Determinants of Pre-exposure Prophylaxis (PrEP) Implementation in Transgender Populations: A Qualitative Scoping Review

Abstract

We conducted a scoping review of contextual factors impeding uptake and adherence to pre-exposure prophylaxis in transgender communities as an in-depth analysis of the transgender population within a previously published systematic review. Using a machine learning screening process, title and abstract screening, and full-text review, the initial systematic review identified 353 articles for analysis. These articles were peer-reviewed, implementation-related studies of PrEP in the U.S. published after 2000. Twenty-two articles were identified in this search as transgender related. An additional eleven articles were identified through citations of these twenty-two articles, resulting in thirty-three articles in the current analysis. These thirty-three articles were qualitatively coded in NVivo using adapted constructs from the Consolidated Framework for Implementation Research as individual codes. Codes were thematically assessed. We point to barriers of implementing PrEP, including lack of intentional dissemination efforts and patience assistance, structural factors, including sex work, racism, and access to gender affirming health care, and lack of provider training. Finally, over 60% of articles lumped cisgender men who have sex with men with trans women. Such articles included sub-samples of transgender individuals that were not representative. We point to areas of growth for the field in this regard.

HIV pre‐exposure prophylaxis programme preferences among sexually active HIV‐negative transgender and gender diverse adults in the United States: a conjoint analysis

“…Finally, the ability to decrease the frequency of PrEPrelated visits to every 6 months was strongly preferred among all respondents regardless of PrEP status. Several next-generation PrEP modalities under development may be amenable to this preference [13,60,62,80]. Future studies should be more inclusive and enrol more substantial numbers of trans participants to obtain more reliable findings related to product efficacy, acceptability and implementation opportunities among this priority population.…”

“…In light of these recommendations, tailored implementation strategies to achieve equitable PrEP delivery for trans populations are needed [3,13]. Regrettably, implementation studies rarely enrol trans participants in numbers sufficient to yield reliable estimates-transfeminine participants are often subsumed into study cohorts comprised predominantly of cisgender sexual minority men, while transmasculine and nonbinary individuals are rarely enrolled at all [13][14][15][16][17][18] Limited inclusion of trans participants in implementation research will hinder efforts to develop strategies that are salient and relevant to trans individuals who might otherwise benefit from PrEP due to their current sexual practices or personalized HIV prevention needs and preferences [3,13,15,19]. However, prior research with trans participants across other fields of research may inform this work.…”

Barriers and facilitators to HIV pre-exposure prophylaxis uptake among transgender women in Colombia: A qualitative analysis using the COM-B model

“…As depicted in Table 1 , studies with TGW demonstrated the relevance of various factors on PrEP use that can be mapped in the COM-B. Factors related to the capability domain include HIV prevention knowledge, and skills; factors related to opportunity dimensions include societal influences, resources, interactions with healthcare systems, family, and peers, and HIV stigma; and motivational factors include beliefs, intentions, concerns, mental health states, and habits [ 8 , 9 , 20 , 21 ]. The COM-B relies on the delineation of explanatory factors that influence a particular behaviour on multiple levels [i.e., individual, interpersonal, and contextual], which helps us to identify barriers and facilitators, and a structured framework for intervention design [Objective 1].…”

Establishing Evidence Criteria for Implementation Strategies: A Delphi Study for HIV Services

“…Furthermore, major biomedical advancements such as pre-exposure prophylaxis (PrEP), have proven to be very effective at preventing HIV. Yet many of these interventions have not been widely implemented with equity to yield their intended bene t. Only an estimated 30% of individuals who would bene t from PrEP receive it, with growing disparities by race, gender, income, citizenship status, and intersectional marginalization (11)(12)(13)(14). Uptake and adherence remain suboptimal along the HIV care continuum (i.e., prevention, testing, diagnosis, linkage-to-care, and treatment), indicating, in part, failed implementation and opportunities to develop evidence-informed implementation strategies (11).…”