Transgender individuals face discrimination, violence, social exclusion, and other social, political, and economic factors that result in increased vulnerability to HIV. Rates of viral suppression and uptake of preexposure prophylaxis are lower among transgender individuals than the general population. HIV clinics can help improve these rates by promoting inclusivity and tailoring care to the specific needs of transgender patients. This article summarizes an International Antiviral Society–USA (IAS-USA) webinar presented by Asa E. Radix, MD, PhD, MPH, on August 18, 2020. This webinar is available on demand at https://www.iasusa.org/courses/on-demand-webinar-2020-radix/.
AbstractIntroductionMultiple studies have demonstrated elevated incidence and prevalence of HIV among transgender women; however, few studies have been conducted among transmasculine individuals. HIV prevalence among transgender men in the United States is estimated to be 0–4%; however, there have not been any US studies examining HIV prevalence that stratify by the gender of sexual partners. The aim of this research was to examine HIV prevalence and its association with socio‐demographic and other factors, including the gender of sexual partners and receipt of gender‐affirming care (hormones/surgery), among transmasculine individuals at the Callen‐Lorde Community Health Center in New York City.MethodsThe Transgender Data Project was an Institutional Review Board‐approved retrospective chart review of all transgender and gender diverse clients at the clinic, ages 18+, between 1 January 2009 and 12 December 2010. Charts were reviewed manually. Data included birth sex, gender, race/ethnicity, education, employment, housing, insurance status, gender of sexual partners, HIV screening and status, and receipt of gender‐affirming care. Bivariate and multivariable logistic regression models were used to assess the association between HIV status and other variables.Results and discussionFive hundred and seventy‐seven transmasculine individuals, mean age 32.1 years (18.3–70.5), were included in this analysis. A small majority were White (55% White, 13.9% Black and 11.7% Hispanic). The majority, 78.9%, had received hormones (testosterone) and 41.6% had received at least one gender‐affirming surgery. The HIV screening rate was 43.4%. HIV prevalence was 2.8%, (95% CI: 1.13%, 5.68%) among those screened, notably higher than the US population prevalence. HIV prevalence was highest among transmasculine individuals who had sex exclusively with cisgender men (11.1%). In the multivariable model (age, education and gender of sexual partners), the adjusted odds ratio of HIV for those who had sex exclusively with cisgender male partners compared to no cisgender male partners was 10.58 (95% CI: 1.33, 84.17).ConclusionsAlthough HIV prevalence has been estimated to be low among transgender men, the analysis found heterogeneous results when stratified by gender of sexual partners. The results underscore the need to understand sexual risk among transmasculine individuals and to disaggregate HIV data for those having sex with cisgender men, thus also allowing for better inclusion in HIV prevention efforts.
AbstractIntroductionTransgender women in the United States experience high HIV incidence and suboptimal Pre‐exposure prophylaxis (PrEP) engagement. We sought to estimate PrEP initiation and discontinuation rates and characterize PrEP discontinuation experiences among a prospective cohort of transgender women.MethodsUsing a sequential, explanatory, mixed‐methods design, 1312 transgender women at risk for HIV acquisition were enrolled from March 2018 to August 2020 and followed through July 2022 (median follow‐up 24 months; interquartile range 15–36). Cox regression models assessed predictors of initiation and discontinuation. In‐depth interviews were conducted among 18 participants, including life history calendars to explore key events and experiences surrounding discontinuations. Qualitative and quantitative data were integrated to generate typologies of discontinuation, inform meta‐inferences and facilitate the interpretation of findings.Results21.8% (n = 286) of participants reported taking PrEP at one or more study visits while under observation. We observed 139 PrEP initiations over 2127 person‐years (6.5 initiations/100 person‐years, 95% CI: 5.5–7.7). Predictors of initiation included identifying as Black and PrEP indication. The rate of initiation among those who were PrEP‐indicated was 9.6 initiations/100 person‐years (132/1372 person‐years; 95% CI: 8.1–11.4). We observed 138 PrEP discontinuations over 368 person‐years (37.5 discontinuations/100 person‐years, 95% CI: 31.7–44.3). Predictors of discontinuation included high school education or less and initiating PrEP for the first time while under observation. Four discontinuation typologies emerged: (1) seroconversion following discontinuation; (2) ongoing HIV acquisition risk following discontinuation; (3) reassessment of HIV/STI prevention strategy following discontinuation; and (4) dynamic PrEP use coinciding with changes in HIV acquisition risk.ConclusionsPrEP initiation rates were low and discontinuation rates were high. Complex motivations to stop using PrEP did not consistently correspond with HIV acquisition risk reduction. Evidence‐based interventions to increase PrEP persistence among transgender women with ongoing acquisition risk and provide HIV prevention support for those who discontinue PrEP are necessary to reduce HIV incidence in this population.
