Facilitators of PrEP Persistence among Black and Latinx Transgender Women in a PrEP Demonstration Project in Southern California

Abstract

Black and Latinx transgender women in the United States (U.S.) are at disproportionately high risk for HIV. Although HIV pre-exposure prophylaxis (PrEP) reduces the risk of HIV infection, uptake and persistence (i.e., ability to continue taking PrEP over time) can be a challenge for Black and Latinx transgender women due to myriad social and structural forces. In this qualitative study, we present unique data on the facilitators of PrEP persistence from Black and Latinx transgender women who initiated PrEP and exhibited varying levels of persistence during a demonstration project in Southern California. PrEP persistence was assessed by collecting quantitative intracellular tenofovir-diphosphate (TFV-DP) levels on dried blood spot (DBS) samples collected at weeks 12 and 48. Informed by the socioecological framework, we conducted and analyzed interviews using qualitative content analysis to determine themes on the facilitators of PrEP persistence. Individual-level facilitators included the use of reminders, having high individual-level HIV risk perception, feeling empowered to take PrEP, and reporting having improved peace of mind and mental health because of taking PrEP. Interpersonal/Community-level facilitators included feeling motivation to prevent HIV in the community, motivation to prevent HIV in the context of sex work, and having high community-level risk perception. Structural-level facilitators included having positive experiences in affirming healthcare settings and having PrEP visits combined with other gender-related healthcare visits. Interventions aiming to increase PrEP uptake and persistence among Black and Latinx transgender women in the U.S. should harness the multiple levels of support exhibited by those who were able to start and persist on PrEP in the face of the myriad social and structural barriers.

Determinants of HIV Pre-Exposure Prophylaxis (PrEP) Retention among Transgender Women: A Sequential, Explanatory Mixed Methods Study

“…Thus, interventions that offset the financial costs of PrEP or medical gender affirmation services may be mutually beneficial. Finally, our findings emphasize the importance of colocation of PrEP care and medical gender affirmation services, in alignment with what others have suggested [28,43,44]. Colocation can support PrEP adherence because TW report being better at attending medical appointments related to gender affirmation services than PrEP, likely due to their motivation for achieving gender affirmation-related goals.…”

“…Medical gender affirmation, such as the use of gender-affirming hormone therapies (GAHTs) and surgical procedures, has been associated with PrEP awareness and PrEP use [24][25][26]. Qualitative research has suggested that lack of access to gender affirmation is an important determinant of PrEP care and that co-location of services may help facilitate PrEP engagement [27,28]. Further, concerns about drug-drug interactions between GAHT and PrEP have been noted by TW [29].…”

Characteristics Associated with Pre-Exposure Prophylaxis Discussion and Use Among Transgender Women Without HIV Infection — National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019–2020

“…To what extent gender-affirming care initiates transgender patients into health care systems where HIV services are more accessible or whether increasing trust in gender-affirming health care systems fosters improved engagement in HIV prevention is unclear. Evidence from a qualitative study of transgender women indicates that both might be operating; having positive experiences within the health care system and combining PrEP and gender-related health care visits were both identified as facilitators for PrEP use ( 33 ). Another study found that, among transgender women with HIV infection, gender affirmation and health empowerment moderated the negative effects of discrimination to improve viral suppression ( 32 ).…”

“…Definitions of certain covariates are available in the overview and methodology report of this supplement (13) and included sociodemographic, HIV-associated, and gender-affirming care characteristics. Sociodemographic characteristics assessed included age group (18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39), and >40 years), race and ethnicity (American Indian or Alaska Native, Asian, Black, Hispanic, Native Hawaiian or other Pacific Islander, White, or persons of multiple races [persons of Hispanic origin might be of any race but are categorized as Hispanic; all racial groups are non-Hispanic]), education (less than high school, high school diploma or equivalent, some college or technical degree, and college degree or more), 2019 poverty level (at or below the Federal poverty level and above the Federal poverty level), and current health insurance.…”

PrEP initiation and discontinuation among transgender women in the United States: a longitudinal, mixed methods cohort study

“…Many socio‐structural drivers of high HIV incidence among transgender women are also barriers to engagement in the HIV prevention cascade [ 3 , 4 , 5 , 6 ]. Observational data on longitudinal PrEP engagement among transgender women are limited [ 7 , 8 ], but data from clinical cohorts suggest that PrEP persistence among transgender women is low [ 9 , 10 ]. A daily, oral PrEP demonstration study with multiple sites in Latin America conducted from 2018 to 2021, ImPrEP, found less than half of transgender women remained on PrEP 52 weeks after initiation [ 11 ].…”