The persistent chasm between PrEP awareness and uptake: characterizing the biomedical HIV prevention continuum in a nationwide cohort of transgender women in the United States and Puerto Rico

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INTRODUCTION: Transgender (trans) women are disproportionately impacted by HIV, yet data on the biomedical HIV PrEP continuum (HIVPC) among trans women are limited. We characterized the HIVPC among a large, nationwide cohort of trans women in the United States and Puerto Rico by pre-exposure prophylaxis (PrEP) modality (daily oral and long-acting injectable, LAI) and identified correlates of uptake and non-adherence. METHODS: From April 2023 to December 2024, we enrolled English and Spanish-speaking adult trans women (age 18 years or older) not living with HIV (laboratory-confirmed via fourth-generation HIV-1/2 antigen/antibody testing) and residing in the United States and Puerto Rico into the cohort. PrEP data were collected via self-administered surveys. We characterized the HIVPC using descriptive statistics and assessed for differences in proportions for each step of the HIVPC by modality. Modified Poisson regression models estimated adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI) for correlates of HIVPC step (e.g. awareness to uptake). RESULTS: We enrolled 2504 participants, 1636 (65%) of whom may have benefitted from PrEP based on self-reported sexual history and/or needle sharing in the prior 6 months at baseline. Forty-two percent were 18-29 years old, 18% identified as Hispanic and/or Latina/x/e and 13% identified as Black (inclusive of multiracial participants). Among participants who may have benefitted from PrEP, 92% (n = 1495) had ever heard of PrEP, 36% (n = 591) had ever used PrEP, 27% (n = 441) had recently used PrEP (past 6 months) and 20% (n = 330) were adherent. The largest proportional difference in HIVPC step was from awareness to uptake (60% of PrEP-aware participants had never used PrEP). This difference was significantly greater for LAI PrEP (96% of LAI PrEP-aware participants had never used LAI). Correlates of PrEP uptake included high perceived HIV acquisition risk (aPR = 2.08, 95% CI = 1.59-2.72; ref = no perceived risk), current use of exogenous oestrogen and/or anti-androgens (aPR = 1.47 95% CI = 1.21-1.79), and receipt of health services at an LGBTQ+ clinic (aPR = 1.34, 95% CI = 1.16-1.55). Correlates of non-adherence among PrEP users included being a non-U.S. citizen (aPR: 2.41, 95% CI = 1.44-4.05) and recent food insecurity (aPR: 1.47, 95% CI = 1.04-2.06). CONCLUSIONS: Interventions to improve HIVPC outcomes-especially PrEP uptake-are needed to optimize HIV PrEP among trans women. PrEP interventions may need to include individually tailored, integrated programming to address risk perception, nutrition, gender-affirming care and comprehensive health, social, and legal needs.

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