Barriers and Facilitators to HIV Testing Among Transgender and Nonbinary Persons in Michigan, United States: Results of a Community-Based Survey

Background and Purpose: Transgender (trans) and nonbinary (TNB) people experience a disproportionate prevalence of HIV, globally, largely driven by stigma and discrimination. HIV testing is a critical first step to engage TNB people in HIV prevention and care. However, scant studies have exampled social and structural factors associated with HIV testing among TNB people of diverse genders inclusive of transfeminine, transmasculine, and nonbinary persons, and in geographies with lower hypothesized trans acceptance, such as the Midwestern United States (U.S.). Our study objectives were to: a) characterize the prevalence of never having been tested for HIV; and b) identify associated factors, among TNB people in Michigan, Midwestern U.S.

Methods: Data were drawn from a community-based participatory cross-sectional survey (n=539 sexually experienced TNB people). The prevalence of never having had an HIV test was reported overall and compared across sociodemographic, clinical, social, and structural factors using bivariable and multivariable logistic regression analyses.

Results: Approximately one-quarter (26.2%) of participants had never had an HIV test (20.8% transfeminine; 30.0% transmasculine; 17.8% nonbinary assigned male at-birth [AMAB]; 32.0% nonbinary assigned female at-birth [AFAB]). In a multivariable sociodemographic model, older age (aOR for 1-year increase: 0.93, 95% CI: 0.90, 0.96, p<0.001) and Black/African American race (vs. White) (aOR: 0.28, 95% CI: 0.09, 0.86, p<0.05) were associated with never HIV testing. In separate multivariable models controlling for sociodemographics, ever experiencing sexual violence (aOR: 0.38, 95% CI: 0.21, 0.67, p<0.001), not having accessed sexual/reproductive healthcare in the past 12 months (aOR: 4.46, 95% CI: 2.68, 7.43, p<0.001), and reporting a very/somewhat inclusive PCP (aOR: 0.29, 95% CI: 0.17, 0.49, p<0.001) were significantly associated with never HIV testing.

Conclusions: Findings contribute to scant literature about gender-based differences in HIV testing inclusive of transmasculine and nonbinary people. Lack of statistically significant gender differences suggests broad TNB interventions may be warranted. These interventions should take into consideration stigma and discrimination, with a focus on training primary care providers in trans-inclusive HIV prevention and care as well as focusing on trans-inclusive practices with survivors of sexual violence. Overall, these findings can be leverage to inform multi-level interventions to increase access to HIV testing and, ultimately, health equity, among TNB persons.