Background : Transgender women sex workers face a unique HIV risk context due to intersectional stigma at interpersonal and structural levels as well as individual and interpersonal risk behaviors. PrEP represents the next generation of high-impact, biomedical HIV prevention. This study examines the socio-structural context in which these women conceptualize HIV risk and PrEP acceptability, to inform PrEP intervention development.
Methods : The study was conducted in Baltimore City, Maryland, between 2017-18 and employed ethnographic and participatory research methods (i.e., observations [n=6], participant photo diaries [n=5], in-depth interviews with transgender women sex workers [n=20] and key informant interviews [n=7]). Analysis followed an inductive and deductive approach.
Results : Preliminary analyses indicate multi-level factors influence the PrEP continuum from awareness, interest, access, uptake to adherence. Awareness to adherence were shaped by a sociocultural context in which PrEP is perceived as marketed to MSM and at-risk individuals, with attending stigmas. Though most participants reported accessing a health provider, stories of institutional and medical mistrust point to complexities in healthcare access and utilization. Individual level factors shaping pill adherence include perception of individual risk level, experimental dosing, and concerns around hormone interactions. The complex web of health priorities and structural vulnerabilities, including client violence, police violence, and drug use, provided insights into barriers and facilitators to PrEP adherence.
Conclusions : PrEP interventions for transgender women sex workers must consider competing priorities and how best to integrate PrEP into trans women's lives. Utilizing existing health regimens, existing prescribers, and social networks- including peers and community leaders, to promote PrEP uptake and adherence should be considered in future intervention development. Further, data indicate a need to consult trans communities to ensure effective PrEP marketing will avoid further stigmatization of transgender women.