Work and health issues of the transgender population: factors associated with entering the labor market in the state of São Paulo, Brazil

Anticipated Stigma and Social Barriers to Communication Between Transgender Women Newly Diagnosed with HIV and Health Care Providers: A Mediation Analysis

Purpose: We assessed whether anticipated stigma (i.e., fear of public mistreatment due to gender identity) impacts communication between transgender women (TGW) living with HIV and health care providers. Methods: This is a secondary analysis of baseline data from Trans Amigas, a study conducted in Brazil, 2018. The study population consisted of TGW living with HIV, older than 18 years, residing in the São Paulo metropolitan area. We used multivariable logistic regression (α = 0.05), mediation, and bootstrapping for the analysis. Results: One hundred and thirteen participants completed the study. Fear of public mistreatment had an adjusted odds ratio (aOR) of 7.42 (p = 0.003) for difficulty reporting new symptoms to providers. Concerning fear of public mistreatment, we found that unemployment had an aOR of 3.62 (p = 0.036); sex work, an aOR of 2.95 (p = 0.041); and issues related to name change in documents, an aOR of 2.71 (p = 0.033). For the indirect effect on difficulty reporting new symptoms, mediated by fear of public mistreatment, unemployment had an aOR of 1.52 (confidence interval [CI] = 0.88-2.24); sex work, an aOR of 1.48 (CI = 0.81-2.52); and name change issues, an aOR of 1.47 (CI = 0.96-2.43). Conclusions: Anticipated stigma was associated with communication difficulties between TGW living with HIV and providers. Our data suggest that structural factors associated with anticipated stigma could indirectly impact on difficulty reporting new symptoms. These findings indicate the importance of considering social contexts that intersect with individual experiences when analyzing communication barriers between providers and patients, and the need to strengthen social policies for TGW in Brazil. Clinical Trial Registration number: R34MH112177.

Prevalence of Mollicutes among men who have sex with men and transgender women aged 15 to 19 years in Salvador, North-eastern Brazil

BACKGROUND

Some species of Mollicutes have been associated with different pathologies of the urogenital tract in humans, with a high prevalence among adult men who have sex with men (MSM) and transgender women (TGW). However, few studies have been performed to investigate its prevalence among adolescents. In this study, we estimated the initial prevalence of Mycoplasma genitalium (MG), Mycoplasma hominis (MH), Ureaplasma urealyticum (UU), and Ureaplasma parvum (UP); the rate of misdiagnosis at different anatomical sites; and the associated factors with positive tests for Mollicutes among MSM and TGW aged 15 to 19 years enrolled in the PrEP1519 study.

METHODS

PrEP-1519 is the first study to investigate the effectiveness of pre-exposure prophylaxis for human immunodeficiency virus among adolescent MSM and TGW aged 15 to 19 in Latin America. Oral, anal, and urethral swabs were taken from 246 adolescents upon enrolment in the study to detect MG, MH, UU, and UP by quantitative polymerase chain reaction (qPCR). Bivariate and multivariate analyses were conducted by Poisson regression and 95% confidence intervals (95% CI) were estimated.

RESULTS

The prevalence of Mollicutes was 32.1%. UU was the most prevalent species (20.7%), followed by MH (13.4%), MG (5.7%), and UP (3.2%); 67.3% of the positive samples would have been missed if only urethral samples had been taken. Receptive anal sex (prevalence ratio [PR] = 1.79; 95% CI = 1.07-3.01) and clinical suspicion of sexually transmitted infection (PR = 1.62; 95% CI = 1.01-2.61) were factors associated with the detection of Mollicutes in general. Group sex (PR = 1.98; 95% CI = 1.12-3.50) and receptive anal sex (PR = 2.36; 95% CI = 0.95-5.86) were associated with the detection of Mycoplasma spp. No sociodemographic, clinical, or behavioural variable was significantly associated with the detection of Ureaplasma spp.

CONCLUSIONS

A high prevalence of Mollicutes was observed among adolescent MSM and TGW, especially at extragenital sites. Further research is required to understand the epidemiological profile of high-risk adolescents in different regions and contexts, and to investigate the pathogenesis of Mollicutes in the oral and anal mucosa before routine screening can be recommended in clinical practice.

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.

Brief Report: Young Age and Sex Work Are Associated With HIV Seroconversion Among Transgender Women in São Paulo, Brazil

BACKGROUND

Transgender women worldwide have the highest prevalence of HIV and the lowest access to prevention among groups at risk of HIV. However, few longitudinal studies have directly measured HIV incidence and identified predictors of HIV acquisition among transgender women.

SETTING

São Paulo, Latin America's largest city.

METHODS

We conducted a longitudinal study among transgender women in São Paulo. Participants were recruited by a long-chain peer referral process from May 2017 to July 2019. Those aged 18 years and older and who were HIV-negative at baseline were retested every 6 months up to 18 months. HIV incidence was calculated by dividing the number of seroconversions by the person-years (PYs) of follow-up; 95% confidence intervals (CIs) were constructed assuming a Poisson distribution. Conditional maximum likelihood ratios assessed differences in HIV incidence by risk factors.

RESULTS

A racially/ethnically diverse sample of 545 HIV-negative transgender women was enrolled. In 485.5 PYs of follow-up, 13 seroconversions were observed, yielding an incidence of 2.68 per 100 PYs (95% CI: 1.43 to 4.58). HIV incidence was significantly higher among transgender women aged 18-24 years (rate ratio 3.85, 95% CI: 1.24 to 12.93) and among those who engaged in sex work in the preceding month (rate ratio 5.90, 95% CI: 1.71 to 26.62).

CONCLUSIONS

HIV transmission continues at a high rate among transgender women in Brazil. Factors such as young age, lower level of education, and limited employment opportunities may lead to dependence on sex work that in turn increases HIV risk. Transgender-friendly prevention services, particularly programs delivering pre-exposure prophylaxis, are urgently needed.

Factors associated with attitudes towards HIV cure research among transgender women and travestis: a cross-sectional survey in São Paulo, Brazil

OBJECTIVE

Characterising the perceptions of groups most affected by HIV is fundamental in establishing guidelines for biomedical advancement. Although Brazil has successfully fought HIV/AIDS through several measures, transgender women still have a likelihood of HIV infection 55 times higher than the general population. This study aimed to better understand the perception and awareness of HIV cure research among the trans-identifying population in São Paulo, Brazil, and to determine factors that motivate or discourage participation in HIV cure studies.

SETTING

This cross-sectional study analysed data collected from a questionnaire administered to 118 transgender women and travestis at 5 sites within the city of São Paulo. It uses quantitative methodology to describe the perspectives of transgender and travesti people in relation to HIV cure research and the context in which such perspectives are produced.

RESULTS

Of 118 participants, most participants (73%) had some knowledge of HIV cure research and were most willing to participate in online surveys (52%), interviews (52%), focus groups (52%) and studies involving blood draws (57%). Those with a higher education or employment status were more likely to agree that someone had been cured of HIV, people living with HIV are discriminated against, and more information about HIV cure research is needed before the community embraces it. Only 55% of participants completely trusted their physician. The biggest motivational factors included gaining additional knowledge about HIV infection (77%) and the potential for a longer, healthier life for all (73%).

CONCLUSIONS

As a primary analysis of HIV cure attitudes among the transgender and travesti population as well as the social context in which they are formed, this study identifies opportunities to strengthen the dialogue and develop more educational collaborations between scientific investigators, community educators and the trans-identifying population to ensure that HIV cure research is inclusive of diverse perspectives.