About 1.2 million individuals in the U. S. have HIV, and in 2021 about 32,000 were previously infected. These figures ought to be lower. Pre-exposure Prophylaxis (PrEP) medication, which has been around since 2012, stops HIV transmission and is available. However, more than a decade later and despite Affordable Care Act (ACA)- mandated insurance for it, access to PrEP is unjust, especially among gender- various and transgender populations.
How can this group’s access to PrEP be improved, particularly for transmasculine and genderfluid people who are underrepresented in the field of research on the subject? In a new investigation, a team led by LDI Associate Fellow Dovie Watson and made up of LDI Senior Colleagues Florence Momplaisir and José Bauermeister. To evaluate the knowledge and use of PrEP, assess five PrEP program attributes, and decide which of these attributes is deemed to be the most crucial, they polled a national sample of 304 trans people (about half of whom identified as transmasculine).
One-fifth of interviewees reported using PrEP before or at the moment, but the majority of those who were not PrEP-savvy reported knowing about it. Among participants, no out-of-bag cost was by far the most appealing factor in decision- making regarding Prepared programs, followed by the bundling of PrEP-associated care with gender-affirming hormone therapy (GAHT) services, shorter travel time (25 minutes than 60 minutes), pharmacies as a dispensing venue (compared to major care), and six- month intervals between visits (compared to two months).
We asked Dr. Watson about this critical research.
Marketing is conducted using simultaneous analysis techniques to identify preferences. Why was it used for this study issue?
Watson: Ultimately, transgender people may be enrolled in substantial numbers at each phase of developing and conducting PrEP-related research. However, that hasn’t been the case. If the features are carefully chosen, a key benefit of using multiple study is that this experimental review technique enables researchers to determine which combination of PrEP program features would be most and least preferred among designed end-users in real-world settings. In the end, these findings may help improve the delivery of PrEP services by “bundling” services to address the needs of transgender populations even if transgender people were not enrolled in substantive numbers in the early clinical trials.
What about study participants’ preferences for receiving PrEP surprised you?
Watson: We were surprised that PrEP-experienced participants preferred PrEP delivery in primary care settings, while PrEP-naïve participants preferred pharmacies. However, one of the most surprising findings of the study was the fact that participants—regardless of PrEP status—strongly preferred not to receive PrEP from HIV/Sexually Transmitted Infection (STI) clinics. Our findings give cred to community stakeholders’ calls to diversify and incorporate PrEP into settings that aren’t just focused on HIV/ST I care.
Did the survey respondents’ use of PrEPs surprise you?
Watson: It was less surprising that the prevalence of PrEP awareness and PrEP use in our study population of transgender adults was comparatively comparable to those reported in recent Centers for Disease Control and Prevention (CDC) PrEP surveillance reports. We were surprised, however, that half of the participants claimed to have not used gender-affirming hormones as a component of their gender affirmation. Further investigation is necessary to determine the extent to which this was caused by personal preference versus structural and systemic barriers to gender-affirming medical care.
How can sexual health services and gender-affirming care be more effectively integrated?
Watson: One approach would be to incorporate gender-affirming hormone therapy and PrEP services into comprehensive primary care. Regrettably, many transgender adults must navigate interpersonal, structural, and systemic barriers to receive PrEP-related care and gender- affirming hormone therapy within formal medical institutions. This integration would require broader training in trans-inclusive preventive, mental, and sexual health service delivery among general health practitioners, including trainees.
How can access to PrEP be reduced across geographic boundaries?
Watson: The lowest rates of PrEP provision in the Southern region of the United States will require system-level policies (and funding), such as Medicaid expansion, and a requirement that all private and public insurance plans cover the costs of PrEP-related care, including medication and labs. PrEP equity varies significantly among PrEP-eligible Black and Latine adults of all genders. Additionally, significant investment in a federally funded national PrEP program that covers PrEP-related care without sharing costs will be essential to address PrEP inequity in communities where governments are particularly hostile to LGBTQ+ people and transgender people in particular.
What role do your findings play in the Philadelphia project that promotes the use of PrEP?
Watson: Based on our findings, expanding PrEP service delivery across a range of dispensing locations outside of HIV/STI-specific silos might be of particular interest to those who have not been successfully engaged in PrEP-related care. The Philadelphia Department of Public Health is evaluating several PrEP implementation strategies, including telehealth programs and in-person care at one-stop shop community-based clinics and pharmacies, as part of its ongoing Ending the HIV Epidemic Initiative efforts.
What modifications are required to the federal laws governing PrEP?
Watson: According to the Trans Legislation Tracker, more bills targeting gender-affirming health care were introduced in the U.S. in 2023 than in the previous five years combined. More than just upholding current federal regulations, which require numerous insurance plans to cover PrEP without cost-sharing, will be required to achieve PrEP equity for transgender people. Policymakers need to anticipate that transgender people will face exclusion and actively create a national PrEP program that is both financially sound and as resistant to anti-trans legislative attacks as possible in addition to significant investment in a federally funded national PrEP program. According to the article, community-engaged implementation research conducted with significant participation of transgender community stakeholders will be crucial in the creation and implementation of any national PrEP program.
The study, “Hyperlinks and Gender Differences in American Adults: A Conjoint Analysis,” was published in the Journal of the International AIDS Society on February 8, 2024. Authors include Dovie L. Watson, Louis Listerud, Ryan A. Drab, Willey Y. Lin, Florence Marie Momplaisir, and José A. Bauermeister.
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