Gender-Based Violence and Post-traumatic Stress Disorder Symptoms Predict HIV PrEP Uptake and Persistence Failure Among Transgender and Non-binary Persons Participating in a PrEP Demonstration Project in Southern California

Background: Transgender women (TW) are highly burdened by HIV. There is increasing interest in digital (i.e., through internet-based interfaces) HIV research; yet few studies have assessed potential biases of digital compared to site-based data collection. This study examined differences in characteristics between TW participating via site-based versus digital-only modes in an HIV incidence cohort. Methods: Between March 2018-Aug 2020, a multisite cohort of 1,312 adult TW in the eastern and southern USA was enrolled in site-based and exclusively digital modes. We evaluated differences in baseline demographics, socio-structural vulnerabilities, healthcare access, gender affirmation, mental health, stigma, social support, and HIV acquisition risk comparing site-based vs digital modes using chi square tests and Poisson regression modeling with robust standard errors. Results: The overall median age was 28 (interquartile range=23-35) years and over half identified as people of color (15% Black, 13% Multiracial, 12% Another Race, 18% Latina/e/x). A higher proportion of site-based (vs. digital mode) participants resided in the Northeast, were younger, identified as people of color, experienced socio-structural vulnerabilities, had a regular healthcare provider, received medical gender affirmation, endorsed mental health symptoms and stigma, reported HIV acquisition risk but also greater experience with biomedical HIV prevention (pre-exposure and post-exposure prophylaxis), and had larger social networks (all p<0.05). Conclusion: Site-based and digital approaches enrolled TW with different demographics, life experiences, and HIV acquisition risks. A hybrid cohort model may achieve a more diverse and potentially representative sample of TW than either site-based or online cohorts alone for HIV research.

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Intentions to use PrEP among a national sample of transgender and gender-expansive youth and emerging adults: Examining gender minority stress, substance use, and gender affirmation.

Cluesman,

Gwadz,

Cleland

2024

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Transgender and gender-expansive youth/emerging adults ages 13–24 years, experience disproportionate HIV risk, yet have among the lowest US PrEP uptake rates (< 10%). Still, factors that promote or impede PrEP outcomes for this population are poorly understood. This study examines the effects of gender minority stressors, gender affirmation, and heavy substance use on their PrEP outcomes. Data were drawn from the CDC’s 2018 START study, which included transgender and gender-expansive youth/emerging adults indicated for PrEP (N = 972). We developed a conceptual model integrating the gender minority stress and gender affirmation models. We mapped START items onto it, including distal (family rejection, medical discrimination) and proximal (internalized transphobia, perceived TGE-stigma) gender minority stressors, heavy substance use, background factors, and gender affirmation across five domains. Structural equation modeling (Mplus-8.9) was used to examine factors related to PrEP intentions. Most participants were 18–24 (68%), trans-female (46%) and White (45%). Additionally, 40% reported heavy substance use behaviors. Medical discrimination increased internalized transphobia (b = 0.097, SE = 0.034, p = 0.005) and perceived stigma (b = 0.087, SE = 0.034, p = 0.010). Family rejection also increased perceived stigma (b = 0.181, SE = 0.032, p < 0.001) and heavy substance use (b = 0.260, SE = 0.053, p < 0.001), and perceived stigma (b = 0.106, SE = 0.037, p = 0.004) increased heavy substance use. Notably, perceived stigma (b = -0.085, SE = 0.027, p = 0.002) and heavy substance use (b = -0.161, SE = 0.031, p < 0.001) decreased intentions to take PrEP, while gender affirmation increased PrEP intentions (b = 0.045, SE = 0.019, p = 0.020). Moreover, a 1-point increase in gender affirmation reduced the risk of heavy substance use by -0.179 (SE = 0.030; p < 0.001) in the presence of family rejection, and by -0.074 (SE = 0.041; p = 0.074) when perceived TGE stigma was present. This study underscores the importance of addressing heavy substance use among transgender/gender-expansive young people as a potential barrier to PrEP uptake. Future research could explore how gender affirmation acts as a protective factor against the negative impact of family rejection and perceived stigma on heavy substance behaviors among these populations.

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Gender-Based Violence and Post-traumatic Stress Disorder Symptoms Predict HIV PrEP Uptake and Persistence Failure Among Transgender and Non-binary Persons Participating in a PrEP Demonstration Project in Southern California

Cited by 5 publications

References 80 publications

Gender-Affirming Care for Older Transgender and Gender Diverse Adults

Gender-Affirming Care for Older Transgender and Gender Diverse Adults

Site-Based and Digital Cohort Participation Among Transgender Women in the Eastern and Southern United States: Findings From the LITE Study

Intentions to use PrEP among a national sample of transgender and gender-expansive youth and emerging adults: Examining gender minority stress, substance use, and gender affirmation.

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