Examining PrEP Cascade Engagement in a Statewide Sample of Transgender, Nonbinary, and Intersex Adults in the United States

Background: Although transgender/gender diverse (TGD) individuals are at increased risk for HIV, few studies have examined engagement of TGD individuals with different gender identities (e.g., transmasculine, transfeminine, nonbinary, intersex) across the PrEP cascade. There is particularly little knowledge regarding PrEP engagement among transmasculine and nonbinary individuals. Accordingly, this study examined engagement in the PrEP cascade among a statewide sample of transfeminine, transmasculine, nonbinary, and intersex individuals and tested for significant differences in engagement by gender.

Methods: Data come from the Colorado Transgender and Nonbinary Health Survey (N=448), a community-engaged research collaboration between the University of Denver and One Colorado. Data were collected in 2021-2022 using a computerized self-report survey. We used frequencies to examine engagement in the PrEP cascade (i.e. education, referral, prescription, use) and Pearson chi-square tests to determine significant differences in engagement by gender.

Results: The analytic sample included all participants who qualified for PrEP due to reporting unprotected receptive anal or vaginal sex and multiple sexual partners, or a sexually transmitted infection diagnosis in the last 12 months (n=146). A majority of participants were White (56.16%). Participants also identified as Black/African American (20.55%), Latinx/Hispanic (17.12%), Alaskan/Native Hawaiian/Indigenous (14.37%), Asian (4.11%), Multiracial (15.07%), and/or Middle Eastern (0.68%) and were an average age of 30.47 years (SD=6.14). Additionally, 32.19% identified as nonbinary, 26.03% identified as transfeminine, 21.23% identified as intersex, and 20.55% identified as transmasculine. Of those who qualified for PrEP, 38 (26.03%) received information about PrEP from a provider, 24 (16.44%) received a referral to PrEP, seven (4.79%) visited a provider who could prescribe PrEP, five (3.42%) received a PrEP prescription and began taking PrEP. Of those five, three (2.05%) reported currently taking PrEP and two (1.37%) planned to continue PrEP use into the foreseeable future. Chi-square results indicated a significant difference by gender in who received a referral to a PrEP provider (χ² (3, N=35) = 2.99, p=.01). All transfeminine and intersex participants who responded to the question reported receiving a referral to PrEP, and approximately 62% of nonbinary and 33% of transmasculine participants reported receiving a referral. There were no significant differences by gender in engagement across the other parts of the PrEP cascade.

Conclusions & Implications: A substantial number of PrEP-eligible TGD individuals reported not receiving information about PrEP from healthcare and/or social service providers, and even fewer engaged further in the PrEP cascade. These findings mirror studies showing provider bias in recommendations of PrEP to sexual and gender minorities related to race/ethnicity. The significant gender differences in PrEP referrals suggests that those who are assessing for PrEP eligibility may be inaccurately measuring risk or allowing bias to influence their referral process for nonbinary and transmasculine individuals. Healthcare and social service provider education on sexual health for TGD individuals is needed to increase PrEP engagement in this population, especially for transmasculine and nonbinary individuals.