Dr Jae Sevelius of the University of California, San Francisco, led a survey of trans people in the US which showed a relative lack of awareness of PrEP by trans people. Interestingly, trans men were more aware of PrEP than were trans women.
In the US, about 14% of trans women and 3% of trans men are estimated to have HIV. Although the Centers for Disease Control and Prevention (CDC) recommend that people who are deemed to be at higher risk of acquiring HIV (including trans persons) get tested every 3 to 6 months, testing remains lower among trans people than among other key groups. Moreover, knowledge of PrEP has been demonstrated to be lower among trans people than among cisgender men who have sex with men.
To date, no clinical trials of PrEP have reported results specific for trans men, and only one has done so for trans women. This was the iPrEx trial, which showed no efficacy for trans women, likely because of low adherence. Furthermore, hormone use was associated with lower levels of tenofovir (the main active ingredient of Truvada). Unsurprisingly then, high levels of adherence to PrEP are recommended for trans women. Nevertheless trans people’s attitudes to PrEP are often mixed, with a fear of negative interactions with hormones, and HIV stigma, discouraging some people from engaging with this prevention method.
The survey organisation Gallup was asked to recruit trans people from across the US into the study. This has the advantage of providing a sample that is reasonably representative of the national trans population, rather than a sample specific to any one treatment centre or locality. Participants were asked to complete a survey that was designed to assess trans population health.
Gallup recruited participants in two stages. In stage 1 they phoned and mailed people at random across US, in order to achieve representative geographical coverage. In total 432,251 persons were contacted in this initial stage, of whom 929 (0.2%) were trans. Of these, 629 agreed to participate and go to stage 2 for the survey itself. Not everyone completed the survey; the final data set includes 274 people. In order to assess attitudes toward PrEP, people with HIV were excluded, as were those who reported having had no sex in the last five years.
This resulted in a study sample of 190 sexually active participants, of whom 120 were deemed to be at risk of sexually acquiring HIV. Trans men made up a high proportion (56%) of the sample. Regarding ethnicity 59% were White while 41% were people of colour (POC). In this study the term POC was inclusive of all ethnicities other than White. Most of the participants (83%) were in urban settings, 58% had achieved education levels more than high school and 23% said that they were living in poverty.
"Only 3% of trans people reported taking PrEP."
About 48% of HIV-negative participants who had had sex in the previous five years were familiar with Truvada as PrEP; 58% of trans men and 35% of trans women said they were familiar with PrEP. People of higher education levels (above high school) were more likely to be aware of PrEP than those with less education.
With regard to testing, almost a quarter of trans people at risk of acquiring HIV through sex with cisgender men and/or trans women had never tested for HIV, and 54% did not meet CDC recommendations for HIV testing once a year or more often.
Study participants of colour were significantly more likely than White participants to meet HIV testing recommendations. This is thought to reflect the success of HIV testing outreach programmes that are aimed at people at higher risk of acquiring HIV and who are vulnerable to forms of social marginalisation such as racism.
Trans people who tested regularly were more familiar with PrEP, perhaps because PrEP is discussed in post-test counselling. In this study a majority (72%) of those who were already familiar with PrEP reported favourable attitudes towards it. Nevertheless, it is a real concern that use of PrEP is relatively low – only 3% in this study reported taking it.
Trans people who report that their gender was not recognised in health settings were less likely to use PrEP. This confirms other studies that have shown gender affirmation to be an important factor in the use of HIV testing and treatment services by trans people, and reinforces the need for gender-affirming PrEP services for trans people who are at risk of acquiring HIV.
The authors recommend that HIV testing and PrEP services might be made more attractive to trans people by locating them in trans-focused healthcare settings such as hormone prescription and monitoring. They also recommend that public health efforts need to be stepped up in order to increase awareness and uptake of PrEP by trans people in the US.
Sevelius JM et al. HIV Testing and PrEP Use in a National Probability Sample of Sexually Active Transgender People in the United States. Journal of Acquired Immune Deficiency Syndromes, 84: 437-442, 2020 (open access).