Black and Latina transgender women (BLTW) in the U.S. are at high risk for HIV with reported annual incidence rates as high as 3.2 per 100 person-years. While PrEP has demonstrated efficacy in multiple clinical trials and implementation projects, uptake and adherence among transgender women (TW) has been low. Adherence was only 18% among TW in the seminal iPrEx trial and did not correlate with HIV risk behavior. Efforts to promote PrEP among key populations have scaled up since FDA approval in 2012. The aims of this study were to estimate PrEP uptake and identify predictors of willingness to take PrEP among BLTW.
We recruited BLTW in Baltimore, MD and Washington, DC from April 2016 – May 2017, via community health centers, outreach, and network referrals. Each participant completed a face-to-face interview in English or Spanish, followed by OraQuick Rapid HIV 1/2 test and linkage to confirmatory testing, if positive. Interviews assessed psychosocial factors and HIV risk behaviors as well as PrEP awareness, willingness, and uptake. Bivariate and multivariable logistic regression models were used to test associations between legal gender affirmation (i.e. name or gender marker that matches current identity), transgender pride (measured via Likert scale), lifetime history of exchange sex, HIV risk perception, and PrEP willingness. Multivariable modeling controlled for age and survey language.
Among 201 BLTW, 86% (n=174) had heard of PrEP. Of those, 80% (n=139/174) knew where to get it. Among self-reported HIV-negative or HIV-unknown BLTW who had not taken PrEP, 78% (n=59/76) were willing to take it, yet only 39% (n=30/76) had ever done so. The small number of participants on PrEP (n=30) limited the power to detect significant predictors of PrEP uptake. On bivariate analyses, greater transgender pride, history of exchange sex, and higher HIV risk perception were positively associated with PrEP willingness, while legal gender affirmation was negatively associated. History of exchange sex and legal gender affirmation remained significant in the multivariable model.
More than three-fourths of HIV-negative BLTW reported awareness and willingness to take PrEP. Nevertheless, uptake remains quite low. More research is needed to improve PrEP uptake as well as to explain potentially complex relationships between gender affirmation, exchange sex, and PrEP acceptability among BLTW.