A study recently published
in The Journal of Acquired Immune
Deficiency Syndromes
indicates that transgender (trans) women in Brazil had
low levels of pre-exposure prophylaxis (PrEP) awareness. This was combined with significant proportions
being willing to use PrEP as a prevention tool and being eligible for PrEP.

Another recent qualitative
study published in Culture, Health and
provides a contextual frame for these findings as it explores the
HIV programming needs of trans women in Brazil. Several social and contextual
factors, such as experienced and anticipated trans discrimination and HIV
stigma, were linked to an avoidance of prevention and treatment services for
both HIV-negative and positive trans women. In addition to biomedical
interventions, socio-structural interventions also emerged as crucial for
trans women in Brazil.

Globally, trans women
are at a disproportionally higher risk of contracting HIV – this is estimated
at 49 times higher than other groups. In the South American context,
particularly Brazil, trans women have substantially higher rates of HIV
prevalence, even when compared to other key populations such as men who have
sex with men. It has been estimated that nearly a third of all trans women in
Brazil may be infected with HIV, often accessing healthcare testing and
treatment services late. This key population has been described as the most
at-risk group in the country.

There is a lack of
specific HIV prevention aimed at trans women in Brazil. The unique needs of this
community raises specific challenges: transphobia and healthcare-related
stigma, social and economic marginalisation, as well as issues related to
gender-related health care (such as concerns about interactions between HIV
medications and hormone therapy).

The first study utilised
respondent-driven sampling to recruit trans women for face-to-face interviews
which assessed PrEP awareness and willingness. It also estimated how many
trans women would be considered eligible for PrEP, based on factors such as not
being in a monogamous relationship, having had condomless anal sex or an STI in
the past 12 months or an HIV-positive sexual partner in the last three months. The
survey was conducted from August 2015 to January 2016 and data was collected
from 345 participants. All participants identified as trans women and resided in
Rio de Janeiro. Most participants were aged 25-35, with eight years or less of
formal education.

Participants were
first asked a question to probe for awareness of PrEP; after a brief
explanation, they were asked about willingness to take PrEP. Additional
questions included concerns about PrEP as well as preferred routes of
administration, sexual behaviour, drug and hormone use, experiences of
health-related stigma and so forth. HIV and STI testing was carried out with
all participants after the survey was conducted.

Of the 345
participants offered HIV testing, 59% were HIV negative, 29% had previously
been diagnosed with HIV and 12% were newly diagnosed with HIV. Thirty-eight per cent of
respondents had heard about PrEP, while 49% had heard about post-exposure
prophylaxis (PEP). However, only 6% of those who were not known to have HIV
infection had ever accessed PEP. Higher PrEP awareness was associated with accessing
health services in the past six months (adjusted odds ratio 2.1, P = 0.004),
having at least one known HIV-positive partner (AOR 2.0, P = 0.04) and more
than eight years of education (AOR 1.5, P = 0.079). Lower PrEP awareness was associated
with condomless anal sex (AOR 0.6, P = 0.04) and a newly diagnosed HIV
infection (AOR 0.4, P = 0.035).

PrEP willingness was
assessed in those who self-reported as HIV negative. The majority of
participants (76%) expressed willingness to use PrEP after a brief explanation,
despite concerns about side-effects and interactions with hormones. Factors
positively associated with PrEP willingness included being younger (aged 18-35)
and high perceived HIV risk (participants’ rating of how likely they were to
contract HIV in the next year). Factors associated with being less willing to
use PrEP included concerns with long-term effects of PrEP and possible
challenges accessing it as a result of stigma encountered in healthcare
settings. A high percentage of HIV-negative trans women met the criteria for
PrEP eligibility criteria (67%), rising to 78% of those discovered to be
newly infected during the study. This indicates a significant need for PrEP as
a prevention tool in this community.