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Perceived HIV Acquisition Risk and Low Uptake of PrEP Among a Cohort of Transgender Women With PrEP Indication in the Eastern and Southern United States
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JAIDS Sept 2021
This study found that expanding current CDC PrEP prescribing criteria to be specific to transgender women can identify a sizeable number of additional women who could benefit from PrEP. Both PrEP uptake and adherence, however, are low among transgender women who are indicated for PrEP, which is matched by low self-perceived risk of HIV acquisition. These findings highlight the need for transgender women to receive individualized PrEP recommendations and effective education concerning the benefits of PrEP to support PrEP uptake and adherence among those who need it the most.
In this study, we found that there would be an additional 12% of study participants who would be PrEP-indicated using prescribing criteria specific to transgender women compared with those using the current CDC prescribing criteria.
Being non-Hispanic/Latinx Black, Hispanic/Latinx, having above-average drug use, ever being homeless, or having a recent (within the past 3 months) occurrence of psychological violence were associated with a higher prevalence of PrEP indication
The study also found a high proportion (more than half) of those indicated for PrEP had reported that they had no or low risk of acquiring HIV, even after analytically excluding participants who reported PrEP use.
Generally, these findings confirm the greater need for health practitioners to proactively engage with these patient populations and to increase opportunities for transgender women to learn about and access PrEP.

Preexposure prophylaxis (PrEP) is effective in preventing HIV among adherent users. However, PrEP uptake among transgender women is low, and current prescribing guidelines from the Centers for Disease Control and Prevention (CDC) are not specific to transgender women. Self-perceived risk of HIV among those who are PrEP-indicated is not well understood.
This cross-sectional analysis included 1293 transgender women screened at baseline from March 2018 to May 2020 for a multisite, prospective cohort study. We compared the prevalence of PrEP indication using current CDC prescribing criteria versus transgender women–specific criteria developed by study investigators with community input. We identified factors associated with study-specific PrEP indication and factors associated with self-perceived low to no HIV risk among those who were PrEP-indicated. We also calculated descriptive statistics to depict the PrEP care continuum.
PrEP indication prevalence using transgender women–specific criteria was 47% (611), 155 more than who were identified using the CDC criteria. Eighty-three percent were aware of PrEP, among whom 38% had ever used PrEP. Among PrEP ever users, 63% were using PrEP at the time of the study. There were 66% of current PrEP users who reported 100% adherence within the previous 7 days. Among those who were PrEP-indicated, 13% were using and adherent to PrEP at the time of the study. More than half (55%) of PrEP-indicated participants had low or no self-perceived HIV risk.

These findings suggest that further guidance is needed for health care providers in prescribing PrEP to transgender women. Greater uptake and adherence are also needed for optimal effectiveness.
As of May 2020, 1293 participants who showed a negative result for HIV test were enrolled in the baseline visit. Among them, 57% were younger than 30 years, 14% were identified as non-Hispanic/Latinx Black, 28% reported less than high school education, and 72% endorsed low perceived HIV acquisition risk (Table 2). Eleven percent of participants reported current PrEP use at the time of enrollment.

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