Photo Credit: JosuOzkaritz

A strategy that addresses socioeconomic barriers and patient preferences will be needed to reach the majority of transgender women who have never used PrEP.

“Many transgender women are likely to benefit from PrEP, but many experience significant barriers to accessing healthcare, including PrEP care,” Erin Cooney, PhD, MSPH, CPH, explains. “It is also critically important to understand the experiences of PrEP discontinuation because some research, including our study, shows that about half of all people who are newly diagnosed with HIV are former PrEP users. By understanding the circumstances and factors that lead to PrEP discontinuation, we can better support transgender women to use PrEP to meet their HIV prevention goals.”

Such estimates allow researchers, clinicians, and policymakers to examine trends and evaluate the impact of public health strategies that aim to increase PrEP uptake, Dr. Cooney continues. “By examining whether these rates are higher or lower for particular groups, such as young transgender women, we can identify subgroups most likely to benefit from additional outreach, programming, and interventions.”

For a study published in JIAS, the researchers examined PrEP initiation and discontinuation rates and the factors that influence PrEP discontinuation. They used Cox regression models to evaluate PrEP initiation and discontinuation predictors, and in-depth interviews were conducted to examine events and experiences related to PrEP discontinuation.

Most Transgender Women Have Never Used PrEP

The analysis included 1,312 transgender women. Approximately half of the cohort had an indication for PrEP at enrollment, and an even larger percentage (69%) had an indication for PrEP on at least one occasion during follow-up.

Less than a quarter of participants (21.8%) reported they used PrEP at one or more study visits. Dr. Cooney and colleagues observed 139 PrEP initiations over 2,127 person-years, for a rate of 6.5 initiations per 100 person-years. The rate of PrEP initiation among those with an indication for PrEP was slightly higher, at 9.6 initiations per 100 person-years. Predictors of PrEP initiation included identifying as Black and having an indication for PrEP, according to the study results.

The researchers also reported 138 PrEP discontinuations over 368 person-years, for a rate of 37.5 discontinuations per 100 person-years. Predictors of discontinuation included having a high school education or less and starting PrEP for the first time during the study.

“Our study is a reminder that even when highly efficacious medications are available, there is a lot of work to be done to ensure that these medications are accessible to those who could most benefit from them,” Dr. Cooney says. “The vast majority of transgender women have never used PrEP. Among those who have, patterns of use vary quite a bit.”

The researchers identified four discontinuation typologies:

• seroconversion after discontinuation;
• continued HIV risk after discontinuation;
• reassessment of HIV/STI prevention strategy after discontinuation; and
• dynamic PrEP use coinciding with changes in HIV risk.

“Some transgender women will consistently use PrEP for years at a time, while others will try it for a short period and then never use it again,” she continues. “Others will start and stop PrEP every few months as needed.”

Improving PrEP Uptake & Informing Future Research

A disproportionate number of participants who discontinued PrEP had incomes below the federal poverty level, public health insurance, and had experienced homelessness, according to Dr. Cooney, who notes that socioeconomic challenges are known to be associated with PrEP discontinuation. However, referrals to supportive services and programs that address these needs, such as housing, may reduce rates of PrEP discontinuation.

“More needs to be done to make PrEP accessible to transgender women who need it and to support transgender women on PrEP so they can continue to use it effectively,” she says. “Clinicians should practice shared decision making to understand the HIV and STI prevention goals of transgender women, as well as relevant values, preferences, and resources. This includes addressing socioeconomic issues.”

Evidence-based interventions to improve PrEP uptake and persistence for transgender women are urgently needed.

“We also need to increase accessibility of long-acting injectable PrEP to those who could benefit,” Dr. Cooney says. “There is still a need for additional long-acting PrEP options, such as implants and semi-annual injections, and it is important that we begin preparing for these future PrEP options now in order to make sure that they reach those who could benefit once they move out of clinical trials and into clinical care.”

Key Takeaways

• Fewer than a quarter of transgender women have ever used PrEP.
• Among those who have, uptake is low, and discontinuation is high.
• Strategies to improve PrEP uptake in this population should consider socioeconomic barriers, patient preferences, and access to resources to address the HIV epidemic.