% had previously been diagnosed with HIV and 12% were newly diagnosed with HIV. Thirty-eight per cent of respondents had heard about PrEP, while 49% had heard about post-exposure prophylaxis (PEP). However, only 6% of those who were not known to have HIV infection had ever accessed PEP. Higher PrEP awareness was associated with accessing health services in the past six months (adjusted odds ratio 2.1, P = 0.004), having at least one known HIV-positive partner (AOR 2.0, P = 0.04) and more than eight years of education (AOR 1.5, P = 0.079). Lower PrEP awareness was associated with condomless anal sex (AOR 0.6, P = 0.04) and a newly diagnosed HIV infection (AOR 0.4, P = 0.035).
PrEP willingness was assessed in those who self-reported as HIV negative. The majority of participants (76%) expressed willingness to use PrEP after a brief explanation, despite concerns about side-effects and interactions with hormones. Factors positively associated with PrEP willingness included being younger (aged 18-35) and high perceived HIV risk (participants’ rating of how likely they were to contract HIV in the next year). Factors associated with being less willing to use PrEP included concerns with long-term effects of PrEP and possible challenges accessing it as a result of stigma encountered in healthcare settings. A high percentage of HIV-negative trans women met the criteria for PrEP eligibility criteria (67%), rising to 78% of those discovered to be newly infected during the study. This indicates a significant need for PrEP as a prevention tool in this community.