A study recently published
in The Journal of Acquired Immune
Deficiency Syndromes indicates that transgender (trans) women in Brazil had
low levels of pre-exposure prophylaxis (PrEP) awareness. This was combined with significant proportions
being willing to use PrEP as a prevention tool and being eligible for PrEP.
Another recent qualitative
study published in Culture, Health and
Sexuality provides a contextual frame for these findings as it explores the
HIV programming needs of trans women in Brazil. Several social and contextual
factors, such as experienced and anticipated trans discrimination and HIV
stigma, were linked to an avoidance of prevention and treatment services for
both HIV-negative and positive trans women. In addition to biomedical
interventions, socio-structural interventions also emerged as crucial for
trans women in Brazil.
Globally, trans women
are at a disproportionally higher risk of contracting HIV – this is estimated
at 49 times higher than other groups. In the South American context,
particularly Brazil, trans women have substantially higher rates of HIV
prevalence, even when compared to other key populations such as men who have
sex with men. It has been estimated that nearly a third of all trans women in
Brazil may be infected with HIV, often accessing healthcare testing and
treatment services late. This key population has been described as the most
at-risk group in the country.
There is a lack of
specific HIV prevention aimed at trans women in Brazil. The unique needs of this
community raises specific challenges: transphobia and healthcare-related
stigma, social and economic marginalisation, as well as issues related to
gender-related health care (such as concerns about interactions between HIV
medications and hormone therapy).
The first study utilised
respondent-driven sampling to recruit trans women for face-to-face interviews
which assessed PrEP awareness and willingness. It also estimated how many
trans women would be considered eligible for PrEP, based on factors such as not
being in a monogamous relationship, having had condomless anal sex or an STI in
the past 12 months or an HIV-positive sexual partner in the last three months. The
survey was conducted from August 2015 to January 2016 and data was collected
from 345 participants. All participants identified as trans women and resided in
Rio de Janeiro. Most participants were aged 25-35, with eight years or less of
formal education.
Participants were
first asked a question to probe for awareness of PrEP; after a brief
explanation, they were asked about willingness to take PrEP. Additional
questions included concerns about PrEP as well as preferred routes of
administration, sexual behaviour, drug and hormone use, experiences of
health-related stigma and so forth. HIV and STI testing was carried out with
all participants after the survey was conducted.
Of the 345
participants offered HIV testing, 59% were HIV negative, 29% had previously
been diagnosed with HIV and 12% were newly diagnosed with HIV. Thirty-eight per cent of
respondents had heard about PrEP, while 49% had heard about post-exposure
prophylaxis (PEP). However, only 6% of those who were not known to have HIV
infection had ever accessed PEP. Higher PrEP awareness was associated with accessing
health services in the past six months (adjusted odds ratio 2.1, P = 0.004),
having at least one known HIV-positive partner (AOR 2.0, P = 0.04) and more
than eight years of education (AOR 1.5, P = 0.079). Lower PrEP awareness was associated
with condomless anal sex (AOR 0.6, P = 0.04) and a newly diagnosed HIV
infection (AOR 0.4, P = 0.035).
PrEP willingness was
assessed in those who self-reported as HIV negative. The majority of
participants (76%) expressed willingness to use PrEP after a brief explanation,
despite concerns about side-effects and interactions with hormones. Factors
positively associated with PrEP willingness included being younger (aged 18-35)
and high perceived HIV risk (participants’ rating of how likely they were to
contract HIV in the next year). Factors associated with being less willing to
use PrEP included concerns with long-term effects of PrEP and possible
challenges accessing it as a result of stigma encountered in healthcare
settings. A high percentage of HIV-negative trans women met the criteria for
PrEP eligibility criteria (67%), rising to 78% of those discovered to be
newly infected during the study. This indicates a significant need for PrEP as
a prevention tool in this community.
Qualitative findings
Qualitative data from
focus groups carried out with trans women in Brazil provides more context to the
quantitative data presented above. Six focus groups were conducted with 36
trans women in 2015 in Rio de Janeiro. Three groups were held with 21 HIV-negative
trans women and three with 15 HIV-positive trans women. Health professionals,
including one trans woman, conducted the focus groups. Topics included HIV prevention
and considered both socio-behavioural factors (such as access to social support
and adherence support) and biomedical strategies (such as PrEP and
self-testing). Forty-two per cent of participants were aged 18-30, with only 6% having college
education.
Transphobia in public
healthcare settings emerged as a strong theme from the focus groups. There was
a link between trans discrimination and HIV-related stigma, with an assumption
that any health problems with trans women were HIV-related. In certain
instances, this interfered with access to care in order to avoid stigma. Transphobia
manifested in ways such as not having one’s social name respected, with health
providers instead using male birth names. Participants also expressed a
disconnect between transgender-affirming social and civil policies and the
reality of day-to-day practice in healthcare settings in Brazil.
“If we arrive in a public hospital now… If I arrive with a pain here…
[the response is] to do an HIV test” (Ana, HIV negative).
“Sometimes, they are dying at home and they don’t want to go to urgent
care because [they think] ‘they are going to associate me with HIV’” (Gabriela, HIV positive).
Additionally, violence
towards trans women (particularly from sexual partners) emerged as a factor that
limited HIV prevention. Trans women are in a particularly vulnerable situation
as many earn a living through sex work and are in precarious economic
positions.
“When I said that I would only have sex with condoms, he had an
extremely aggressive attitude… he tried to physically hurt me.” (Juliana, HIV negative).
While biomedical
strategies such as PrEP and Treatment as Prevention (TasP) were considered
attractive options beyond condoms, there were concerns related to PrEP making
individuals feel invulnerable, doubts about the efficacy of PrEP and doubts
about having correct and accurate information. There was also concern about
PrEP being another source of stigma as those in the community might not fully
understand it.
“Let’s talk about PrEP… for as much as I had said it was a treatment for
pre-exposure, people called me, sent Facebook messages, others more openly
asked if I was sick.” (Juliana,
HIV negative).
An important theme
that emerged was that participants trusted information more when it came from
other trans women. This emphasises the need for peer-based information and
support networks. Prevention and treatment services that employed trans women
were seen as more desirable and welcoming.
“There is a trans person who knows how to talk like me, like all of us,
she speaks the same language and makes us feel considered, we feel welcome
thanks to her.” (Ana, HIV negative).
Considering the
findings from both these studies, it is evident that trans women are at
high risk of contracting HIV and that the combination of low awareness, high
willingness and substantial PrEP eligibility means that there is a definite
need to upscale PrEP education and access in trans communities.
Brazil is currently in
the process of national PrEP implementation through its public health system
yet trans-specific interventions are lacking. Additionally, biomedical
interventions cannot be removed from their social context and thus social
strategies to combat stigma, violence and discrimination – in both healthcare
settings and in broader communities – while implementing gender-affirming and
empowering services are crucial for trans women in Brazil.
