What are the Opportunities and Challenges?

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What are the Opportunities and Challenges? PrEP for Trans Women: What are the Opportunities and Challenges? JoAnne G. Keatley, MSW Center of Excellence for Transgender Health Director and Co-Principal Investigator © University of California, San Francisco Center of Excellence for Transgender Health

Our mission is to increase access to comprehensive, effective, and affirming healthcare services for trans communities

PrEP Considerations Is PrEP a viable option for trans women? Why are trans women enrolled in PrEP demonstration projects not retained in the research? Why are trans women included in MSM demonstration projects? Why are all women underrepresented? Are there cs hormone interactions to consider? Who pays for PrEP?

Trans women in iPrEx In iPrEx, a subanalysis found zero effectiveness among trans women on an intention to treat basis. 2 iPrEx investigators have speculated that this was likely due to barriers to uptake and adherence among transwomen in iPrEx. PrEP use was not linked to behavioral indicators of HIV risk among trans women in iPrEx, while MSM at highest risk were more adherent.

Community awareness of PrEP We conducted two series of a total 5 focus groups of HIV-negative trans women in San Francisco to explore their knowledge, beliefs, and attitudes toward PrEP as a prevention tool 3 One group in Spanish, 4 in English N=49

No participants reported having taken PrEP or having been offered PrEP by a provider. The vast majority of participants had never heard of PrEP, demonstrating that trans women are not reached by programs that serve MSM. Levels of interest in PrEP as a potential prevention tool were mixed, with most frequently voiced concerns about safety, side effects, and cost. Participants expressed high levels of medical mistrust. Hormones are the most important medical priority for many transgender women.

Medical Mistrust “Most [providers] see us as gay men and most don’t understand that we’re women and most don’t treat us as such…So, I have gone to [a PrEP clinic in San Francisco] before for testing and I felt completely uncomfortable because I am the only trans woman sitting there, and yet they see me as just another guy. It’s like, it’s not fair...Everyone has the right to the same healthcare.” - Focus group 2

Facilitators Competent, sensitive, culturally aware providers serve as a strong link to the community Structural interventions (ie. job training, housing, diversion programs, behavioral health services) More research needed on csHT and ARV drug interactions

References Baral SD, Poteat T, Stromdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis. 2013;13(3):214-222. Deutsch M, Sevelius J, Glidden D, Keatley, J., Grant R. Preexposure Chemoprophylaxis for HIV Prevention In Transgender Women. European Professional Association for Transgender Health; 2015; Ghent, Belgium. Sevelius JM, Keatley J, Calma N, Arnold E. “I am not a man”: Trans-specific barriers and facilitators to PrEP acceptability among transgender women. Global Public Health. (provisional acceptance) Special issue, The Trouble with ‘Categories’: Rethinking MSM, Trans and their Equivalents in HIV Prevention and Health Promotion.