U.S. transgender women (TGW) have a disproportionate burden of HIV, with an estimated prevalence of 28%. Pre-exposure prophylaxis (PrEP) is effective in preventing HIV acquisition among adherent users. However, the PrEP care continuum among TGW as well as factors associated with high risk for HIV and subsequent PrEP indication (e.g. condomless anal sex, high sex partner number, having an STI, etc.) are not well understood.
The LITE study is a multi-site cohort enrolling TGW across six cities in the southern and eastern U.S. Upon screening, participants underwent HIV/STI testing and completed a socio-behavioral survey in which they reported experiences with PrEP. We identified factors associated with PrEP indication using prevalence ratios from a multivariate Poisson regression with robust variance. We also calculated descriptive statistics to depict the PrEP care continuum.
As of April 2019, there were 751 participants not living with HIV at baseline. Among this group, 293 (39%) met PrEP indication based on the following: had a laboratory confirmed STI, recent partner who was known to be living with HIV, reported recent sex work, and/or recent condomless anal sex. Participants who were Non-Hispanic Black [ref: Non-Hispanic White, PR: 1.98, p=<0.0001] or had self-perceived low risk of HIV [ref: no risk, PR: 2.09, p=0.012], medium risk of HIV [ref: no risk, PR: 3.33, p<0.001], or high risk of HIV [ref: no risk, PR: 3.81, p<0.0001,] were more likely to be indicated for PrEP. Having some college education or above was associated with being less likely to be PrEP indicated [ref: high school education or less, PR: 0.79, p=0.04]. Ultimately, among those indicated for PrEP, 42 (14%) were currently using and adherent to PrEP (Figure 1). Eighty-four percent of those indicated were aware of PrEP, 76% of those aware of PrEP had health insurance, 63% of those insured were taking PrEP, and 68% of PrEP users reported 100% adherence within the prior 7 days of the survey (14% among all who were indicated for PrEP).
Over a third of TGW not living with HIV at baseline were indicated for PrEP. Although most PrEP users were adherent, overall uptake and adherence among those PrEP indicated were low. Improving uptake and adherence among TGW warrants further investigation, particularly with respect to development of culturally appropriate strategies to increase uptake and adherence among Black TGW for whom PrEP indication is higher.