Abstract
Adult trans women in Brazil are highly impacted by HIV, but little is known about the risk for thee younger generation of trans women. The objective of our study was to compare the HIV prevalence and correlates of risk for young trans women ages 18–24 years old to adult trans women in Brazil. Trans women were recruited from Rio de Janeiro and Baixada (the metropolitan area of Rio de Janeiro), Brazil (N=345). Youth ages 18–24 years of age had significantly greater odds of being HIV negative than adults (OR 0.4, 95% CI 0.2–0.6, p=0.0002), but significantly lower odds of having post-exposure prophylaxis (PEP) knowledge (OR 0.5, 95% CI:0.3–0.9, p=0.02) and PrEP awareness (OR 0.5, 95% CI: 0.3–0.8, p=0.01). Young trans women also had significantly higher odds of using substances (OR 1.8, 95% CI 1.1–2.9, p=0.02) and condomless anal intercourse with their last three sexual partners (OR 1.8, 95% CI: 1.1–3.0, p=0.03) compared to adults. Already by age 24, one in four trans women in Brazil were infected with HIV pointing to a new generation at high risk of acquiring HIV. HIV prevention interventions are needed to change the healthcare system to reach and engage young trans women.
Keywords: youth, HIV, Brazil, trans women, transgender
Introduction
Brazil’s HIV epidemic is concentrated among key populations at elevated risk, including trans women (De Boni, Veloso, & Grinsztejn, 2014). As many as half of adult trans women in Brazil may be living with HIV (Ferreira et al., 2019). Though Brazil’s epidemic is stable at .5% of the adult population living with HIV (UNAIDS, 2017), there is a rise in new HIV cases among young people. From 2007 to 2019, the proportion of HIV cases among 15 to 19 year old people in Brazil doubled (2.5% to 5.1) and almost doubled among 20–24 year olds (12.8% to 20.9) (Secretaria de Vigilância em Saúde, 2019). Despite rising rates and studies showing the impact of HIV on youth, we identified no studies of young trans women in Brazil.
Research with young trans women in the U.S. finds consistently high HIV prevalence rates in studies ranging from 19% in 2007 to 30.9% in 2015 (Reisner et al., 2017; E. C. Wilson et al., 2009). Young trans women face stigma and discrimination towards transgender people, that leads to unequal access to education, employment, and economic insecurity. Economic insecurity results in a host of structural and behavioral factors that raises their risk for HIV and other sexually transmitted infections (STIs) (Clements-Nolle, Marx, Guzman, & Katz, 2001; Nemoto, Operario, Keatley, Han, & Soma, 2004; Sugano, Nemoto, & Operario, 2006; Erin C. Wilson et al., 2009). Stigma also explains low engagement in HIV prevention and care among young trans women in the U.S. (Jadwin-Cakmak et al., 2019; Poteat, Scheim, Xavier, Reisner, & Baral, 2016). Compounding stigma, young trans women must also reconcile gender issues internally, medically and socially and navigate the process of transitioning during typical adolescent development. A recent study found that that younger age was associated with HIV incidence in a sample of trans women in the San Francisco Bay Area (McFarland et al., 2020).
This study was conducted to determine the HIV prevalence of young trans women in our sample of trans women and identify HIV risk and prevention factors that were significantly different. Using these findings, we aimed to identify points of intervention that may be unique to young trans women.
Materials and Methods
This is a secondary analysis using data from “Transcender,” which was a respondent driven sampling study (RDS) of trans women in Rio de Janeiro, Brazil, conducted from August 2015 to January 2016. Study methods, including survey measures are described in detail elsewhere (Grinsztejn et al., 2017; Jalil et al., 2018). Briefly, the study was conducted using RDS to obtain a robust and diverse sample of trans women. A total of 345 trans women were recruited to participate in the study. Incentives for study participation consisted of snacks, sexual health materials, make-up, a medical visit, and transportation reimbursement. STI testing included Venereal Disease Research Laboratory tests (VDRL) for syphilis screening (confirmed positive results with a microhaemagglutination assay for Treponema pallidum), HIV rapid test, and rectal Chlamydia and gonorrhea detection by molecular biology. We defined active syphilis as a VDRL equals or higher than 1:8 plus a positive treponemal test. All participants with identified STI were provided treatment either onsite or through referrals within Oswaldo Cruz Foundation (Fiocruz). The Evandro Chagas National Institute of Infectious Diseases (INI)-Fiocruz Institutional Review Board provided ethical approval for this project. All participants consented with their participation before any study procedure was performed.
Data Analysis
All variables were re-coded to be categorical. Descriptive statistics were calculated for the study sample using proportions for categorical variables. Our outcomes were health behaviors, health status, sexual and substance use behaviors. We assessed odds ratios (OR) by univariable logistic regression model considering youth/adults as our exposition factor to identify the odds for each outcome. All p values were two-sided, and p-value < 0.05 was considered significant. Data analysis was performed using R software.
Results
Of 345 trans women enrolled, 95 (27.5%) were aged 18–24 years. Table 1 presents the demographics of the youth and adult participants in Transcender. More young trans women identified as women (35.8% of youth and 24.8% of adults) and fewer as travesti (29.5% of youth and 41.2% of adults). About one quarter of youth tested positive for HIV (24.5%), compared to almost half (47.6%) of adults. About one third (29.5%) of young trans women and 34% of adults tested positive for active syphilis, and 15.9% of young trans women and 13.4% of adults with rectal chlamydia. More young trans women were living with rectal gonorrhea (15.7%) than adult trans women (4.6%).
Table 1 –
Demographic characteristics of youth and adult trans women in Rio de Janeiro, Brazil, 2015–20161
| Characteristic | Youth* n=95 (%) | Adults** n=250 (%) |
|---|---|---|
| Gender identity | ||
| Travesti | 28 (21.4) | 103 (78.6) |
| Trans woman | 28 (26.2) | 79 (73.8) |
| Other definitions | 5 (45.5) | 6 (54.5) |
| Woman | 34 (35.4) | 62 (64.6) |
| Self-declared race/color | ||
| White | 18 (22.8) | 61 (77.2) |
| Mixed/other | 54 (29.7) | 128 (70.3) |
| Black | 23 (27.4) | 61 (72.6) |
| Income (in R$)2,3 | ||
| <=130.00 | 36 (25.7) | 104 (74.3) |
| 131.00–260.00 | 26 (23.9) | 83 (76.1) |
| >260.00 | 23 (31.5) | 50 (68.5) |
| Years of education2 | ||
| 8 or less | 56 (26.7) | 154 (73.3) |
| 8+ | 39 (28.9) | 96 (71.1) |
Proportions calculated for valid data; missing excluded
Continuous variables were reclassified as categorical
US$1.00=R$3.85
18–24 years old
25 years old and older.
OR: Odds Ratio, 95%CI: 95% Confidence Interval.
Health care and hormones use, sexually transmitted infections and HIV
Young trans women had significantly higher odds of not accessing health care in the last six months (OR 2.7, 95% CI 1.7–4.4, p<0.0001) and not accessing trans-related health care (OR 2.7, 95% CI 1.2–6.7, p=0.02) compared to adult trans women. Young trans women also had significantly higher odds of taking hormones (OR 2.4, 95% CI 1.4–4.0, p=0.0009) and lower odds of using fillers (OR 0.2, 95% CI 0.1–0.4, p<0.0001) compared to adults. Young trans women had significantly higher odds of having rectal gonorrhea (via testing) (OR 3.9, 95% CI 1.7–9.1, p=0.001) than adult trans women (Table 2). Youth had significantly greater odds of being HIV negative than adults (OR 7.6, 95% CI 3.6–18.6, p<0.0001).
Table 2 –
Difference in health care access, use and sexual health indicators of young trans women compared to adult trans women in Rio de Janeiro, Brazil, 2015–20161
| Characteristic | OR (95%CI) | p-value |
|---|---|---|
| Health care visit in the last 6 mo | ||
| Yes | 1 | |
| No | 2.7 (1.7–4.4) | <0.0001 |
| Access to trans-related health care | ||
| Yes | 1 | |
| No | 2.7 (1.2–6.7) | 0.02 |
| Ever had gender-related surgery | ||
| Yes | 1 | 0.21 |
| No | 2.2 (0.7–9.7) | |
| Ever used soft fillers | ||
| Yes | 0.2 (0.1–0.4) | <0.0001 |
| No | 1 | |
| Currently taking hormones | ||
| Yes | 2.4 (1.4–4.0) | 0.0009 |
| No | 1 | |
| Self-reported HIV-positive status | ||
| Yes | 1 | |
| No | 7.6 (3.6–18.6) | <0.0001 |
| HIV-positive status via testing | ||
| Yes | 0.4 (0.2–0.6) | 0.0002 |
| No | 1 | |
| Unknown HIV status3 | ||
| Yes | 1.9 (0.9–3.7) | 0.06 |
| No | 1 | |
| Active syphilis4 | ||
| Yes | 0.8 (0.5–1.3) | 0.42 |
| No | 1 | |
| Rectal chlamydia | ||
| Yes | 1.2 (0.6–2.4) | 0.56 |
| No | 1 | |
| Rectal gonorrhea | ||
| Yes | 3.9 (1.7–9.1) | 0.001 |
| No | 1 |
Proportions calculated for valid data; missing excluded
Using 10-item CES-D (Center for Epidemiologic Studies Depression Scale)
Only HIV-positive transwomen included
Defined as a VDRL ≥1:8 plus positive treponemal test
18–24 years old
25 years old and older. OR: Odds Ratio, 95%CI: 95% Confidence Interval.
Substance use and sexual behaviors
Young trans women had significantly higher odds of using illicit substances compared to adults (OR 1.8, 95% CI 1.1–2.9, p=0.02), and significantly higher odds of condomless anal intercourse with their last three sexual partners (OR 1.8, 95% CI 1.1–3.0, p=0.03) than adult trans women (Table 3).
Table 3 –
Sexual and substance use risk behavior differences between young trans women compared to adult trans women in Rio de Janeiro, Brazil, 2015–2016.1
| Characteristic | OR (95%CI) | p-value |
|---|---|---|
| Engagement in sex work | ||
| Current | 0.7 (0.4–1.3) | 0.28 |
| Former | 0.6 (0.3–1.2) | 0.16 |
| Never | 1 | |
| Illicit drug use in the last 12 mo | 1.8 (1.1–2.9) | 0.02 |
| Binge drinking2 | 1.2 (0.7–2.0) | 0.52 |
| More than 4 sex partners last 6 mos3 | 1.5 (0.9–2.7) | 0.14 |
| HIV-positive status among last 3 partners | 0.7 (0.4–1.4) | 0.34 |
| Condomless anal intercourse with last 3 partners | 1.8 (1.1–3.0) | 0.03 |
Proportions calculated for valid data; missing excluded
Defined as six or more alcohol drinks on any occasion
Continuous variables were reclassified as categorical
18–24 years old
25 years old and older. OR: Odds Ratio, 95%CI: 95% Confidence Interval.
HIV knowledge, HIV testing, and PEP and PrEP awareness, PEP use
Young transwomen had significantly higher odds of no HIV knowledge (OR 1.9, 95% CI 1.1–3.2, p=0.03) compared to adults. Among those who self-reported being HIV negative, young trans women had significantly lower odds of ever being tested for HIV compared to adults (OR 0.4, 95% CI 0.2–0.7, p =0.0009). HIV negative young trans women also had significantly lower odds of having post-exposure prophylaxis (PEP) knowledge (OR 0.5, 95% CI 0.3–0.9, p=0.02) and PrEP awareness (OR 0.5, 95% CI 0.3–0.8, p=0.01) compared to adults (Table 4).
Table 4 –
Differences in HIV prevention behaviors between young trans women and adult trans women in Rio de Janeiro, Brazil, ‘2015–20161
| Characteristic | OR (95%CI) | p-value |
|---|---|---|
| HIV knowledge | 1.9 (1.1–3.2) | 0.03 |
| HIV status discussion with all sexual partners | 0.7 (0.3–1.6) | 0.37 |
| Aware of HIV status of all sexual partners | 2.6 (0.1–67.4) | 0.49 |
| No condom use with the last 3 partners | 1.8 (1.1–3.0) | 0.03 |
| Sero sorting | 0.8 (0.5–1.3) | 0.40 |
| Risk perception among those for who self-reported HIV negative2 | 1.3 (0.8–2.3) | 0.34 |
| High HIV risk perception | 0.7 (0.2–2.1) | 0.59 |
| Self-report prior HIV testing | 0.4 (0.2–0.7) | 0.0009 |
| HIV testing in the last year | 1.3 (0.6–2.6) | 0.52 |
| Repeat HIV testing (in the last year)3 | 0.6 (0.3–1.3) | 0.19 |
| Condom use 100% of time4 | 0.8 (0.4–1.3) | 0.36 |
| PEP awareness | 0.5 (0.3–0.9) | 0.02 |
| PEP use | 0.4 (0.1–1.4) | 0.19 |
| PrEP awareness | 0.5 (0.3–0.8) | 0.01 |
Proportions calculated for valid data; missing excluded
Only self-reported HIV-negative included (youth - N=88, adults - N=156)
Among those who reported HIV-testing in the last year
Calculated based on the last 3 partners
18–24 years old
25 years old and older. OR: Odds Ratio, 95%CI: 95% Confidence Interval.
Discussion
Already by age 24, one in four trans women in Brazil were infected with HIV. These data reflect the rising rates of HIV globally as young people were the only age group that has not seen a recent decline in new HIV infections (Bekker, Johnson, Wallace, & Hosek, 2015). These data also suggest that young trans women in Rio de Janeiro face risk for HIV that may be worse that generations of trans women prior. Studies from Brazil found that 20–60% of trans women around cities throughout Brazil were living with HIV (Bastos et al., 2018). The HIV prevalence among young trans women has already surpassed the prevalence found in studies of all adult trans women. Young trans women exhibited risk in higher odds of condomless anal intercourse with their last three sexual partners and significantly more drug use than adults. Young trans women’s HIV knowledge was also significantly lower than among adults. Biomarkers of risk among young trans women were also present in that younger trans women had higher odds of having rectal gonorrhea than adults and almost one fifth tested positive for rectal gonorrhea and rectal syphilis.
We also found lower health care utilization, HIV testing, PEP and PrEP awareness in youth compared to adults. Health care is universally accessible in the Brazilian public health system, or ‘Sistema Único de Saúde’ (SUS); however, many young trans women may avoid SUS where HIV information and services are available due to discrimination and mistreatment related to their gender identity (Costa et al., 2018; Wilson et al., 2017). As the scale-up of new biomedical prevention begins to turn the tide on the HIV epidemic in Brazil, efforts will be needed to improve utilization of HIV prevention services readily available in SUS.
Our data point to specific areas for intervention to work toward higher healthcare engagement. Health education on HIV is needed for young trans women that promotes accurate HIV risk assessments and condom use. Widespread HIV testing, available in the community outside SUS is also highly needed could also be an entrée to other HIV prevention services like PEP and PrEP. Perhaps most importantly, systems must focus on reducing stigma and discrimination towards trans women.
Limitations of this study include that it was cross-sectional, preventing determination of temporal trends. This study was also not conducted to assess specific developmental and youth-related factors that may be associated with HIV risk and are unique to young people. To avert an enormous burden of infection, there is urgent need for interventions to increase condom use, HIV testing, PEP, and PrEP access and use among young trans women. Providing trans affirming health services to engage young trans women in the healthcare system by addressing their specific needs may be an avenue to reach young trans women for HIV prevention.
Acknowledgments
Funding details
Transcender, the population-based study of transwomen in Rio de Janeiro study was sponsored by the US National Institutes of Health with co-funding from the Brazilian Ministry of Health; Brazilian Ministry of Health, CNPq, Fiocruz, Faperj sponsored the multi-site PrEP Brasil study; Gilead Sciences supported the analysis of medication adherence for PrEP Brasil.
Footnotes
Declaration of interests
There are no conflicts of interest.
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