Global scoping review of HIV prevention research with transgender people: Transcending from trans-subsumed to trans-centred research

The gender of PrEP: Transgender men negotiating legitimacy in France

Transmasculine people (TM) constitute an invisibilized group within the transgender population. Little is known about their relationship to sexuality in transgender medicine. Their presence and needs are still unacknowledged within HIV prevention research and services. Pre-exposure prophylaxis (or PrEP) is an oral medication that prevents HIV in HIV-negative individuals at risk of infection with the virus. This paper proposes to bring TM back into the focus of PrEP research by questioning how they navigate and situate themselves in relation to existing PrEP categorization and services, and how they think about and (re)shape the meanings of PrEP. It is based on the "interpretative descriptive" method and a transfeminist theoretical framework applied to the analysis of ten semi-structured interviews with TM conducted in France between 2019 and 2023. Findings show that PrEP is gendered. We identify specific barriers to getting PrEP as well as to access healthcare and we show that a cisnormative and homonormative approach to prevention generates them. PrEP use and PrEP disclosure are embedded in structural and symbolic power relations between cisgender and transgender MSM that are reflected in the intimate sphere. TM use PrEP to prevent sexual assault and to alleviate the difficulty of condom negotiation. PrEP comes into play following major changes in TM's sexualities and is integrated post-exposure.

HIV pre-exposure prophylaxis programme preferences among sexually active HIV-negative transgender and gender diverse adults in the United States: a conjoint analysis

INTRODUCTION

Current implementation efforts have failed to achieve equitable HIV pre-exposure prophylaxis (PrEP) provision for transgender and gender-diverse (trans) populations. We conducted a choice-based conjoint analysis to measure preferences for key attributes of hypothetical PrEP delivery programmes among a diverse online sample predominantly comprised of transmasculine and nonbinary individuals in the United States.

METHODS

Between April 2022 and June 2022, a national online survey with an embedded conjoint analysis experiment was conducted among 304 trans individuals aged ≥18 years in the United States to assess five PrEP programme attributes: out-of-pocket cost; dispensing venue; frequency of visits for PrEP-related care; travel time to PrEP provider; and ability to bundle PrEP-related care with gender-affirming hormone therapy services. Participants responded to five questions, each of which presented two PrEP programme scenarios and one opt-out option per question and selected their preferred programme in each question. We used hierarchical Bayes estimation and multinomial logistic regression to measure part-worth utility scores for the total sample and by respondents' PrEP status.

RESULTS

The median age was 24 years (range 18-56); 75% were assigned female sex at birth; 54% identified as transmasculine; 32% as nonbinary; 14% as transfeminine. Out-of-pocket cost had the highest attribute importance score (44.3%), followed by the ability to bundle with gender-affirming hormone therapy services (18.7%). Minimal cost-sharing ($0 out-of-pocket cost) most positively influenced the attribute importance of cost (average conjoint part-worth utility coefficient of 2.5 [95% CI 2.4-2.6]). PrEP-experienced respondents preferred PrEP delivery in primary care settings (relative utility score 4.7); however, PrEP-naïve respondents preferred pharmacies (relative utility score 5.1).

CONCLUSIONS

Participants preferred programmes that offered PrEP services without cost-sharing and bundled with gender-affirming hormone therapy services. Bolstering federal regulations to cover PrEP services and prioritizing programmes to expand low-barrier PrEP provision are critical to achieving equitable PrEP provision. Community-engaged implementation research conducted by and in close collaboration with trans community stakeholders and researchers are needed to streamline the design of patient-centred PrEP programmes and develop implementation strategies that are salient to the diverse sexual health needs of trans patients.

Structural and Psychosocial Syndemic Conditions and Condomless Anal Intercourse Among Transgender Women - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020

Psychosocial and structural syndemic conditions, including polydrug use and experiencing homelessness, frequently co-occur and might jointly increase HIV risk. Limited studies have assessed racial and ethnic differences in exposure to syndemic conditions and behaviors associated with HIV transmission among transgender women. This report examines the relation between syndemic conditions and condomless anal intercourse (CAI) among transgender women in seven urban areas in the United States to develop HIV prevention interventions for transgender women. During 2019-2020, transgender women in seven urban areas were recruited using respondent-driven sampling for a biobehavioral survey. Reported syndemic conditions (psychosocial: polydrug use, sexual violence, and psychological distress; structural: homelessness, incarceration, and exchange sex) were summed to create a syndemic score. Using modified Poisson regression to account for RDS, the study assessed whether the strength of the association between syndemic score and CAI differed by race and ethnicity. To assess additive interaction, the relative excess prevalence owing to interaction (REPI) and 95% CIs for selected pairs of syndemic conditions on CAI prevalence stratified by race and ethnicity were estimated. Of 1,348 transgender women (Black = 546, White = 176, and Hispanic = 626), 55% reported CAI; and 24% reported ≥3 syndemic conditions. Reporting additional syndemic conditions was associated with CAI for White, Hispanic, and Black participants. The association was significantly stronger for White than Black and Hispanic participants. Limited significant superadditive interactions were found, although the majority were between structural syndemic conditions. Racial and ethnic differences in REPI estimates were observed. Reporting more syndemic conditions was associated with increased CAI across racial and ethnic groups, demonstrating that HIV prevention efforts for transgender women should address structural and psychosocial syndemic conditions. Results differed by race and ethnicity, indicating that syndemic-focused interventions for transgender women should be tailored to racial and ethnic groups.

Neglected gaps in improving the health, wellbeing, and care for sexual and gender minority young people living in low- and lower-middle- income countries: a scoping review

BACKGROUND

There is a lack of reliable data on the size, characteristics, and experiences of sexual and gender minority (SGM) young people (ages 10-24) in low- and lower-middle- income countries (LMICs). This review examines the research conducted in the last thirteen years with and about SGM young people living in low-income settings and seeks to answer the question: What is known about the mental and physical health needs, safety, and wellbeing of SGM young people living in LMICs?

METHODS

We conducted a scoping review informed by the methodological frameworks put forth by Arksey and O'Malley and the Joanna Briggs Institute. We systematically searched two general social science databases and one topic-specific database for peer-reviewed papers, of any research design, that included SGM young people or explored attitudes toward SGM young people in LMICs. We included papers that reported on factors influencing the health and wellbeing of SGM populations, including physical and mental health, healthcare-seeking behaviors, substance use, experiences of discrimination and/or stigma, experiences of violence and abuse (emotional, physical, and/or sexual), economically motivated paid sex practices, housing or economic security, and attitudes of others toward SGM populations.

RESULTS

Of the 5,409 unique records identified, 79 papers drawing from data collected from 74 unique studies met the inclusion criteria. Only 50 of the 79 papers included SGM young people as participants, with just 13 focusing exclusively on SGM young people ages 10-24. The included papers were classified into three thematic groupings: attitudes toward SGM populations (n = 26), risks to health (n = 40), and experiences of stigma and discrimination (n = 13).

CONCLUSION

The findings indicate that the health and wellbeing of SGM young people in LMICs has been historically under-researched. While SGM young people have received more attention from researchers in recent years, the body of literature as a whole is disjointed and sparse, and often studies are about SGM young people, rather than with and for them. Our review highlights the need for more and better research, more accurate and disaggregated demographic data, and leadership and participation of SGM-led community-based organizations in the co-design of studies that focus on SGM young people.

Improving access for and experience of transgender and non-binary patients in clinical research: Insights from a transgender patient focus group and targeted literature reviews

INTRODUCTION

The transgender and non-binary communities make up a significant, growing proportion of the population, but, to date, few clinical trials report including transgender and non-binary individuals.

METHODS

As part of a mixed-method approach, multiple literature searches for articles published from January 2018 to July 2022 and a Patient Advisory Council (a semi-structured patient focus group) meeting were conducted to identify challenges faced by the transgender and non-binary communities when accessing healthcare and participating in clinical research. A set of guidelines to promote inclusivity in clinical research was developed using these findings.

RESULTS

During this time period, only 107 (0.08%) of 141,661 published articles of clinical trials reported participation of transgender or non-binary patients. A targeted search identified only 48 articles reporting specific barriers to inclusion in clinical research, while an expanded search identified 290 articles reporting barriers to healthcare access for transgender and non-binary patients. Several key considerations to promote study inclusivity emerged from the literature searches and Patient Advisory Council: adjust clinical protocols, informed consent documents, and data collection forms to distinguish sex assigned at birth from gender identity; involve members of the transgender and non-binary communities in research whenever possible; provide communication training to personnel involved in clinical research; and maximize accessibility for potential participants.

CONCLUSION

Future research on investigational drug dosing and drug interactions in transgender and non-binary patients, along with regulatory guidance, are recommended to ensure clinical trials' processes, designs, systems, and technologies are transgender and non-binary patient-friendly, inclusive, and welcoming.

Inclusion of Transgender and Gender Diverse People in Phase III Trials: Examples from HIV Pharmacologic Prevention Studies

Although at least 25 million adults are transgender worldwide, few phase III clinical trials have enrolled transgender and gender diverse (TGD) people. HIV is the only therapeutic area to include TGD people intentionally in phase III randomized clinical trials during the development of certain newer HIV pharmacologic prevention interventions. Pharmacologic assessments for HIV prevention efficacy in TGD populations are important, as there may be specific considerations for product use and potential interactions with hormone therapies. Herein, we summarize ongoing and completed phase III HIV trials that included TGD people as part of the study population, we examine investigators' strategies for recruiting and engaging TGD priority populations in these phase III trials, and we comment on the implications of these studies for prioritizing TGD populations in clinical pharmacology research within the phase III clinical trial landscape.

Ethical HIV research with transgender and non-binary communities in the United States

INTRODUCTION

Because transgender individuals experience disproportionately high rates of HIV infection, this population is an increasing focus of epidemiological and implementation science research to combat the epidemic. However, study participants, providers and other advocates have become increasingly concerned about research practices that may alienate, objectify, exploit or even re-traumatize the communities they are designed to benefit. This commentary explores the common pitfalls of HIV research with transgender communities and provides a potential framework for ethical, community-engaged research practice.

DISCUSSION

We review some of the critical challenges to HIV research with transgender and non-binary communities that limit the potential for such studies to improve practice. For example, scales that measure stigma perceptions/experiences often include activating language, while the consistent focus in research on risk and trauma can often feel judgemental and redundant. Because of limited employment opportunities, some participants may feel undue influence by research stipends; others may perceive their participation as fuelling the larger research economy without providing research jobs to community members. Questions remain regarding optimal strategies for authentic research partnership beyond community advisory boards or focus groups. Transgender and non-binary researchers are under-represented and may be tokenized. Many demonstration projects provide much-needed services that disappear when the research funding is over, and community-based dissemination efforts are often perceived as "too little, too late" to effect change.

CONCLUSIONS

Based on this review and input from study participants across the United States, we detail six recommendations for ethical HIV research with transgender and non-binary communities, including (1) equitable budgeting with community-based programme partners; (2) representation in the development of both research agenda and methods; (3) integration of research activities into the ongoing work of any clinical or service site, so that individuals' needs as "clients" can continue to be prioritized over their role as "participants;" (4) mindfully considered compensation that values the contributions of community members, but avoids undue influence; (5) transparent, community-focused and timely communication at every stage of the study, including research purpose, data usage, preliminary findings and full-scale results; and (6) planning for sustainability of any programme or services beyond the life of the research project.

Factors associated with long-term HIV pre-exposure prophylaxis engagement and adherence among transgender women in Brazil, Mexico and Peru: results from the ImPrEP study

Introduction

The HIV epidemic continues to disproportionately impact Latin‐American transgender women (TGW). We assessed factors associated with long‐term pre‐exposure prophylaxis (PrEP) engagement and adherence among TGW enrolled in the Implementation of PrEP (ImPrEP) study, the largest PrEP demonstration study in Latin America.

Methods

HIV‐negative TGW aged ≥18 years reporting 1+eligibility criteria in the 6 months prior to enrolment (e.g. sex partner known to be living with HIV, condomless anal sex [CAS], transactional sex or having a sexually transmitted infection [STI]) who could safely take PrEP were enrolled. Follow‐up visits were conducted at 4 weeks and then quarterly. We conducted logistic regression to identify factors associated with long‐term PrEP engagement (3+ follow‐up visits in 52 weeks) and complete self‐reported adherence (no missed pills in the past 30 days) during follow‐up. For both outcomes, we constructed multivariable models controlling for country, socio‐demographics, sexual behaviour, substance use, STIs and self‐reported adherence at 4 weeks (long‐term engagement outcome only).

Results

From March 2018 to June 2021, ImPrEP screened 519 TGW, enrolled 494 (Brazil: 190, Mexico: 66 and Peru: 238) and followed them for 52 weeks. At baseline, 27.5% of TGW were aged 18–24 years, 67.8% were mixed‐race and 31.6% had >secondary education. Most, 89.9% reported CAS, 61.9% had >10 sex partners and 71.9% reported transactional sex. HIV incidence was 1.82 cases per 100 person‐years (95% confidence interval [CI]: 0.76–4.38). Almost half of TGW (48.6%) had long‐term PrEP engagement, which was positively associated with reporting complete adherence at week 4 (aOR:2.94 [95%CI:1.88–4.63]) and was inversely associated with reporting CAS with unknown‐HIV partner (aOR:0.52 [95%CI:0.34–0.81]), migration (aOR:0.54 [95%CI:0.34–0.84]), and being from Mexico (aOR:0.28 [95%CI:0.14–0.53]). Self‐reported adherence was associated with TGW aged >34 (aOR:1.61 [95%CI:1.10–2.34]) compared to those aged 25–34 and those with >secondary education (aOR:1.55 [95%CI:1.10–2.19]) and was lower among TGW from Peru (aOR:0.29 [95%CI:0.21–0.41]) or reporting PrEP‐related adverse effects (aOR:0.63 [95%CI:0.42–0.92]).

Conclusions

Although TGW were willing to enrol in ImPrEP, long‐term PrEP engagement and complete self‐reported adherence were limited, and HIV incidence remained relatively high. A successful HIV prevention agenda should include trans‐specific interventions supporting oral PrEP and exploring long‐acting PrEP strategies for TGW.

HIV prevalence among transmasculine individuals at a New York City Community Health Centre: a cross-sectional study

INTRODUCTION

Multiple 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.

METHODS

The 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 DISCUSSION

Five 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).

CONCLUSIONS

Although 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.