PrEP is for trans people too. Why is access still falling short?

“I tried to get PrEP,” a transfeminine friend told me, “but it got complicated and I already take many meds.” Between referrals, labs and coverage questions and other concerns, she stopped trying. “It just felt like too much.” 

Pre-exposure prophylaxis (PrEP) is a highly effective way to prevent HIV, but access has not been equitable across communities. For trans and gender-diverse people* in Canada, the problem is not whether PrEP works. It is whether PrEP is offered in ways that feel safe, relevant and encouraging. This article will help prepare service providers to address common concerns and support trans and gender-diverse clients to use PrEP.

* Note on language about gender: In this article, “trans and gender-diverse” refers broadly to trans women, trans men, nonbinary people and others whose gender differs from sex assigned at birth. Studies do not always use the same categories. Where a source focuses on a specific group, such as trans women or transfeminine people, that source’s original language is used.

Impact of HIV on trans and gender-diverse communities

Canada lacks national data on HIV for trans and gender-diverse (TDG) communities. However, evidence from studies conducted in Canada points to a disproportionate impact of HIV. In 2011, an Ontario Trans PULSE survey found a self-reported HIV prevalence of 3.0% among transfeminine people and 0.6% among transmasculine people, compared with a 2008 provincial HIV prevalence estimate of 0.25% among the general population.¹ A study conducted in Toronto and Montreal in 2018 and 2019 found an HIV prevalence of 7.5% among trans women receiving care at six different clinical sites.² Although this clinic-based sample may not be representative of the broader TGD population, these findings reinforce that some trans communities are disproportionately impacted by HIV. 

What are the PrEP options for trans and gender-diverse communities? 

There are several PrEP options available for TGD communities in Canada, as recommended by the 2025 Canadian PrEP guideline.³ It is important to note that TGD communities are comprised of a varied group of individuals, who also are at variable risk of getting HIV on the basis of their anatomy, their sexual partner types and the kinds of sex they are having. The guideline recommends that PrEP options should be selected on the basis of these factors. Before certain types of PrEP are prescribed, an individual’s use of gender-affirming hormones may also need to be considered. Providers should approach discussions about PrEP options in a culturally sensitive and gender-affirming way.

The following is a summary of the PrEP guideline^3,4  recommendations as they apply to trans and gender-diverse people: 

• Oral daily PrEP using tenofovir disoproxil fumarate and emtricitabine (TDF/FTC; commonly known by the brand name Truvada) is recommended for all HIV-negative people, including all trans and gender-diverse individuals, regardless of their sexual practices. 
• Oral TDF/FTC taken on demand (PrEP 2-1-1) is recommended for HIV-negative trans women whose HIV risk is related to having sex with cisgender men. It is not recommended for trans men, because there are no data on this regimen in this population and no clinical data supporting on-demand dosing for frontal exposure.
• Daily oral PrEP using tenofovir alafenamide and emtricitabine (TAF/FTC; commonly known by the brand name Descovy) is recommended for trans women whose HIV risk is related to having sex with cisgender men. It can also be considered as a PrEP option by trans men or other gender-diverse individuals, depending on their sexual practices and partners.
• Long-acting injectable cabotegravir (CAB-LA) is recommended for trans women whose HIV risk is related to having sex with cisgender men. It can also be considered as a PrEP option by trans men or other gender-diverse individuals, depending on their sexual practices and partners.

Note that the PrEP guideline does not include recommendations about long-acting injectable lenacapavir; however, guideline recommendations for this PrEP option are forthcoming. 

The Canadian PrEP guideline also recommends that all sexually active adolescents and adults, and people who inject drugs, receive counselling about the safety and efficacy of PrEP and how to access it. This information should be framed positively to reduce stigma. The guideline supports prescribing PrEP to anyone who requests it and encourages routine HIV risk assessments in clinical care to identify people who may benefit from PrEP, even if they do not ask for it.^3,4

What do we know about PrEP and gender-affirming hormones?

A common concern for gender-diverse people is that PrEP medications may affect their gender-affirming hormone therapy (GAHT). Another concern is whether GAHT impacts the effectiveness of PrEP. 

PrEP impact on hormone effectiveness

According to the Canadian PrEP guideline, evidence indicates that the use of available PrEP options (i.e., both types of oral PrEP and CAB-LA) by trans women does not impact the effectiveness of feminizing hormones.^4,5,6, Evidence also suggests that there is no impact on the effectiveness of masculinizing hormones, but data are more limited, especially for CAB-LA.⁵ This means that taking PrEP is not expected to make a person’s voice change back, their hair regrow or their body fat redistribute. 

Impact of hormones on PrEP effectiveness 

There is some evidence that gender-affirming hormones may slightly decrease PrEP effectiveness when oral TDF/FTC is taken on demand. Although on-demand PrEP is recommended as an option for trans women whose HIV risk is related to having sex with cisgender men, the guideline advises that people who use feminizing hormones should be counselled about the possible effects of these hormones on PrEP levels. Limited research suggests that it may take longer to reach protective levels of PrEP drugs in the body with on-demand dosing in people using feminizing hormones.^4,7 This research found that trans women taking GAHT require at least two weeks of on-demand PrEP dosing to reach levels of PrEP drugs similar to those seen after one week of dosing in cisgender men.

Summary table of PrEP considerations for TGD communities

What do we know about PrEP awareness and use among TGD communities in Canada?

Data show a clear gap between PrEP awareness and PrEP use among trans and nonbinary people, with especially low uptake among trans women and inequities across age, Indigeneity, education and region. In a 2019 Canadian survey of 1,965 trans and nonbinary people, 71.0% had heard of PrEP, 2.2% had ever used it and 0.9% were currently using it.⁸ Among participants with indications for PrEP use, awareness was 82.3%, ever use was 7.3% and current use was 3.8%. Trans women had lower awareness overall (61.2%) and lower current use (0.4%) than all of the other trans and nonbinary participants. Awareness was also lower among trans participants aged 45 years and older, Indigenous people, people with a lower education level and people living in Quebec or Atlantic Canada. Despite awareness being moderately high, use of PrEP among trans and gender-diverse people is extremely low, especially given the disproportionate impact of HIV on TGD communities. 

What are the barriers to accessing PrEP for TGD communities? 

Canadian and U.S. research suggests that there are barriers to PrEP initiation, adherence and ongoing use across clinical, organizational and structural levels among TGD communities. Common barriers include the following:^{3,9,10,11,12,13,14,15}

• concerns about drug interactions with gender-affirming hormones 
• concerns about PrEP side effects 
• cost and insurance coverage 
• lack of trans-competent or gender-affirming providers 
• medical mistrust and stigma in care 
• weak navigation support through testing, prescribing, pharmacy access and follow-up 
• low perceived relevance of PrEP, particularly among some trans men 
• provider discomfort or lack of knowledge in discussing sexual health 
• structural, cultural and language-related barriers, especially for Black and Latina trans women 
• the need to prioritize accessing hormones and addressing other immediate survival needs over PrEP 

Research also points to several factors that can help improve uptake. These include trans-affirming and culturally responsive care, better provider knowledge about PrEP and gender-affirming care, practical navigation support, peer- or community-based support, and integration of PrEP into services that trans people are already using. ^11,12,13,14

Recommendations for service providers

Service providers can play an important role in supporting trans and gender-diverse clients through awareness and education about PrEP, as well as system navigation and support to address their needs with healthcare providers:

Discuss PrEP with clients, even if they don’t bring it up. Discuss PrEP routinely and in a positive light, to help normalize the conversation and raise awareness about PrEP. Explain the available PrEP options and who they are recommended for, in plain language.

Support clients to find a gender-affirming PrEP provider, by providing referrals to local healthcare providers who are culturally sensitive to TGD communities. Service providers can also play a role in advocating for gender-affirming practices and policies in their organizations and with their partners in the healthcare system.

Encourage and support clients to address medication-related side effects and other concerns. When a trans client raises concerns, support them to identify potential strategies to address their concerns, and encourage them to speak to their PrEP provider about managing side effects or exploring alternative PrEP options.

Encourage and support clients to be open with their healthcare provider about their sexual practices. Healthcare providers should be making PrEP recommendations on the basis of their patient’s specific anatomy, sexual partner type and route(s) of exposure rather than relying on identity assumptions.

Address concerns about hormones directly. Some trans and gender-diverse people may avoid taking PrEP for fear that it will affect their hormone therapy. Explain that PrEP is not expected to impact the effectiveness of feminizing hormones or of masculinizing hormones. However, trans women using feminizing hormones should be counselled about the small impact of such hormones on the effectiveness of TDF/FTC when taken on demand. They should talk to their healthcare provider about their PrEP options and how to use on-demand PrEP as safely as possible.

Discuss PrEP as part of a comprehensive plan for sexual health and encourage trans and gender diverse clients to talk openly with their healthcare provider about other aspects of their sexual health, including GAHT; using condoms and/or lubricant; pregnancy prevention; and testing, prevention and treatment for bacterial sexually transmitted infections (STIs).

Offer support to overcome barriers to PrEP access and retention. Clients may need support to attend appointments or to navigate insurance coverage and pharmacy issues, or they may need referrals to other services, including trans-inclusive clinics.

Integrate PrEP into broader care. PrEP works best when it sits alongside gender-affirming care, STI testing, harm reduction, mental health support and community linkage.^8,9 

References

1. Bauer GR, Travers R, Scanlon K et al. High heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada: a province-wide respondent-driven sampling survey. BMC Public Health. 2012;12(1):292.
2. Lacombe-Duncan A, Persad Y, Shokoohi M et al. HIV prevalence among a retrospective clinical cohort of transgender women in Canada: results of the Montreal-Toronto Trans study, collected 2018-2019. International Journal of STD & AIDS. 2023;34(14):1062-71.
3. Tan DHS, Hull MW, Onyegbule SO et al. Canadian guideline on HIV pre- and postexposure prophylaxis: 2025 update. Canadian Medical Association Journal. 2025;197(41):E1374-91.
4. Tan DHS, Hull MW, Onyegbule SO et al. Appendix 1. In: Canadian guideline on HIV pre- and postexposure prophylaxis: 2025 update. Canadian Medical Association Journal. 2025;197(41):E1374-91.
5. Senneker T. Drug–drug interactions between gender-affirming hormone therapy and antiretrovirals for treatment/prevention of HIV. British Journal of Clinical Pharmacology. 2024;90(1):2366-82.
6. Marzinke MA, Hanscom B, Wang Z et al. Efficacy, safety, tolerability, and pharmacokinetics of long-acting injectable cabotegravir for HIV pre-exposure prophylaxis in transgender women: a secondary analysis of the HPTN 083 trial. Lancet HIV. 2023;10:e703-12.
7. Tanaudommongkon A, Chaturvedula A, Hendrix CW et al. Population pharmacokinetics of tenofovir, emtricitabine and intracellular metabolites in transgender women. British Journal of Clinical Pharmacology. 2022;88:3674-82.
8. Hallarn J, Scheim AI, Bauer GR. Pre-exposure prophylaxis awareness and use among transgender and nonbinary individuals in Canada. Journal of Acquired Immune Deficiency Syndromes. 2024;96(4):341-9.
9. Lacombe-Duncan A, Kia H, Logie CH et al. A qualitative exploration of barriers to HIV prevention, treatment and support: perspectives of transgender women and service providers. Health & Social Care in the Community. 2021;29(5):e33-46.
10. Bruxvoort K, Portugal C, Munis M et al. Understanding barriers and facilitators of pre-exposure prophylaxis (PrEP) among transgender and gender diverse adults in an integrated health care system. AIDS and Behavior. 2023;27(8):2579-91.
11. Rowniak S, Ong-Flaherty C, Selix N et al. Attitudes, beliefs, and barriers to PrEP among trans men. AIDS Education and Prevention. 2017;29(4):302-14.
12. Nieto O, Fehrenbacher AE, Cabral A et al. Barriers and motivators to pre-exposure prophylaxis uptake among Black and Latina transgender women in Los Angeles: perspectives of current PrEP users. AIDS Care. 2021;33(2):244-52.
13. Reback CJ, Clark KA, Rünger D et al. A promising PrEP navigation intervention for transgender women and men who have sex with men experiencing multiple syndemic health disparities. Journal of Community Health. 2019;44(6):1193-1203.
14. Quinn KG, Randall L, Wesp LM et al. PrEP use among Black transgender women: a qualitative study on barriers to PrEP use and the power and promise of community. Archives of Sexual Behavior. 2025;54(5):1769-80.
15. Dang M, Scheim AI, Teti M et al. Barriers and facilitators to HIV pre-exposure prophylaxis uptake, adherence, and persistence among transgender populations in the United States: a systematic review. AIDS Patient Care and STDs. 2022;36(6):236-48.
     

Externally reviewed by: Dr. Darrell Tan  

About the author(s)

Asya Gunduz, PhD (c), (she/her) is policy lead for trans and gender diverse HIV prevention and health promotion at the Ontario HIV Treatment Network. She is a doctoral candidate at York University in Gender, Feminist and Women’s Studies. Her research focuses on healthcare access and sexual health outcomes for trans and gender-diverse newcomer populations and community building. Asya is the founder of LubunTO, a queer newcomer organization in Toronto. Her work is dedicated to bridging the gap between clinical research and community-led health advocacy.