Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy that involves an HIV-negative person taking anti-HIV medication to lower their chance of getting HIV. Understanding barriers and facilitators to PrEP use can help improve uptake and adherence to PrEP. This article summarizes a systematic review that identified barriers and facilitators to PrEP use among trans people.1
PrEP and transgender people
Transgender people are people whose gender identity/expression is different from the sex they were assigned at birth. Trans people are diverse and use different terms to identify themselves, including but not limited to the following:
- transgender or trans woman: a person who was assigned a male sex at birth and has a female gender identity/feminine gender expression
- transgender or trans man: a person who was assigned a female sex at birth and has a male gender identity/masculine gender expression
In contrast, people whose gender identity/expression is the same as the sex they were assigned at birth are referred to as cisgender people.
Canadian PrEP guidelines2 recommend PrEP for people who are at increased risk of getting HIV. This includes transgender people if they have condomless anal or vaginal/frontal sex with partners of unknown HIV status or with partners who have HIV and are not virally suppressed. It also includes transgender people who use drugs and share injection drug use equipment.
Despite these recommendations, low rates of PrEP use have been observed among trans people. The 2018 Sex Now survey, a periodic survey on the health and well-being of people who identify as men (i.e., cis or trans men), non-binary or Two-Spirit, and non-heterosexual (e.g., gay, bisexual, queer) found that HIV-negative trans and non-binary respondents were two to three times less likely to report PrEP use than cisgender respondents.3 A 2017 survey of trans men in the United States found that 24% of survey respondents met the US eligibility criteria for PrEP use, but only 11% of those eligible were currently on PrEP.4 Understanding the barriers and facilitators to PrEP use for trans people can help service providers better engage and support them in PrEP care.
What kind of research does the systematic review include?
Thirty-three articles were included in the review. A study was included if it:
- included HIV-negative participants who were trans or non-binary
- examined biological, psychological or social facilitators and barriers to PrEP interest, uptake, adherence, effectiveness or ongoing use in trans people in the United States
- was published after the approval of PrEP in the United States in 2012
Thirty studies included trans women and 11 studies included trans men. There were approximately 3,600 trans women and 2,400 trans men represented in these studies.
What are the barriers and facilitators to HIV PrEP use among trans people?
The authors reviewed the barriers and facilitators to PrEP use experienced by trans people in the 33 studies and grouped the results into themes.
1. Concerns about interactions between PrEP drugs and gender-affirming hormone therapy are a barrier to PrEP use
Ten studies examined trans people’s attitudes and beliefs about the interactions between PrEP drugs and gender-affirming hormone therapy. Overall, the studies found that concerns about interactions created a barrier to PrEP use. For example, in four studies, despite mid-to-high levels of PrEP awareness among trans people, the rate of PrEP initiation was low because of concerns and beliefs related to the interaction of hormone therapy and PrEP drugs.
Two additional studies examined the potential interactions between feminizing hormones and the PrEP drug tenofovir/emtricitabine (TDF/FTC, also known as Truvada). Both studies found that TDF/FTC did not affect hormone concentrations among trans women using feminizing hormones. However, both studies found that PrEP levels may have been affected by the use of hormone therapy. Truvada concentrations were lower among the trans women in the studies compared with the cisgender men who also participated in the studies. Although the concentrations of TDF/FTC were lower for trans women using feminizing hormones, these levels were still within the range needed for PrEP to be protective against HIV infection.
2. Negative experiences with medical institutions are a barrier to PrEP uptake
Multiple studies observed that negative experiences with medical institutions decreased PrEP uptake. These barriers to PrEP uptake included:
- decreased PrEP knowledge due to trans people’s lack of trust in medical institutions and incomplete information about PrEP efficacy and potential side effects provided by physicians to trans people
- decreased PrEP interest and uptake due to experiences of transphobia in medical/healthcare settings
Additional negative experiences with medical institutions that affect healthcare engagement included:
- concern that care is focused on HIV when holistic care and prioritization of hormone therapy were preferred
- concern that discussion of sexual behaviour would result in judgment from medical providers or discontinuation of gender-affirming hormone therapy
- lack of trans-affirming medical clinics and services
3. Systemic and social marginalization of trans people are barriers to PrEP uptake
In addition to barriers that trans people face within medical institutions, the review found that the broader systemic and social marginalization they experienced were also barriers to PrEP uptake. These barriers included:
- criminalization of sex work
- housing insecurity
- sigma, discrimination and transphobia
- HIV stigma and concerns that taking anti-HIV medications may lead to assumptions a person is living with HIV
- lack of trans-specific messaging around PrEP, with current PrEP promotion often focusing on PrEP as a prevention strategy for cisgender men who have sex with men
4. Social networks can influence PrEP knowledge, interest and adherence
The review found PrEP knowledge, interest and adherence were influenced by social networks, both positively and negatively. Friends can positively influence PrEP use by being sources of information and support. Social networks were also found to be potential sources of stress for individuals who were not open or out about their gender identity or who were worried about social stigma because of their interest in PrEP.
5. PrEP use can have a positive impact on self-advocacy and self-acceptance
The review found PrEP use can have a positive impact on self-advocacy and self-acceptance among trans people. These positive impacts included:
- increased control over HIV prevention decisions, including among trans sex workers and within relationships affected by intimate partner violence
- improved social interactions and mental health, such as increased comfort with one’s sexuality and increased communication about PrEP with others in their community
What are the implications of the review for service providers?
This review identified a number of barriers to PrEP use by trans people. Barriers included concerns about the interaction of gender-affirming hormone therapy and PrEP, negative interactions with medical institutions and the broader systemic and social issues affecting trans people, such as poverty, criminalization of sex work, housing insecurity, stigma, discrimination and transphobia. The review also identified facilitators and positive benefits of PrEP use by trans people. Social networks facilitated increased PrEP knowledge and interest and provided support for PrEP use. PrEP use was also empowering for trans people and provided increased control over HIV prevention decisions and improved social interactions and mental health.
To address barriers to PrEP use among trans people, service providers can:
- provide services that are gender affirming and welcoming to trans people
- include PrEP services as part of broader, holistic care that includes the health care priorities of trans people such as gender-affirming hormone therapy
- promote PrEP use with trans-specific messaging and address concerns related to the potential interactions between gender-affirming hormone therapy and PrEP
- engage trans people to promote information about PrEP within their social networks
- address social determinants of health such as poverty and housing insecurity that can affect PrEP uptake
When considering this review, it is important to remember that:
- The review focused on barriers and facilitators to PrEP use among trans people in the United States. While the review can help inform our understanding of PrEP use among trans people in Canada, there may be differences in the barriers and facilitators experienced by trans people in Canada.
- Of the 33 studies included in the review, 30 included trans women and 11 included trans men. There may be differences between the barriers and facilitators to PrEP use experienced by trans woman and trans men that were not identified through this review.
- The review found that the interactions between PrEP and feminizing hormone therapy were not clinically significant. These results are reassuring but only based on two studies. Further research is needed to expand our understanding of the interactions between PrEP and gender-affirming hormone therapy for both trans women and trans men.
What is a systematic review?
Systematic reviews are important tools for informing evidence-based programming. A systematic review is a critical summary of the available evidence on a specific topic. It uses a rigorous process to identify all the studies related to a specific research question. Relevant studies can then be assessed for quality and their results summarized to identify and present key findings and limitations. If studies within a systematic review contain numerical data, these data can be combined in strategic ways to calculate summary (“pooled”) estimates. Combining data to produce pooled estimates can provide a better overall picture of the topic being studied. The process of pooling estimates from different studies is referred to as a meta-analysis.
- 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.
- Tan DHS, Hull MW, Yoong D et al. Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. Canadian Medical Association Journal. 2017 Nov 27;189(47):E1448-58. Available from: http://www.cmaj.ca/content/189/47/E1448
- Rutherford L, Stark A, Ablona A et al. Health and well-being of trans and non-binary participants in a community-based survey of gay, bisexual, and queer men, and non-binary and Two-Spirit people across Canada. PLOS ONE. 2021 Feb 11;16(2):e0246525. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246525
- Golub SA, Fikslin RA, Starbuck L et al. High rates of PrEP eligibility but low rates of PrEP access among a national sample of transmasculine individuals. Journal of Acquired Immune Deficiency Syndrome. 2019 Sep 1;82(1):e1-7. Available from: https://journals.lww.com/jaids/Fulltext/2019/09010/High_Rates_of_PrEP_Eligibility_but_Low_Rates_of.6.aspx
About the author(s)
Erica Lee is CATIE’s manager of website content and evaluation. Since earning her master of information studies, Erica has worked in the health library field, supporting the information needs of frontline service providers and service users. Before joining CATIE, Erica worked as the Librarian at the AIDS Committee of Toronto (ACT).