Factors Associated with HIV Pre-Exposure Prophylaxis Use Among Transmasculine People Who Have Sex with Cisgender Men, at a Federally Qualified Health Center in Chicago, Illinois

Abstract

Transmasculine individuals who have sex with cisgender men (TMSM) remain an understudied population regarding pre-exposure prophylaxis (PrEP). We used electronic medical record data to assess PrEP eligibility and initiation in TMSM in a large LGBTQ+ focused federally qualified health center in Chicago, Illinois. We examined a sample of 430 TMSM from January 1, 2015 to December 31, 2019, and used logistic regression to model PrEP eligibility and initiation. Overall, 37% of participants were eligible for and 18% initiated PrEP. Eligibility was not associated with initiation. National PrEP guidance should be tailored to include transmasculine people.

Introduction

As efforts to increase oral pre-exposure prophylaxis (PrEP) awareness and initiation continue to help end the HIV epidemic, transmasculine people remain an understudied population.¹ Widely held misconceptions of transmasculine people as being predominantly attracted to cisgender women, a general lack of provider knowledge and trans-competency, and current PrEP awareness focusing on cisgender men and transgender women who have sex with cisgender men have contributed to a dearth of information about transmasculine people who have sex with cisgender men.^2,3

Even less is known about nonbinary individuals, those who fall outside of binary gender categories, although they may also have cisgender male sex partners or be at risk for HIV acquisition. Using the term “transmasculine people” to refer to transgender men and nonbinary people assigned female at birth, the remainder of our article will use the abbreviation TMSM to refer to transmasculine people who have sex with cisgender men.

Across studies, 7–69% of TMSM engaged in sexual behaviors contributing to HIV risk, including sex work, unprotected anal or frontal sex with male, casual partners, low utilization of sexually transmitted infection (STI) screening, and high prevalence of psychological distress and substance use.⁴ Additional emerging risk factors reported by TMSM include a lack of available information regarding safe sex practices for nonheterosexual transmasculine people, increased interest in sex after/while taking hormones, mood and gender role triggers.⁵ Finally, anti-trans stigma and nonaffirmation from cisgender male sex partners has been reported by many TMSM as a major trigger and sexual health stressor contributing to increased HIV and sexual health risk.⁶

The population of PrEP-eligible TMSM is steadily rising as a 2021 study found more than half of respondents to be PrEP eligible and just less than half reporting at least two cisgender male sex partners in the past 90 days.⁵ Researchers suggest that a large proportion of the TMSM community would benefit from PrEP to prevent HIV acquisition.⁷ However, important questions remain surrounding PrEP eligibility and initiation as well as how nonbinary TMSM may display different risks and behaviors than TMSM who report a binary gender and may face misclassification and erasure by health care providers.

This exploratory analysis uses electronic medical record (EMR) data at Howard Brown Health (HBH), a large sexual and gender minority-health focused Federally Qualified Health Center in Chicago, Illinois, to better understand the relationship between PrEP eligibility and initiation for TMSM.

Methods

Participants and procedures

Using EMR data, patients were classified as TMSM if they self-identified as Trans Men/Transmasculine or Genderqueer/Gender nonconforming and were assigned female at birth (AFAB) or were AFAB and had received testosterone prescription. All participants had an HIV-negative study visit from 2015 to 2019 and reported a cisgender male sex partner during the study period. This project was approved and consent waived by the HBH Institutional Review Board. This project was completed in accordance with the Declaration of Helsinki as revised in 2013.

Measures

PrEP eligibility was determined using a previously described algorithm based on a current negative HIV status, having had an STI in the previous 12 months, indicating sex with a partner living with HIV or with multiple partners, indicating inconsistent or no condom use, indicating commercial sex work, and/or reporting use of shared injection equipment, per 2017 Centers for Disease Control and Prevention (CDC) PrEP Guidelines.⁸ Patients starting an oral prescription of emtricitabine and tenofovir disoproxil fumarate prescribed for HIV prevention and not for postexposure prophylaxis, HIV treatment, or Hepatitis B treatment, on or before their last visit date, are included as PrEP initiates in the data set. HIV and STI testing dates and laboratory results came from the EMR.

Age, race and ethnicity, and sexual orientation were self-reported and included as categorical variables. Gender was dichotomized (binary vs. nonbinary). Postal zip codes beginning with 606 were used to indicate residence in Chicago. Patients with insurance on file at their last visit were classified as insured and split into private versus public insurance. Self-pay, sliding scale, walk-in, grant funding, and workers compensation were classified as uninsured. Public included all Medicare and Medicaid plans. Last visit types were recorded as primary care or nonprimary care, which includes walk-in STI screenings, dental appointments, and substance use treatment appointments. STIs screened for included Treponema pallidum, Trichomoniasis, Chlamydia trachomatis, or Neisseria gonorrhea.

Having a patient health questionnaire (PHQ-9) score conducted within 6 months before the patients' last visit was used as a binary variable for receipt of the questionnaire, and a three-level categorical variable: no screening in the past 6 months, a score <10, or a score ≥10 indicating possible depression.⁹ Patients with a testosterone prescription started within the study timeframe, on or before their reference visit are considered as having a history of testosterone use. The reference date of each patient was included to control for temporal effects.

Data analyses

Univariate and bivariate descriptive statistics, by PrEP eligibility and initiation, were calculated. Logistic regression was used to model two separate outcomes, PrEP eligibility, and initiation. For each outcome, all demographics and predictor variables were included, and backward selection was used with a p-value of 0.10. In a sensitivity analysis, we added PrEP eligibility as a predictor to the final PrEP initiation model. All analyses were conducted in SAS Software, version 9.4.

Results

Between 2015 and 2019, 477 of 4423 (10%) transmasculine patients who visited a HBH clinic self-reported having sex with a cisgender man in the same period. After excluding individuals who were living with HIV (n=1), missing demographic data, and those under age 18, the final analytic data set sample contained 430 TMSM.

Sample characteristics

Descriptive sample statistics (n=430) are presented in Table 1. Most of the sample was under age 30 (72.8%) and non-Hispanic White (66.5%), whereas 16.1% were non-Hispanic Black, 4% were non-Hispanic Asian, and 13.5% were Hispanic or Latinx. One third indicated their gender was nonbinary. Of those reporting their sexual orientation, 44.4% identified as queer, 18.1% as gay, 17% as bisexual, and 12.8% as straight; the remaining “Other” includes lesbian, questioning, and something else. Most (72.1%) had addresses within Chicago city limits. Most (64.4%) had some form of insurance, 46.1% held private and 18.4% held public insurance.

Table 1.

Demographic Characteristics, by Pre-Exposure Prophylaxis Eligibility and Initiation, Among Transmasculine People Who Have Sex with Cisgender Men, at Howard Brown Health, 2015–2019

	Total sample (N=430)	PrEP eligible		PrEP Initiated
		Yes (N=157) 36.5%	No (N=273)	Yes (N=79) 18.3%	No (N=351)
Age	N (%)	N (%)	N (%)	N (%)	N (%)
18–24	181 (42.1)	82 (52.2)	99 (36.3)	25 (31.7)	156 (44.4)
25–29	132 (30.7)	41 (26.1)	91 (33.3)	26 (32.9)	106 (30.2)
30–39	83 (19.3)	25 (15.9)	58 (21.3)	18 (22.8)	65 (18.5)
40+	34 (7.9)	9 (5.7)	25 (9.2)	10 (12.7)	24 (6.8)
Gender nonbinary	107 (24.9)	56 (35.7)	51 (18.7)	8 (10.1)	99 (28.2)
Sexual orientation
Gay	78 (18.1)	26 (16.6)	52 (19.1)	18 (22.8)	60 (17.1)
Queer	191 (44.4)	66 (42.0)	125 (45.8)	36 (45.6)	155 (44.2)
Bisexual	73 (17.0)	35 (22.3)	38 (13.9)	10 (12.7)	63 (18.0)
Other	33 (7.7)	7 (4.5)	26 (9.5)	10 (12.7)	23 (6.6)
Straight	55 (12.8)	23 (14.7)	32 (11.7)	5 (6.3)	50 (14.3)
Race
Non-Hispanic Black	69 (16.1)	32 (20.4)	37 (13.6)	11 (13.9)	58 (16.5)
Non-Hispanic Asian	17 (4.0)	5 (3.2)	12 (4.4)	3 (3.8)	14 (4.0)
Hispanic	58 (13.5)	23 (14.7)	35 (12.8)	12 (15.2)	46 (13.1)
Non-Hispanic White	286 (66.5)	97 (61.8)	189 (69.2)	53 (67.1)	233 (66.4)
Lives in Chicago city limits	310 (72.1)	120 (76.4)	190 (69.6)	63 (79.8)	247 (70.4)
Insured	277 (64.4)	80 (51.0)	197 (72.2)	61 (77.2)	216 (61.5)
Insurance type
Uninsured	153 (35.6)	77 (49.0)	76 (27.8)	18 (22.8)	135 (38.5)
Public	79 (18.4)	23 (14.7)	56 (20.5)	20 (25.3)	59 (16.8)
Private	198 (46.1)	57 (36.3)	141 (51.7)	41 (51.9)	157 (44.7)
Patient health questionnaire conducted in past 6 months	195 (45.4)	46 (29.3)	149 (54.6)	49 (62.0)	146 (41.6)
Categorical patient health questionnaire
Score <10	153 (35.6)	77 (49.0)	76 (27.8)	18 (22.8)	135 (38.5)
Score 10–27	79 (18.4)	23 (14.7)	56 (20.5)	20 (25.3)	59 (16.8)
Not conducted	198 (46.1)	57 (36.3)	141 (51.7)	41 (51.9)	157 (44.7)
Had a primary care visit	257 (59.8)	56 (35.7)	201 (73.6)	62 (78.5)	195 (55.6)
History of testosterone prescription	231 (53.7)	49 (31.2)	182 (66.7)	60 (76.0)	171 (48.7)
HIV tested in past 6 months	140 (32.6)	67 (42.7)	73 (26.7)	56 (70.9)	84 (23.9)
STI diagnosis in past 6 months	44 (10.2)	37 (23.6)	7 (2.6)	15 (19.0)	29 (8.3)

PrEP, pre-exposure prophylaxis; STI, sexually transmitted infection.

Clinical characteristics

Within the past 6 months, 45.4% of the sample had received a PHQ-9 screening for depression. 18.4% of the sample (n=79) scored >10—indicating depression. Most (58.4%) patients had established themselves with primary care. 53.7% of the sample had testosterone prescribed for transition before or on their last visit. HIV testing within the prior 6 months was reported by 32.6% of the sample, whereas 10.2% were diagnosed with one or more STIs in that same period.

PrEP eligibility and initiation

PrEP eligibility was indicated for 37% (n=157) of the sample and PrEP was initiated by 18% (n=79) of the sample; specifically, 30 (38%) of the 79 initiators were also eligible. Models for unadjusted and adjusted regression of PrEP eligibility and initiation are presented in Table 2.

Table 2.

Unadjusted and Adjusted Odds Ratios of Bivariate and Multivariate Models of Pre-Exposure Prophylaxis Eligibility and Initiation

	PrEP eligibilitya						PrEP initiation
	OR	95% CI	P	aOR	95% CI	p	OR	95% CI	p	aOR	95% CI	p
Age
18–24	REF		0.01	REF		0.03	REF
25–29	0.54	0.34–0.87		0.59	0.34–1.05		1.53	0.84–2.79
30–39	0.52	0.30–0.90		0.51	0.26–0.99		1.73	0.88–3.38
40+	0.44	0.19–0.98		0.36	0.13–0.99		2.60	1.11–6.08
Gender binary
Nonbinary gender	2.41	1.54–3.77	0.0001				0.343	0.12–0.97	0.044	0.22	0.09–0.50	<0.0001
Binary gender	REF						REF			REF
Sexual orientation
Gay	0.70	0.34–1.42	0.07				3.00	1.04–8.65	0.09
Queer	0.74	0.40–1.36					2.32	0.86–6.24
Bisexual	1.28	0.63–2.60					1.59	0.51–4.94
Other	0.38	0.14–1.01					4.35	1.33–14.17
Straight	REF						REF
Bisexual
Yes	1.77	1.07–2.95	0.03	2.35	1.25–4.39	0.04
No	REF			REF
Race
Non-Hispanic Black	1.69	0.99–2.87	0.23				0.83	0.41–1.70	0.92
Non-Hispanic Asian	0.81	0.28–2.37					0.94	0.26–3.40
Hispanic	1.28	0.72–2.29					1.15	0.57–2.31
Non-Hispanic White	REF						REF
Lives in Chicago city limits
Outside Chicago city limits	0.71	0.45–1.11	0.13				0.528	0.27–1.03	0.10
Within Chicago city limits	REF						REF
Insurance type
Uninsured	2.51	1.66–3.76	<0.0001				0.51	0.28–0.93	0.02
Public	1.02	0.57–1.81					1.30	0.70–2.40
Private	REF						REF
Patient Health Questionnaire conducted in past 6 months
Yes	0.35	0.23–0.52	<0.0001	0.36	0.21–0.63	<0.0001	2.29	1.39–3.79	0.0012
No	REF			REF			REF
Last visit typeb
Non-primary care	REF		<0.0001	REF		<0.0001	REF		0.0006
Primary care	0.23	0.15–0.35		0.23	0.14–0.39		2.65	1.52–4.62
Testosterone in past 6 months
Yes	0.39	0.20–0.67	0.0006				2.334	1.06–5.11	0.034
No	REF						REF
History of testosterone prescription
Yes	0.23	0.15–0.35	<0.0001				3.32	1.91–5.80	<0.0001
No	REF
Have been HIV tested in past 6 months
Yes	2.04	1.35–3.09	0.00	3.85	2.17–6.81	<0.0001	7.74	4.49–13.33	<0.0001	7.36	4.09–13.24	<0.0001
No	REF			REF			REF			REF
STI diagnosis in past 6 months
Yes	11.92	5.08–27.03	<0.0001	17.07	6.66–43.71	<0.0001	2.60	1.32–5.13	0.01
No	REF			REF			REF

^a Adjusted for time by including patients' reference date in each model.

^b Primary care versus walk-in STI screening or outreach.

aOR, adjusted odds ratio; CI, confidence interval; OR, odds ratio; REF, reference.

Among TMSM, predictors associated with a higher likelihood of PrEP eligibility included HIV testing in the past 6 months (adjusted odds ratio [aOR]=3.85, 95% confidence interval, CI, [2.17–6.81]), having an STI diagnosis in the past 6 months (aOR=17.07, 95% CI [6.66–43.71]), and bisexual orientation (aOR=2.35, 95% CI [1.25–4.49]). Factors associated with lower odds of PrEP eligibility included being screened for depression through PHQ-9 (aOR=0.36, 95% CI [0.21–0.63]) and being established with primary care (aOR=0.23, 95% CI [0.14–0.39]). Age appears to hold an ordinal trend, with each greater age category exhibiting lower odds of PrEP eligibility compared with those 18–24 years old (25–29, aOR=0.59, 95% CI [0.34–1.05]; 30–39, aOR=0.51, 95% CI [0.26–0.99]; 40+, aOR=0.36, 95% CI [0.13–0.99]). In sensitivity analysis, we found minimal estimate change with the re-addition of previously excluded covariates.

Among TMSM, HIV testing in the previous 6 months was associated with increased odds of PrEP initiation (aOR=7.36, 95% CI [4.09–13.24]). The odds of PrEP initiation were decreased for nonbinary TMSM (aOR=0.22, 95% CI [0.09–0.50]). In sensitivity analyses, the addition of PrEP eligibility into the final model of PrEP initiation was not significant (aOR=0.92, 95% CI [0.49–1.74]), nor did any other estimates change meaningfully.

Discussion

As TMSM remain an understudied population, our study aimed to better understand factors related to their PrEP eligibility and initiation. We found that PrEP eligibility was not associated with PrEP initiation for TMSM. Increased odds of PrEP eligibility were associated with bisexuality, HIV testing in the previous 6 months and STI diagnosis in the previous 6 months. All ages >24 showed decreased odds of PrEP eligibility, continuing to decrease as patients age. It appears that patients who are established in primary care, even at a sexual and gender minority clinic, may be less eligible for PrEP overall.

Nonbinary patients were less likely to initiate PrEP. This may be related to provider perceptions around nonbinary identities or awareness and views around PrEP in different sexual and gender minority communities. Two studies using online sampling in this population found no association between eligibility and age, orientation, or ever HIV testing;⁷ conversely, they found age, race/ethnicity, orientation, and PrEP eligibility to be associated with PrEP initiation.¹⁰ There are important demographic differences with our study, including higher rates of insurance, testosterone use, and gay sexual orientation, and a larger proportion of Black or nonbinary individuals; the online study also controlled for stigma and other variables we did not have access to.⁴

Sexual orientation, race, and a lack of insurance were not associated with PrEP eligibility or initiation; however, compared with other studies, financial burdens such as marginal employment, housing insecurity, and the cost of PrEP medications regardless of insurance status are experienced by transgender men.³ We may not have detected these associations due to a small sample size. Being bisexual does seem to increase TMSM's odds of PrEP eligibility; provider perceptions around bisexuality may have affected results, as evidenced in another study, although we cannot further confirm that.¹¹

Strengths and limitations

Strengths of this study include the use of PrEP initiation and eligibility data from a racially and ethnically diverse cohort of TMSM. In addition, we were able to include nonbinary people, a historically underrepresented population. Limitations include a modest sample size and some sexual history variables may have been documented differentially by gender or orientation. This measurement error could bias results in either direction. Some transmasculine people were excluded based on their sexual history, although very few of those excluded were on PrEP; this suggests the sexual history variables were useful in selecting the appropriate sample of patients for our research question. Mapping the CDC Guidelines to data in the EMR may have resulted in some outcome misclassification. Finally, because patients were attending a sexual and gender minority supportive clinic, with integrated gender-affirming care, results may not be generalizable to nonspecialized clinics.

Conclusion

In conclusion, we found that more than a third of TMSM were eligible for PrEP, by the 2017 CDC Guidelines;⁸ however, only 18% initiated PrEP. From our study, possible explanations for this include differences in our EMR version of PrEP eligibility and the general exclusion of transmasculine people in 2017 CDC PrEP guidelines.⁸ We are encouraged by the 2021 CDC PrEP guidelines recommendations of PrEP access for people of all genders; however, specific guidance for TMSM is still lacking in the updated version.¹² Other researchers have found that stigma and nonaffirmation negatively affect protective health behaviors of TMSM.

Additional research supports the claim that current PrEP guidelines do not provide adequate guidance for TMSM.⁶ Differences by bisexual identity and gender binary status require additional research. Updates to the CDC guidelines specifically addressing the needs of TMSM will be critical for continued HIV prevention in this population. This study supports previous assertions¹³ that a shift in the dominant cultural narrative regarding transmasculine people to be more expansive of their myriad gender identities, sexual orientations and behaviors, and social risks will be essential to providing adequate care for this community.

Abbreviations Used

PHQ

patient health questionnaire

CDC

Centers for Disease Control and Prevention

AFAB

assigned female at birth

HBH

Howard Brown Health

EMR

electronic medical record

TMSM

transmasculine individuals who have sex with cisgender men

aOR

adjusted odds ratio

CI

confidence interval

OR

odds ratio

REF

reference

PrEP

pre-exposure prophylaxis

STI

sexually transmitted infection

Authors' Contributions

T.S. contributed to this study as first author by conceptualizing the project, performing the data analysis, interpreting the analysis, cowriting the article and approving the final version to be published. A.D. contributed to this study by cowriting the article, coordinating subsequent revisions, and interpreting the analysis. L.R. contributed to this study in the conceptualization of the project and analyzing data. N.R. contributed to the conceptualizing of the project. J.S. contributed by conceptualizing the project and revising the article. M.P. contributed to the project by conceptualizing the project, interpretation of the study, revising the article, and corresponding with the journal.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Schafer T, Davis A, Rusie L, Ross N, Schneider J, Pyra M (2023) Factors associated with HIV pre-exposure prophylaxis use among transmasculine people who have sex with cisgender men, at a federally qualified health center in Chicago, Illinois, Transgender Health X:X, 1–6, DOI: 10.1089/trgh.2021.0180.