Transgender women and transfeminine nonbinary individuals
suggested a number of key issues that health services need to address in order
to increase the uptake of pre-exposure prophylaxis (PrEP) among transgender people. These included addressing the contextual factors associated with HIV in this
community, developing more inclusive messaging and imagery, healthcare
providers having an ongoing dialogue about PrEP with patients, and community
mobilisation.
The research is notable for including the voices of transgender
women who are taking PrEP – almost all previous studies have sampled
transgender women who are not taking PrEP to gauge their interest in and knowledge
of it.
Dr Augustus Klein and Professor Sarit Golub of the City
University of New York’s study is published in the June issue of AIDS Patient Care and STDs. Two transgender-identified research team members conducted 30 in-depth, semi-structured
interviews with transgender women and transfeminine nonbinary people
living in New York City, half of whom were on PrEP at the time of the
interview.
Two of the 30 interviewees identified as nonbinary. Over
half were under the age of 30, three-quarters identified as a person of colour,
almost all were not in the workforce, most had an annual income below $12000
and almost all were publicly insured.
The research is notable for including the voices of transgender women who are taking PrEP.
All interviewees, including those not taking PrEP, were
eligible for it based on the CDC’s criteria.
Several critical components to PrEP implementation emerged
from participant’s personal experiences accessing sexual health care and HIV
prevention services:
Programmes must be inclusive of diverse gender
identities and bodies. Specifically, lumping together transfeminine
individuals with cisgender men who have sex with men forces people to seek
healthcare in a system that is not affirming of self-identified gender identity,
as this interviewee explained:
‘‘Like when I went to
a city sexual clinic, they gave me a piece of paper that said are you a man who
has sex with men/trans woman. And I literally looked at them and was like: ‘Are
you comparing a man and a trans woman on this piece of paper? This is
completely ridiculous.’ When you put man and trans woman together, you’re
already off the bat saying that these two [are] comparable. I feel like those
questions impose transphobic ideas in them and a lot people are not going to want
to answer these kinds of questions because, if you answer it, you may be
validating this transphobic thing, but if you don’t answer it, you might not
get the care that you need.’’
The questions individuals are asked about sexual risks do
not accurately reflect their sexual activities or the context in which they are
having sex.
‘‘Like no doctor has
ever really asked me if my dick still worked or if I could top with it, unless
I brought something up about it.’’
HIV prevention interventions must acknowledge
and address the contextual and structural factors associated with HIV risk in
this community. A lack of housing and employment opportunities forced people
into situations (such as sex work) where survival is intrinsically linked to
HIV risk. Being vulnerable to sexual assault was also described as a fact of life.
‘‘Not every time I
have had sex have I been a willing participant. I’ve been sexually assaulted a
few times. I mean, definitely when it happened, one of the first things I
worried about was HIV. Now, at least I’m taking PrEP, if, god forbid, it [being
sexually assaulted] were to happen again, at least it’s one less thing for me
to really worry about. You know, because the chance is so miniscule [of getting
HIV], if you’re taking your PrEP.’’
Messaging needs to be transgender inclusive
and gender-affirming, with imagery reflecting diversity within the transgender community. Interviewees suggested that including different types of people in campaign imagery sends messages about who would (and would not) benefit from PrEP.
‘‘A lot of the trans
people that they’ve been using in a lot of these campaigns and stuff have been.
Quote, unquote, for lack of a better term, more passable. And that’s not always
the reality with our community, and that’s not always what our community looks
like.”
Another aspect of messaging is reflecting the structural
factors mentioned above. Non-PrEP users who engaged in survival sex explicitly said
that they did not know if PrEP was right for them because the PrEP pamphlets
they had seen did not address the issue.
Healthcare providers need to be actively
engaged with patients, having ongoing (rather than one-off) discussions
about PrEP. These should occur within a person’s ongoing gender-affirming
healthcare, rather than requiring people to seek out PrEP related care
specifically. Clinicians need to provide detailed information about PrEP so
that patients can make informed decisions about whether to take it, as this
interviewee explained:
“When I was asked – I mean
I knew what PrEP was, I’d heard of it, but I was just asked if I was interested
in PrEP. And so, if I didn’t know what it was, I would’ve just said no, not
really knowing what I was being asked.’’
Community
mobilisation and activism around PrEP should be bolstered. Participants
spoke about the impact of friends on their willingness to use PrEP. They
indicated that learning about PrEP from someone they trusted, with whom they
had established relationship, and who they felt was ‘like’ them, opened the
door to seek out more information and ultimately get on PrEP.
“While I was
considering if I wanted to take it or not – I was seeing people who were on it
talk about it. Like friends of mine who were on it. So, encouraging people to
talk about being on it [PrEP] is important.”