Understanding PrEP Intentions Among Black and Latine Transgender and Gender-Expansive Youth in the Context of Gender Minority Stress, Substance Use, and Gender Affirmation

Background/Purpose: Black and Latine transgender and gender-expansive (i.e., gender nonbinary, non-conforming, or genderqueer) youth and emerging adults ages 13-24 years (YEA), a large and growing population, experience a disproportionate risk for HIV. However, their rates of preexposure prophylaxis (PrEP) uptake to prevent HIV are the lowest of any key risk group in the United States (<8%). Additionally, the factors that promote or impede PrEP outcomes for this population are poorly understood. This study examines the effects of gender minority stress and gender affirmation, including proximal and distal stressors, and behavioral responses to stress (i.e., heavy substance use) on PrEP outcomes among Black and Latine transgender and gender-expansive YEA who evidence HIV risk.

Methods: Data were drawn from a national, cross-sectional online survey, the CDC’s 2018 Survey of Today’s Adolescent Relationships and Transitions (START) study, that included Black and Latine transgender and gender-expansive YEA for whom PrEP is indicated (N=423). We developed a conceptual model which integrates the gender minority stress and the gender affirmation models. We mapped START items onto it, including distal (family rejection, medical discrimination) and proximal (internalized transphobia, perceived stigma) stressors, heavy substance use behaviors, and background factors (e.g., region, socioeconomic barriers). Gender affirmation was measured as an observed construct across five domains. We examined factors related to PrEP intentions with structural equation modeling using MLR, in Mplus 8.9.

Results: The majority of participants were between 18-24 years of age (77.3%), identified as transfemale (69.7%), as Latine (63.1%), and evidenced heavy substance use behaviors (50.6%). Family rejection increased perceived stigma (b = 0.209, SE = 0.050, p < 0.001) and heavy substance use behaviors (b = 0.972, SE = 0.260, p < 0.001). Perceived TGE stigma also increased heavy substance use behaviors (b = 0.084, SE = 0.041, p 0.041). Heavy substance use, in turn, decreased PrEP intentions (b = -0.160, SE = 0.049, p < 0.001), while gender affirmation increased PrEP intentions (b = 0.087, SE = 0.030, p < 0.004). Also, the impact of family rejection on heavy substance use was muted by increasing levels of gender affirmation, a significant moderation effect (-.21*).

Conclusions/Implications: This study underscores the importance of addressing heavy substance use among Black and Latine transgender and gender-expansive YEA as a potential barrier to PrEP uptake, a critical tool for HIV prevention. The significant negative association between heavy substance use and PrEP intentions highlights the need for further research to investigate this complex relationship and identify effective strategies to improve PrEP outcomes among this population. This study also underscores the importance of gender affirmation across multiple levels as a facilitator of PrEP uptake. Future studies could explore the potential protective role of gender affirmation in mitigating the impact of family rejection on heavy substance use behaviors among these populations.