Black and Latinx transgender women expressed high levels of HIV risk perception at the individual and community level, both of which played major roles in their decision to start and continue pre-exposure prophylaxis (PrEP).
Among Black and Latinx transgender women in the United States, there are several facilitators of HIV pre-exposure prophylaxis (PrEP) persistence at individual, interpersonal or community, and structural levels, according to a study published in Behavioral Medicine.
Past research has shown HIV prevalence is much higher among women who are transgender compared with the general US population, with transgender women being 34 times more likely to have HIV than other adult populations. This disparity is even greater among transgender women who are also part of racially diverse groups, with approximately 44% of Black and 26% of Latinx transgender women living with HIV, compared with 7% of White transgender women.
Because of this gap in HIV prevalence, the study authors conducted interviews with 30 participants from the California Collaborative Treatment Group (CCTG), a PrEP demonstration project including transgender and non-binary individuals.
After exclusions, 23 transgender and non-binary women were included in the study, with 13 Latinx participants, 6 Black participants, and 4 participants of mixed Black and Latinx race. The mean (SD) age was 30.73 (8.55), with participants ranging in age between 21 and 47 years.
The goal of these interviews was to better understand what facilitators Black and Latinx transgender women who have received tenofovir disoproxil fumarate (TDF) or emtricitabine (FTC) experience regarding PrEP uptake and persistence.
After conducting these interviews, the authors used a thematic content analysis to assess the facilitators of PrEP uptake and persistence at different levels.
They found these facilitators existed at the individual, interpersonal or community, and structural levels.
Individual-level facilitators included high personal HIV risk perception, improved peace of mind and mental health due to PrEP use, the use of reminders via phone or other source to take PrEP, and feeling empowered to take PrEP.
According to some participants, being part of multiple demographic groups at increased risk for HIV was a major motivator to begin PrEP use.
“I just feel like... there’s a lot of intersectionality that I have,” said an anonymous participant. “I’m gender nonconforming. I’m Black. I was assigned male at birth, and so there’s these expectations of masculinity and all of that kind of thing and just like a lot sort of coming together. And I think statistically I’m at very high risk.”
Interpersonal– or community-level facilitators also included having high community-level HIV risk perception, as well as motivation to prevent the spread of HIV within the community and in the context of sex work.
Some participants said their motivation to begin taking PrEP was a result of an identity-based fear of spreading HIV as part of the lesbian, gay, bisexual, transgender (LGBT) community, and the decision to take PrEP was an empowering way to take care of one another in the community.
“I feel like there’s a lot of fear in the LGBT community about diseases. Especially a lot of HIV-related diseases,” said a participant. “There’s a lot of fear, and that’s just pushed on us basically from the moment we walk over to the LGBT side. There’s not a lot of empowerment. I feel like PrEP can be super empowering because it’s not just taking care of yourself, you are taking care of the LGBT community.”
Finally, structural-level facilitators included having positive experiences in gender-affirming health care settings and combining PrEP visits with gender-related health care visits.
“Being able to talk to my doctor about PrEP and my hormones at the same time has been huge for me,” said another participant. “I think if it wasn’t for starting hormones, it would have been much harder to take [PrEP].”
The authors noted interpretations of these findings should be made carefully, as these interviews took place in the middle of the larger CCTG project and some may have stopped taking PrEP shortly after, and because the sample was small and limited to the Southern California area.
However, their main takeaway was that transgender women described high levels of resilience, agency, and fortitude both as individuals and as members of the LGBT community.
“Understanding the factors that bolster and leverage resilience are paramount for informing ongoing efforts to enhance HIV prevention and promote health equity among Black and Latinx TGW,” the authors concluded.
Storholm ED, Ogunbajo A, Nacht CL, et al. Facilitators of PrEP persistence among Black and Latinx transgender women in a PrEP demonstration project in Southern California. Behav Med. Published online August 22, 2022. doi:10.1080/08964289.2022.2105794