Facilitators and Barriers to Pre-Exposure Prophylaxis (PrEP) Among Transgender Women in New York City

Background and Purpose:   Transgender women are disproportionately at risk for HIV.  Substance use, survival sex work, depression, unstable housing, and high levels of victimization and violence are commonly reported by transgender women, indicating the potential for multiple concurrent HIV risks and underlying vulnerabilities.  Structural forms of discrimination may contribute to these risk factors, possibly leading to poor outcomes such as unemployment or underemployment, homelessness, and lack of access to gender affirming health care. Given this context, a biomedical intervention such as pre-exposure prophylaxis (PrEP), which can address risks from multiple types of exposure (i.e. sexual or parenteral) and be used effectively without negotiation between sexual partners, may be critical for effective HIV prevention packages that meet the needs of transgender women.  This study explored the social and behavioral factors that are likely to influence PrEP acceptance, use, and adherence among transgender women considered at risk for HIV infection. 

Methods:  Forty in depth semi-structured interviews were conducted with three groups: a) transgender women currently on PrEP (n=15); b) transgender women not on PrEP (n=15); and c) medical and social service providers working with the transgender community (n=10).  Participants were recruited throughout New York City using flyers, online social media postings, targeted emails to community-based organizations, and word of mouth.   All interviews contained a core set of questions regarding factors at the individual, community, and systems level that might influence PrEP adoption, adherence, access, and willingness to use future biomedical PrEP interventions.  Interviews were transcribed verbatim and coded thematically using Dedoose Qualitative Software.

Results:  Themes associated with barriers to PrEP included: 1) limited knowledge of PrEP, 2) a dearth of transgender competent health care providers, 3) lack of trans-specific sexual health information and messaging, and 4) concerns about interactions with hormones and prioritization of hormone therapy.  Participants who engaged in sex work expressed a willingness to use PrEP as a form of occupational safety.  Across groups participants identified a desire to live long and be healthy as a facilitator to adopting and using PrEP.  Social support was identified as a facilitator for PrEP use and adherence, participants on PrEP said that having friends and family who were supportive contributed their PrEP use. All participants stated that sexual health programs, which include PrEP, need to be integrated into gender affirming health care and that sexual health and HIV prevention materials and messaging need to be more sex positive and reflect the lived experience and bodies of transgender women.  

Conclusion and Implications: Findings highlight the need for transgender specific PrEP education and messaging campaigns that provides accurate information that is relevant to transgender bodies and sexuality.   Integrating PrEP into gender affirming health care may help to destigmatize a community that is highly targeted for HIV prevention yet, low utilizers of such services.  Future research is needed that is designed with and for transgender women to ensure the development of PrEP interventions that accurately reflect the structural, social, and behavioral factors that influence HIV risk among this community.