Individual, interpersonal, community, and structural barriers to pre-exposure prophylaxis (PrEP) uptake and adherence of Black and Hispanic transgender women were identified in a substudy published in the journal AIDS and Behavior.
Transgender women, assigned male gender at birth and identifying as female, are affected by HIV disproportionately. This population represents 84% of transgender people infected with HIV between 2009 and 2014. A higher percentage of Black (44%) and Hispanic (26%) transgender women are living with HIV than those who are White (7%).
Between July 2018 and August 2019, participants were recruited from a parent study of a Southern California-based PrEP demonstration project among transgender people conducted by the California Collaborative Treatment Group. Participants who completed week 12 data collection were eligible to participate in this substudy, consisting of a qualitative interview about PrEP uptake and adherence that followed a socioecological framework.
Additionally, 10 healthcare providers (HCPs) who provided healthcare and PrEP-related services to Black and Hispanic transgender women were also interviewed. A total of 30 transgender women (16 Hispanic, 10 Black, 4 mixed race) who participated in this substudy had the following characteristics:
- 29.8 years was their average age
- 77% had stable housing
- 53% were employed in the previous 6 months
- 57% used marijuana
- 47% met criteria for post-traumatic stress disorder (PTSD) according to the screening tool used
PrEP adherence data were collected via blood samples, and the results were as follows:
- 14 (46.7%) had perfect adherence (7 doses/wk)
- 5 (16.7%) were adherent or protected (4-6 doses/wk)
- 11 (36.7%) were nonadherent (<4 doses/wk)
Individual-level barriers were defined as experiences that heavily influence individual attitudes and behaviors, such as cost concerns, mental health issues, substance use, and PrEP adverse effects, including interactions with feminizing hormone therapy. The transgender women conveyed the primary reason they were currently on PrEP was due to the substudy providing PrEP free-of-charge, and they would not otherwise pay for the treatment out of pocket.
Interpersonal-level barriers were defined as factors related to interactions between the participant and other important people in their lives, including intimate partners and HCPs. Some women revealed that their partner may interpret the idea of PrEP as dishonesty within the relationship. Others described negative experiences with HCPs due to cultural insensitivity and a lack of knowledge about transgender health.
Stigma, negative community opinions, and uncomfortable encounters in healthcare settings were some community-level barriers mentioned. Transgender women revealed the stigma of being on PrEP and being perceived as overly sexually active were obstacles to PrEP uptake and adherence. HCPs indicated misinformation, medical mistrust, and myths concerning PrEP are also hindrances.
Structural-level barriers were defined as elements that significantly influence participants’ social capital and access to resources, including housing insecurity, employment issues, and reliable transportation. Both participants and HCPs recognized obtaining stable housing was a higher priority than initiating PrEP.
Along with PrEP promotional materials that specifically feature and target Black and Hispanic transgender women, interventions for structural-level barriers “should be prioritized and implemented in order to increase PrEP uptake and improve adherence,” study authors concluded.
Ogunbajo A, Storholm ED, Ober AJ, et al. Multilevel barriers to HIV PrEP uptake and adherence among Black and Hispanic/Latinx transgender women in southern California. AIDS Behav. Published online January 29, 2021. doi:10.1007/s10461-021-03159-2