Share your thoughts on this presentation with #IAS2019 Evaluation of syndemics in transgender women (TGW) using pre-exposure prophylaxis (PrEP) for HIV prevention: preliminary findings Michelle Ramos¹, Emilia Jalil¹, Flavia Lessa¹, Cristiane Castro¹, Cristina Jalil¹, Eduardo Carvalheira¹, Laylla Monteiro¹, Cléo Souza¹, Biancka Fernandes¹, Luciana Kamel¹, Ronaldo I. Moreira¹, Vinicius Pacheco¹, Valdilea Veloso¹, Beatriz Grinsztejn¹, Raquel B. De Boni¹. 1 LAPCLIN-AIDS, Instituto Nacional de Infectologia Evandro Chagas (INI) FIOCRUZ, Rio de Janeiro, Brazil Share your thoughts on this presentation with #IAS2019

BACKGROUND What is syndemic? Transgender women (TGW) The cluster of ≥2 health/social conditions that interact and increase the occurrence of other health problems. Transgender women (TGW) Key- population for HIV infection 19.1% of HIV prevalence worldwide ² Brazil : 31.2% population estimates by Transcender³, 30.0% by DIVAS (12 Brazilian cities) Limited academic literature on syndemics among TGW PrEP : Available at no cost at Brazilian public health system (SUS) since 2017 ¹Singer M, 1994;²Baral et al., 2013; ³ GRINSZTEJN et al., 2018; (BASTOS et al., 2018)

OBJECTIVE To assess syndemics prevalence and its associated factors among TGW screened for the PrEParadas Study – first Brazilian trans-specific PrEP demonstration project (initial primary findings presented at IAS 2019 session: TUAC0302 – Start stop restart: Supporting effective PrEP use)

METHODS Secondary cross-sectional analysis of PrEParadas study Inclusion criteria for PrEParadas: being TGW, living at Rio de Janeiro or metropolitan area, 18+ years, at risk for HIV infection All TGW with valid results for the primary outomes at screening were included in this analysis Data collection at screening visit Measures OUTCOME: Syndemic Standardized and validated questionnaires screening for: Polysubstance use (ASSIST)¹ Binge drinking² Depression(PHQ-9)³ Sexual compulsive behavior (SCB) Intimate partner violence (IPV) Syndemic ≥ 2 ¹ASSIST (WHO), ² Binge drinking (NIAAA,2004), ³ PHQ-9(KROENKE et. al, 2001,  SCB(PARSONS, 2016)

METHODS Study variables Sociodemographics (age, race/color, education, employment status, marital status) Sexual risk : condomless anal sex, sexually transmitted infections (STI), sex with a HIV positive partner, transactional sex, post-exposure prophylaxis (PEP), HIV testing, perceived likelihood of getting HIV Mental health: anxiety (GAD-7)*, high impulsivity (Barrat Impulsiveness Scale-11)*², substance abuse/dependence, suicide risk Vulnerabilities: physical/ sexual violence, child abuse, school dropout Gender discrimination Statistical Analysis Bivariate analysis: Chi-square, Fisher’s exact test and Mann–Whitney U test Multiple logistic regression including variables with p<0.2 at bivariate *SPITZER RL, et al, 2006;*²PATTON JH, 1995

147 TGW screened and 143 had valid results for outcome variables. Prevalence of syndemic conditions among 143 TGW screened for PrEPARADAS study. Rio de Janeiro, Brazil, 2018 

NUMBER OF SYNDEMIC CONDITIONS AMONG TGW SCREENED FOR PrEPARADAS STUDY, RIO DE JANEIRO, 2017-2018 Syndemics prevalence 49.7% (n=71) N=143

DEMOGRAPHIC CHARACTERISTICS OF TGW SCREENED FOR PrEPARADAS STUDY ACCORDING TO SYNDEMICS, RIO DE JANEIRO, BRAZIL, 2017-2018 Total (N = 143) No Syndemics (N = 72) Syndemics (N = 71) p-value* Age – median (IQR) 30 (24,36) 32 (26.8,40) 27 (23,34) 0.003 Self-declared color/Race   <0.001 White 38 (26.6) 28 (38.9) 10 (14.1) Non- White 105 (73.4) 44 (61.1) 61 (85.9) Years of schooling 0.811 < 8 39 (27.3) 19 (26.4) 20 (28.2) ≥ 8 104 (72.7) 53 (73.6) 51 (71.8) Employment status 0.053 Employed 66 (46.2) 39 (54.2) 27 (38) Not Employed 77 (53.8) 33 (45.8) 44 (62) Marital Status 0.127 Married 109 (76.2) 51 (70.8) 58 (81.7) Single or other 34 (23.8) 21 (29.2) 13 (18.3) Monthy individual income (US$) - median (IQR) ꝉ 206.7 (99,333.3) 236.7 (125,360) 200 (66.7,270) 0.152 ꝉ Categories with missing data.*chi-square, Fisher's or Mann–Whitney U test.1U$ = R$3.75

SEXUAL RISK BEHAVIOR AND RISK PERCEPTION AMONG TGW SCREENED FOR PrEPARADAS’ STUDY ACCORDING TO SYNDEMICS, RIO DE JANEIRO, BRAZIL, 2017-2018 Total (N = 143) No Syndemics (N = 72) Syndemics (N = 71) p-value* Condomless anal sex (6 months) 116 (81.1) 54 (75) 62 (87.3) 0.06 HIV-positive partner 7 (4.9) 3 (4.2) 4 (5.6) 0.719 STI (6 months) 36 (25.2) 18 (25) 18 (25.4) 0.961 Transactional sex (ever) 106 (74.1) 50 (69.4) 56 (78.9) 0.198 PEP (12 months) 31 (21.7) 14 (19.4) 17 (23.9) 0.514 HIV testing (12 months) 130 (90.9) 67 (93.1) 63 (88.7) 0.369 Perceived likelihood of getting HIV (next 12 months) (High)¹ 40 (28.2) 22 (31.4) 0.395 *Chi-square or Fisher's exact test;¹ missing data(n=1)

Substance use (3 months) SUBSTANCE USE AMONG TGW SCREENED FOR PrEPARADAS STUDY ACCORDING TO SYNDEMICS, RIO DE JANEIRO, BRAZIL, 2017-2018 Substance use (3 months) Total (N = 143) No Syndemics (N = 72) Syndemics (N = 71) p-value* Tobacco 72 (50.3) 24 (33.3) 48 (67.6) < 0.001 Alcohol 116 (81.1) 50 (69.4) 66 (93) Marijuana 48 (33.6) 12 (16.7) 36 (50.7) Cocaine 29 (20.3) 6 (8.3) 23 (32.4) Amphetamine² 5 (3.5) 0 (0) 5 (7) 0.028 Inhalants² 10 (7) 10 (14.1) Hypnotic 11 (7.7) 3 (4.2) 8 (11.3) 0.111 Hallucinogen² 3 (2.1) 1 (1.4) 2 (2.8) 0.62 *Chi-square ;2Fisher's exact test.aASSIST score≥4; bASSIST score ≥10; There were no cases of hypnotic abuse and opioid use or abuse

Substance abuse/dependence SUBSTANCE ABUSE/DEPENDENCE AMONG TGW SCREENED FOR PrEPARADAS STUDY ACCORDING TO SYNDEMICS, RIO DE JANEIRO, BRAZIL, 2017-2018 Substance abuse/dependence Total (N = 143) No Syndemics (N = 72) Syndemics (N = 71) p-value * Any substance abuse, except alcohol 82 (57.3) 33 (45.8) 49 (69) 0.005 Tobaccoa 62 (43.4) 20 (27.8) 42 (59.2) < 0.001 Alcoholb 18 (12.6) 1 (1.4) 17 (23.9) Marijuanaa 39 (27.3) 10 (13.9) 29 (40.8) Cocainea 24 (16.8) 6 (8.3) 18 (25.4) 0.006 Amphetaminea ² 1 (0.7) 0 (0) 0.497 Inhalanta ² 3 (2.1) 3 (4.2) 0.12 Hallucinogena 2 2 (1.4) 1 *Chi-square ;2Fisher's exact test.aASSIST score≥4; bASSIST score ≥10; There were no cases of hypnotic abuse and opioid use or abuse

MENTAL HEALTH, VULNERABILITIES AND DISCRIMINATION AMONG TGW SCREENED FOR PrEPARADAS STUDY ACCORDING TO SYNDEMICS, RIO DE JANEIRO, BRAZIL, 2017-2018 Mental Health Total (N = 143) No Syndemics (N = 72) Syndemics (N = 71) p-value* High Impulsivity (BIS11 > 77) 34 (23.8) 6 (8.3) 28 (39.4) < 0.001 Anxiety (GAD7 > 9) 40 (28) 9 (12.5) 31 (43.7) Suicide risk 23 (16.1) 3 (4.2) 20 (28.2) Vulnerabilities School dropout 61 (42.7) 24 (33.3) 37 (52.1) 0.023 Child abuse 44 (30.8) 18 (25) 26 (36.6) 0.132 Sexual/physical violence 81 (56.6) 27 (37.5) 54 (76.1) < 0.001 Gender discrimination 93 (65) 44 (61.1) 49 (69) 0.322 *Chi-square test

Independent variables MULTIPLE LOGISTIC REGRESSION MODEL EVALUATING FACTORS ASSOCIATED WITH SYNDEMICS AMONG TGW SCREENED FOR PrEPARADAS STUDY, RIO DE JANEIRO, BRAZIL, 2017-2018 Independent variables aOR(95%CI) P(LR-test) Age (per one year increase) 0.96 (0.9,1.0) 0.191 Non-white self-declared race/color: (ref. white) 4.1 (1.5,11.5) 0.005 Any isubstance abuse , except alcohol (ref. No) 2.0 (0.83,4.9) 0.12 Anxiety 2.8 (0.96,8.3) 0.056 High Impulsivity 3.8 (1.1,12.0) 0.021 Suicide risk 4.0 (0.9,18.3) 0.051 Sexual/physical violence 6.0 (2.4,15.0) <0.001 Note: Most parcimounious model was selected including only variables p<0.05 or those found to be counfunders. Missing income cases (n=15) were imputed with median income. Anxiety (GAD7 >10); High impulsiveness = BIS11 >77)

CONCLUSIONS High prevalence of syndemics (49.7%) among Brazilian TGW More likely to occur among non-white, those reporting history of sexual/physical violence and high impulsivity History of sexual/physical violence + anxiety symptoms Post–Traumatic Stress Disorder? No association between syndemics and sexual risk behavior Due to high prevalence in both groups as sexual risk behavior was an inclusion criteria High demand of mental health treatment vs. low availability in LMIC PrEP is an opportunity to screen and treat mental health and substance use disorders in this vulnerable and stigmatized population

ACKNOWLEDMENTS Study participants PrEPARADAS Demonstration Project team Community educators: Laylla Monteiro, Cléo Souza, Biancka Fernandes, Toni dos Santos, and Josias Freitas LAPCLIN-AIDS, INI, FIOCRUZ, Rio de Janeiro, Brazil Brazilian National Department of Surveillance, Prevention and Control of sexually transmitted diseases (STIs), HIV/AIDS and Viral Hepatitis, Brazilian Ministry of Health CNPq FAPERJ Gilead Dep. Jean Wyllys