Factors Associated with HIV Infection among Transgender Women in Cambodia: Results from a National Integrated Biological and Behavioral Survey Siyan Yi, MD, MHSc, PhD Director, KHANA Center for Population Health Research, Cambodia Adjunct Ass. Professor, Touro University California, USA Email: siyan@doctor.com July 25, 2017 11/20/2018

Global HIV Epidemic among TG Women Challenges in HIV programs: Long been known to be at high risk for HIV acquisition and transmission Poor access to intervention programs, and not well understood due to their hidden and stigmatized nature HIV prevalence (2000–2011): Global: 19.1% LMIC: 17.7% High-income countries: 21.6% (Baral et al., Lancet 2013)

Objectives To explore HIV prevalence and examine risk factors for HIV infection among transgender women in Cambodia

Methods Cross-sectional survey: Inclusion criteria Data collection: Dec 2015 – Feb 2016 Study sites: Phnom Penh and 12 provinces Sample: 1,375 Sampling method: Respondent driven sampling Inclusion criteria Being TG women by definition Age 18 years old or older Sexually active (having sex with at least one man in past 12M) Able and willing to provide written informed consent Ethical consideration: Approval from NECHR, written informed consent, privacy and confidentiality protection Data analyses: χ2 test, Fisher’s exact test, ANOVA, multivariate logistic regression

Independent Factors Associated with HIV Infection Variables in the final model AOR (95% CI) P-value Community type Rural Reference Urban 2.7 (1.1-6.5) 0.026 Age groups (in years) <25 25-34 2.1 (1.2-3.6) 0.012 ≥35 2.6 (1.3-5.4) 0.010 Education level High school or higher (≥7 years) Primary (0-6 years) 1.7 (1.1-2.9) 0.04 Frequency of express/dressing up as a woman Not all the time All the time 2.1 (1.2-3.8) 0.014

Independent Factors Associated with HIV Infection Variables in the final model AOR (95% CI) P-value Ever self-injected hormone No Reference Yes 4.4 (1.1-17.3) 0.032 Had cut or sores in the genital area in the past 12 months 3.0 (1.2-7.8) 0.023 Ever used online services developed for TG (e.g. Facebook, website) 1.9 (1.2-3.2) 0.012

Conclusions In Cambodia, TG women remain at an increased HIV risk (5.9%) despite the decline in the general population (0.3%). Recommendations: Priorities geared towards older and urban TG women with lower level of formal education and stronger feminine identity Education on safe hormone injection Prevention and treatment of STI

Acknowledgements Funders: Co-Investigators: President’s Emergency Fund for AIDS Relief (PEPFAR) through United States Agency for International Development (USAID) in Cambodia The Global Fund to Fight AIDS, Tuberculosis and Malaria Co-Investigators: Srean Chhim, MPH, FHI 360, Cambodia Chanrith Ngin, PhD, KHANA Center for Population Health Research Pheak Chhoun, MPH, KHANA Center for Population Health Research Sovannary Tuot, MA, KHANA Center for Population Health Research Jean-philippe Dousset, MD, FHI 360, Cambodia Khuondyla Pal (MHSc), KHANA Center for Population Health Research Phalkun Mun, MPH, National Center for HIV/AIDS, Dermatology and STD (NCHADS), Cambodia