Understanding Psychosocial and Behavioral Constructs Related to PrEP Interest Among Trans-Masculine People Assigned Female at Birth

Background and Purpose: Trans-masculine people assigned female at birth (TM/AFAB) are at high risk of HIV acquisition, but demonstrate low uptake of pre-exposure prophylaxis (PrEP). TM/AFAB are vulnerable to HIV infection when they have condomless anal or frontal/vaginal intercourse with partners assigned male at birth (AMAB), or share needles for recreational drug or hormone injections. A national sample found that 24.3% of TM/AFAB met one or more criterion for PrEP eligibility. Yet, few studies have examined barriers and facilitators of PrEP interest amongst and uptake by TM/AFAB. Minimal existing literature indicates that PrEP knowledge, interest, and adherence are influenced by intersectional factors, including those that are specific to transgender identity as well as being assigned female at birth. Despite their elevated risk, TM/AFAB have thus far been absent in PrEP guidance from Centers for Disease Control and Prevention. To address these gaps, this study will explore psychosocial factors that influence adoption of harm reduction behavior (i.e. PrEP) among TM/AFAB individuals.

Methods: Utilizing a cross-sectional convergent mixed methods design, the study engaged 30 self-reported HIV-negative TM/AFAB participants, divided into two distinct groups based on their PrEP awareness, interest, and usage. This study integrated a variety of methodologies, including surveys, semi-structured interviews, focus groups, and PrEP informational network mapping, to provide a comprehensive exploration of the factors shaping PrEP engagement among TM/AFAB individuals. The unique combination of qualitative and network analysis methods, anchored in a validated theoretical framework tailored for transgender and gender-expansive populations, further enhances the study’s potential for impact.

Results: Findings discerned that, rather than relying on clinical providers, TM/AFAB turn to other trusted sources of information regarding sexual health and harm reduction, particularly queer elders from within their social networks. Popular public health campaigns promoting PrEP were found to target cismen who have sex with men, resulting in discordance of messaging resonance for TM/AFAB. Social networks – both supportive interpersonal relationships and having a sense of belonging within the transgender community – were found to facilitate PrEP continuum outcomes. Barriers to PrEP uptake included lack of trust in medical institutions, and fear regarding pharmacological interactions between gender-affirming hormone therapy and PrEP. By elucidating the interplay between psychological distress, social support, and information networks, this study contributes significantly to the field. Themes included psychosocial factors, such as improved individual self-efficacy, advocacy, and self-acceptance after PrEP initiation.

Conclusions and Implications: In summary, this study represents a crucial step towards understanding and enhancing PrEP engagement among TM/AFAB individuals, contributes to national HIV prevention efforts and addresses the urgent need for inclusive and contextually relevant public health interventions. This research not only mirrors the NIH Office of AIDS Research's priority of bolstering avenues into HIV prevention services, but also champions innovative PrEP delivery methodologies. This study explores the interplay between mental health and HIV vulnerability; as such, we set the stage for integrated strategies that simultaneously address mental health outcomes and fortify HIV prevention measures.