Abstract
Pre-exposure prophylaxis (PrEP) can efficaciously avert HIV acquisition for individuals at risk, including transgender individuals (trans) in the Philippines. We conducted multivariate logistic regression procedures in an online sample of Filipina trans women (n = 139) to examine associations of PrEP awareness. In this sample, 53% of Filipina trans women were unaware of PrEP, but almost all (93%) expressed interest in taking PrEP once learning about it. Greater odds of PrEP awareness was associated with discussion of HIV services with their health care providers, higher HIV knowledge, and discussion of PrEP among trans friends. Lower odds of PrEP awareness was associated with reporting being currently unemployed. The findings underscore a subset of trans women who might be early adopters of PrEP, and highlight PrEP inequities among trans women most marginalized, including those who are unemployed and have engaged in sex work.
Keywords: pre-exposure prophylaxis, HIV prevention, transgender, Philippines
Globally, transgender women (trans women) are a community of women in high need of HIV prevention interventions (World Health Organization [WHO], 2016). Trans women are 49 times more likely to be living with HIV compared to cisgender (i.e., non-transgender) adults of reproductive age. In low- and middle- income countries, the estimated HIV prevalence rate among trans women is 17% (Baral et al., 2013). The Philippines is a middle-income Southeast Asian country where HIV is rapidly expanding (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2019). Since 2010, new HIV infections have increased by 174% in Philippines, and Filipina trans women are one of the key affected populations highly impacted by the epidemic (Philippines Department of Health, 2018; WHO, 2019). The estimated population size of trans women in the Philippines is 122,800 and 1.7% are diagnosed living with HIV (UNAIDS, 2019). Despite this rapid increase in new HIV diagnoses, only a small portion (27%) of Filipina trans women have been reached by HIV prevention programs.
Pre-exposure prophylaxis (PrEP) oral formulation (emtricitabine/tenofovir disoproxil fumarate) is an effective biomedical strategy for HIV prevention for individuals at highest risk, including trans women (Deutsch et al., 2015; Grant et al., 2016). Studies examining PrEP among trans women, primarily involving U.S.-based samples, have identified several barriers to PrEP use across multiplelevels (i.e., personal, social, and structural levels). Personal barriers include low HIV knowledge, younger age, concerns about PrEP cost, having no insurance, and concerns about side effects with hormones (Galindo et al., 2012; Hoagland et al., 2017; Sevelius, Deutsch, & Grant, 2016; Sevelius, Keatley, Calma, & Arnold, 2016; Yang et al., 2013). At the social level, barriers include social marginalization (e.g., engagement in sex work, homelessness, and unemployment), having negative health care experiences (e.g., discrimination), and mistrust with medical providers (Restar, Kuhns et al., 2018). Other studies noted participants’ social concerns regarding PrEP, which reflect culturally stigmatizing beliefs about promiscuity or immorality given that PrEP is indicated for use in the context of sexual behavior where HIV transmission is likely (Calabrese & Underhill, 2015; Spieldenner, 2016). The Philippines is largely a Catholic country (Pew Research Center, 2016), where sex-related topics are predominantly taboo and social norms specific to stigma and discrimination among trans women are widespread (Asuncion, Segarra, Samonte, Palaypayon, & Bermejo, 2017; Ross et al., 2013). In the context of health care settings, structural barriers can include lacking anti-discrimination policies on the basis of gender identity, traveling long distances to/from health care facility where necessary services are available, as well as lack of routine professional training on PrEP and trans medicine for service providers (Eaton et al., 2017; Escudero et al., 2015; Golub, Gamarel, Rendina, Surace, & Lelutiu-Weinberger, 2013; Yang et al., 2013).
A recent literature review on HIV research in the Philippines showed that there are few empirical studies on HIV prevention among trans women in the Philippines (Restar, Nguyen, et al., 2018). While the Philippines’ Department of Health is currently considering approval of PrEP for public use and there is one ongoing PrEP demonstration project (PrEPWatch, 2019), these initiatives are currently limited and focused only towards cisgender (i.e., non-transgender) men who have sex with men (UNAIDS, 2019). To our knowledge, there are no published studies on Filipina trans women’s PrEP awareness and interest (Restar, Nguyen, et al., 2018), which are critical factors for engaging individuals in the PrEP continuum of care (Kelley et al., 2015; Liu et al., 2012; Nunn et al., 2017; Poteat et al., 2019). Given the current national consideration to make PrEP available in the future, it is imperative to examine disparities of PrEP awareness and interest among Filipina trans women to inform development and implementation of PrEP programs in the Philippines, particularly among trans women who engage in high HIV risk behaviors. As such, understanding the factors associated with PrEP awareness and interest among Filipina trans women can facilitate identifying individuals who are and are not aware and amenable to take PrEP.
The purpose of this study was to examine PrEP awareness and interest, and associations with related factors (e.g., socio-demographics, social marginalization and other community-level factors, and HIV and health care indicators), among an online-recruited sample of Filipina trans women in two Philippines cities. Among those who reported not interested in taking PrEP, we detailed reasons for why not.
METHODS
PARTICIPANTS AND PROCEDURES
We utilized data from Project #ParaSaAtin, a cross-sectional online study with Filipina trans women (n = 139). The purpose of the study was to examine social, community, and structural-related factors that impact access to and uptake of HIV/AIDS prevention services, including condoms, HIV testing, and biomedical modalities like PrEP. This analysis focuses specifically on PrEP awareness and interest. Participants were eligible to be part of this study if they self-reported: (1) being 18 years old or above, (2) identify as transgender, (3) sexually active within the past year (i.e., having had condomless anal sex in the past 12 months), (4) currently living in two highest HIV burden areas of Metro Manila/National Capital Region (NCR) or Central Visayas, and (5) demonstrated English and consent comprehension. Although English is one of Philippines’ national languages (Gonzalez, 1998), we ensured that participants completing the survey had adequate English comprehension and were eligible to participate by implementing a brief cognitive screening form that tested participants’ capacity to consent and understand English. The cognitive screening form asked participants definition or true/false questions based on the consent form. We also used the Flesch-Kincaid Reading Level Test (Kincaid, Fishburne, Rogers, & Chissom, 1975) that ensured the survey questionnaire had maintained language readability and comprehension at the 6th grade level.
Between June 2018 and May 2019, we conducted convenience online recruitment sampling by posting our study link via banners, flyers, and advertisements through social media sites and private online groups (e.g., Facebook, Twitter) of community-based organizations specific to trans communities in the Philippines. Participants who clicked on the survey link completed an online screening and consent process and, if eligible, completed the survey. We also utilized a series of standard online survey protective measures such a captcha box, which is a challenge-response test that online surveys use to confirm that participants taking the survey are humans and not robots (Umbach, 2004; Van Selm & Jankowski, 2006). Moreover, to eliminate participants from taking multiple surveys, we programmed our online survey to allow only those with unique IP addresses to take the survey (King, O’Rourke, & DeLongis, 2014; Van Selm & Jankowski, 2006). The survey lasted between 20 to 25 minutes. All participants received a P300 (approximately $5.85 U.S.D) electronic prepaid mobile load card for their time and completion of the survey.
All of the study procedures were informed and deemed appropriate by three local community-based organizations that provide HIV services and serve trans communities in the Philippines and that collaborated in the development and implementation of this project. The Brown University Human Research Protection Program Institutional Review Committee in Providence, Rhode Island approved the study procedures.
MEASURES
Socio-demographics.
We asked participants a series of demographic factors including age (18–24, 25–29, 30–34, and 35 or more years old), current living location (Metro Manila/NCR, or Central Visayas), highest educational attainment (high school or below, some college, or college and beyond), past year income (less than P10,000, P10,000–P20,000, P20,000–P30,000, P30,000+, or no income), religious affiliation (Catholic, non-Catholic, e.g., Protestant, Christian, or non-religious]), and sexual identity (gay, bisexual, straight, or not listed). With the exception of sexual identity, all socio-demographic variables were adapted from the Philippines National Demographic and Health Survey (Philippine Statistics Authority, 2018).
Social Marginalization Variables.
To measure factors related to social marginalization, we asked participants about their experience of ever being homeless (yes or no), currently unemployed (yes or no), and recent engagement (< 4 months) in sex work (yes or no).
Community-Level Factors.
We measured three community-level variables: social cohesion (e.g., perception of mutual aid, trust, and support), social participation, and health care accessibility. We adapted a nine-item social cohesion scale by Lippman and colleagues (2010) to specifically refer to trans communities (Cronbach’s alpha = 0.87). Some item examples included: “You can count on your transgender friends if you need to talk about your problems” and “You can count on your transgender friends to accompany you to the doctor or hospital” with each item consisting of 5-level Likert response options ranging from strongly agree to strongly disagree. Scores were summed (median = 20, range = 9–43) and dichotomized at the median to categorize low vs. high social cohesion. We adapted a social participation scale from Fonner and colleagues (2014) by asking participants about engagements or participation in general community events (i.e., general social participation) such as cultural activities, church, community events, and LGBT-specific activities (i.e., LG-BT-specific social participation) like joining pageants and local LGBT organizations. Responses were either yes or no. We categorized low vs. high general social participation (Cronbach’s alpha = 0.76) or LGBT-specific social participation (Cronbach’s alpha = 0.75) by summing and dichotomizing at the median for each measure (2 and 3, respectively). Researchers examining social cohesion and participation have performed similar procedures previously (Fonner et al., 2014; Grover et al., 2016).
To assess health care accessibility, we utilized Haggerty and colleagues’ (2011) scale on care accessibility from the patient perspective (Cronbach’s alpha = 0.93). This six-item scale with 6-level Likert response options ranging from very poor to excellent asks participants to rate health care accessibility dimensions regarding: convenience of provider’s office; office hours for medical appointments; duration of next open appointments; waiting times during appointment; traveling doctor’s office; and ability to reach provider when needed. Scores were summed (median = 18, range = 6–30) and dichotomized at the median to categorize as poor/fair vs. good/excellent health care accessibility.
HIV and Other Health Care Indicators.
We asked participants a series of yes-or-no questions about their health care experiences. This includes whether they currently have health care insurance, ever had surgery or taken hormones for gender affirmation, and have ever experienced health care discrimination due to their trans identity. Based on literature on HIV prevention and trans women (e.g., Garofalo et al., 2012; Hughto, Reisner, & Pachankis, 2015; Operario, Soma, & Underhill, 2008; Reisner, et al., 2016), we adapted questions across personal, social, and community-related experiences relating to HIV services and asked participants if they had ever had an HIV test before, have discussed HIV services with a health care provider, and have avoided seeking HIV services due to: cost of services, distance of travel to/from health care facility, having a trans identity, and lack of facility-level policy on LGBT anti-discrimination. Lastly, we asked participants about their HIV knowledge using the International AIDS Questionnaire (Cronbach alpha = 0.84, with median = 45, range = 28–85), and dichotomized scores at the median to categorize as high vs. low HIV knowledge (Davis, Sloan, Macmaster, & Hughes, 2007).
PrEP Variables.
We asked three PrEP-related variables, of which two are outcomes for this article (i.e, PrEP awareness and interest). We adapted PrEP-related questions from Restar, Kuhns and colleagues (2018). To assess for PrEP awareness, we as asked participants, “Have you heard of people taking HIV medication before sex because they thought it would lower their chances of getting HIV (also known as PrEP)? (yes or no).” Following this question, all participants were then provided a brief definition of PrEP and assessed if they were interested in PrEP use by asking, “If the possibility of taking a daily pill to prevent HIV (‘oral PrEP’), would you be interested in taking it? (not interested at all vs. somewhat/very interested).” To assess PrEP awareness at the community-level, we asked participants if they have had PrEP discussions among their trans friends by rating how true is the following statement, “My transgender friends talk about PrEP,” with response options very/somewhat true vs. not true at all.
Participants who were not interested in PrEP were subsequently prompted to complete a follow-up question with a list of reasons for their lack of interest in PrEP. These reasons were generated based from our formative work as well as the HIV prevention and PrEP literature on this population (Escudero et al., 2015; Galindo et al., 2012; Restar et al., 2017; Restar, Kuhns, et al., 2018; Sevelius, Keatley, et al., 2016). Reasons included: needing to know more information before taking PrEP, worrying about general negative side effects as well as side effects specifically with hormone use, worrying about the cost of PrEP, disliking taking pills, and fearing that people will think of them as risky if they are seen taking PrEP.
ANALYSIS
We utilized data from 134 Filipina trans women who completed the survey questionnaire. We performed descriptive analysis to determine proportions and χ2 tests to examine associations between our outcomes, PrEP awareness and interests, by various characteristics including socio-demographics, social and community-level factors, health care indicators, and PrEP indicators. We performed sensitivity analysis to determine the internal consistency of our scale variables (e.g., social cohesion, social participation, etc.), providing Cronbach alphas. Since almost all participants were interested in taking PrEP (92.81%), conducting logistic regression procedure was deemed not appropriate due to having very few or no cell counts observed in the comparison group. Reasons for not having interest in PrEP were therefore examined descriptively.
To examine characteristics associated with PrEP awareness, we performed bivariate and multivariable logistic regression analyses. All variables that were statistically significant in the bivariate model were included in the final adjusted multivariable logistic regression model. Prior to running our final model, we conducted a multicollinearity test using the standard procedure for assessing variance inflation factor (VIF) to examine collinearity effects and determined that this was not a concern (all VIFs < 4; O’Brien, 2007). Alpha was set to < 0.05 a priori, and all analytical procedures were performed using StataSE version 15.1 (StataCorp, 2018).
RESULTS
SAMPLE CHARACTERISTICS
Table 1 characterizes the demographics and experiences of the sample population by PrEP awareness and interest.
TABLE 1.
Study Sample Characteristics of Filipina Transgender Women (n = 139)
| Total | PrEP Aware | χ2 test, p value | PrEP Interest | χ2 test, p value | |
|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | |||
| Total | 139 | 74 (53.24) | 129 (92.81) | ||
| Demographics | |||||
| Age | ns | ns | |||
| 18–24 | 45 (33.58) | 19 (27.14) | 41 (33.06) | ||
| 25–29 | 54 (40.30) | 29 (41.43) | 53 (42.74) | ||
| 30–34 | 20 (14.93) | 15 (21.43) | 18 (14.52) | ||
| 35+ | 15 (11.19) | 7 (10.00) | 12 (9.68) | ||
| Current living location | ns | ns | |||
| Metro Manila/National Capital Region | 110 (79.14) | 56 (75.68) | 102 (79.07) | ||
| Central Visayas | 29 (20.86) | 18 (24.32) | 27 (20.93) | ||
| Highest educational attainment | .038 * | ns | |||
| High school and below | 55 (39.57) | 22 (29.73) | 50 (38.76) | ||
| Some college | 23 (16.55) | 15 (20.27) | 21 (16.28) | ||
| College and beyond | 61 (43.88) | 37 (50.00) | 58 (44.96) | ||
| Past year income | .009 ** | ns | |||
| Less than P10,000 | 39 (28.06) | 18 (24.32) | 34 (26.36) | ||
| P10,000–20,000 | 27 (19.42) | 17 (22.97) | 27 (20.93) | ||
| P20,000–30,000 | 11 (7.91) | 8 (10.81) | 11 (8.53) | ||
| P30,000+ | 24 (17.27) | 18 (24.32) | 23 (17.83) | ||
| No income in the past year | 38 (27.34) | 13 (17.57) | 34 (26.36) | ||
| Religious affiliation | <.001 *** | ns | |||
| Catholic | 110 (79.14) | 50 (67.57) | 101 (78.29) | ||
| Non-Catholic (e.g., Protestant, Christian) | 21 (15.11) | 19 (25.68) | 50 (15.50) | ||
| Non-religious | 8 (5.76) | 5 (6.76) | 6 (6.20) | ||
| Sexual orientation | ns | ns | |||
| Gay | 77 (55.40) | 41 (55.41) | 71 (55.04) | ||
| Bisexual | 18 (12.95) | 10 (13.51) | 18 (13.95) | ||
| Straight | 26 (18.71) | 15 (20.27) | 24 (18.60) | ||
| Not listed | 18 (12.95) | 8 (10.81) | 16 (12.40) | ||
| Social Marginalization Factors | |||||
| Ever experienced homelessness | ns | ns | |||
| No | 101 (73.19) | 49 (67.12) | 93 (72.66) | ||
| Yes | 37 (26.81) | 24 (32.88) | 35 (27.34) | ||
| Currently unemployed | <.001 *** | ns | |||
| No | 80 (57.55) | 53 (71.62) | 76 (58.91) | ||
| Yes | 59 (42.45) | 21 (28.38) | 53 (41.09) | ||
| Recent (< 4 mos) sex work engagement | .029 * | ns | |||
| No | 27 (27.27) | 19 (36.54) | 24 (26.37) | ||
| Yes | 72 (72.73) | 33 (53.46) | 67 (73.63) | ||
| Community-Level Factors | |||||
| Social cohesion | .037 * | .033 * | |||
| Low | 66 (47.48) | 29 (39.19) | 58 (44.96) | ||
| High | 73 (52.52) | 45 (60.81) | 71 (55.04) | ||
| General social participation | .018 * | ns | |||
| Low | 53 (38.13) | 35 (47.30) | 51 (39.53) | ||
| High | 86 (61.87) | 39 (52.70) | 78 (60.47) | ||
| LGBT-specific social participation | .002 ** | ||||
| Low | 81 (58.27) | 34 (34.95) | 74 (57.36) | ||
| High | 58 (41.73) | 40 (54.05) | 55 (42.64) | ||
| Health Care Accessibility | .012 * | ns | |||
| Poor/Fair | 74 (53.24) | 32 (43.24) | 67 (51.94) | ||
| Good/Excellent | 65 (46.76) | 42 (56.76) | 62 (48.06) | ||
| HIV and Other Health Care Indicators | |||||
| Current health insurance | <.001 *** | ns | |||
| No | 94 (67.63) | 40 (54.05) | 85 (65.89) | ||
| Yes | 45 (32.37) | 34 (45.95) | 44 (34.11) | ||
| Ever taken hormones for gender affirmation | ns | ns | |||
| No | 49 (35.25) | 24 (32.43) | 45 (34.88) | ||
| Yes | 90 (64.75) | 50 (67.57) | 84 (65.12) | ||
| Ever had surgery for gender affirmation | ns | ns | |||
| No | 112 (80.58) | 58 (78.38) | 102 (79.07) | ||
| Yes | 27 (19.42) | 16 (21.62) | 27 (20.93) | ||
| Health care discrimination due to transgender identity | ns | .022 * | |||
| No | 77 (55.40) | 37 (50.00) | 68 (52.71) | ||
| Yes | 62 (44.60) | 37 (50.00) | 61 (47.29) | ||
| Ever had HIV test | <.001 *** | ns | |||
| No | 45 (32.37) | 5 (6.76) | 40 (31.01) | ||
| Yes | 94 (67.63) | 69 (93.24) | 89 (68.99) | ||
| Discussed HIV services with a health care provider | <.001 *** | ns | |||
| No | 41 (29.50) | 4 (5.41) | 36 (27.91) | ||
| Yes | 98 (70.50) | 70 (94.59) | 93 (72.09) | ||
| HIV knowledge | <.001 *** | ns | |||
| Low | 69 (49.69) | 19 25.68) | 64 (49.61) | ||
| High | 70 (50.36) | 55 (74.32) | 65 (50.39) | ||
| Avoided HIV services due to cost of services | .005 ** | ns | |||
| No | 69 (49.64) | 45 (60.81) | 63 (48.84) | ||
| Yes | 70 (50.36) | 29 (39.19) | 66 (51.16) | ||
| Avoided HIV services due to distance of travel to/from health care facility | .037 * | ns | |||
| No | 73 (52.52) | 45 (60.81) | 69 (53.49) | ||
| Yes | 66 (47.48) | 29 (39.19) | 60 (46.51) | ||
| Avoided HIV services due to transgender identity | .004 ** | ns | |||
| No | 76 (54.68) | 49 (66.22) | 70 (54.26) | ||
| Yes | 63 (45.32) | 25 (33.78) | 59 (45.74) | ||
| Avoided HIV services due to lack of LGBT anti-discrimination policy | .002 ** | ns | |||
| No | 73 (52.52) | 48 (64.86) | 68 (51.71) | ||
| Yes | 66 (47.48) | 26 (35.14) | 61 (47.29) | ||
| PrEP-Related Indicators | |||||
| PrEP discussion among friends | <.001 *** | .009** | |||
| No | 85 (61.15) | 34 (45.95) | 75 (58.14) | ||
| Yes | 54 (38.85) | 40 (54.05) | 54 (41.86) | ||
| PrEP interest | .045 * ^ | ||||
| Not at all | 129 (92.81) | 72 (97.30) | |||
| Very/somewhat | 10 (7.19) | 2 (2.70) |
Note. ns = not significant.
p < .05.
p < .01.
p < .001.
Fisher’s exact test.
Demographics.
Filipina trans women included in this sample were mostly between ages 25–29 (40.30%), living in Metro Manila/NCR (79.14%), had attained college-level education and beyond (43.88%), had either no income (27.34%) or had less than P10,000 income (28.06%) in the past year, Catholic (79.14%), and sexual identify as gay (55.40%).
Social Marginalization.
A total of 26.81% of participants had ever experienced homelessness, 42.45% are currently unemployed, 72.73% recently engaged in sex work.
Community-Level Factors.
About half of the sample population had high social cohesion (52.52%), high general social participation (61.87%), high LGBT-specific social participation (41.73%), and have poor/fair health care accessibility (53.24%).
HIV and Other Health Care Indicators.
More than half of the participants had no current health insurance (67.63%). The majority reported ever taking hormones (64.75%) and had no surgery (80.58%) for gender affirmation. About half (44.60%) experienced health care discrimination due to their trans identity. For HIV indicators, the majority of the sample had ever taken an HIV test (67.63%) and discussed HIV services with a health care provider (70.50%). About half avoided services because of cost (50.36%), the distance of travel to/from health care facility (47.48%), having a trans identity (45.32%), and lack of LGBT anti-discrimination policy (47.48%). About half (50.36%) displayed high HIV knowledge.
PrEP Awareness and Interest.
More than a third (38.85%) of our sample had discussed PrEP among trans friends, about half were aware of PrEP (53.24%), and almost all were interested in taking PrEP (92.81%).
Reasons for Not Being Interested in PrEP.
In Table 2, a total of 10 (7.19%) Filipina trans women were not interested in taking PrEP. Reasons for not being interested in PrEP included: needing to know more information before taking PrEP (50%), worried generally about negative side effects (40%), worried about negative side effects specifically with hormone use (20%), worried about cost of PrEP (60%), do not like taking pills (20%), and fearing that people will think that they are risky if they were seen taking PrEP (10%).
TABLE 2.
Reasons for Not Being Interested in Taking PrEP (n = 10)
| Reason | % |
|---|---|
| I need to know more information before taking PrEP | 50 |
| I worry about side effects | 40 |
| I worry about side effects specifically with my hormone use | 20 |
| I worry about cost of PrEP | 60 |
| I don’t like taking pills | 20 |
| I’m afraid people will think I’m “risky” if they see me taking the HIV medication | 10 |
BIVARIATE LOGISTIC REGRESSION ANALYSES
Bivariate unadjusted regression models examining factors associated with PrEP awareness are displayed in Table 3. The following are factors independently associated with PrEP awareness (all ps < .05): For demographics, PrEP awareness was associated with having some college (odds ratio [OR] = 2.81, 95% confidence interval [95% CI] [1.02, 7.74]), or completing college and beyond (OR = 2.31, 95% CI [1.09, 4.87]), having P30,000 or more income in the past year (OR = 3.50, 95% CI [1.14, 10.70]), and non-Catholic religious affiliation (OR = 11.4, 95% CI [2.35, 51.32]).
TABLE 3.
Bivariate and Multivariable Logistic Regression Models
| PrEP Awareness | ||||||
|---|---|---|---|---|---|---|
| Unadjusted Model |
Adjusted Modela |
|||||
| OR | 95% CI | p value | aOR | 95% CI | p value | |
| Demographics | ||||||
| Age | ||||||
| 18–24 | ref | |||||
| 25–29 | 1.58 | 0.71, 3.52 | .256 | |||
| 30–34 | 4.10 | 0.27, 13.25 | .188 | |||
| 35+ | 1.19 | 0.37, 3.87 | .764 | |||
| Current living location | ||||||
| Metro Manila/National Capital Region | ref | |||||
| Central Visayas | 1.04 | 0.94, 1.14 | .397 | |||
| Highest educational attainment | ||||||
| High school and below | ref | |||||
| Some college | 2.81 | 1.02, 7.74 | .046 * | |||
| College and beyond | 2.31 | 1.09, 4.87 | .027 * | |||
| Past year income | ||||||
| Less than P10,000 | ref | |||||
| P10,000–20,000 | 1.98 | 0.72, 5.40 | .181 | |||
| P20,000–30,000 | 3.11 | 0.71, 13.51 | .130 | |||
| P30,000+ | 3.50 | 1.14, 10.70 | .028 * | |||
| No income in the past year | 0.60 | 0.24, 1.52 | .287 | |||
| Religious affiliation | ||||||
| Catholic | ref | |||||
| Non-Catholic (e.g., Protestant, Christian) | 11.4 | 2.53, 51.32 | .002 ** | |||
| Non-religious | 2.00 | 0.45, 8.78 | .359 | |||
| Sexual orientation | ||||||
| Gay | ref | |||||
| Bisexual | 1.09 | 0.39, 3.08 | .860 | |||
| Straight | 1.19 | 0.48, 2.93 | .694 | |||
| Not listed | 0.70 | 0.25, 1.97 | .502 | |||
| Social Marginalization Factors | ||||||
| Ever experienced homelessness | ||||||
| No | ref | |||||
| Yes | 1.95 | 0.89, 4.27 | .091 | |||
| Currently unemployed | ||||||
| No | ref | |||||
| Yes | 0.28 | 0.13, 0.57 | <.001 *** | 0.36 | 0.14, 0.96 | .046 ** |
| Recent (< 4 mos) sex work engagement | ||||||
| No | ref | |||||
| Yes | 0.35 | 0.13, 0.91 | .029 * | |||
| Community-Level Factors | ||||||
| Social cohesion | ||||||
| Low | ref | |||||
| High | 2.05 | 1.04, 4.03 | .037 * | |||
| General social participation | ||||||
| Low | ref | |||||
| High | 2.34 | 1.15, 4.76 | 0.018 * | |||
| LGBT-specific social participation | ||||||
| Low | ref | |||||
| High | 3.07 | 1.51, 6.24 | .002 ** | |||
| Health care accessibility | ||||||
| Poor/fair | ref | |||||
| Good/excellent | 2.39 | 1.20, 4.75 | .012 * | |||
| HIV and Other Health Care Indicators | ||||||
| Current health insurance | ||||||
| No | ref | |||||
| Yes | 22.08 | 7.83, 62.23 | <.001 *** | |||
| Ever taken hormones for gender affirmation | ||||||
| No | ref | |||||
| Yes | 1.30 | 0.64, 2.61 | .458 | |||
| Ever had surgery for gender affirmation | ||||||
| No | ref | |||||
| Yes | 0.99 | 0.98, 1.00 | .486 | |||
| Health care discrimination due to transgender identity | ||||||
| No | ref | |||||
| Yes | 1.60 | 0.81, 3.14 | .173 | |||
| Ever had HIV test | ||||||
| No | ref | |||||
| Yes | 22.08 | 7.83, 62.23 | <.001 *** | |||
| Discussed HIV services with a health care provider | ||||||
| No | ref | |||||
| Yes | 23.12 | 7.53, 70.93 | <.001 *** | 10.38 | 2.84, 37.91 | .022 * |
| HIV knowledge | ||||||
| Low | ref | |||||
| High | 9.64 | 4.43, 21.00 | <.001 *** | 10.34 | 3.27, 32.63 | .018 * |
| Avoided HIV services due to cost of services | ||||||
| No | ref | |||||
| Yes | 0.37 | 0.18, 0.74 | .005 ** | |||
| Avoided HIV services due to distance of travel to/from health care facility | ||||||
| No | ref | |||||
| Yes | 0.48 | 0.24, 0.96 | .037 * | |||
| Avoided HIV services due to transgender identity | ||||||
| No | ref | |||||
| Yes | 0.36 | 0.18, 0.72 | .004 ** | |||
| Avoided HIV services due to lack of LGBT anti-discrimination policy | ||||||
| No | ref | |||||
| Yes | 0.33 | 0.16, 0.67 | .002 ** | |||
| PrEP-Related Indicators | ||||||
| PrEP discussion among friends | ||||||
| No | ref | |||||
| Yes | 4.28 | 2.02, 9.05 | <.001 *** | 9.23 | 2.74, 31.09 | .007 ** |
| PrEP interest | ||||||
| Not at all | ref | |||||
| Very/somewhat | 5.05 | 1.03, 24.72 | .046 * | |||
Note. OR = odds ratio; aOR = adjusted odds ratio; 95% CI = 95% confidence interval.
Model is adjusted for all variables that were significant in the bivariate model.
p < .05.
p < .01.
p < .001.
For social marginalization factors, being currently unemployed (OR = 0.28, 95% CI [0.13, 0.57]) and recently engaging in sex work (OR = 0.35, 95% CI [0.13, 0.91]) was associated with lower PrEP awareness.
Filipina trans women in this sample with high social cohesion (OR = 2.05, 95% CI [1.04, 4.03]), high general social participation (OR = 2.34, 95% CI [1.15, 4.76]), LGBT-specific social participation (OR = 3.07, 95% CI [1.51, 6.24]), and good/excellent health care accessibility (OR = 2.39, 95% CI [1.20, 4.75]) had greater odds of PrEP awareness. Having current health insurance was associated with greater odds of PrEP awareness (OR = 22.08, 95% CI [7.83, 62.23]).
HIV-related factors that were associated with greater odds of PrEP awareness included: ever taken an HIV test (OR = 22.08, 95% CI [7.83, 62.23]), discussed HIV services with a health care provider (OR = 23.12, 95% CI [7.53, 70.93]), and having high HIV knowledge (OR = 9.64, 95% CI [4.43, 21.00]). Filipina trans women who experienced avoiding HIV services due to cost of services (OR = 0.37, 95% CI [0.18, 0.74]), distance of travel to/from health care facility (OR = 0.48, 95% CI [0.24, 0.96]), having trans identity (OR = 0.36, 95% CI [0.18, 0.72]), and lack of LGBT anti-discrimination policy (OR = 0.33, 95% CI [0.16, 0.67]) displayed lower odds of PrEP awareness.
Filipina trans women who reported discussing PrEP among trans friends (OR = 4.28, 95% CI [2.02, 9.05]), and being interested in PrEP (OR = 5.05, 95% CI [1.03, 24.72]) displayed greater odds of PrEP awareness.
PrEP interest was significantly associated with social cohesion, health care discrimination due to trans identity, and PrEP discussion among friends (all ps < .05).
MULTIVARIABLE LOGISTIC REGRESSION ANALYSIS
In Table 3, our multivariable logistic regression model controlled for the variables that were found independently associated with PrEP awareness based on the bivariate model. We found that Filipina trans women who reported being currently unemployed had lower odds of PrEP awareness (adjusted OR [aOR] = 0.36, 95% CI [0.14, 0.96]). Filipina trans women who discussed HIV services with their health care providers had greater odds of PrEP awareness (aOR = 10.38, 95% CI [2.84, 37.91]) than those who did not. Higher HIV knowledge was also associated with greater odds of PrEP awareness (aOR = 10.34, 95% CI [3.27, 32.63]). Filipina trans women who discussed PrEP among trans friends had greater odds of PrEP awareness (aOR = 9.23, 95% CI [2.74, 31.09]) than those who did not.
DISCUSSION
To our knowledge, this is the first empirical study that examines self-reported PrEP awareness and interest among a sample of Filipina trans women. Our findings provide early insights for this group’s awareness and interest of PrEP at a time when the Philippines is experiencing an emerging HIV crisis and PrEP is being considered for public use approval (PrEPWatch, 2019; UNAIDS, 2019). Results of this study suggests that while almost all Filipina trans women surveyed are interested in PrEP once they learn about it, though disparities exist on having initial PrEP awareness within this group. Disparities in PrEP awareness were found at the personal, social, and structural levels. Specifically, Filipina trans women who reported having high HIV knowledge at the personal level, having discussed HIV services with their health care provider at the social level, and discussed PrEP among trans friends at the community-level have greater odds of PrEP awareness; while those who experience social marginalization by being currently unemployed have lower PrEP awareness. Our multivariable findings that observed several indicators across multiple levels are independently predictive of PrEP awareness expand the literature on PrEP, particularly in the context of the Philippines.
Specifically, we found that about one in two Filipina trans women are unware of PrEP, but almost all (93%) expressed interest in taking PrEP once learning about it. This finding suggests that there may already be a considerable support for using PrEP from this group, if and when it becomes approved for public use. However, this finding also highlights a considerable gap between awareness and interest in the steps of PrEP continuum care, particularly the role of PrEP education in increasing awareness and interest (Poteat et al., 2019). Currently, there are no existing formal PrEP education campaigns or programming the Philippines (PrEPWatch, 2019; UNAIDS, 2019), and the country’s national HIV strategic plan also does not include PrEP implementation as a target goal (Asuncion et al., 2017). As such, this finding underscores the importance of such educational campaigns in tandem with future scale-up of PrEP programs in the Philippines.
Our findings also reveal disparity on PrEP awareness by current employment status. Specifically, trans women who were unemployed had lower awareness of PrEP. This corroborates with other studies that identified social marginalization experiences like unemployment as a barrier to PrEP knowledge and access (Poteat et al., 2019; Restar, Kuhns, et al., 2018; Wood, Lee, Barg, Castillo, & Dowshen, 2017; Yang et al., 2013), and for which greater efforts to overcome this barrier must be considered and prioritized in PrEP scale-up designs among populations who face this barrier. In the context of the Philippines, our finding indicates that future PrEP implementation strategies and materials (e.g., intervention recruitment materials) aimed at reaching higher yield in interest and utilization of PrEP must cater not only to the broader population of Filipina trans women, but particularly targeted toward those who experience unemployment. As such, careful segmentation may be necessary for specifically inviting unemployed trans women in future PrEP programs in the Philippines. PrEP scale-up programs that aim to target trans women successful, including those who are unemployed, should first examine how well strategies and materials resonate with trans women in the Philippines broadly (Sevelius, Keatley et al., 2016), and consider the need for specific program messaging components that are important to underline when targeting specific subset of trans women (Wood et al., 2017).
Despite the absence of targeted PrEP information and education campaigns for trans women in the Philippines, our findings revealed that PrEP awareness was higher among trans women with high HIV knowledge and who discuss HIV services with their health care provider. This finding is consistent with diffusion of innovation theory (Rogers, 2010). This theory suggests that adoption of product (i.e., PrEP) originates with a group of people (i.e., early adopters) and over time disseminates or spreads through social systems (Rogers, 2010). Previous HIV research has found that high HIV knowledge and having health care providers who are knowledgeable about HIV prevention are associated with having access to and better engagement with HIV services (Baral et al., 2014), including PrEP (Kuhns et al., 2016). As such, trans women who are already well connected to HIV services could likely to be early adopters of PrEP and could play a vital role in the dissemination information about PrEP to their communities. Future research should examine their role as peers as well as early adopters of PrEP, including ways to engage them in the scale-up of PrEP to increase dissemination of PrEP information throughout other members of trans communities who may not be well connected to HIV and/or health care systems in the Philippines.
We found that social cohesion and social participation were not associated with PrEP awareness in this sample. This finding was counter to our prediction, that community engagement would be associated with greater PrEP awareness which has been reported in studies from other communities (Mehrotra et al., 2018; Yang et al., 2013). One possible explanation for this non-significant association is due to measurement imprecision, as the scales utilized for measuring social cohesion and participation assessed general types of social cohesion/participation but were not developed to capture patterns of social engagement specific to trans women in the Philippines. Indeed, we found that a more specific indicator of trans community engagement, i.e., PrEP discussion among trans friends, was significantly associated with greater PrEP awareness. A second explanation for this non-significant finding is that PrEP awareness has not yet penetrated into trans social networks in the Philippines, and thus general engagement with trans-specific communities does not yet confer opportunities for learning about PrEP. Altogether, these findings can suggest that scaling of PrEP will benefit from fostering relationships among trans community members in the Philippines as well as providing targeted PrEP education and awareness campaigns to members of these communities. As such, in this early stage of PrEP development in the Philippines, future research is needed to examine how to leverage trans networks for HIV prevention, as demonstrated in other studies of PrEP (Mehrotra et al., 2018; Yang et al., 2013), as well as how to empower trans community members to actively discuss PrEP with their network members.
Though very few members of this sample (n = 10) were uninterested in taking PrEP, it is noteworthy that the primary reason for lack of interest was related to lack of awareness about PrEP. Specifically, we found that about half of these individuals expressed needing more information about PrEP in general. Other common reasons for lack of interest included it’s the potential for negative side effects, impact on hormone use, and cost. These reasons corroborate findings from other research about informational/knowledge-related barriers to the PrEP continuum of care among trans women (Golub et al., 2013; Poteat et al., 2019; Yang et al., 2013). As such, this further supports the need for PrEP educational campaigns to overcome knowledge-based barriers and to empower Filipina trans women with PrEP awareness.
A major strength of this study is first known effort to characterize multi-level factors associated with PrEP awareness among Filipina trans women. HIV prevention research in the Philippines has predominantly centered on condom use, which limits our understanding about biomedical approaches that could be applicable in the context of the Philippines (Gangcuangco, 2019; Marston, Marín-Hernández, & Nixon, 2019). These findings bring attention to an understudied and high-risk population that has previously reported vulnerability to gender-related social stigma, internalized shame for their sexual activity, and negative judgement in community venues and health care locations for HIV prevention. We also expanded the PrEP literature by pointing out indicators that can be used to leverage PrEP awareness across multiple levels. These findings also identify multi-level targets that can be leveraged to enhance PrEP awareness, which has been called for in previous PrEP research involving trans women (Operario & Nemoto, 2010; Underhill, Operario, Mimiaga, Skeer, & Mayer, 2010).
Our research had several limitations. First, we utilized convenience sampling (i.e., non-probability sampling) to enroll participants, which may have resulted in sampling bias such that participants represented in the study might not reflect the broader trans community in the Philippines (e.g., those who do not have access to the internet or who do not frequent transgender-specific websites). Second, due to the low number of participants who expressed lack of interest in using PrEP, we were unable to examine co-factors of this variable. Third, this study was conducted during an early phase of the Philippines’ response to the national HIV epidemic, when PrEP is still being considered for public use. As such, prevalence and correlates of PrEP awareness and interest among Filipino trans women are likely to change as the epidemic matures. Lastly, trans women in this study represent a small subset of the gender expansive population in the Philippines, and future research is needed to examine HIV prevention and PrEP awareness across the diverse range of gender expression in the Philippines (Bumanglag, 2018).
CONCLUSION
This study found disparities on PrEP awareness across personal, social, and community-levels among Filipina trans women living in the two highest HIV burden areas in the Philippines. Despite these disparities, almost all trans women in this sample were interested in PrEP after learning about the potential protective effects of this medication. The findings of this study point to the role of a subset of trans women who might be early adopters of PrEP—i.e., those who are more affluent, currently employed, well-connected to HIV and health care system, and empowered to actively discuss PrEP among their friends. Future studies should leverage the role of this subgroup in diffusing PrEP awareness and scaling-up PrEP implementation that is inclusive and equitable for all trans women in the Philippines, particularly those who are most marginalized.
Acknowledgments
This research was supported by the National Institute on Drug Abuse of the National Institutes of Health (R36DA048682), the National Institute of Health-Fogarty International Center (D43TW010565), Providence/Boston Center for AIDS Research (P30AI042853), and the NIH-National Institute on Minority Health and Health Disparities (5T37MD008655) at Brown University’s Global Health Initiative. Ms. Restar is a recipient of the Robert Wood Johnson Foundation Health Policy Research Scholars and a Public Policy Fellow at amFAR, the Foundation for AIDS Research. The views and opinions expressed in this article are solely those of the authors and do not necessarily represent the official views of the sponsors.
Contributor Information
Arjee J. Restar, Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, and the Philippine Health Initiative for Research, Service, and Training, Brown University Global Health Initiative, Providence, Rhode Island; amfAR, The Foundation of AIDS Research, Washington, DC..
Alexander Adia, Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, and the Philippine Health Initiative for Research, Service, and Training, Brown University Global Health Initiative, Providence, Rhode Island; Providence-Boston Center for AIDS Research and Miriam Hospital, Department of Medicine, Providence, Rhode Island..
Susan Cu-Uvin, Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, and the Philippine Health Initiative for Research, Service, and Training, Brown University Global Health Initiative, Providence, Rhode Island..
Don Operario, Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, and the Philippine Health Initiative for Research, Service, and Training, Brown University Global Health Initiative, Providence, Rhode Island..
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