Pre-Exposure Prophylaxis (PrEP) for HIV Infection in Cisgender and Transgender Women in the U.S.: A Narrative Review of the Literature

Outcomes of a policy to prioritize populations with expected healthcare barriers for subsidized preexposure prophylaxis care in Amsterdam, the Netherlands

OBJECTIVE

The Dutch HIV preexposure prophylaxis (PrEP) pilot provided subsidized PrEP care to maximum 2900 individuals at a time in Amsterdam. Populations with expected barriers to accessing PrEP elsewhere were prioritized for program inclusion. We evaluated their prior sexual health service engagement and PrEP need.

DESIGN

Cross-sectional analysis using enrolment data.

METHODS

We included individuals ever enrolled in the PrEP program at the Center for Sexual Health (CSH) Amsterdam between 2019 and 2023. We calculated the proportion belonging to higher-priority groups (i.e., <25 years old, transgender, sex worker, uninsured or migrant). We defined classes of sexual health service engagement in the 12 months preceding enrolment using latent class analysis (LCA). We compared engagement classes, sexual behavior and positivity of HIV and sexually transmitted infections (STI) between higher- and lower-priority groups.

RESULTS

2004/4075 (49%) individuals enrolled belonged to higher-priority groups. LCA showed three classes of prior engagement: "newly engaged" (14%, n  = 551) were new to the CSH-Amsterdam; "PrEP initiators" (40%, n  = 1642) previously visited the CSH-Amsterdam but had not used PrEP; "PrEP experienced" individuals (46%, n  = 1882) previously accessed PrEP. Higher-priority groups were more often "newly engaged" or "PrEP-initiators" than "PrEP-experienced". Higher-priority groups less often had condomless anal sex with casual partners or chemsex in the prior 6 months. Positivity of bacterial STI was similar between higher-priority ( n  = 300/2004, 15.0%) and lower-priority ( n  = 315/2071, 15.2%) groups. 13/14 HIV diagnoses at enrolment were in higher-priority groups.

CONCLUSION

Higher-priority populations had less often previously used sexual health services and accounted for most new HIV diagnoses at enrolment. Engaging these populations in sexual healthcare, including PrEP, should be stressed.

Facilitators and barriers of HIV pre-exposure prophylaxis use among four key populations in Iran

BACKGROUND

Pre-exposure prophylaxis (PrEP) significantly reduces HIV transmission, but it is not commonly prescribed in Iran. Therefore, this study aimed to identify facilitators and barriers to PrEP use among four key populations (KPs) in Iran.

METHODS

We conducted in-depth qualitative interviews with female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), and sexual partners of people living with HIV (PLHIV) to obtain deep insights into the participants' experiences, beliefs, and viewpoints. We included HIV experts, including staff from the HIV control department, healthcare providers with HIV experience, health policymakers, infectious disease specialists, and university professors. We performed a content analysis to identify facilitators and barriers to PrEP implementation among KPs.

RESULTS

We interviewed seven FSW, seven MSM, four PWID, four sexual partners of PLHIV, and 18 HIV experts. The facilitator's theme emerged in four main categories, including eight different factors: 1) Individual and interpersonal factors (motivations, fear of testing positive for HIV, and safety nets and financial support), 2) Age and sex differences, 3) Organizational factors (appropriate PrEP distribution, information sharing, and receipt of high-quality services, 4) Efficacy of PrEP. The barrier's theme emerged in three main categories, including four factors: 1) Individual factors (insufficient knowledge and awareness, and fragile trust), 2) Cultural barriers, and 3) Organizational factors (inadequate infrastructure and organizational barriers).

CONCLUSIONS

We identified key facilitators and barriers to successful PrEP implementation among KPs in Iran. By addressing these barriers, Iran has an opportunity to include PrEP programs in its HIV prevention efforts for KPs.

A Systematic Review and Narrative Synthesis of Factors Affecting Pre-exposure Prophylaxis Willingness Among Black Women for HIV Prevention

Pre-exposure prophylaxis (PrEP) can significantly reduce human immunodeficiency virus (HIV) transmission among Black women in the United States (U.S.), a group disproportionately affected by HIV. However, PrEP uptake in this HIV-vulnerable population is low. This review analyzes the factors influencing Black women's PrEP willingness using the Behavioral Model for Vulnerable Populations (BMVP). Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Population, Intervention, Comparison, Outcome, Study Design (PICOS) framework, we conducted a systematic literature search and selected 24 peer-reviewed studies on PrEP willingness. Narrative synthesis revealed a heterogeneous landscape of the determinants affecting PrEP willingness among Black women, categorized into three main domains. Predisposing demographic and social factors included younger age, unmarried status, higher education, sexual or gender minority identity, trust in healthcare providers, and perceived HIV risk. Predisposing behavioral factors included condomless sex, multiple partners, and engagement in sex work. Socioeconomic status, health insurance, healthcare access, support systems, and structural challenges were identified as enabling factors influencing Black women's PrEP willingness. Finally, the perceived need domain and health-related factors influencing the perceived need for PrEP included a history of sexually transmitted infections (STI), intimate partner violence (IPV), and birth control interference. This study emphasizes the complexity of the barriers and facilitators of PrEP uptake and, thus, the need for tailored interventions and health strategies to promote its use. Addressing the interconnected individual, interpersonal, and structural determinants of PrEP access is crucial for improving PrEP willingness and thereby advancing health equity in this population.

Ending HIV Transmission in Australia: Expanding PrEP to Cisgender Women: A Scoping Review

Pre-exposure prophylaxis (PrEP) availability through the Pharmaceutical Benefits Scheme provides real potential for the elimination of HIV transmission in Australia, as evidenced by a rapid decline in HIV incidence among gay and bisexual men (GBM). However, HIV elimination will not be possible without also extending PrEP to other populations, including cisgender women. We conducted a scoping review to examine the extent to which PrEP access for cisgender women has been considered in Australia. A comprehensive search across five databases, grey literature, and hand search of references was conducted. A single reviewer conducted title and abstract screening and two reviewers completed full-text screening and data extraction. Nineteen documents were included in the final review and included both peer-reviewed journal articles and guidelines and strategies. Focused discussion of cisgender women's use of PrEP was largely missing from the literature and, although their use of PrEP is supported in some relevant guidelines, little has been done to actively develop strategies to inform cisgender women about PrEP as a precursor to prescribing for HIV prevention. Healthcare providers' narrow view of PrEP as being the domain of GBM further limits cisgender women's potential access. If HIV elimination in Australia is to be a reality, we need to develop mechanisms to specifically engage with cisgender women about PrEP.

Acceptability and appropriateness of information sessions to increase knowledge and awareness of PrEP and TelePrEP among Latina Women

Women of color are disproportionately impacted by HIV. Although PrEP effectively prevents HIV infection, PrEP coverage and knowledge remain low in this population. To address barriers to PrEP, we implemented women-centered and culturally appropriate Information Sessions (IS) delivered by staff from the population they serve to increase knowledge, awareness, and use of PrEP through telemedicine (e.g., PlushCare). Our analysis focuses on Latina women (LW) participants, given the dearth of literature dedicated to the needs of LW. We partnered with a woman-led community-based organization (CBO) to implement the strategy with LW clients. Health educators conducted 26 IS with 94 LW (20 in Spanish and 6 in English). Participants who completed the IS were invited for interviews to assess the acceptability and appropriateness of the IS to increase knowledge and awareness of PrEP and PlushCare. Four themes emerged from the thematic analysis: (1) IS increased knowledge and awareness of PrEP and PlushCare; (2) perceived acceptability and appropriateness of IS; (3) insufficient reasons to warrant use of PrEP; and (4) positive attitudes about PlushCare. Our findings suggest that a women-centered and culturally appropriate IS implemented through a trusted, woman-led CBO is an acceptable and appropriate implementation strategy to inform LW about PrEP.

Pre-exposure and postexposure prophylaxis access in rural versus urban pharmacies in Georgia and Pennsylvania

BACKGROUND

Pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) prevent HIV among individuals at high risk for acquisition. Pre-existing structural barriers to PrEP/PEP access among rural patients may be exacerbated further if pharmacies do not keep PrEP/PEP in stock, constituting a significant barrier to mitigating the HIV epidemic.

OBJECTIVES

To compare PrEP/PEP availability for same-day pickup in rural vs urban Georgia and Pennsylvania pharmacies.

METHODS

We conducted a cross-sectional simulated patient caller study, calling pharmacists in Georgia and Pennsylvania to see whether PrEP/PEP was available for same-day pickup. We identified retail pharmacies through state pharmacy boards and categorized rurality using state-based definitions. We used multivariable logistic regression to assess PrEP availability by rurality and Ending the HIV Epidemic (EHE) designation, accounting for chain pharmacy status and county-level racial composition.

RESULTS

Among 481 pharmacies contacted (304 in Pennsylvania and 177 in Georgia), only 30.77% had PrEP for same-day pickup and only 10.55% had PEP for same-day pickup. PrEP availability did not differ significantly by state. Urban pharmacies had 2.02 (95% CI: 1.32-3.09) greater odds of PrEP same-day availability compared to rural pharmacies. Pharmacies in EHE counties had 3.45 (95% CI: 1.9-6.23) times higher odds of carrying PrEP compared to non-EHE counties.

CONCLUSIONS

Pharmacies were unlikely to carry PrEP or PEP. Pharmacies in rural compared to urban, and non-EHE compared to EHE locations were less likely to carry PrEP. Addressing pharmacy barriers to PrEP/PEP may enhance access to HIV prevention for those living at high risk of HIV.

Sexual and Reproductive Justice and Health Equity for LGBTQ+ Women

LGBTQ+ women have long been overlooked in sexual and reproductive health research. However, recent research has established that LGBTQ+ women have unique and specific needs that need to be addressed in order to improve effectiveness of sexual health education and practice with this historically and presently underserved population. Informed by a reproductive justice framework coupled with liberation psychology theory, this review discusses the current state of sexual and reproductive health and technologies among LGBTQ+ women. In particular, we focus on a range of HIV prevention and reproductive technologies and their use and promotion, including the internal condom, abortion, oral contraceptives, dapivirine ring, HIV pre-exposure prophylaxis, intrauterine device, and other less studied options, such as the contraceptive sponge. Grounded in an intersectional framing, this review acknowledges the intersecting systems of oppression that affect multiply marginalized women inequitably and disproportionately. A sociohistorical, critical lens is applied to acknowledge the well-documented racist origins of reproductive health technologies and ongoing coercive practices that have led to medical mistrust among marginalized and stigmatized communities, particularly racialized LGBTQ+ women, women with disabilities, and women who are poor or incarcerated. Moreover, we discuss the urgent need to center LGBTQ+ women in research and clinical care, community-engaged health promotion efforts, affirming non-heteronormative sexual health education, and health policies that prioritize autonomy and dismantle structural barriers for this population. We conclude with recommendations and future directions in this area to remedy entrenched disparities in health.

Intention to Use Different Formulations of Longer Acting HIV Pre-Exposure Prophylaxis Among Transgender and Gender Expansive Individuals: The Roles of Social Vulnerability and Medical Mistrust

In 2012, the Federal Drug Administration approved daily oral pre-exposure prophylaxis (PrEP) for HIV prevention in adults. Longer acting injectable PrEP (LA PrEP) has been approved and other formulations are in development. A successful LA PrEP rollout requires examining potential facilitators and barriers to PrEP uptake. Given that transgender and gender expansive (TGE) individuals experience more social vulnerability and higher levels of medical mistrust compared to other populations, examining the role of these two factors in LA PrEP uptake is important. This study, PrEP for ALL, is a community-based participatory research project in Texas that engaged TGE community members and organizational partners through a community advisory board. In total, 482 TGE individuals were recruited and responded to all relevant questions in an online survey, including their intentions to use three formulations: a monthly oral pill, a bimonthly intramuscular injection, and an annual subdermal implant. Multiple regression analysis was used to examine the influence of social vulnerability and medical mistrust on intention to use each LA PrEP formulation adjusting for other relevant factors. Findings suggest that individuals with higher levels of social vulnerability had greater intentions to use the monthly oral pill (β = 0.12, p = 0.009), the bimonthly intramuscular injection (β = 0.18, p < 0.001), and annual subdermal implant (β = 0.17, p < 0.001), whereas medical mistrust reduced intentions to use the bimonthly intramuscular injection (β = -0.18, p < 0.001) and annual subdermal implant (β = -0.11, p = 0.021). Improvements in gender-affirming clinical care are needed along with LA PrEP formulations that allow for greater autonomy and reduced clinical contact. Clinical Trial Registration number: NCT05044286.

Provider views of pre-exposure prophylaxis (PrEP) for cisgender women - where do women fit in HIV elimination in Australia?

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) in Australia has largely been targeted at gay, bisexual and other men who have sex with men. In the context of HIV elimination, the aim of this qualitative study was to explore PrEP prescribing for Australian cisgender women from the provider's perspective.

METHODS

Semi-structured interviews were held with Australian prescribers in 2022. Participants were recruited through relevant clinical services, newsletter distribution and snowball sampling. Interviews were audio-recorded, transcribed and analysed thematically.

RESULTS

Seventeen prescribers participated, of whom 9 were sexual health physicians and 10 worked in New South Wales. All reported limited clinical experience prescribing PrEP for women. Potential enablers to PrEP prescribing to women included education for women and clinicians, easily identifiable risk factors, individualised risk assessment and expansion of existing services. Barriers were limited PrEP awareness among women and prescribers, difficulties with risk assessment and consult and service limitations. The type of service recommended for PrEP provision varied among participants.

CONCLUSIONS

Clinician experience of PrEP prescribing to Australian cisgender women is limited, with substantial barriers to access perceived by prescribers. Targeted education to PrEP prescribers, updated national PrEP guidelines to include women as a distinct group and further research regarding women's preferred model of PrEP access are required. Clarity of clinical ownership over PrEP implementation for women and, more broadly, women's sexual health, is essential in order to achieve HIV elimination in Australia.

PrEP initiation and discontinuation among transgender women in the United States: a longitudinal, mixed methods cohort study

INTRODUCTION

Transgender 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.

METHODS

Using 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.

RESULTS

21.8% (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.

CONCLUSIONS

PrEP 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.

Uptake and Discontinuation of Pre-Exposure Prophylaxis Among Uninsured Transgender and Cisgender Women: A Public-Private Partnership Model in North Carolina

HIV pre-exposure prophylaxis (PrEP) remains underutilized among cis and trans women. The PrEP Initiative Program (PIP) is a novel public-private partnership implemented at 12 local clinics in North Carolina. PIP provides HIV/sexually transmitted infection (STI) testing and clinical and laboratory monitoring for PrEP to uninsured/underinsured clients. We sought to understand service-related differences among both cis and trans women enrolled in PIP, including STIs diagnoses, clinic type, sources of referral, services needed, and reasons for PrEP discontinuation. The Kaplan-Meier curves display retention on PrEP over the duration of the program. Since 2018, 142 women (cis n = 113; trans n = 29) enrolled, and 136 started PrEP. The majority were ages 25-34 years (31.7%) or 18-24 years (29.6%), Black (57.8%) or Latinx (24.7%). Approximately 20.6% of recipients reported at least one STI while enrolled. Overall, trans women requested fewer services than cis women. After accounting for the amount of time each patient was taking PrEP, there were higher rates of trans women diagnosed with syphilis than cis women. Rates of persons with other STIs were not notably different between trans and cis women. Clinic access varied by gender: 69% of trans women were enrolled at only one site. Trans women were retained significantly longer: The Kaplan-Meier adjusted median time to discontinuation was 560 and 238 days for trans and cis women, respectively. PIP successfully reached historically marginalized and uninsured cis and trans women who may benefit from PrEP. Further investigations into factors contributing to recruitment and retention of women in HIV prevention programs are needed.

Barriers and facilitators to HIV pre-exposure prophylaxis uptake among transgender women in Colombia: A qualitative analysis using the COM-B model

Transgender women [TGW] in Colombia are disproportionately affected by HIV due to their low sociodemographic conditions, varied risk behaviours, difficulty accessing health services, and discrimination. Offering pre-exposure prophylaxis [PrEP] as part of a combination of prevention strategies is an appropriate option for this population to reduce their risk of HIV infection. However, little is known about how to implement a PrEP program for TGW in Colombia. Between June and October 2020, we conducted individual interviews with 16 TGW from four different cities in Colombia. The interviews assessed contextual influences, knowledge, skills, perceptions, and beliefs. We used qualitative thematic analysis to identify themes and the Capability, Opportunity, Motivation, and Behavior framework to further delineate barriers and possible interventions. After delineating the main themes across the three subdomains of the model, nine barriers were identified: one related to capability, knowledge, and perception of PrEP; six related to opportunity, which includes, family relations, sexual work environment, stable partner relations, interactions with healthcare workers, health service provision, and community interactions and opportunities; and two related to motivation, mental health, and concerns about medication side effects. Mapping barriers with interventions generated the following intervention functions: education, training, enablement, and environmental structure; and the following policy functions: communication/marketing, legislation, and changes in service provision. Examples of possible interventions are presented and discussed.

Barriers and facilitators to HIV pre-exposure prophylaxis for cisgender and transgender women in the UK

Uptake of oral HIV pre-exposure prophylaxis (PrEP) among cisgender and transgender women in the UK has been low. In this Review, we explore the barriers and facilitators to PrEP access for these groups, with a focus on health equity. We included 20 studies, including seven abstracts presented at conferences. The study samples were disparate, with minimal overlap between papers. We identified barriers at the individual, interpersonal, and structural levels, including poor awareness and acceptability; stigma, race, and ethnicity; restricted access to PrEP; and exclusion from clinical trials. We found hidden subpopulations of women who could potentially benefit from PrEP, of whom little is known about their PrEP knowledge, preferences, and access due to a lack of UK research. These subpopulations include non-Black African women, transgender women, sex workers, migrant women, women experiencing intimate partner violence, incarcerated women, and women who inject drugs. We highlight opportunities to address these obstacles. Research on the use of PrEP by women in the UK is scarce, and existing research has poor granularity. Without a better understanding of the needs and preferences of the full spectrum of women who could benefit from PrEP, the UK will not reach zero transmissions by 2030.

Gender-Based Violence and Post-traumatic Stress Disorder Symptoms Predict HIV PrEP Uptake and Persistence Failure Among Transgender and Non-binary Persons Participating in a PrEP Demonstration Project in Southern California

Gender-based violence (GBV) against transgender and nonbinary (TGNB) persons is a pervasive public health issue. GBV has been linked to mental health problems such as depression and posttraumatic stress disorder (PTSD), as well has risk for HIV seroconversion and HIV treatment nonadherence. However, the impact of GBV on HIV pre-exposure prophylaxis (PrEP) use among TGNB persons has yet to be investigated. In the current study we assessed longitudinal PrEP persistence data from dried blood spots (DBS) collected from 172 racially and ethnically diverse TGNB participants during a 48-week PrEP demonstration project in Southern California from June 2017 to September 2020. Participants were categorized into three levels of PrEP uptake and persistence based on their PrEP levels at the start and end of the study: low-low, high-low, and high-high. Individual-, social-, and structural-level variables were then entered into multinomial logistic regression models to predict levels of PrEP uptake and persistence based on hypotheses informed by syndemic and minority stress theories. The models demonstrated that experience of GBV predicted significantly lower odds of PrEP uptake and persistence and greater PTSD symptoms predicted significantly greater odds of early PrEP discontinuation. Higher levels of coping skills, already being on PrEP at baseline, and being in a steady relationship were associated with greater odds of PrEP uptake and persistence. Implications for future GBV research, advocacy, interventions, and much needed structural changes focused on improving the health and safety of TGNB individuals are discussed.

Provision of HIV preexposure prophylaxis to female patients seeking family planning services in the United States

OBJECTIVE

We conducted a scoping review to assess barriers to and facilitators of integrating HIV preexposure prophylaxis (PrEP) and family planning (FP) at the patient, provider, and implementation levels, and to identify gaps in knowledge.

METHODS

We conducted a search of five bibliographic databases from database inception to March 2022: PubMed, CINAHL, Embase, Web of Science and Scopus. Two reviewers screened abstracts and full texts to determine eligibility based on a priori inclusion and exclusion criteria. We categorized studies by their relevance to patient, provider, and implementation barriers, and extracted data based on prespecified elements.

RESULTS

Our initial search strategy yielded 1151 results, and 34 publications were included. Barriers to PrEP implementation in family planning settings included low PrEP knowledge among patients, hesitance to take PrEP due to perceived stigma, decreased willingness of providers unfamiliar with PrEP to prescribe PrEP, and limited financial and staffing resources that make prescribing and monitoring PrEP difficult. Facilitators included robust training for providers, stigma reduction efforts, leadership engagement, and increased resources specifically in settings with processes in place that ease the process of prescribing and monitoring PrEP.

CONCLUSIONS

Advances in implementation strategy development, stigma reduction, and drug development will be essential to reinforcing PrEP care in family planning settings and thereby reducing the incidence of HIV in women through highly effective pharmacologic HIV prevention methods.

Determinants of Pre-exposure Prophylaxis (PrEP) Implementation in Transgender Populations: A Qualitative Scoping Review

We conducted a scoping review of contextual factors impeding uptake and adherence to pre-exposure prophylaxis in transgender communities as an in-depth analysis of the transgender population within a previously published systematic review. Using a machine learning screening process, title and abstract screening, and full-text review, the initial systematic review identified 353 articles for analysis. These articles were peer-reviewed, implementation-related studies of PrEP in the U.S. published after 2000. Twenty-two articles were identified in this search as transgender related. An additional eleven articles were identified through citations of these twenty-two articles, resulting in thirty-three articles in the current analysis. These thirty-three articles were qualitatively coded in NVivo using adapted constructs from the Consolidated Framework for Implementation Research as individual codes. Codes were thematically assessed. We point to barriers of implementing PrEP, including lack of intentional dissemination efforts and patience assistance, structural factors, including sex work, racism, and access to gender affirming health care, and lack of provider training. Finally, over 60% of articles lumped cisgender men who have sex with men with trans women. Such articles included sub-samples of transgender individuals that were not representative. We point to areas of growth for the field in this regard.

Trends in preexposure prophylaxis use among sex partners as reported by persons with HIV - United States, May 2015-June 2020

OBJECTIVE

To estimate trends in the proportion of sexually active U.S. adults with HIV (PWH) reporting an HIV-discordant sexual partner taking preexposure prophylaxis (PrEP) and proportion of partners taking PrEP.

DESIGN

The Medical Monitoring Project is a complex sample survey of U.S. adults with diagnosed HIV.

METHODS

We used annual cross-sectional data collected during June 2015-May 2020 to estimate the annual percentage change (EAPC), overall and by selected characteristics, in reported partner PrEP use among PWH with HIV-discordant partners (N = 8707) and reported PrEP use among these partners (N = 15 844).

RESULTS

The proportion of PWH reporting PrEP use by one or more HIV-discordant sex partner rose 19.5% annually (11.3 to 24.4%). The prevalence rose from 6.0 to 17.4% (EAPC, 25.8%) among Black PWH, 10.1 to 26.0% (EAPC, 19.5%) among Hispanic/Latino PWH, and 20.8 to 34.6% (EAPC, 16.3%) among White PWH. Among MSM with HIV, the prevalence increased from 9.6 to 32.6% (EAPC, 28.2%) among Black MSM, 16.6 to 36.0% (EAPC, 15.6%) among Hispanic/Latino MSM, and 24.9 to 44.1% (EAPC, 17.9%) among White MSM. Among HIV-discordant sex partners, the proportion reported to be taking PrEP increased 21.1% annually (7.8 to 18.8%). Reported PrEP use rose from 4.9 to 14.2% (EAPC, 29.9%) among Black partners, 6.5 to 16.8% (EAPC, 20.3%) among Hispanic/Latino partners, and 12.7 to 26.1% (EAPC, 17.0%) among White partners.

CONCLUSIONS

One in five HIV-discordant sexual partners of PWH was reported to be taking PrEP. PrEP use rose among all examined populations, although the increases did not eliminate disparities in PrEP use.

Factors Associated with Intention to Initiate Pre-exposure Prophylaxis in Cisgender Women at High Behavioral Risk for HIV in Washington, D.C

Pre-exposure prophylaxis (PrEP) for HIV prevention is underutilized by cisgender women at risk for HIV in the USA. Published research on PrEP initiation among cisgender women at risk for HIV focuses on identifying barriers and facilitators associated with intention to initiate, but few apply a behavioral theoretical lens to understand the relative importance of these diverse factors. This study provides a theoretically grounded view of the relative importance of factors associated with intention to initiate PrEP. We conducted an anonymous, cross-sectional survey of 1437 cisgender women seeking care at family planning and sexual health clinics to evaluate hypothesized barriers and facilitators of PrEP initiation. We categorized cisgender women with ≥ 3 behavioral risk-factors as "high-risk" for HIV acquisition; 26.9% (N = 387) met high-risk criterion. Among cisgender women in the high-risk sample, the majority were Black and single. Perceived risk of HIV acquisition was low and 13.7% reported intention to initiate PrEP. Positive attitudes toward PrEP, self-efficacy, perceived support from medical providers and social networks, and prior discussion about PrEP with medical providers were associated with intention to initiate PrEP; stigma was negatively associated. Background characteristics (other than age), risk factors for HIV acquisition, prior awareness of PrEP, and perceived risk of HIV were not associated with uptake intention. These findings support interventions that center on the role of providers in the provision of PrEP and on social networks in destigmatization of PrEP use.

Prevention-effective adherence trajectories among transgender women indicated for PrEP in the United States: a prospective cohort study

PURPOSE

Adherence to pre-exposure prophylaxis (PrEP) during periods of PrEP-indication (i.e., prevention-effective adherence) is critical for preventing HIV. We sought to describe factors associated with prevention-effective adherence trajectories among transgender women (TW) to inform PrEP implementation strategies.

METHODS

Using data from The LITE American Cohort (n = 728), we performed group-based multi-trajectory modeling (GBMTM) to identify clusters of TW with similar trajectories of PrEP adherence and indication, and sociodemographic, biobehavioral, and structural correlates of each trajectory.

RESULTS

We identified five trajectories: (1) consistent indication/no PrEP (15.3%), (2) initial indication/no PrEP (47.1%), (3) declining indication/discontinued PrEP (9.5%), (4) consistent indication/PrEP adherent (18.5%), and (5) increasing indication/initiated PrEP (9.6%). TW diagnosed with an STI were more likely to follow a consistent indication/no PrEP trajectory compared to consistent indication/PrEP adherent trajectory (adjusted Relative Risk Ratio [aRRR], 2.54; 95% confidence interval [CI], 1.16-5.57). TW who experienced homelessness were more likely to follow PrEP discontinuation and initiation trajectories relative to PrEP adherence (aRRR, 2.71; 95% CI, 1.10-6.70 and 2.83; 95% CI, 1.13-7.05, respectively).

CONCLUSIONS

Over a quarter of TW followed trajectories suggestive of prevention-effective adherence, while 15% did not initiate PrEP despite consistent indication. Findings highlight missed opportunities for PrEP engagement at STI diagnosis and suggest structural interventions addressing housing instability may improve prevention-effective adherence among TW.

Brief Report: Transgender Women and Preexposure Prophylaxis Care: High Preexposure Prophylaxis Adherence in a Real-World Health Care Setting in New York City

BACKGROUND

Transgender women and trans feminine individuals (TGW/TFI) are a high priority population for the provision of HIV preexposure prophylaxis (PrEP) care within the United States, but there is limited research that focuses specifically on PrEP adherence within this population.

SETTING

Observational study of patients prescribed PrEP at a community-based health center.

METHODS

We enrolled 100 TGW/TFI PrEP patients at a community health center during clinic visits. Adherence data were collected at 3 time points, using self-report surveys, patient interviews, and urine assays measuring tenofovir. Data were summarized descriptively.

RESULTS

The sample was diverse in age, race/ethnicity, and socioeconomic characteristics. Participants demonstrated strong PrEP adherence; at least 80% of the sample reported 90% or greater adherence at each time point. Concordance between self-report and urine assay was high. Among patients who reported taking PrEP within the past 48 hours, 82%-92% had detectable urine tenofovir. However, many patients reported PrEP stop periods of 4 or more days (28%-39% per time point).

CONCLUSIONS

Our data highlight TGW/TFI's capacity to adhere to daily PrEP and sustain PrEP use over time. The concordance between patient self-report and urine TFV levels suggest that providers can trust patient reports of PrEP adherence behavior and support the use of adherence conversations in clinical settings, without the need for point of care biological monitoring. Findings also underscore the importance of continued attention to drivers of PrEP stops at the patient, clinic, and systems levels and the development of strategies that support sustained PrEP use.

Brief Report: Transgender Women and Preexposure Prophylaxis Care: High Preexposure Prophylaxis Adherence in a Real-World Health Care Setting in New York City

BACKGROUND

Transgender women and trans feminine individuals (TGW/TFI) are a high priority population for the provision of HIV preexposure prophylaxis (PrEP) care within the United States, but there is limited research that focuses specifically on PrEP adherence within this population.

SETTING

Observational study of patients prescribed PrEP at a community-based health center.

METHODS

We enrolled 100 TGW/TFI PrEP patients at a community health center during clinic visits. Adherence data were collected at 3 time points, using self-report surveys, patient interviews, and urine assays measuring tenofovir. Data were summarized descriptively.

RESULTS

The sample was diverse in age, race/ethnicity, and socioeconomic characteristics. Participants demonstrated strong PrEP adherence; at least 80% of the sample reported 90% or greater adherence at each time point. Concordance between self-report and urine assay was high. Among patients who reported taking PrEP within the past 48 hours, 82%-92% had detectable urine tenofovir. However, many patients reported PrEP stop periods of 4 or more days (28%-39% per time point).

CONCLUSIONS

Our data highlight TGW/TFI's capacity to adhere to daily PrEP and sustain PrEP use over time. The concordance between patient self-report and urine TFV levels suggest that providers can trust patient reports of PrEP adherence behavior and support the use of adherence conversations in clinical settings, without the need for point of care biological monitoring. Findings also underscore the importance of continued attention to drivers of PrEP stops at the patient, clinic, and systems levels and the development of strategies that support sustained PrEP use.

PrEP Use and Adherence Among Transgender Patients

This cross-sectional study used 2012 to 2019 Oregon Medicaid claims to estimate the prevalence of PrEP use and identify determinants of high adherence across transgender and cisgender men and women. Gender identity (cisgender woman/man; transgender, assigned female sex at birth [AFAB]; transgender, assigned male sex at birth [AMAB]) was based on medical history and enrollment records. Proportion of days covered ≥ 0.80 was considered high adherence to PrEP. The association between gender identity and PrEP uptake or high adherence was estimated using multivariable logistic regression. 1555 PrEP users, including 171 (11.0%) cis women, 1171 (75.3%) cis men, 67 (4.3%) AFAB, and 146 (9.4%) AMAB individuals, were included. The probability of PrEP use per 10,000 people was highest in transgender groups (AMAB 546.8, 95% CI 462.4-631.3; AFAB 226.5, 95% CI 173.4-279.6), followed by cisgender men (20.6, 95% CI 19.4, 21.8) and women (2.6, 95% CI 2.2, 3.0). High adherence was significantly lower in AMAB recipients (72.6%) than cisgender women (86.0%) and cisgender men (82.2%). Among the 279 PrEP users with female on their enrollment record, 76 (27.2%) were AMAB, while among the 1276 PrEP users with male on their enrollment record, 35 (2.7%) were AFAB. This demonstrates the importance of surveillance methods that take gender identity into account in addition to sex assigned at birth. There were significant differences in PrEP use and adherence by gender identity. PrEP surveillance, outreach, and prescribing practices must consider gender identity-unique risk factors.