Determining Knowledge, Attitudes, and Beliefs About Pre-Exposure Prophylaxis (PrEP) Among Transgender Men
Repository Posting Date2017-06-12T19:48:49Z
Author DetailsStefan Rowniak, PhD, RN, FNP; Chenit Ong-Flaherty; Nancy Selix; Niko Kowell
Lead Author Sigma AffliationNon-member
Other Title(s)Global Sexual Health
Level of EvidenceN/A
The United States has witnessed a real shift in HIV prevention practices over the past several years. The prevention techniques that had been employed since the beginning of the epidemic have focused on behavior change. This meant the promotion of condoms for safer sex and engaging high-risk individuals in intensive behavior change counseling, among other interventions. The current shift has been away from individual behavioral approaches to more community-based biological approaches that include testing and immediate treatment and the lowering of the community viral load to ensure that transmission is significantly decreased (Centers for Disease Control and Prevention, 2012, 2014b; San Francisco Department of Public Health, 2014).
The biological intervention that has engendered some of the most interest is pre-exposure prophylaxis (PrEP). The iPrEx study demonstrated that with the daily use of emtricitabine and tenofovir disoproxil fumarate (FTC-TDF), also known as Truvada, participants had a 44% lower rate of infection with HIV compared to those who received placebo. In the same study, those participants who had detectable blood levels of the drug had a 92% lower rate of infection with HIV as compared to those without detectable levels. This suggests an even greater protection for those who are able to take the drug on a daily basis (Centers for Disease Control and Prevention, 2012, 2014b, 2014c; Cohen, Liu, Bernstein, & Philip, 2013).
Since the results of the study were reported, the US Food and Drug Administration approved the emtricitabine and tenofovir combination for PrEP in 2012. Though uptake of PrEP among providers has been slow throughout the country, in locations such as San Francisco, the Health Department and other health providers have been engaged in active promotion of PrEP in a campaign to “get to zero” with regard to new HIV infections (San Francisco Department of Public Health, 2014).
One of the most important questions with regard to PrEP is at whom should the promotion and use of PrEP should be aimed. The iPrEx study recruited primarily men who have sex with men (MSM). This makes perfect sense since MSM have been documented as the population most profoundly impacted by HIV since the epidemic began. Also young MSM of color represent the only group demonstrating increasing incidence of HIV in the US (Centers for Disease Control and Prevention, 2014a).
HIV disproportionally affects transgender women on a worldwide basis (World Health Organization, 2015). Currently there are attempts to actively recruit more transgender women into PrEP programs in San Francisco and throughout California. However, there has been little attention paid to transgender men as being at risk for HIV and also as candidates for PrEP. Several studies have demonstrated that there are transgender men who are the sexual partners of gay men, identify as gay men, and are embedded within the gay male community thus having the same risks for HIV as non-transgender gay men (Rowniak & Chesla, 2012; Rowniak, Chesla, Rose, & Holzemer, 2011; Sevelius, 2009). The lack of inclusion of transgender men in the discussions and promotion of PrEP has meant that not only are many medical providers overlooking transgender men as PrEP candidates, many in the community of transgender men have not understood how PrEP may be relevant to their lives and health. The purpose of this study was to examine the knowledge, attitudes and beliefs of transgender men (trans men) regarding pre-exposure prophylaxis (PrEP) for HIV
Three focus groups of trans men were conducted with a trans male facilitator for a total of 21 participants. Each of the primary researchers attended one of the focus groups. They took field notes during the session and wrote up their impressions of the focus groups within 24 hours. All focus groups were recorded and then transcribed. Transcripts were placed in the Atlas.ti computer program and a thematic analysis was conducted comparing each focus group to the others.
Six themes were identified; a lack of adequate information about PrEP and possible side effects, the economic realities for trans men, finding a trans competent provider, trans male sexuality, the importance of contraception, and condom use.
Despite identified risk, many trans men still lack adequate information regarding PrEP. There exist significant barriers to PrEP access for trans men including economic hardship that is impacted by a person’s transgender status and a lack of cultural competent providers for transgender people. Also, participants commented how many providers avoid important discussions regarding sexuality. As a result, most stated that their medical providers assumed that the participants had female sex partners and did not know that they had gay male sex partners and were therefore at risk for HIV infection and appropriate for PrEP. Interestingly, most participants reported a high level of condom use and stated they would continue to use condoms even if they were taking PrEP. This could, in part, be explained by the concern voiced over the risks of pregnancy and the need for contraception. There is a need for PrEP education and outreach to the trans male community. The education of healthcare professionals must include competency in working with transgender populations, which includes an understanding and appreciation of the variabilities in transgender sexuality. More research is needed with regard to interactions between PrEP, testosterone, and hormonal contraception.