Abstract
Purpose: High levels of human immunodeficiency virus (HIV) prevalence and inconsistent condom use among transgender women in India highlight the need for additional effective HIV prevention methods like preexposure prophylaxis (PrEP). We examined the extent of and factors influencing willingness to use PrEP among trans women in India.
Methods: Between June and August 2017, we conducted a cross-sectional survey among 360 trans women recruited through community-based organizations in six cities. We assessed PrEP knowledge, condom use, attitudes toward PrEP (after providing information on PrEP), preferences in PrEP pricing and access venues, discrimination experiences, and the likelihood of using PrEP. Logistic regression analyses were conducted.
Results: Participants' median age was 26 years; 50.7% had not completed high school, and 24.8% engaged in sex work. Only 17.1% reported having heard of PrEP before the survey, and 80.6% reported that they would definitely use PrEP. Trans women in sex work had 28 times higher odds of reporting willingness to use PrEP than those not in sex work (adjusted odds ratio [aOR]=28.9, 95% confidence interval [CI]=8.79–95.16, p<0.001). When compared with trans women who did not experience discrimination, the odds of reporting willingness to use PrEP was lower among trans women who had experienced discrimination from health care providers (aOR=0.25, 95% CI=0.06–0.97, p=0.04) and family members (aOR=0.08, 95% CI=0.05–0.14, p<0.001).
Conclusion: Willingness to use PrEP was high among trans women, especially those in sex work, despite identified barriers (e.g., discrimination experiences). To promote PrEP uptake among at-risk trans women, the steps needed are as follows: increasing awareness about PrEP; providing easy-to-understand information on PrEP's effectiveness, side effects and interactions between PrEP and hormones; training health care providers on PrEP and cultural competency; and reducing stigmas related to PrEP use and HIV. PrEP implementation research projects to identify effective PrEP delivery strategies are urgently needed to reduce the disproportionate HIV burden among trans women in India.
Keywords: HIV, India, preexposure prophylaxis, PrEP, trans women, transgender
Introduction
Globally, transgender (trans) women have high levels of human immunodeficiency virus (HIV) infection and face barriers in accessing HIV prevention and treatment services.1 Trans women in India too are disproportionately affected by the HIV epidemic—with a national average HIV prevalence of 7.5% (95% confidence interval [CI]=6.2–9.0) reported in a large-scale survey of India's National AIDS Control Organization (NACO).2 Over the past decade, through the projects supported by NACO, free condoms are being provided to key populations, including trans women. Despite this, inconsistent condom use among trans women is ∼45%2—suggesting the need for other ways of HIV prevention as well. HIV preexposure prophylaxis (PrEP) has been demonstrated to be effective, especially in combination with condoms, in drastically reducing the HIV risk. Daily PrEP can reduce the risk of contracting HIV through sex by >90%,3 and thus World Health Organization (WHO) has released guidelines to offer PrEP to key populations, including trans women.3,4 In India, despite the availability of a licensed generic PrEP pill (a combination of tenofovir and emtricitabine) that costs about 12 USD per month, PrEP is not available through national health programs and not widely prescribed in private health settings.5,6
In South Asia, little information is available on trans women's awareness of and willingness to use PrEP. In general, studies have demonstrated low PrEP awareness and reasonably good levels of acceptability once brief information on PrEP is provided.7–9 A recent study from South India documented a high level of acceptability (99%) in a combined sample of men who have sex with men (MSM) and trans women.10 Similarly, a qualitative study conducted among MSM in India11 has demonstrated high levels of willingness to use PrEP although barriers such as PrEP use-related stigma, stigma related to same-sex sexuality, and concerns about side effects were also documented.11 Although similar issues may be relevant to trans communities, given the specific subcultural issues and dynamics among diverse subgroups of trans women,12 it is crucial that studies among trans women are needed to understand the factors influencing PrEP uptake. Thus, this study examined the extent of awareness of and willingness to use PrEP among trans women, and explored the factors that influence PrEP uptake. The study findings are expected to contribute to national policies and programs on PrEP.
Methods
Between June and August 2017, a cross-sectional survey was conducted among a convenience sample of 360 trans women in six cities (n=60/city) located in six states in India. These six cities were Bengaluru (Karnataka), Delhi, Hyderabad, Jalandhar (Punjab), Kolkata (West Bengal), and Vadodara (Gujarat). Participants were recruited by word-of-mouth from drop-in centers and clinics in community-based organizations (CBOs) and nongovernmental organizations (NGOs) that provide HIV prevention services such as condom distribution, HIV testing, and treatment of sexually transmitted infections (STIs). Inclusion criteria were as follows: age 18 years and older, self-identification as transgender or those with indigenous trans identities (e.g., hijra, Shiva-Shakthi),13 and ability to give informed consent. HIV-positive status was not explicitly listed as an exclusion criterion as individuals deemed ineligible might be stigmatized and presumed to be HIV positive by other participants. The study received ethics approval (protocol number 217) from the Institutional Review Board of Centre for Sexuality and Health Research and Policy. Informed consent was obtained from all the participants. Participants did not receive any monetary compensation but they were provided refreshment. As the participants were interviewed at their homes or when they visited CBOs/NGOs for receiving services, there was no financial burden for participating in this survey.
Survey measures
The survey questions were based on prior literature on PrEP acceptability among vulnerable populations, including trans women.14,15 Sociodemographic information that were collected include age, self-reported trans identities, highest level of education completed, main occupation, and personal monthly income.
Sexual behaviors
HIV-related risk was assessed by number of male sex partners (past month); frequency of anal sex (past month); consistency of condom use with different types of cisgender male partners (regular, casual, paying, and paid) in the past month; condom use in last anal sex; alcohol use before last anal sex, history of diagnosis of STIs in the past year, and HIV testing.16 Risk perception for HIV was assessed by: “You think your chances of getting infected with HIV are: zero, almost zero, small, moderate, large, very large.”17 For analysis, a binary variable of inconsistent condom use (no or yes) with all types of cisgender male partners was created from the responses to the questions on condom use with different types of cisgender male partners. Similarly, a binary variable on the frequency of anal sex was created that classified the participants into those who engage in low-frequency anal sex (about once a week or month, or no anal sex) and high-frequency anal sex (every day or several times a week).
Discrimination experiences and forced sex experience
Two items assessed the frequency of discrimination experiences from health care providers and family members18 (“How often have you experienced discrimination from…”) with response options of never, once or twice, a few times, and many times. Forced sex experience was assessed by a single item: “In the past 12 months, did any man force you to have sex with him, even though you did not want to have sex?”19
Prior awareness of and attitudes toward PrEP
Two items assessed participants' prior awareness of PrEP and source of information. Prior awareness was assessed by the question: “Before this interview, have you heard or read anything about antiretroviral drugs used for HIV prevention (PrEP)?” A brief description of PrEP was provided to all before proceeding to the other sections. Attitudes toward PrEP were assessed using a four-point Likert scale (ranging from 1=very unlikely to 4=very likely) or 1=yes, definitely to 4=no, definitely). Example: “How likely would you be to take PrEP: if it was prescribed a medical doctor? and if it has to be taken daily?”
Perceived benefits and disadvantages of PrEP, and risk compensation
The five items that measured perceived benefits were adapted from an HIV vaccine perceived benefits scale20: “It could prevent me from getting HIV; It would reduce my worry about getting HIV; It would prevent me against getting HIV from forced sex; It would reduce my worry about giving HIV to my sex partner(s); and I could tell my partners that I am protected against HIV.” These items were combined into a single scale, which had good reliability (Cronbach's α=0.80). Perceived disadvantages were measured by seven items: “I would worry about what my (trans) friends think of me; I would worry that people would think I am HIV-positive if I am on PrEP”; “I would worry about what my regular male sex partner thinks of me”; “I would worry that I have to get an HIV test before getting PrEP”; “I would worry that people would think I am HIV-positive if I am on PrEP”; “I would not be able to take medications daily”; “I would worry that PrEP may interact with hormones that I take now or in the future.” As some of the items were created for this study, a composite score was not used. Potential behaviors related to risk compensation were measured by two items20 using a five-point Likert scale (1=strongly disagree to 5=strongly agree): “It would avoid the hassle of using condoms”; and “It would allow me to have sex with more sexual partners.” As there were only two items, a composite score was not used.
Willingness to use PrEP
This was assessed by asking participants about their likelihood of PrEP use: “PrEP is now available in India. In general, do you think you would use PrEP?” Another question was, “If PrEP is available for free, do you think you would use PrEP?” Both these questions used a four-point Likert Scale (1=yes, definitely, 2=yes, probably, 3=no, probably not, 4=no, definitely not”).21 For the logistic regression analysis, the first question was used with the four response options recoded into two options: yes (“yes, definitely”) or no (2–4).
Data analysis
Five self-reported HIV-positive participants were excluded from all analyses, leaving a total analytical sample of N=355. Descriptive univariate analysis (e.g., frequencies/percentages) was conducted on all key variables. Bivariate analysis (chi-square tests) was conducted to identify associations between key variables and the willingness to use PrEP. Given that the five items in the “perceived benefits of PrEP” scale were adapted from previously published studies,20 and the scale's good reliability (Cronbach's α=0.84), a composite score was used. For ease of interpretation, the response options of the perceived disadvantages and risk compensation constructs were dichotomized in the logistic regression analysis. Factors associated with willingness to use PrEP were identified using multivariable logistic regression analysis. Those variables with p<0.10 in bivariate analysis or those variables that have been shown to be associated with willingness to use PrEP (e.g., risk perception and condom use) were included in the initial logistic models that eventually led to a parsimonious model. In logistic regression results, adjusted odds ratios and corresponding 95% CIs are reported. All statistical analyses were conducted using Stata (version 16; College Station, TX). In logistic regression analysis, to adjust for intragroup correlations at the city level, we used vce(cluster clustervar) command, with city ID as the clustervar.
Results
Characteristics of participants
Table 1 provides the sociodemographic-related characteristics. Participants' median age was 26 years (interquartile range [IQR]=18–43). About half (50.7%) had not completed high school; only 10% had completed a bachelor's degree or higher. Nearly one-third (31.5%) reported mangti (begging) or badhai (offering blessings for money) as their main occupation, whereas 24.8% reported engaging in sex work. The median monthly income was INR 10000 (USD 145) (IQR INR 3000–35,000). Forty-four percent were living with parents, 19% with gurus (masters), and 15% with peers or guru-bhai (co-disciples of their guru). Three-fourths (74.6%) self-identified as “transgender” (English term), 17.4% as hijra, and 5.9% as Mangalmukhi or Shiva-Shakthi. Nearly one-third (30.9%; n=110/355) reported currently being on hormones, mostly self-prescribed (83.6%; n=92/110).
Table 1.
Associations Between Sociodemographic Characteristics, Sexual Behaviors, Risk Perception, Discrimination Experiences, and Willingness to Use Preexposure Prophylaxis Among Trans Women (N=355)
| Variables | Total (N=355), n (%) | Willingness to use PrEP n (%) |
p Value | |
|---|---|---|---|---|
| No (n=69) | Yes (n=286) | |||
| Sociodemographic characteristics | ||||
| Agea (years) | ||||
| ≤26 | 159 (52.6) | 14 (34.1) | 145 (55.6) | 0.01 |
| 27 and above | 143 (47.4) | 27 (65.9) | 116 (44.4) | |
| Incomeb (INR) | ||||
| <10,000 | 82 (23.1) | 16 (25.0) | 66 (28.0) | 0.63 |
| 10,000 and above | 218 (61.4) | 48 (75.0) | 170 (72.0) | |
| Education | ||||
| <High school | 180 (50.7) | 43 (62.3) | 137 (47.9) | 0.03 |
| High school or more | 175 (49.3) | 26 (37.7) | 149 (52.1) | |
| Occupation | ||||
| Not in sex workc | 267 (75.2) | 66 (95.7) | 201 (70.3) | <0.001 |
| Sex worker | 88 (24.8) | 3 (4.3) | 85 (29.7) | |
| Identity | ||||
| Transgender (English term) | 265 (74.6) | 47 (68.1) | 218 (76.2) | 0.16 |
| Hijra, Mangalmukhi, Shiva-Shakthi | 90 (25.4) | 22 (31.9) | 68 (23.8) | |
| City | ||||
| Bengaluru | 60 (16.9) | 4 (5.8) | 56 (19.5) | <0.001 |
| Kolkata | 60 (16.9) | 28 (40.5) | 32 (11.1) | |
| New Delhi | 59 (16.2) | 2 (2.9) | 57 (19.9) | |
| Jalandhar | 59 (16.2) | 0 (0) | 59 (20.6) | |
| Hyderabad | 60 (16.9) | 0 (0) | 60 (20.9) | |
| Vadodara | 57 (16.0) | 35 (50.7) | 22 (7.6) | |
| HIV risk-related characteristics | ||||
| Number of male sex partners in the past 1 monthd | ||||
| ≤5 | 174 (49.0) | 35 (52.2) | 139 (48.9) | 0.62 |
| >5 | 177 (49.9) | 32 (47.8) | 145 (51.1) | |
| Frequency of anal sex in the past 1 month | ||||
| Once in a week or less | 182 (51.3) | 25 (36.2) | 157 (54.9) | <0.01 |
| Every day or several times a week | 173 (48.7) | 44 (63.8) | 129 (45.1) | |
| Inconsistent condom use for anal sex with any type of male partner in the past month | ||||
| No | 138 (38.9) | 17 (24.6) | 121 (42.3) | <0.01 |
| Yes | 217 (61.1) | 52 (75.4) | 165 (57.7) | |
| Last anal sex and condom useb | ||||
| No | 140 (39.4) | 34 50.7) | 106 (37.7) | 0.05 |
| Yes | 208 (58.6) | 33 (49.3) | 175 (62.3) | |
| Forced sex in the past 12 months | ||||
| No | 281 (79.2) | 63 (91.3) | 218 (76.2) | <0.01 |
| Yes | 74 (20.8) | 6 (8.7) | 68 (23.8) | |
| STIs in the past 12 months | ||||
| No | 261 (73.5) | 64 (92.8) | 197 (68.9) | <0.001 |
| Yes | 94 (26.5) | 5 (7.2) | 89 (31.1) | |
| HIV risk perception | ||||
| Low | 69 (19.4) | 58 (84.1) | 264 (92.3) | 0.03 |
| High | 286 (80.6) | 11 (15.9) | 22 (7.7) | |
| Discrimination experiences | ||||
| Discrimination by health care providers | ||||
| No | 180 (50.7) | 16 (23.2) | 164 (57.3) | <0.001 |
| Yes | 175 (49.3) | 53 (76.8) | 122 (42.7) | |
| Discrimination by family members | ||||
| No | 138 (38.9) | 10 (14.4) | 128 (44.8) | <0.01 |
| Yes | 217 (61.1) | 59 (85.6) | 158 (55.2) | |
Data on age for 53 participants were missing in the filled-in questionnaires.
Numbers may not add to total owing to “not applicable” values.
Numbers may not add to total owing to “system missing.”
12.9% were unemployed, 31.5% engaged in mangti (begging) or badhai (offering blessings for money), and 7.9% as bar dancer, 6.2% as private company staff, and 5.4% as self-employed.
HIV, human immunodeficiency virus; PrEP, preexposure prophylaxis; STI, sexually transmitted infection.
Sexual behaviors, forced sex, and STI/HIV diagnosis
Participants had a median of six partners (IQR=1–80) in the past month; 98.0% reported having had anal sex in the past month, with 48.7% engaging in anal sex every day or several times a week. A relatively higher proportion of participants reported inconsistent condom use during anal sex (past month) with paying (34.3%) and regular partners (32.3%), compared with casual partners (24.7%). Among the trans women who did not use condom the last time they had anal sex with a male partner (40.2%; n=140/348), 40.0% (n=56/140) reported having had sex under the influence of alcohol. About one-fifth (20.8%) reported that they had been forced to have sex with a man in the past year. About one-fourth (26.4%) reported having had an STI in the past year. Of 346 participants (97.4%) who had ever been tested for HIV, 75.2% had an HIV test within the past 6 months.
Prior awareness of and willingness to use PrEP
Only 17.1% reported having heard of PrEP before the survey, and almost all of them had heard of it from their peers or CBOs. A majority (80.6%; n=286/355) said that they would definitely use PrEP and an additional 14.1% (n=50/355) said that they would probably use it. When asked whether they would be willing to use PrEP if it is provided for free, a similar percentage reported that they would use it definitely (83.1%) or probably (11.1%).
Findings from bivariate analyses
Table 1 also summarizes the bivariate analysis results for the associations between sociodemographics, sexual risk-related characteristics and discrimination experiences, and willingness to use PrEP. Trans women who were younger, more educated and in sex work, and those with previous experience of forced sex and low risk perception, and who reported high-frequency anal sex were significantly more likely to report willingness to use PrEP. Trans women who reported inconsistent condom use with cisgender male partners and those who had experienced discrimination from health care providers were less likely to report willingness to use PrEP.
Table 2 summarizes the bivariate analysis results for the associations between PrEP-related variables and willingness to use PrEP. Those who had prior knowledge of PrEP and positive attitude toward the benefits of PrEP reported willingness to use PrEP. Among those who reported willingness to use PrEP, nearly three-fifths (59%) endorsed free access to PrEP, whereas 39% opted for subsidized PrEP; and many wished to access PrEP from CBOs (60%) followed by government hospitals (22%). Trans women who reported that PrEP use would avoid the hassle of using condoms and PrEP use would allow them to have sex with more sexual partners were more likely to report willingness to use PrEP.
Table 2.
Associations Between Attitudes, Perceived Benefits and Disadvantages, Risk Compensation, and Willingness to Use Preexposure Prophylaxis Among Trans Women (N=355)
| Variables | Total (N=355) n (%) | Willingness to use PrEP n (%) |
p Value | |
|---|---|---|---|---|
| No (n=69) | Yes (n=286) | |||
| PrEP-related attitude measures | ||||
| How likely would you be to take PrEP, if it was prescribed by a medical doctor? | ||||
| Very unlikely/unlikely | 32 (9.0) | 19 (27.5) | 13 (4.5) | <0.01 |
| Very likely/likely | 323 (91.0) | 50 (72.5) | 273 (95.5) | |
| Would you take PrEP, if you still had to use condoms? | ||||
| No | 34 (9.6) | 24 (34.8) | 10 (3.4) | <0.01 |
| Yes | 321 (90.4) | 45 (65.2) | 276 (96.6) | |
| If you are on PrEP, would you want your main partner to know about it? | ||||
| No | 88 (24.8) | 41 (59.4) | 47 (16.4) | <0.01 |
| Yes | 267 (75.2) | 28 (40.6) | 239 (83.6) | |
| How likely would you be to take PrEP, if it has to be taken daily? | ||||
| Very unlikely/unlikely | 48 (13.5) | 21 (30.4) | 27 (9.4) | <0.01 |
| Very likely/likely | 307 (86.5) | 48 (69.6) | 259 (90.6) | |
| How likely would you be to take PrEP, if it has some minor side effects? | ||||
| Very unlikely/unlikely | 93 (26.2) | 45 (65.2) | 48 (16.8) | <0.01 |
| Very likely/likely | 262 (73.8) | 24 (34.8) | 238 (83.2) | |
| Perceived benefits | ||||
| It could prevent me from getting HIV | ||||
| No | 13 (3.7) | 10 (14.4) | 3 (1.0) | <0.001 |
| Yes | 342 (96.3) | 59 (85.6) | 283 (99.0) | |
| It would reduce my worry about getting HIV | ||||
| No | 15 (4.2) | 12 (17.4) | 3 (1.0) | <0.001 |
| Yes | 340 (95.8) | 57 (82.6) | 283 (99.0) | |
| It would reduce my worry about giving HIV to my sex partner(s) | ||||
| No | 51 (14.4) | 28 (40.6) | 23 (8.0) | <0.001 |
| Yes | 304 (85.6) | 41 (59.4) | 263 (92.0) | |
| It would prevent me getting HIV from forced sex | ||||
| No | 48 (13.5) | 30 (43.4) | 18 (6.2) | <0.001 |
| Yes | 307 (86.5) | 39 (56.6) | 268 (73.8) | |
| I could tell my partners that I am protected against HIV | ||||
| No | 100 (28.2) | 48 (69.5) | 52 (18.2) | <0.001 |
| Yes | 255 (71.8) | 21 (30.5) | 234 (81.8) | |
| Perceived disadvantages | ||||
| I would worry about what my hijra/trans friends think of me | ||||
| No | 183 (51.5) | 36 (52.1) | 147 (51.3) | 0.90 |
| Yes | 172 (48.5) | 33 (47.9) | 139 (48.7) | |
| I would worry about what my family thinks of me | ||||
| No | 186 (52.4) | 41 (59.4) | 145 (50.7) | 0.19 |
| Yes | 169 (47.6) | 28 (40.6) | 141 (49.3) | |
| I would worry about what my male regular partner thinks of me | ||||
| No | 207 (58.3) | 50 (72.4) | 157 (54.9) | <0.01 |
| Yes | 148 (41.7) | 19 (27.6) | 129 (45.1) | |
| I would worry that I have to get an HIV test before getting PrEP | ||||
| No | 209 (58.9) | 61 (88.4) | 148 (51.8) | <0.001 |
| Yes | 146 (41.1) | 8 (11.6) | 138 (48.2) | |
| I would worry that people would think I am HIV-positive if I am on PrEP | ||||
| No | 215 (60.6) | 45 (65.2) | 170 (59.4) | 0.37 |
| Yes | 140 (39.4) | 24 (34.8) | 116 (40.6) | |
| I would not be able to take medications (PrEP) daily | ||||
| No | 210 (59.2) | 33 (47.9) | 177 (62.0) | 0.03 |
| Yes | 145 (40.8) | 36 (52.1) | 109 (38.0) | |
| I would worry that PrEP may interact with hormones that I take now or in the future | ||||
| No | 191 (53.8) | 35 (50.7) | 156 (54.5) | 0.56 |
| Yes | 164 (46.2) | 34 (49.3) | 130 (45.5) | |
| Preferences in pricing and access venue | ||||
| Pricing of PrEP | ||||
| Free | 224 (63.1) | 56 (81.1) | 168 (58.8) | <0.01 |
| Subsidized/charged | 131 (36.9) | 13 (18.9) | 118 (41.2) | |
| Venue preference to receive PrEP | ||||
| Govt. hospitals and other venues | 97 (27.3) | 3 (4.3) | 94 (32.9) | <0.001 |
| CBOs/NGOs | 258 (72.7) | 66 (95.7) | 192 (67.1) | |
| Risk compensation | ||||
| PrEP use would avoid the hassle of using condoms | ||||
| No | 180 (50.7) | 16 (23.2) | 164 (57.3) | <0.001 |
| Yes | 175 (49.3) | 53 (76.8) | 122 (42.7) | |
| PrEP use would allow me to have sex with more sexual partners | ||||
| No | 97 (27.3) | 3 (4.3) | 94 (32.9) | <0.001 |
| Yes | 258 (72.7) | 66 (95.7) | 192 (67.1) | |
CBO, community-based organization; NGO, nongovernmental organization.
Findings from multivariable analysis
In the adjusted model, several characteristics were found to be significantly associated with willingness to use PrEP (Table 3). Trans women in sex work had 28 times higher odds (adjusted odds ratio [aOR]=28.92, 95% CI=8.79–95.16, p<0.001) to report willingness to use PrEP than those not in sex work. Those who had studied high school or above had two times higher odds (aOR=2.00, 95% CI=1.17–3.42, p=0.01) to report willingness to use PrEP than those who studied less than high school. When compared with trans women who did not experience discrimination, the odds of reporting willingness to use PrEP was lower among trans women who had experienced discrimination from health care providers (aOR=0.25, 95% CI=0.06–0.97, p=0.04) and family members (aOR=0.08, 95% CI=0.05–0.14, p≤0.001). Trans women who had higher scores on perceived benefits of PrEP had higher odds (aOR=2.17, 95% CI=1.91–2.47, p<0.001) of willingness to use PrEP. Similarly, those who reported that it would be difficult to take PrEP daily had lower odds (aOR=0.30, 95% CI=0.18–0.49, p<0.001) of willingness to use PrEP. Trans women who reported a higher frequency of anal sex had lower odds (aOR=0.21, 95% CI=0.12–0.37, p<0.001) of willingness to use PrEP than those with a lower frequency of anal sex. HIV risk perception, access venue, prior awareness of PrEP, pricing of PrEP, and risk compensation (not using condoms if on PrEP) were not independently associated with willingness to use PrEP.
Table 3.
Factors Associated with Willingness to Use Preexposure Prophylaxis Among Trans Women: Multivariable Logistic Regression Results (N=355)
| Variables | Adjusted odds ratio | 95% Confidence interval | p Value |
|---|---|---|---|
| Sociodemographic characteristics | |||
| Age (years) | 1.00 | 0.87–1.15 | 0.96 |
| Monthly income (INR) | 1.00 | 0.99–1.00 | 0.36 |
| Education (<high school vs. ≥high school) | 2.00 | 1.17–3.42 | 0.01 |
| Sex work (no vs. yes) | 28.92 | 8.79–95.16 | <0.001 |
| Prior PrEP awareness (no vs. yes) | 0.91 | 0.25–3.33 | 0.89 |
| Sexual risk | |||
| Inconsistent condom use with any type of male partners (no vs. yes) | 0.34 | 0.08–1.37 | 0.13 |
| Frequency of anal sex (low vs. high) | 0.21 | 0.12–0.37 | <0.001 |
| Forced sex in the past 12 months (no vs. yes) | 0.78 | 0.22–2.74 | 0.70 |
| Perceived risk of contracting HIV (low vs. moderate/high) | 1.07 | 0.30–3.78 | 0.91 |
| Ever had an HIV test (no vs. yes) | 2.06 | 0.50–8.50 | 0.31 |
| Discrimination experiences | |||
| Discrimination by health care providers (no vs. yes) | 0.25 | 0.06–0.97 | 0.04 |
| Discrimination by family members (no vs. yes) | 0.08 | 0.05–0.14 | <0.001 |
| Preferences (venue and pricing) | |||
| Access venue for PrEP (Govt. hospitals/other venues vs. CBOs/NGOs) | 0.58 | 0.31–1.10 | 0.09 |
| Pricing of PrEP (charged vs. free) | 2.46 | 0.36–16.53 | 0.35 |
| Perceived benefits of taking PrEP (total score) | 2.17 | 1.91–2.47 | <0.001 |
| Perceived disadvantages of PrEP | |||
| Worried that others might think PrEP user as HIV positive (no vs. yes) | 1.32 | 0.52–3.34 | 0.55 |
| Worried about what male regular partner might think if PrEP is used (no vs. yes) | 8.25 | 4.46–15.24 | <0.001 |
| Difficult to take PrEP daily (no vs. yes) | 0.30 | 0.18–0.49 | <0.001 |
| Risk compensation: “PrEP use would avoid the hassle of using condoms” (no vs. yes) | 0.41 | 0.07–2.42 | 0.33 |
Discussion
This study among trans women in India examined the extent of and factors influencing willingness to use PrEP. The findings showed that a vast majority of trans women (80.6%) reported willingness to use PrEP, which is consistent with the levels of PrEP acceptability found among trans women in Brazil (82.1%),22 Argentina (89.3%),23 and Vietnam (79.7%),9 but higher than the levels found among trans women from China (61.2%)7 and Thailand (37%).8 However, the PrEP acceptability level reported by trans women in this study was lower than the level (95%) reported by female sex workers in India,24 and in a combined sample of MSM and trans women (99%) in South India.10 Thus, in general, PrEP acceptability level among trans women in this study is similar to or higher than those reported among trans women in other developing countries.
Prior knowledge of PrEP among trans women in this study was 17.1%, much lower than that reported among trans women from most developing countries—for example, 61.3% in Brazil22 and 66% in Thailand,8 but higher than that reported from Vietnam (13.1%).9 This low PrEP awareness among Indian trans women reflects the lack of PrEP awareness campaigns by the government and NGOs,25 and highlights the need to provide comprehensive education, in easy-to-understand formats and ways, so that even less-educated trans women can make informed choices on using PrEP. In this study, all participants with prior knowledge of PrEP had received information about it from peers or voluntary organizations. Other potential channels of information for trans women in India could include social media (e.g., WhatsApp groups of trans women).26
A key issue is to understand whether those trans women who are willing to use PrEP are those who would benefit from it. In this study, sex work status was a significant independent predictor of willingness to use PrEP, pointing out that indeed trans women at risk opt for PrEP. However, the lack of significant associations between PrEP acceptability and risk perception, inconsistent condom use, and history of STIs indicate that not all trans women at risk might want to use PrEP. In fact, in this study, trans women who reported high-frequency anal sex were less likely to willing to use PrEP compared with those who reported low-frequency anal sex. The reason for this finding is not clear.
In this study, consistent with studies conducted among sexual and gender minorities from other countries,23,27 trans women who experienced discrimination from health care providers were less likely to report willingness to use PrEP. This has implications for PrEP delivery strategies as it is often the health care providers who prescribe and monitor PrEP. It also points out the need to train health care providers to offer sensitive and competent PrEP-related services to key populations, including trans women.11,28
This study found that prior knowledge of PrEP was not related to PrEP acceptability, although a study among trans women in Thailand had shown the opposite.8 This finding indicates that information alone is insufficient to promote PrEP use, and possibly points out the need to provide support to those who might be good candidates for PrEP use.
Although many participants expressed concerns about potential side effects, it was not found to be significantly associated with willingness to use PrEP. Similarly, although quantitative studies have reported trans women's concerns about potential interactions between hormonal therapy and PrEP,28 in this study no such association was found in the adjusted analysis. Nevertheless, PrEP educational programs need to address side effects, and potential interactions with hormonal therapy.29 In this study, trans women who had concerns about taking PrEP daily (reflecting low self-efficacy) had lower odds of willingness to use PrEP. Therefore, in addition to offering adherence counseling, as soon as available, long-acting PrEP formulations can be offered as alternatives to daily oral PrEP,30 especially as the WHO has not yet approved event-driven PrEP for trans women.31
Although the participants who reported willingness to use PrEP were more likely to endorse the statement that PrEP use would avoid the hassle of using condoms, this relation was not significant in the adjusted analysis. Assessment of risk compensation among users of PrEP projects too has documented that in almost none of those projects was there an indication of risk compensation.32
In the adjusted analysis we could not find any significant association between access venue preference and PrEP acceptability or between pricing and PrEP acceptability. Although in India, citing resource limitations, policymakers had argued that improving access to antiretroviral treatment for people living with HIV was a priority over providing PrEP to HIV-negative people,11 ongoing discussions on ethics in providing PrEP to vulnerable populations strongly suggest that while those concerns about resource limitations and access to antiretroviral treatment are valid, that should not be an excuse to offer affordable PrEP to people who would benefit from it.32
The study findings also revealed PrEP use-related stigma that users might encounter. A significant proportion of participants were worried about what other trans people would think of them if they use PrEP, and worried about having to undergo HIV testing before initiation of PrEP. These concerns reflect the fear of discrimination related to both PrEP use and HIV status, pointing out the need to address both PrEP use-related stigma and HIV-related stigma. Studies from other countries too have documented PrEP use-related stigma among trans women and MSM,33–35 with a study from Thailand reporting that trans women with higher HIV-related stigma scores had lower odds of PrEP acceptability.36 Given that trans communities in India are much more closely connected12 and dependent on peer support, fear of losing trans community support might prevent trans women from initiating PrEP, which would otherwise benefit them.
Limitations
This study has several limitations. First, the survey had a convenience sample of trans women recruited through CBOs/NGOs. Thus, the results are not generalizable. Future studies need to employ probability-based sampling procedures and/or use both offline and online recruitment to increase sample diversity. Second, willingness to use PrEP was assessed by a single question on the potential use of a product that was not currently available to them, and the responses to that question were collapsed and dichotomized to suit statistical analysis—both these issues could influence the interpretation of results. Third, the expressed attitudes toward and intentions to use PrEP may not be the same if PrEP is offered. Fourth, recall bias and social desirability bias would have affected answering sensitive questions on sexual behavior and willingness to use PrEP.
Conclusions
High willingness to use PrEP was found among trans women, including those in sex work, in India. To ensure that PrEP is taken by those who would benefit the most from it, and to assist trans women in making informed decisions on PrEP use, steps that need to be taken include increasing awareness about PrEP and promoting accurate self-assessment of HIV risk; providing comprehensive yet easy-to-understand information on PrEP's effectiveness, side effects and interactions with hormones; and reducing stigmas related to PrEP use and HIV. Trans community's preferences on access venues and pricing need to be further explored. To start with, PrEP may be offered for free or at subsidized prices to at least a subset of trans women at high risk. PrEP implementation research projects to identify effective PrEP delivery strategies are urgently needed to reduce the disproportionate HIV burden among trans women in India.
Acknowledgments
The authors thank the partners of India HIV/AIDS Alliance—Shaan Samarth Clinic, Delhi Samarth Clinic, Lakshya Samarth Clinic, Alliance India Regional Office (AIRO) Clinic, Sangama and Amitie Trust—for their help in data collection. Also, the authors thank Abhina Aher, trans activist and consultant, who executed the survey protocol, and Murali Shunmugam and Mr. Ruban Nelson of Centre for Sexuality and Health Research and Policy (C-SHaRP) for their help in coordination and data management that contributed to successful completion of this study.
Abbreviations Used
- aOR
adjusted odds ratio
- CBO
community-based organization
- CI
confidence interval
- HIV
human immunodeficiency virus
- IQR
interquartile range
- MSM
men who have sex with men
- NACO
National AIDS Control Organization
- NGO
nongovernmental organization
- PrEP
preexposure prophylaxis
- STI
sexually transmitted infection
- WHO
World Health Organization
Disclaimer
Part of this article was presented as a poster entitled “Community preparedness for HIV Pre-Exposure Prophylaxis (PrEP) among transgender women (TGW) in India: A cross-sectional survey,” at the 22nd International AIDS Conference, Amsterdam, the Netherlands, July 23–27, 2018.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This study was supported by ViiV Health Care (reference number: 1795557/ChCP045) to India HIV/AIDS Alliance.
V.C.'s contribution was in part supported by the DBT/Wellcome Trust India Alliance Senior Fellowship (IA/CPHS/16/1/502667) awarded to him.
Cite this article as: Chakrapani V, Shaikh S, Arumugam V, Chawla U, Mehta S (2021) Factors influencing willingness to use human immunodeficiency virus preexposure prophylaxis among transgender women in India, Transgender Health 6:2, 64–73, DOI: 10.1089/trgh.2019.0076.
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