High Awareness But Low Uptake of Pre-Exposure Prophylaxis in a Community Sample of Trans Masculine Adults in Massachusetts

Abstract

To the Editor:

Transgender people made up 2% of the 36,801 new HIV diagnoses in the United States in 2019, of which 6% of cases were diagnosed among trans masculine (TM) people and 94% were among trans feminine people.¹ Research shows that TM adults have diverse sexual partners and may engage in a wide range of sexual behaviors that can place them at risk for HIV.^2

–6 Despite documented sexual risk, a high prevalence of lifetime sexually transmitted infections (STIs), and a sizable prevalence of HIV infection in some TM populations, there have been few studies exploring TM adults' awareness and use of HIV pre-exposure prophylaxis (PrEP).^2,4,7
–9

Between March 2015 and September 2016, 148 TM adults enrolled in a Massachusetts-based sexual health study. Eligible participants were (1) ages 21–64 years, (2) assigned female sex at birth and had a masculine-spectrum gender identity, (3) have a cervix, (4) were sexually active within the past 3 years with partners of any gender, (5) able to speak and understand English, and (6) willing/able to provide informed consent. After consenting to the study, participants were surveyed about their sociodemographics, HIV risk behavior, PrEP awareness, and use. The study was IRB approved.

Bivariate and multi-variable logistic regression analyses examined the relationship between sociodemographics, gender affirmation, HIV status and testing history, sexual orientation and partnerships, HIV risk factors, and PrEP awareness (outcome). In the final age-adjusted model, the number of HIV risk factors was utilized as the primary independent variable to maximize statistical power (alpha <0.05).

The sample was primarily White non-Hispanic/Latinx (73.6%), had a binary gender identity (76.4%), had a college degree or more (62.2%), were employed (75.7%), and had a mean age of 27.3 years [standard deviation (SD) = 5.5]. Half the sample (50.0%) had a household income of >$32,000 a year, and 34.5% were current students. Three-quarters (75.0%) were currently taking gender-affirming hormones, and 40.5% had received one or more types of gender-affirming surgery. Most participants were HIV negative (81.1%); 18.9% did not know their status. Participants reported being tested for HIV 5.2 times in their lifetime (SD = 4.5; range, 0–25).

The majority had a sexual minority identity (87.8%), with the most common identity being queer (45.3%). Participants reported engaging in sexual contact with partners of diverse genders, though most (60.8%) reported sexual contact with a cisgender woman, and 41.2% reported sexual contact with a cisgender man in the past 12 months. Half the sample (50.5%) reported one or more HIV risk factors (mean = 0.9; SD = 1.1). In the past 12 months, 20.3% of the sample reported condomless receptive penile sex, 23.0% reported low-risk penile sex, 23.0% reported five or more sex partners, 4.1% reported sex work, and 3.4% reported having been diagnosed with an STI. Less than 2% of the sample (1.4%) reported injection drug use in the past 6 months. Much of the sample (76.7%) were aware of PrEP, and 1.4% had used PrEP (Table 1).

Table 1.

Descriptive Characteristics of Trans Masculine Sample (n = 148)

	Mean	SD
Sociodemographics
Age (in years)
Range: 21–50 years	27.3	5.5

	n	%
Race/ethnicity
White, non-Hispanic/Latinx	109	73.6
Person of color	39	26.4
White, Hispanic/Latinx	3	2.0
Asian, non-Hispanic/Latinx	9	6.1
Black/African American, non-Hispanic/Latinx	3	2.0
Black/African American, Hispanic/Latinx	1	0.7
Multi-racial, non-Hispanic/Latinx	13	8.8
Multi-racial, Hispanic/Latinx	10	6.8
Gender identity
Nonbinary	35	23.6
Binary	113	76.4
College degree or higher
Some college or less	56	37.8
College graduate or more	92	62.2
Employment status
Employed (full or part time)	112	75.7
Unemployed	33	22.3
Prefer not to answer	3	2.0
Student
No	96	64.9
Yes	51	34.5
Prefer not to answer	1	0.7
Annual household income
$32,000 or less	59	39.9
More than $32,000	74	50.0
Do not know	13	8.8
Prefer not to answer	2	1.4
Medical gender affirmation
Hormone use—current
No	37	25.0
Yes	111	75.0
Gender confirmation surgeries
No	88	59.5
Yes	60	40.5
HIV status and testing history
HIV status
Negative	120	81.1
Do not know	28	18.9

	Mean	SD
Number of times tested for HIV—lifetime (n = 141)
Range (0–25 times)	5.2	4.5

	n	%
Sexual orientation and partnering
Sexual minority identity
No	18	12.2
Yes	130	87.8
Gay/homosexual/same-gender attraction	13	8.8
Bisexual	17	11.5
Queer	67	45.3
Pansexual	17	11.5
Asexual	2	1.4
Questioning	4	2.7
Other	10	6.8
Gender of sexual partners—past 12 months
MAB
Cisgender man	61	41.2
Transgender woman	18	12.2
Male assigned sex at birth—gender nonconforming	8	5.4
FAB
Cisgender woman	90	60.8
Transgender man	23	15.5
Female assigned sex at birth—gender nonconforming	30	20.3
HIV risk factors
Condomless receptive penile sex—past 12 months^a
No penile sex	74	50.0
Yes, but low risk penile sex	34	23.0
Yes, condomless receptive penile sex	30	20.3
Prefer not to answer	10	6.8
Sex work—past 12 months
No	142	95.9
Yes	6	4.1
Five or more sex partners—past 12 months^b
No	113	76.4
Yes	34	23.0
Prefer not to answer	1	0.7
STI diagnosis—past 12 months
No	143	96.6
Yes	5	3.4
Injection drug use—past 6 months
No	146	98.6
Yes	2	1.4
Any HIV risk factor^c
No	74	50.0
Yes	74	50.0

	Mean	SD
Number of HIV risk factors
Range: 0–4	0.9	1.1

	n	%
Count
0	73	49.3
1	30	20.3
2	28	18.9
3	13	8.8
4	4	2.7
PrEP awareness and use
Awareness of PrEP
No	33	22.3
Yes	113	76.4
Do not know	2	1.4
Taken PrEP
No	146	98.6
Yes	2	1.4

Condomless receptive penile sex includes vaginal or anal sex; low-risk penile sex includes sex with a condom and/or oral sex.

Multiple sex partners includes two or more sex partners where sex is defined as genital to genital anal or vaginal sex.

HIV risk factors include condomless receptive penile sex, sex work past 12 months, STI in past 12 months, five or more sex partners in the past 12 months, and injection drug use—past 12 months.

FAB, female assigned sex at birth; MAB, male assigned sex at birth; PrEP, pre-exposure prophylaxis; SD, standard deviation; STI, sexually transmitted infection.

In the age-adjusted multi-variable model, having a college degree or more [adjusted odds ratio (aOR) = 4.35, p = 0.005], HIV-negative status (aOR = 7.37, p < 0.001), and the number of PrEP indications (aOR = 2.76, p = 0.008) were each associated with an increased odds of PrEP awareness (Table 2).

Table 2.

Factors Associated with Pre-Exposure Prophylaxis Awareness in a Sample of Trans Masculine Adults (n = 148)

	Bivariate models			Multi-variable model
	OR	95% CI	p	aOR	95% CI	p
Sociodemographics
Age in years, continuous
Range: 21–50 years	1.09	1.00–1.19	0.06	1.01	0.92–1.12	0.79
Race/ethnicity
White, non-Hispanic	Ref	—	—
Person of color	1.28	0.50–3.27	0.6
Gender identity
Nonbinary	Ref	—	—
Binary	1.02	0.41–2.52	0.97
Educational attainment
Some college or less	Ref	—	—	Ref	—	—
College graduate or more	4.07	1.80–9.19	<0.001	4.35	1.58–11.98	0.005
Employment status
Employed (full or part time)	Ref	—	—	Ref	—	—
Unemployed	2.60	0.84–8.02	0.098	2.97	0.81–10.92	0.10
Student
No	Ref	—	—
Yes	1.11	0.49–2.52	0.80
Annual household income
$32,000 or less	0.97	0.42–2.23	0.95
More than $32,000	Ref	—	—
Medical gender affirmation
Hormone use—current
No	Ref	—	—
Yes	0.75	0.29–1.89	0.54
Gender confirmation surgeries
No	Ref	—	—
Yes	1.48	0.65–3.33	0.35
HIV status and testing history
HIV status
Negative	6.20	2.49–15.46	<0.001	7.37	2.33–23.32	<0.001
Do not know	Ref	—	—	Ref	—	—
Number of times tested for HIV—lifetime (n = 141)
Range (0–25 times)	1.21	0.99–1.48	0.06	—	—	—
Sexual orientation and partnering
Sexual minority identity
No	Ref	—	—	Ref	—	—
Yes	5.71	2.03–16.04	0.001	3.29	0.92–11.82	0.07
HIV risk factors
STI diagnosis—past 12 months
No	Ref	—	—
Yes	1.17	0.13–10.88	0.89
Condomless receptive penile sex—past 12 months
No penile sex	Ref	—	—
Yes, but low-risk penile sex	10.20	1.30–80.01	0.03	—	—	—
Yes, condomless receptive penile sex	1.10	0.42–2.85	0.85	—	—	—
Sex work—past 12 months^c
No	—	—	—
Yes	—	—	—
Five or more sex partners—past 12 months
No	Ref	—	—	—	—	—
Yes	3.83	1.09–13.45	0.04	—	—	—
Injection drug use—past 6 months
No	Ref	—	—	—	—	—
Yes	0.29	0.02–4.70	0.38	—	—	—
Number of HIV risk factors
Continuous	1.93	1.21–3.07	0.01	2.76	1.30–5.86	0.008

Bolded p-value = significant at the p < 0.05 level. All of the participants who engaged in sex work were aware of PrEP, thus it was not possible to conduct bivariate analyses with the sex work variable. Variables with a p-value of <0.10 in the bivariate were included in the final multi-variable model. With the exception of HIV status, participants who reported “don't know” or “prefer not to answer “were excluded from analysis. The same size for the final model is n = 143. Although HIV status and number of times tested for HIV were both significant in the bivariate analyses, the majority of those who did not know their status had never been tested for HIV. Given the multi-collinearity between HIV status and number of times tested, HIV status was selected for inclusion in the final multi-variable over number of times tested to maximize the sample size. Because condomless receptive penile sex was used in the coding of number PrEP-related HIV risk factor indications, it was excluded from the final multi-variable model.

95% CI, 95% confidence interval; aOR, adjusted odds ratio; OR, odds ratio.

To our knowledge, this is one of the first studies to explore factors associated with PrEP awareness in a community sample of TM adults with a history of low- to high-risk sexual behavior. Notably, 76.7% of the sample were aware of PrEP, which was slightly lower than that of a 2017 national sample of higher risk TM who have sex with men (84.1%).⁹ However, only a minority of TM adults in the sample (1.4%) had ever utilized PrEP, despite 50% of the sample reporting one or more HIV risk factors in the past year.

Overall, these results suggest considerable gaps between PrEP awareness, HIV risk, and PrEP uptake. Study findings expand previous PrEP studies among TM adults,^2,4,7,8 and underscore the importance of future public health research and practice efforts to explore and address factors that can potentially be leveraged to inform PrEP uptake for this underserved population.

Half of our sample did not have any HIV risk factors (e.g., condomless penile sex, five or more partners, sex work history, injection drug use, and prior STI) and thus may not have been good candidates for PrEP.¹⁰ Yet, in the multi-variable model, as the number of HIV risk factors increased, so too did the odds of being aware of PrEP, suggesting that PrEP information appears to be reaching the TM adults in our sample who are most at risk for HIV. One method through which at-risk TM adults may be learning about PrEP is through HIV testing. In our sample, participants had been tested for HIV 5.2 times in their lifetime, and those who reported knowing their HIV-negative status were more likely to be aware of PrEP.

In addition, having a college degree (vs. some college or less) was also positively associated with PrEP awareness, even while controlling for age, suggesting that higher education may provide an avenue through which TM people can learn about PrEP. Together these findings highlight the potential importance of higher education, knowing one's HIV status, and individually recognizing one's HIV risk in becoming aware of PrEP as an HIV prevention modality.

Although our study was conducted in 2016, somewhat more contemporary data still suggest an underutilization of PrEP even among those at greater risk for HIV. Indeed, a 2017–2018 national online study of 157 HIV-negative TM people found that 26.1% had taken PrEP in their lifetime.⁷ Relatedly, a 2017–2018 national probability study found that of the 55 HIV-negative TM adults who had sex with cisgender men or trans women, only 3.2% were currently taking PrEP.⁸

One potential driver in the underutilization of PrEP among at-risk TM adults is adverse health care experiences, including limited provider knowledge of TM-specific health issues, mistreatment in health care, and TM adults' anticipation and avoidance of stigmatizing health care encounters.¹¹ Since PrEP access requires patients and providers to engage in conversations about sexual health, TM adults who experience discrimination or discomfort within their health care environment may not disclose their HIV risk behaviors, thereby preventing providers from having the requisite knowledge to educate at-risk patients about the benefits of PrEP.¹² Further, TM adults who avoid in-person health care encounters for fear of mistreatment may be unable to learn about PrEP or receive a prescription.

Ongoing efforts must be made to educate TM adults at risk for HIV to facilitate PrEP uptake. To increase PrEP awareness and uptake among at-risk TM adults, PrEP campaigns should be tailored to reach TM adults, and structural and interpersonal interventions are needed to remove barriers to HIV testing and health care more generally. Telehealth methods and care delivery outside of medical settings are possible avenues to explore for future intervention efforts to increase PrEP awareness and uptake in TM adults.

Finally, TM community collaboration is vital to developing and disseminating effective strategies to reach TM individuals who are most vulnerable to HIV infection and who may be missed by PrEP campaigns and the delivery of PrEP care. Through the employment of these strategies, we can help to ensure that all people who are at risk for HIV and could benefit from PrEP can access and use this lifesaving treatment.

Footnotes

Authors' Contributions

S.L.R. was the principal investigator of the parent study on which these data are based; M.B.D., J.P., and S.P. were coinvestigators on the parent study. J.M.W.H. and the investigators conceptualized the analysis, and J.M.W.H. conducted the analysis, created the tables, and wrote the methods, results, and discussion. Y.F., A.R., and L.B.K.-F. conducted a literature review and helped to write the article. All authors were involved in interpreting the data and editing the article. All authors approved this article.

Acknowledgments

We thank our participants and community partners for their time.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This research was partly supported by the Patient-Centered Outcomes Research Institute (PCORI) no. CER-1403-12625, awarded to S.L.R.

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