Determinants of HIV Pre-Exposure Prophylaxis (PrEP) Retention among Transgender Women: A Sequential, Explanatory Mixed Methods Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Data Collection
2.3. Analysis
3. Results
3.1. Sex Work
3.1.1. Non-Survival Sex Work
Besides initially experiencing headaches when taking PrEP, she did not experience other challenges: “Nothing, I’ve nothing. Oh! Ahm. No, not even the financial thing, no. Cause ahm the insurance covered it. I only pay like 4 dollars or something” (47 years old, on PrEP, engaged in sex work).“Now I always. Uhmm. I always use condoms for everything. You know. Usually, I would be like if I knew the client or whatever maybe I would do oral without it. But now I do not even do that anymore. I just it’s automatic. You know what I mean? Cause it’s just not me, I have to think about him. You know and that really scared me. You know. When she [the doctor] said I had gonorrhea and chlamydia, I was fucking really scared. You know. And then, I was worried about him [her partner]”(47 years old, on PrEP, engaged in sex work).
3.1.2. Survival Sex Work
This participant later described how cost was a major barrier to PrEP, which leads TW to make trade-offs between protecting themselves from HIV and achieving their gender affirmation goals, which could lead to more income through sex work as clients sometimes prefer TW who have undergone more gender-affirming medical treatments. She also noted that TW often access hormones and silicone injections outside of medical settings to save money.“There has been so many times where I’ve applied for jobs, and they told me that I couldn’t work there once they’d seen my ID. Uhm, sex work I consider is a form of survival… There’s been plenty of times where I’ve had to have sex with people just to pay my rent at the end of the month or even just to stay the night at somebody’s place just to survive”(26 years old, on PrEP, engaged in sex work).
Further, she reported being unable to attend PrEP appointments, which led to her discontinuing PrEP use, and she has yet to re-initiate PrEP despite wanting to.“Not well. I am. I’ve asked for them to wear condoms. I’ve asked of them to be respectful in that manner, but if they uhm… refuse I don’t really know how to say no. Because, I should have a hard, a hard line that I don’t want them to cross that, because I don’t want them to cross that line. But, when they do, I don’t know how to just say ‘No, this isn’t happening’ like because at the end of the day they have something I want, or need, and… It’s… I’m playing by their rules”(28 years old, not on PrEP, engaged in sex work).
“They’re scared to go fill out an application for a house cause they don’t have a W2. Or their money is coming from sex work. They can’t, you know. It’s just. I, I just think that people need to, you know, just be open minded about, you know. Transexuals are out there. You know, they they are escorting and they do make money they can pay their bills. You know, so maybe help them get into housing and stuff like that, cause, it’s a lot. That’s what happened to me a lot. I couldn’t, you know, go and fill an application. They’re gonna be like ‘Okay, well where is your pay stubs? Where is your W2s?’ And, you know. I could be making more money than a lot of people but I can’t prove it. You know, so. And housing is a big thing for transexuals. A lot of them don’t have it”(47 years old, on PrEP, engaged in sex work).
This quote suggests that clinical services and health promotion interventions targeting TW engaged in sex work should consider the risk of exposing the patient’s/participant’s sex work status, as this may lead to violence against them.“I mean, as far as like sex work goes it’s uh, it’s, it’s something that people often have to like hand like they have to go about it with a level of privacy and uh discretion. So, just like. Is like as long as the other people can have that discretion as well. And not, not in like a shameful way but just in like you have to be strategic and uhm people, people can be hostile towards you. So, just. It doesn’t have to be like screamed at you but uh just being able, so being able to relate that relate stuff to you in a way that uhm is secure”(28 years old, on PrEP, engaged in sex work).
3.2. Substance Use
3.3. Gender Affirmation
4. Discussion
Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Centers for Disease Control and Prevention. HIV Infection, Risk, Prevention, and Testing Behaviors Among Transgender Women—National HIV Behavioral Surveillance, 7 U.S. Cities, 2019–2020. In HIV Surveillance Special Report 27 April 2021; Centers for Disease Control and Prevention: Atlanta, GA, USA, 2021. [Google Scholar]
- Malone, J.; Reisner, S.L.; Cooney, E.E.; Poteat, T.; Cannon, C.M.; Schneider, J.S.; Radix, A.; Mayer, K.H.; Haw, J.S.; Althoff, K.N.; et al. 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. JAIDS J. Acquir. Immune Defic. Syndr. 2021, 88, 10–18. [Google Scholar] [CrossRef]
- Spinner, C.D.; Boesecke, C.; Zink, A.; Jessen, H.; Stellbrink, H.-J.; Rockstroh, J.K.; Esser, S. HIV pre-exposure prophylaxis (PrEP): A review of current knowledge of oral systemic HIV PrEP in humans. Infection 2016, 44, 151–158. [Google Scholar] [CrossRef]
- Chan, P.A.; Patel, R.R.; Mena, L.; Marshall, B.D.; Rose, J.; Coats, C.S.; Montgomery, M.C.; Tao, J.; Sosnowy, C.; Mayer, K.H.; et al. Long-term retention in pre-exposure prophylaxis care among men who have sex with men and transgender women in the United States. J. Int. AIDS Soc. 2019, 22, e25385. [Google Scholar] [CrossRef] [PubMed]
- Lennon, E.; Mistler, B.J. Cisgenderism. Transgender Stud. Q. 2014, 1, 63–64. [Google Scholar] [CrossRef]
- Zamantakis, A.; Li, D.H.; Benbow, N.; Smith, J.D.; Mustanski, B. Determinants of Pre-exposure Prophylaxis (PrEP) Implementation in Transgender Populations: A Qualitative Scoping Review. AIDS Behav. 2022, 27, 1600–1618. [Google Scholar] [CrossRef]
- Sevelius, J.M. Gender Affirmation: A Framework for Conceptualizing Risk Behavior Among Transgender Women of Color. Sex Roles 2013, 68, 675–689. [Google Scholar] [CrossRef] [PubMed]
- Gebru, N.M.; Canidate, S.S.; Liu, Y.; Schaefer, S.E.; Pavila, E.; Cook, R.L.; Leeman, R.F. Substance Use and Adherence to HIV Pre-Exposure Prophylaxis in Studies Enrolling Men Who Have Sex with Men and Transgender Women: A Systematic Review. AIDS Behav. 2023, 27, 2131–2162. [Google Scholar] [CrossRef] [PubMed]
- Kuhns, L.M.; Reisner, S.L.; Mimiaga, M.J.; Gayles, T.; Shelendich, M.; Garofalo, R. Correlates of PrEP Indication in a Multi-Site Cohort of Young HIV-Uninfected Transgender Women. AIDS Behav. 2016, 20, 1470–1477. [Google Scholar] [CrossRef] [PubMed]
- Marshall, B.D.L.; Mimiaga, M.J. Uptake and effectiveness of PrEP for transgender women. Lancet HIV 2015, 2, e502–e503. [Google Scholar] [CrossRef]
- Nadal, K.L.; Davidoff, K.C.; Fujii-Doe, W. Transgender Women and the Sex Work Industry: Roots in Systemic, Institutional, and Interpersonal Discrimination. J. Trauma Dissociation 2014, 15, 169–183. [Google Scholar] [CrossRef]
- Logie, C.H.; Wang, Y.; Lacombe-Duncan, A.; Jones, N.; Ahmed, U.; Levermore, K.; Newman, P.A. Factors associated with sex work involvement among transgender women in Jamaica: A cross-sectional study. J. Int. AIDS Soc. 2017, 20, 21422. [Google Scholar] [CrossRef]
- Cooney, E.E.; Reisner, S.L.; Saleem, H.T.; Althoff, K.N.; Beckham, S.W.; Radix, A.; Cannon, C.M.; Schneider, J.S.; Haw, J.S.; Rodriguez, A.E.; et al. Prevention-effective adherence trajectories among transgender women indicated for PrEP in the United States: A prospective cohort study. Ann. Epidemiol. 2022, 70, 23–31. [Google Scholar] [CrossRef]
- Cooney, E.E.; Footer, K.H.A.; Glick, J.L.; Passaniti, A.; Howes, M.; Sherman, S.G. Understanding the social and structural context of oral PrEP delivery: An ethnography exploring barriers and facilitators impacting transgender women who engage in street-based sex work in Baltimore, Maryland. AIDS Res. Ther. 2023, 20, 69. [Google Scholar] [CrossRef] [PubMed]
- Becasen, J.S.; Denard, C.L.; Mullins, M.M.; Higa, D.H.; Sipe, T.A. Estimating the Prevalence of HIV and Sexual Behaviors Among the US Transgender Population: A Systematic Review and Meta-Analysis, 2006–2017. Am. J. Public Health 2019, 109, e1–e8. [Google Scholar] [CrossRef]
- Kcomt, L. Profound health-care discrimination experienced by transgender people: Rapid systematic review. Soc. Work Health Care 2019, 58, 201–219. [Google Scholar] [CrossRef]
- Wilson, E.C.; Garofalo, R.; Harris, R.D.; Herrick, A.; Martinez, M.; Martinez, J.; Belzer, M. Transgender Female Youth and Sex Work: HIV Risk and a Comparison of Life Factors Related to Engagement in Sex Work. AIDS Behav. 2009, 13, 902–913. [Google Scholar] [CrossRef] [PubMed]
- Basu, A.; Ketheeswaran, N.; Cusanno, B.R. Localocentricity, mental health and medical poverty in communication about sex work, HIV and AIDS among trans women engaged in sex work. Cult. Health Sex. 2022, 24, 125–137. [Google Scholar] [CrossRef]
- Poteat, T.; White, R.H.; A Footer, K.H.; Park, J.N.; Galai, N.; Huettner, S.; E Silberzahn, B.; Allen, S.T.; Glick, J.; Beckham, S.W.; et al. Characterising HIV and STIs among transgender female sex workers: A longitudinal analysis. Sex. Transm. Infect. 2021, 97, 226–231. [Google Scholar] [CrossRef]
- Operario, D.; Soma, T.; Underhill, K. Sex work and HIV status among transgender women: Systematic review and meta-analysis. JAIDS J. Acquir. Immune Defic. Syndr. 2008, 48, 97–103. [Google Scholar] [CrossRef]
- Budhwani, H.; Hearld, K.R.; Hasbun, J.; Charow, R.; Rosario, S.; Tillotson, L.; Waters, J. Transgender female sex workers’ HIV knowledge, experienced stigma, and condom use in the Dominican Republic. PLoS ONE 2017, 12, e0186457. [Google Scholar] [CrossRef]
- Brooks, R.A.; Cabral, A.; Nieto, O.; Fehrenbacher, A.; Landrian, A. Experiences of Pre-Exposure Prophylaxis Stigma, Social Support, and Information Dissemination Among Black and Latina Transgender Women Who Are Using Pre-Exposure Prophylaxis. Transgender Health 2019, 4, 188–196. [Google Scholar] [CrossRef]
- Reisner, S.L.S.; Radix, A.; Deutsch, M.B. Integrated and Gender-Affirming Transgender Clinical Care and Research. J. Acquir. Immune Defic. Syndr. 2016, 72, S235–S242. [Google Scholar] [CrossRef]
- Rivera, A.V.; Lopez, J.M.; Braunstein, S.L. Exploring the Association Between Gender Affirmation and PrEP use Among Transgender Women in New York City. AIDS Behav. 2022, 27, 1523–1530. [Google Scholar] [CrossRef] [PubMed]
- Andrzejewski, J.; Dunville, R.; Johns, M.M.; Michaels, S.; Reisner, S.L. Medical gender affirmation and HIV and sexually transmitted disease prevention in transgender youth: Results from the Survey of Today’s Adolescent Relationships and Transitions. LGBT Health 2021, 8, 181–189. [Google Scholar] [CrossRef] [PubMed]
- Dang, M.; Scheim, A.I.; Teti, M.; Quinn, K.G.; Zarwell, M.; Petroll, A.E.; Horvath, K.J.; John, S.A. Barriers and Facilitators to HIV Pre-Exposure Prophylaxis Uptake, Adherence, and Persistence Among Transgender Populations in the United States: A Systematic Review. AIDS Patient Care STDs 2022, 36, 236–248. [Google Scholar] [CrossRef] [PubMed]
- Cahill, S.R.; Keatley, J.; Wade Taylor, S.; Sevelius, J.; Elsesser, S.A.; Geffen, S.R.; Mayer, K.H. Some of us, we don’t know where we’re going to be tomorrow. Contextual factors affecting PrEP use and adherence among a diverse sample of transgender women in San Francisco. AIDS Care 2022, 32, 585–593. [Google Scholar] [CrossRef] [PubMed]
- Storholm, E.D.; Ogunbajo, A.; Nacht, C.L.; Opalo, C.; Horvath, K.J.; Lyman, P.; Flynn, R.; Reback, C.J.; Blumenthal, J.; Moore, D.J.; et al. Facilitators of PrEP Persistence among Black and Latinx Transgender Women in a PrEP Demonstration Project in Southern California. Behav. Med. 2022, 1, 1–12. [Google Scholar] [CrossRef] [PubMed]
- Sevelius, J.M.; Deutsch, M.B.; Grant, R. The future of PrEP among transgender women: The critical role of gender affirmation in research and clinical practices. J. Int. AIDS Soc. 2016, 19, 21105. [Google Scholar] [CrossRef] [PubMed]
- Yager, J.L.; Anderson, P.L. Pharmacology and drug interactions with HIV PrEP in transgender persons receiving gender affirming hormone therapy. Expert Opin. Drug Metab. Toxicol. 2020, 16, 463–474. [Google Scholar] [CrossRef]
- Ivankova, N.V.; Creswell, J.W.; Stick, S.L. Using mixed-methods sequential explanatory design: From theory to practice. Field Methods 2006, 18, 3–20. [Google Scholar] [CrossRef]
- Morris, S.R.; Jain, S.; Blumenthal, J.; Bolan, R.; Dubé, M.P.; Henderson, P.; Moore, D.J. Randomized trial of individualized texting for adherence building (iTAB) plus motivational interviewing for PrEP adherence in transgender individuals: The iM-PrEPT study. JAIDS J. Acquir. Immune Defic. Syndr. 2022, 91, 453–459. [Google Scholar] [CrossRef] [PubMed]
- Onwuegbuzie, A.J.; Collins, K.M. A typology of mixed methods sampling designs in social science research. Qual. Rep. 2007, 12, 281–316. [Google Scholar] [CrossRef]
- Skinner, H.A. The drug abuse screening test. Addict. Behav. 1982, 7, 363–371. [Google Scholar] [CrossRef] [PubMed]
- Guest, G.; MacQueen, K.M.; Namey, E.E. Applied Thematic Analysis; Sage Publications: Thousand Oaks, CA, USA, 2011. [Google Scholar]
- Dedoose Version 9.0.17. In Cloud Application for Managing, Analyzing, and Presenting Qualitative and Mixed Method Research Data; SocioCultural Research Consultants, LLC.: Los Angeles, CA, USA, 2021.
- Sevelius, J.M.; Keatley, J.; Calma, N.; Arnold, E. ‘I am not a man’: Trans-specific barriers and facilitators to PrEP acceptability among transgender women. Glob. Public Health 2016, 11, 1060–1075. [Google Scholar] [CrossRef]
- Strathdee, S.A.; Crago, A.-L.; Butler, J.; Bekker, L.-G.; Beyrer, C. Dispelling myths about sex workers and HIV. Lancet 2015, 385, 4–7. [Google Scholar] [CrossRef] [PubMed]
- Downing, J.; Yee, K.; Sevelius, J.M. PrEP use and adherence among transgender patients. AIDS Behav. 2022, 26, 1251–1259. [Google Scholar] [CrossRef]
- Millar, B.M.; English, D.; Moody, R.L.; Rendina, H.J.; Cain, D.; Antebi-Gruszka, N.; Parsons, J.T. Day-level associations between substance use and HIV risk behavior among a diverse sample of transgender women. Transgender Health 2018, 3, 210–219. [Google Scholar] [CrossRef]
- Bielenberg, J.; Swisher, G.; Lembke, A.; Haug, N.A. A systematic review of stigma interventions for providers who treat patients with substance use disorders. J. Subst. Abus. Treat. 2021, 131, 108486. [Google Scholar] [CrossRef]
- Glick, J.L.; Zhang, L.; Rosen, J.G.; Yaroshevich, K.; Atiba, B.; Pelaez, D.; Park, J.N. A novel capacity-strengthening intervention for frontline harm reduction workers to support pre-exposure prophylaxis awareness-building and promotion among people who use drugs: Formative research and intervention development. JMIR Form. Res. 2023, 7, e42418. [Google Scholar] [CrossRef]
- Wood, S.M.; Lee, S.; Barg, F.K.; Castillo, M.; Dowshen, N. Young transgender women’s attitudes toward HIV pre-exposure prophylaxis. J. Adolesc. Health 2017, 60, 549–555. [Google Scholar] [CrossRef]
- Poteat, T.; Wirtz, A.L.; Reisner, S. Strategies for engaging transgender populations in HIV prevention and care. Curr. Opin. HIV AIDS 2019, 14, 393–400. [Google Scholar] [CrossRef] [PubMed]
24 Weeks | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Total (N = 170) | Retained (N = 114) | Lost to Follow-Up (N = 56) | ||||||||||
Characteristic | n | % | Mean | SD | n | % | Mean | SD | n | % | Mean | SD |
Age in years | - | - | 33.1 | 10.2 | - | - | 34.0 | 0.7 | - | - | 31.2 | 8.8 |
Race/ethnicity | ||||||||||||
White | 35 | 20.8 | - | - | 25 | 22.3 | - | - | 10 | 17.9 | - | - |
Latinx/Hispanic | 60 | 35.7 | - | - | 35 | 31.3 | - | - | 25 | 44.6 | - | - |
Black/African American | 24 | 14.3 | - | - | 17 | 15.2 | - | - | 7 | 12.5 | - | - |
Asian/Native Hawaiian/Pacific Islander | 20 | 11.9 | - | - | 14 | 12.5 | - | - | 6 | 10.7 | - | - |
Other | 29 | 17.3 | - | - | 21 | 18.8 | - | - | 8 | 14.3 | - | - |
Sexual orientation | ||||||||||||
Heterosexual | 85 | 50.0 | - | - | 49 | 43.0 | - | - | 36 | 64.3 | - | - |
Gay | 9 | 5.3 | - | - | 6 | 5.3 | - | - | 3 | 5.4 | - | - |
Lesbian | 7 | 4.1 | - | - | 6 | 5.3 | - | - | 1 | 1.8 | - | - |
Queer | 10 | 5.9 | - | - | 8 | 7.0 | - | - | 2 | 3.6 | - | - |
Bisexual | 19 | 11.2 | - | - | 16 | 14.0 | - | - | 3 | 5.4 | - | - |
Pansexual | 26 | 15.3 | - | - | 19 | 16.7 | - | - | 7 | 12.5 | - | - |
Other | 14 | 8.3 | - | - | 10 | 8.8 | - | - | 4 | 7.1 | - | - |
Relationship status | ||||||||||||
Single | 111 | 65.3 | - | - | 72 | 63.2 | - | - | 39 | 69.6 | - | - |
In a monogamous relationship | 21 | 12.4 | - | - | 11 | 9.7 | - | - | 10 | 17.9 | - | - |
In an open/polyamorous relationship | 23 | 13.5 | - | - | 20 | 17.5 | - | - | 3 | 5.4 | - | - |
Married | 7 | 4.1 | - | - | 4 | 3.5 | - | - | 3 | 5.4 | - | - |
Separated, divorced, or widowed | 4 | 2.4 | - | - | 3 | 2.6 | - | - | 1 | 1.8 | - | - |
Other | 4 | 2.4 | - | - | 4 | 3.5 | - | - | 0 | 0.0 | - | - |
Highest level of education | ||||||||||||
Less than high school | 11 | 6.6 | - | - | 6 | 5.4 | - | - | 5 | 9.3 | - | - |
High school diploma or GED | 46 | 27.7 | - | - | 26 | 23.2 | - | - | 20 | 37.0 | - | - |
Some college or technical training | 83 | 50.0 | - | - | 59 | 52.7 | - | - | 24 | 44.4 | - | - |
Bachelor’s degree | 16 | 9.6 | - | - | 13 | 11.6 | - | - | 3 | 5.6 | - | - |
Some post-graduate training | 1 | 0.6 | - | - | 1 | 0.9 | - | - | 0 | 0.0 | - | - |
Graduate degree | 9 | 5.4 | - | - | 7 | 6.3 | - | - | 2 | 3.7 | - | - |
Employment status | ||||||||||||
Full-time employment | 36 | 21.7 | - | - | 31 | 27.7 | - | - | 5 | 9.3 | - | - |
Part-time employment | 30 | 18.1 | - | - | 24 | 21.4 | - | - | 6 | 11.1 | - | - |
Unemployed | 81 | 48.8 | - | - | 45 | 40.2 | - | - | 36 | 66.7 | - | - |
Retired | 2 | 1.2 | - | - | 2 | 1.8 | - | - | 0 | 0.0 | - | - |
Student | 8 | 4.8 | - | - | 4 | 3.6 | - | - | 4 | 7.4 | - | - |
Unable to work (i.e., due to disability) | 9 | 5.4 | - | - | 6 | 5.4 | - | - | 3 | 5.6 | - | - |
Engages in sex work as full or part-time employment | 17 | 10.8 | - | - | 8 | 7.4 | - | - | 9 | 18.4 | - | - |
Health Insurance | 116 | 68.2 | - | - | 83 | 72.8 | - | - | 33 | 58.9 | - | - |
Substantial or severe drug use problem (past 12 months) | 16 | 10.9 | - | - | 8 | 7.8 | - | - | 8 | 17.8 | - | - |
Hormone therapy use | 111 | 66.1 | - | - | 80 | 70.8 | - | - | 31 | 56.4 | - | - |
Gender | Female/woman, n (%) | 5 (33.3) |
Trans female/trans woman, n (%) | 7 (46.7) | |
Transfeminine, male to female, transgender, or transsexual woman, n (%) | 4 (26.7) | |
Race and ethnicity | Black or African American, n (%) | 3 (20.0) |
Latina/x, n (%) | 6 (40.0) | |
White, n (%) | 9 (60.0) | |
Spanish or multiracial, n (%) | 2 (13.3) | |
Currently on PrEP, n (%) | 10 (66.7) | |
Sex work experienced, n (%) | 9 (60.0) | |
Age, mean (standard deviation) | 35.8 (9.7) |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Andrzejewski, J.; Pines, H.A.; Morris, S.; Burke, L.; Bolan, R.; Sevelius, J.; Moore, D.J.; Blumenthal, J. Determinants of HIV Pre-Exposure Prophylaxis (PrEP) Retention among Transgender Women: A Sequential, Explanatory Mixed Methods Study. Int. J. Environ. Res. Public Health 2024, 21, 133. https://doi.org/10.3390/ijerph21020133
Andrzejewski J, Pines HA, Morris S, Burke L, Bolan R, Sevelius J, Moore DJ, Blumenthal J. Determinants of HIV Pre-Exposure Prophylaxis (PrEP) Retention among Transgender Women: A Sequential, Explanatory Mixed Methods Study. International Journal of Environmental Research and Public Health. 2024; 21(2):133. https://doi.org/10.3390/ijerph21020133
Chicago/Turabian StyleAndrzejewski, Jack, Heather A. Pines, Sheldon Morris, Leah Burke, Robert Bolan, Jae Sevelius, David J. Moore, and Jill Blumenthal. 2024. "Determinants of HIV Pre-Exposure Prophylaxis (PrEP) Retention among Transgender Women: A Sequential, Explanatory Mixed Methods Study" International Journal of Environmental Research and Public Health 21, no. 2: 133. https://doi.org/10.3390/ijerph21020133