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. Author manuscript; available in PMC: 2022 Oct 6.
Published in final edited form as: Arch Sex Behav. 2021 Oct 6;50(7):3287–3295. doi: 10.1007/s10508-021-02019-3

Self-identity, beliefs, and behavior among men who have sex with transgender women: Implications for HIV research and interventions

Jessica E Long 1, Michalina Montaño 1, Hugo Sanchez 2, Leyla Huerta 2, Dania Calderón Garcia 2, Javier R Lama 4, Michele Andrasik 3, Ann Duerr 3
PMCID: PMC8784120  NIHMSID: NIHMS1770478  PMID: 34617189

Abstract

While transgender women have been identified as a global priority population for HIV prevention and treatment, little is known about the cisgender male partners of transgender women, including their sexual behavior and HIV prevalence. Previous research has suggested that these male partners have varied identities and sexual behavior, which make identifying and engaging them in research difficult. This paper describes interviews conducted with fifteen cisgender men who reported recent sexual activity with transgender women in Lima, Peru. The purpose of this research was to explore how these men reported their identities and sexual behavior, to better understand how they would interact with HIV outreach, research, and care. The major themes were sexual orientation and identity; view of transgender partners; social ties to transgender women and MSTW; disclosure of relationships; HIV knowledge and risk perception; and attitudes toward interventions. We found that language used to assess sexual orientation was problematic in this population, due to lack of consistency between orientation and reported behavior, and unfamiliarity with terms used to describe sexual orientation. In addition, stigma, lack of knowledge of HIV prevention methods, and fear of disclosure of sexual behavior were identified as barriers that could impact engagement in HIV research, prevention, and care. However, participants reported social relationships with both transgender women and other men who have transgender partners, presenting possible avenues for recruitment into HIV research and healthcare services.

Keywords: Sexual identity, stigma, sexual behavior, HIV, transgender women

INTRODUCTION

With the advent of highly effective biomedical interventions for both the prevention and treatment of HIV, the Joint United Nations Programme on HIV/AIDS (UNAIDS) announced in 2014 the 95-95-95 goals to achieve knowledge of HIV status in 95% of people living with HIV (PLWH), linkage to antiretroviral treatment (ART) in 95% of PLWH who know their status, and maintenance of viral suppression in 95% of PLWH on ART by 2030 (UNAIDS, 2014). A critical strategy toward achieving this goal is to target high prevalence subpopulations that have historically been underrepresented in both research and HIV outreach programs. Transgender women, who have a global HIV prevalence of 19% (Baral et al., 2013), are increasingly being recognized as a key population in the HIV epidemic, resulting in improved efforts to engage them in HIV research and care. However, cisgender male sexual partners of transgender women (MSTW) have received much less focus from the HIV research community (Poteat et al., 2020; Restar et al., 2019).

As the sexual partners of a population with high HIV prevalence, MSTW are likely to also have a high HIV prevalence. However, because they are rarely purposefully included in research and interventions, evidence about HIV prevalence and sexual behavior in MSTW is sparse and is primarily focused on high-income settings (Poteat et al., 2020; Restar et al., 2019). Recent research suggests that MSTW are a diverse demographic group, with varied sexual orientations, partner preferences, and participation in behavior such as sex work and injection drug use (Operario et al., 2011; Poteat et al., 2020; Restar et al., 2019; Wilson et al., 2014). HIV prevalence among MSTW has only been measured in a few small studies, but these findings suggest that HIV prevalence among MSTW may be comparable to that of bisexual and homosexual men (Coan et al., 2005; Long et al., 2020; Operario et al., 2008, 2011; Reback & Larkins, 2013; Restar et al., 2019). Further, some researchers have hypothesized that men who have sex with both men and transgender women may play a role in transmission of HIV across sexual networks of transgender women and men who have sex with men (MSM) (Ragonnet-Cronin et al., 2019; Truong et al., 2019). Despite this, research among MSTW in Latin America has suggested that a majority of MSTW perceive their risk of acquiring HIV as low or moderate (Degtyar et al., 2018), and HIV testing appears to be significantly lower among MSTW than among transgender women and MSM (Reisner, Perez-Brumer, et al., 2019). However, information about MSTW in Latin America is limited, derived primarily through studies conducted among sex workers and their clients(Degtyar et al., 2018) or studies of MSM with post-hoc characterization of MSTW found within the sample (Long et al., 2020; Reisner, Perez-Brumer, et al., 2019).

The varied identities and sexual behavior of MSTW make identifying and engaging them in research and prevention interventions more difficult as it is challenging to categorize them as a recognizable demographic. To address this, we conducted semi-structured interviews in 2018 among a sample of 15 MSTW in Lima, Peru who were enrolled in a research study through their transgender women partners. The purpose of this research was to better understand the identities and behavior of MSTW to provide insight into how these characteristics might influence their access to HIV prevention, and to identify how investigators may reach MSTW for HIV research and interventions.

METHODS

Study context

Semi-structured interviews were conducted with MSTW in Lima, Peru. These qualitative interviews were an ancillary activity of a study that used a modified respondent-driven sampling study design to recruit transgender women and MSTW for a survey study (Long et al., 2019). Respondent-driven sampling uses a chain-based recruitment approach to engage populations not well represented in research, relying on social network ties within the population of interest (Heckathorn, 1997). While this approach has been successfully employed among transgender women (J. L. Clark et al., 2014; Silva-Santisteban et al., 2012), it was unknown if social ties among MSTW were sufficiently strong to support this type of sampling. Instead, recruitment for the parent study was conducted through the sexual network to facilitate recruitment and unambiguously identify MSTW. Data collection used an online survey, and names were not collected to provide anonymity in answering questions about highly stigmatized behavior. Once they completed the survey, all eligible MSTW from the parent study were invited to participate in an additional semi-structured interview; recruitment continued until the desired sample size was met. To be eligible for interview, participants had to identify as cisgender men, have reported a transgender woman sexual partner in the previous three months, and have participated in the parent study.

This study was approved by the ethics committees at IMPACTA (Lima, Peru) and the Fred Hutchinson Cancer Research Center (Seattle, WA). Verbal consent was obtained from all participants prior to the interview. Participants received 40 soles (approximately $12 USD) for participation. The research team for this study includes researchers from the University of Washington with expertise in HIV research among LGBTQ communities, including a clinical health psychologist focused on community-based participatory research in marginalized communities. In Peru, the team includes a Lima-based clinical psychologist, a clinician researcher, and LGBTQ rights activists based at two healthcare NGOs in Lima that serve gay men and transgender women (IMPACTA and Epicentro). The researcher performing the interviews (HS) was selected based on his expertise and positionality in the community under research.

Data collection

A clinical psychologist who works with MSM and transgender women populations (HS) conducted all study interviews by phone. HS contacted the interview participants recruited through the parent study, explained that call would last approximately 30 minutes, up to an hour, and reviewed consent information with participants. He then used an interview guide that probed about sexual orientation, attitudes and behaviors toward sexual partners, knowledge of HIV, risk perception, sexual behavior, drug and alcohol use, and attitudes toward HIV interventions. All interviews were conducted in Spanish and audio recorded. A verified translator transcribed the interviews and translated them to English after data collection was complete.

Data analysis

Transcripts were evaluated using the framework analysis approach (Gale et al., 2013). Interviews were independently coded by two researchers (JEL and MM), who met to review the codes and reach consensus. An initial set of codes and codebook were derived using the interview guide and in consultation with a qualitative researcher with extensive experience working with transgender women (MA). Codes were then adapted based on the topics discussed in the interviews. The two coders independently coded three interviews, then reviewed the coding together to determine discordance and reach consensus. The initial three interviews were recoded based on findings from this review. This process was repeated on additional batches of interviews until the reviewers found complete concordance. All subsequent interviews (n=8) were divided between the two researchers and independently coded, using the codebook. The coders identified and coded all information relating to the topics of interest. Codes were then compiled into themes, which both researchers co-reviewed for relevance, and selected quotes to represent important themes identified in the interviews. Microsoft Excel was used to compile codes into thematic categories. In addition to themes of interest, basic demographic information about the interview participants was compiled.

RESULTS

The purpose of this research was to collect data on the identities and behavior of MSTW, to better understand how they fit into the existing target criteria for HIV outreach, research, and care. Interviews were conducted with 15 MSTW from May – June 2018; participants engaged in interview questions for an average of 20 minutes. The median age of participants was 27 years (range 19–60). The major themes that were elicited in these interviews related to sexual orientation and identity; view of transgender partners; social ties to transgender women and MSTW; disclosure of relationships; HIV knowledge and risk perception; and attitudes toward interventions.

Sexual orientation and identity

When asked about their sexual orientation and who they are attracted to, most participants identified as bisexual (N=10), but for many this required prompting from the interviewer with an explanation of what the terms heterosexual, homosexual, and bisexual meant. Seven of those who identified as bisexual reported being primarily or solely attracted to cisgender and transgender women. Of three participants who reported primarily being attracted to cisgender men and transgender women, one reported being heterosexual, one homosexual, and one bisexual. The responses suggested both lack of consistency in how men identified, and confusion about the meaning of the terminology used. One participant, after reporting attraction to cis and transgender women, expressed uncertainty about how to define his sexual orientation:

“I don’t know what you could call that. What do you call that?”

(Participant 2, Age 27)

For some, attraction was more aligned with gender expressions of femininity and masculinity than about gender or sex of the partner. One participant who identified as bisexual and reported primarily having cis- and transgender female partners described their attraction as follows:

“[I feel attracted to] the ones that are very feminine, and the ones who are very good-looking, who have a more feminine bearing.”

(Participant 14, Age 24)

This reported attraction to feminine traits did not necessarily align with any particular sexual orientation. While participants who were attracted to cis- and transgender women were most likely to identify as bisexual, one such participant identified as heterosexual. His sexual orientation/identity appeared to stem from a recognition of transgender women as women:

“I am more attracted to [cisgender] women, but I am attracted to trans women because I feel they are women as well, not because I know they are transgender.”

(Participant 15, Age 60)

View of transgender partners

A set of interview questions assessed the attitudes of MSTW toward their transgender women partners and other MSTW. Generally, participants were affirming of the gender of transgender women (73%), and some (27%) demonstrated empathy for the discrimination and abuse that transgender women face in Peruvian society:

“I see her as a woman. To me, she’s a woman. Not the opposite. I mean, to me, she will always be a woman, and that’s it, you know?”

(Participant 1, Age 24)

“I try to be gentle with her, polite, because she’s obviously a lady and she must be respected as any other woman that has been born with a vagina, the same. … They are people who are like me, who feel, have feelings, problems … it’s a good moment because how long will [transwomen] keep dying … because of nothing? They die because of nothing, I don’t understand why they mistreat them, why does the municipality security come and beat them, some of them are minors, raped, abused, thrown out of their families.”

(Participant 5, Age 24)

However, not all participants always expressed such open views toward their transgender partners. One participant reported how their views of transgender women have changed over time:

“My point of view has changed over time because I was homophobe years ago, including with trans…. then let’s say that over the years I changed my position. I wasn’t so … let’s say … so drastic with those kinds of people.”

(Participant 15, Age 60).

Social ties to transgender women and MSTW

Friendships with transgender women, gay men, and MSTW appeared to play an important role in the social networks of many participants. Most participants reported friendships or social relationships with transgender women (80%), and some reported friendships or social relationships with other MSTW or MSM. Of the 15 participants included in this analysis, six discussed friendships with other MSTW, however, these friendships generally account for a small portion of their social network.

“Yes [my friends know I go out with trans women] but only a few, two or three, no more…, they do [go out with trans women], too.”

(Participant 3, Age 30)

“Some of my friends that are straight do go out with trans girls. I mean, out of the 8 friends I’ve got, two of them go out with trans girls.”

(Participant 5, Age 24)

Despite reporting small numbers of MSTW friends, some expressed spending more time with these friends:

“In my spare time? Well, I spend more time with friends who like trans women.”

(Participant 2, Age 27)

Disclosure of relationships

In addition to support within the community of transgender women and MSTW, most participants (80%) reported that they disclose their partnerships to a small number of friends outside transgender women and MSTW communities. Disclosing to a small group of friends, such as Participant 13 reported, was common among the study participants:

“There are some people [that know I date men and transgender women] but it isn’t most of them, maybe 3 people, no more.”

(Participant 13, Age 19)

One participant commented on how this disclosure was an important source of comfort:

“With my close friends, I’m free because I feel comfortable, they know I have my trans women friends.”

(Participant 2, Age 27)

While many reported having friends that knew about their sexual partners, most were not out to their families. Societal stigma against transgender populations, as well as homophobia, appeared to have a strong influence on disclosure to family. About half of the participants expressed fear of disclosing their partnerships with transgender women, and this was primarily related to anticipated negative reactions from their families. The anticipated reactions included familial rejection, violence, and fears of being labeled as gay:

“[If I disclose to my family] they could have an idea about me as a person who has wrong likes, perhaps.”

(Participant 2, Age 27)

“We talked about that [men being attracted to transgender women], because they think that being attracted to a trans woman would mean that I’m homosexual, but I’m not homosexual.”

(Participant 15, Age 60)

“Of course, many things could happen [if my family found out about sex with transgender women]. … I don’t know, they would freak out, they may suddenly hit me, or throw me out of the house.”

(Participant 13, Age 19)

In contrast, three participants expressed being open about their identities and partnerships with transgender women, and having support from their families. These three participants all reported attraction to cisgender men and transgender women, though they each identified their sexual orientation differently. These participants described being out as “freeing”, and expressed resilience to stigma:

“Well, before someone came to bully me or before someone comes to bother me, I tell them directly that what they were about to say will slide right off me. I mean, ‘there’s nothing you can [say] to get me’, that’s something I’ve always paid attention to. You can’t get me.”

(Participant 5, Age 24)

“ Yes [I have felt the necessity to hide my attraction to transgender women and men], but when I was 18 years old. Now, I have freed myself a little bit.”

(Participant 10, Age 23)

HIV Knowledge and risk perception

Of the participants interviewed, twelve (80%) reported knowing their HIV status, one of whom reported being HIV-positive. Most demonstrated general knowledge about HIV transmission. Reporting casual sex partners was also very common, and seven participants spoke about selling sex. When probed about risk perception, a third reported that they were more likely to use condoms with transgender women partners than cisgender women, or that they believed that having transgender women partners increased their risk of acquiring HIV. Of these, one participant reported anal sex as the reason for increased risk of transmission, while four reported the belief that transgender women themselves, or their behavior, were associated with higher HIV risk:

“Well, at first, I didn’t know because of the taboo about trans girls… the taboo like you don’t know if she has had sex with several guys… and that’s the reason why I asked them, when we met, how many guys they had had sex with and they told me something like ‘I’m dating one or two’… it’s not like they were easy to get or they had sex with anyone. And then, talking and talking, I felt a little more comfortable, but I always used condoms when I was with them.”

(Participant 8, Age 24)

One participant reported always using condoms when having sex with transgender women, but when asked if they used a condom with cisgender women, said the following:

“No, because I usually get involved with the ones I know, which are few, right? But if it’s one that I don’t know, yes, I would use it. … But in general I consider that they are potentially less dangerous than a trans [woman].”

(Participant 15, Age 60)

However, despite this, risk perception among this group was generally low. All participants reported some use of condoms as a way to protect themselves against infection, and credited this as the reason for low HIV risk:

“No [I haven’t had an HIV test], because I think I always use protection.”

(Participant 2, Age 27)

Those who reported inconsistent condom use generally also reported higher risk perception. Inconsistent condom use was attributed either to enjoying sex more without a condom, or not consistently using condoms with partners that are well known. One participant suggested that a lack of trust in their partners led to increased fear of HIV acquisition:

“[I am at risk for HIV] because sometimes I trust too much, and I believe that’s a risk.”

(Participant 7, Age 35)

Another indicated that they sometimes initially trust a sexual partner and do not use protection, but then regret that decision later:

“I can tell that I am [at risk for HIV], because sometimes … I find a person I feel confident with … but at the same time, the next day I start thinking that I had to protect myself anyway, because it doesn’t matter if I know her, [HIV risk] is there, or could be there.”

(Participant 1, Age 24)

Knowledge of prevention methods aside from condom use was low among this population. When asked about PrEP, only three participants reported any knowledge of it. One of these participants reported distrust of PrEP based on information given by a friend:

“No [I haven’t considered using PrEP], because I have a friend outside Peru, and I asked him, and he told me not to do it, that is not 100% secure. “

(Participant 7, Age 35)

Attitudes toward interventions

In Peru, the HIV epidemic is concentrated in MSM and transgender populations. As a result, these groups are also the target of most HIV prevention strategies, which include pre-exposure prophylaxis (PrEP), condom distribution, peer outreach, and social-venue based HIV testing (Allan-Blitz et al., 2019; Bórquez et al., 2019). While these methods are thought to be effective among MSM and transgender women communities, we were interested in understanding how MSTW respond to these interventions. Participants offered mixed opinions when asked how they would feel about taking part in some common community outreach HIV interventions. Information such as brochures provided in bars and clubs appeared to be the most acceptable. About half supported the provision of free condoms at clubs and bars:

“I think that to enter the discos and find condoms and everything else, on the contrary, it’s like an angel that is taking care of you.”

(Participant 1, Age 24)

Others, however, expressed discomfort with condom distribution. Venue-based testing was the least accepted among the interventions posed to the participants. The primary reason given for their discomfort was finding testing in bars awkward, embarrassing, or too public. When asked about their opinion about venue-based testing, one participant responded that they would prefer if it occurred at a health facility, where testing would be more concealed:

“I think it would be better and disguised at the health post, right?”

(Participant 13, Age 19)

One participant said that he would only accept HIV testing because he knew he was negative already. Some participants expressed distrust of HIV testing in general. One participant believed that venue-based testing could result in him becoming infected with HIV.

DISCUSSION

Engaging MSTW in the HIV care continuum is a necessary step toward curbing the HIV epidemic, particularly among transgender women. This will require a better understanding of who they are, how they identify, and how likely they are to participate in HIV research and prevention interventions. We found that MSTW in Lima are a diverse group, with varied sexual orientations, partnership types, and perceptions of HIV risk. This paper highlights some key themes that are important to consider when approaching research or programmatic HIV interventions among this population.

One critical finding from this work was that language used to assess sexual orientation may not be relevant to this population, and further may result in misleading findings if not interpreted with caution. There was very low consistency in how the men in this study categorized themselves, and many seemed to be unfamiliar with common terminology describing sexual orientation, such as the term “bisexual”. Terminology such as heterosexual, homosexual, and bisexual are commonly used in both health care and research settings, with use of broader and more inclusive terminology (including pansexual, queer, and asexual) becoming more common (Goldberg et al., 2020; Timmins et al., 2020). However, recognition and use of these terms did not appear to be a norm in this population. Further, participants seemed unsure of how to label their own sexual behavior or sexual orientation. These results corroborate similar findings from a qualitative study conducted among MSM in Peru, which showed that behaviorally-bisexual men indicated uncertainty about the implications of their behavior on their sexual identity (J. Clark et al., 2013). This has important repercussions for survey-based research that uses sexual orientation language both in data collection and in determining study eligibility. Our findings are consistent with other studies that have reported varied sexual orientations among MSTW (Carballo-Diéguez et al., 2011; Long et al., 2020; Operario et al., 2011; Poteat et al., 2020). One systematic review of literature published on cisgender men with transgender partners noted that predicating eligibility criteria on sexual orientation may negatively affect recruitment of MSTW, or may lead to biased samples in research (Poteat et al., 2020). Further, our findings suggest that the way these men self-identify may result in exclusion of MSTW from HIV messaging in health care settings or targeted outreach. HIV interventions, particularly in Lima, are often targeted to homosexual men, or are conducted at venues that cater to a gay male population. Among the men interviewed, only one identified as homosexual, only half reported any attraction to or sexual activity with men, and men were more likely to report attendance at venues and locations specific to transgender women populations as opposed to MSM populations. Our results point to the need for more formative research to identify terminology that is used by this population, to describe their own identities and behaviors, in order to design more effective survey instruments and recruitment materials. Engaging MSTW in research and care will require context-appropriate and non-stigmatizing language to properly identify this population.

Stigma appeared to play a role in participant behavior, and resulted in reluctance to disclose their relationships with transgender women to their family and some friends. Previous studies among MSTW have found partnership stigma can have harmful effects on relationships and is associated with poor mental health outcomes (Gamarel et al., 2014, 2019). Stigma can be detrimental to health access, as enacted stigma and discrimination within the community and within the healthcare system can result in both poorer quality of care and reduced engagement in care among members of stigmatized groups or those who participate in stigmatized behavior (Heckathorn, 1997; Nyblade et al., 2019). Among transgender women, fear of mistreatment and mistrust are barriers to seeking HIV interventions and care (Reisner et al., 2020). If MSTW do not feel comfortable reporting their sexual behavior to researchers or healthcare workers, it may result in missed opportunities to offer appropriate care, and misclassification or exclusion of MSTW from research.

The majority of participants in this study reported some knowledge of HIV, HIV testing, and condom use. The high prevalence of recent HIV testing among this study sample contrasts with a recent study which found only 27% of MSTW in Lima reported HIV testing in the prior 12 months (Long et al., 2020). However, the MSTW in that study were drawn from a sample of men who have sex with men, so they are likely not representative of MSTW in Lima. Reported condom use among the MSTW interviewed in our study was high, however condom use still appeared to be inconsistent among some participants, and there was low knowledge about other prevention methods.

When probed about their attitudes toward common HIV prevention interventions, the responses were mixed, with some resistance to venue-based testing and condom provision. This contrasts with research among both transgender women and MSM, in whom venue-based testing and condom provision have been found as feasible and acceptable interventions in a variety of settings, including Peru (Allan-Blitz et al., 2019; Raymond et al., 2010; Singh et al., 2012; Strömdahl et al., 2019). Our findings suggest that MSTW may respond differently to these interventions, and this population may require specifically tailored outreach. Further, while the discomfort with venue-based testing appeared to primarily stem from stigma associated with HIV, there was some evidence of misinformation among this population. Some participants reported general distrust of HIV interventions, or specific fear of being infected by an HIV test.

The issues identified in these interviews present opportunities to consider expanded approaches to successfully recruit MSTW in HIV prevention research, interventions, and programs. The social ties participants reported with transgender women and other MSTW could have important implications for recruitment. The participants largely reported friendships or romantic relationships with transgender women, even in settings where their sexual behavior may be described as transactional. If transgender women partners are trusted contacts, partner referrals and snowball recruitment could be more widely used to find and engage MSTW in research and interventions through their transgender women partners. Further, our results suggest some level of social network among MSTW in Peru. To our knowledge, no literature exists describing social connections among MSTW. If MSTW do represent a social network, standard methods used to enroll marginalized populations could be employed, such as respondent-driven sampling. Engagement through transgender women partners could also be extended to improve outreach for HIV prevention services. Couple’s HIV testing and counseling has been found to be acceptable in qualitative research among transgender women and their cisgender male partners (Reisner, Menino, et al., 2019), and one study piloting a couples-based HIV testing and counseling approach among transgender women and their partners found significant reductions in condomless sex and sex with casual partners (Operario et al., 2017).

Moreover, meaningful involvement of MSTW in the research process could be an important strategy to improve MSTW engagement. This could be done through focus groups, community advisory boards, member checks (also known as respondent validation), or inclusion of MSTW as staff and outreach coordinators. Improving MSTW representation in the research would strengthen the ability to enroll in a non-stigmatizing way and would improve the possibility of enrolling through targeted venue-sampling or peer outreach. Finally, addressing the challenges of conducting research among MSTW may provide an opportunity to test HIV prevention methods that are not as well studied in Peru, including PrEP, HIV testing coupled with campaigns focused on how an undetectable viral load eliminates HIV transmission (“Undetectable = Untransmittable”, or “U=U”), or community-based interventions.

To our knowledge, this study is the first to specifically target sexual partners of transgender women in Peru for qualitative research, and to provide evidence that MSTW report friendships with other MSTW, opening the potential for use of these social ties to engage MSTW in HIV care and research. Mistrust of research and fear of being “outed” can be barriers to research participation among stigmatized communities (Owen-Smith et al., 2016). A primary strength of this study was the use of a trained local clinical psychologist who has experience, trust, and community support to conduct all interviews. Additionally, the use of interview questions targeted to understudied topics allowed for results that provide specific avenues for future research.

This analysis is limited by a few factors. Interviews were conducted with a small sample, but we believe we reached saturation in responses for questions of interest. However, because this population is highly marginalized and the topics under study are sensitive, the research team took steps to ensure the comfort of participants that may have resulted in reduced depth of responses. Interviews were conducted over the phone to protect anonymity, and the interviewer was careful to not probe too deeply if it appeared that doing so would make participants more uncomfortable. As a result, some questions elicited either yes/no answers, or required extensive dialog with the interviewer to clarify responses, limiting the number of in-depth qualitative responses that we received. The fact that this analysis was part of a larger study may limit how representative the sample is, as participants had to meet inclusion criteria of the primary study, including having a recent transgender woman sexual partner. Future research should be conducted among a wider representation of MSTW to provide additional perspectives. Finally, gender and sexual orientation identities are often culture specific, so the findings of this study may not provide insight to MSTW in other parts of the world. However, given the limited knowledge to date about MSTW, this study provides important context for future research.

Conclusions

This study provides valuable insight into the identities and behaviors of MSTW in Peru and could help to guide future research and outreach among this understudied population. There is an urgent need to engage this population in HIV research, but few studies have identified and enrolled MSTW. The findings from these interviews highlight how current survey designs and study sampling may not be appropriately capturing this demographic. Our results point to the need of more formative research to better understand how MSTW identify, how to better engage them in research, and how to tailor HIV prevention and treatment interventions to better reach this population.

Acknowledgements:

We would like to thank the study participants, and acknowledge the contribution of the staff at Impacta and Epicentro, and the contribution of Féminas Perú.

Funding:

This work was funded by the NIH National Institute on Drug Abuse, through a Sexual and Gender Minorities Administrative Supplementary (3R01DA040532-03S2) to an R01 (R01 grant DA032106, PI: AD), and by NIH Research Training Grant #D43 TW009345 awarded to the Northern Pacific Global Health Fellows Program by the Fogarty International Center (Fellow: JEL).

Footnotes

Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.

Conflicts of interest: The authors have no relevant financial or non-financial interests to disclose.

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