Photo Credit: YakubovAlim
Researchers discuss efforts to improve PrEP access in transgender and other transmasculine men who are under-represented in research and prevention efforts.
“In HIV prevention, there has been remarkable community-led research by experts such as Sari Reisner, Asa Radix, Jae Sevelius, and others highlighting that transgender MSM (TMSM) are a key group in the fight to end HIV,” Pedro B. Carneiro, PhD, MPH, notes. “Their behaviors and HIV incidence are comparable to, and at times higher than, their cisgender counterparts.”
However, despite the importance of reaching TMSM to achieve HIV elimination goals, this group is “under-represented in research, excluded from guidelines and clinical trials, and overlooked in our national strategy to end HIV,” Dr. Carneiro says. “Moreover, much of the existing research has been cross-sectional, which limits our ability to explore the long-term challenges (ie, PrEP uptake and use) faced by this community and advocate for change.”
Dr. Carneiro, Christian Grov, PhD, MPH, and colleagues aimed to characterize PrEP use among TMSM. They examined annual PrEP uptake, discontinuation, and other HIV prevention measures in a cohort of TMSM over 24 months.
Physician’s Weekly (PW) spoke with Dr. Carneiro and Dr. Grov to learn more about the study results, which were published in JAIDS.
PW: What served as the impetus for this work?
Dr. Carneiro: When the opportunity arose to work with data from Guys Like Us, a longitudinal national cohort led by Dr. Grov and other respected researchers, I saw it as an invaluable chance to address these gaps. This project represents a critical step in supporting TMSM and enhancing our understanding of HIV prevention across diverse US communities.
Dr. Grov: Although this research began before the GATE policy brief on effective inclusion of TMSM in responses to HIV globally and health and development more broadly, there is a strong movement to be more inclusive of gender-diverse populations, specifically of transgender men. in research to make a meaningful dent in the HIV epidemic.
Can you provide a brief overview of the results?
Dr. Carneiro: Overall, we found that only about a third of our national sample initiated PrEP during the study period, despite 100% of participants meeting the objective clinical criteria for PrEP at baseline. This mirrors findings from another study where only a third of participants, including cisgender MSM and transgender people, who met clinical criteria for PrEP had even discussed it with a clinician. In our study, PrEP use was primarily driven by access and behavior, and we did not observe the same demographic disparities in PrEP uptake that are seen nationally, such as lower adoption among Black and Brown individuals.
Health insurance was a particularly strong driver of PrEP use, highlighting the critical importance of ensuring that those who need and want PrEP can easily access it. Health insurance is just one piece of a larger set of constructs that make PrEP accessible, ranging from having competent clinicians to creating seamless experiences at clinics and pharmacies. While we couldn’t capture all these factors in our study, it offers a glimpse into how complex PrEP accessibility can be.
We also observed an association between PrEP use and certain gender-affirming surgeries, which underscores the unique healthcare needs and approaches of this community about PrEP.
Were any of the findings unexpected or surprising to you?
Dr. Carneiro: As someone who is not of transgender experience, I was surprised by the association we found between certain types of gender-affirming surgeries and PrEP use. What caught me off guard wasn’t the association itself, but the fact that it was specific to only one of the gender-affirming variables we included in our analysis. This suggests that community engagement and leadership will be crucial moving forward as we seek to explore these topics further and understand these findings in greater depth. Ensuring that these conversations actively involve TMSM is the first step to ensuring competency and authenticity in addressing the needs of this community.
How can clinicians use the results to improve PrEP use in TMSM?
Dr. Carneiro: First and foremost, clinicians need to consistently engage their TMSM patients in conversations about HIV prevention and PrEP to increase the number of individuals utilizing PrEP. It’s important for clinicians to be aware of the unique challenges that transgender men may face in accessing PrEP and to make PrEP a part of an ongoing dialogue about behavior, health, and empowerment.
Health systems also play a critical role by developing supportive structures, such as PrEP navigation services, to assist patients in overcoming access-related barriers—something that individual clinicians may not always be equipped to handle on their own.
Dr. Grov: Adding PrEP care to gender-affirming care is truly the lowest-hanging fruit and can meet multiple needs of transgender men by opening two doors with one key.
What research is needed to improve PrEP use in TMSM?
Dr. Carneiro: When it comes to HIV prevention research for TMSM, there is still much work to be done. We need to ensure that clinical trials include TMSM, that studies focus on this community as a primary stakeholder, and that clinical guidelines are inclusive of transgender men. Additionally, surveillance systems must be adapted to capture the unique epidemiological dynamics of this community, and updates are needed in our national strategy to reflect their needs. While some of this work may already be in progress, it’s long overdue and essential for making meaningful progress in HIV prevention for TMSM.
Dr. Grov: What Dr. Carneiro has highlighted is very much in alignment with the GATE policy brief on effective inclusion of TMSM. I echo it!
