Transgender women (TW) are at extremely high risk of HIV, even compared to men who have sex with men (MSM). MSM and TW and their sexual networks are often conflated in research. While studies of MSM show transmission in ‘closed’ networks comprised almost exclusively of MSM, sexual networks of TW have not been characterized. Understanding TW sexual networks, including identity and behavior of sexual partners of TW (PTW), is important to better explain the high HIV incidence in TW.
We used modified respondent-driven sampling to collect cross-sectional data from TW and their sex partners in Lima, Peru (February – July 2018). TW seed participants completed a survey and invited up to 3 sex partners using a WhatsApp referral system. In each wave of forward partner referral, invited partners could complete the survey and were provided referral coupons. The questionnaire assessed gender and sexual identity, sexual behavior, and self-reported HIV status. We constructed a sexual network map and characterized sociodemographics and behavior of PTW.
In total, 470 eligible respondents completed the survey, including 203 PTW, defined as reporting a TW partner within 3 months. The network diagram (Figure) shows that almost all partners invited by TW were cisgender (cis-) men, who almost always invited only TW sexual partners in the next wave. In the survey, 41% of PTW reported exclusively TW partners in the previous 3 months and 52% reported both cis-women and TW partners; only 7% reported cis-male partners. TW primarily reported cis-male partners, with only 2% reporting other gendered partners. PTW reported attraction to TW (83%) and cis-women (68%), with only 9% reporting attraction to cis-men. Most PTW reported being the insertive partner in anal sex (88%); most also reported ever purchasing (78%) or selling (56%) anal sex. Condomless anal intercourse in the past 3 months was reported by 60% of PTW and 65% of TW. Over half of PTW did not know their HIV status (54%), compared to 42% of TW and 20% of other network members (primarily MSM).
We found almost no overlap between MSM and TW sexual networks. Nearly all PTW were bi-/hetero-sexual cis-men who partner with trans- or cis-women. Most reported HIV-risk behaviors and did not know their HIV status. Our results do not fully explain the high HIV rates in TW, but highlight the need for HIV prevention interventions specifically designed for TW and PTW, particularly in settings where interventions focus mostly on MSM.