Photo Credit: Daniel Megias

Research shows many transgender women in the U.S. express interest in long-acting injectable PrEP but face barriers to accessing preventive treatment.

Many transgender women in the United States want access to long-acting injectable pre-exposure prophylaxis (LAI PrEP), but the barriers to care they experience need to be addressed, according to the results of a survey-based study.

“Nearly half the transgender women in our study expressed interest in long-acting injectable PrEP, with interest significantly higher among those most likely to benefit from PrEP,” lead study author Erin Cooney, PhD, MSPH, tells Physician’s Weekly. “These findings demonstrate that people want LAI PrEP, and they underscore the need to increase transgender women’s access to the treatment as one component of a comprehensive strategy to achieve optimal PrEP use in this population.” 

Transgender women—especially Black and Latina/x transgender women—have some of the highest HIV incidence rates among priority populations in the US, but too few of them use daily oral PrEP, Dr. Cooney and her colleagues reported in JAIDS.

To investigate how interested transgender women would be in LAI PrEP—a bimonthly injectable alternative to daily oral PrEP—the researchers analyzed data from the large, diverse Leading Innovation for Transgender Women’s Health and Empowerment (LITE) cohort that began in 2018 to prospectively follow transgender women in the eastern and southern US at risk for HIV.

The 867 respondents (mean age, 28; 19% Black) enrolled in the LITE cohort completed 12-month surveys between March 2019 and September 2021.

Most participants (75%) were PrEP-naïve, 15% reported current oral PrEP use, and 11% reported prior oral PrEP use. More than a third (37%) of participants had used PrEP.

Dr. Cooney and colleagues found that:

• 47% of participants reported interest in LAI PrEP: Interest was more common among Black (PR, 1.28; 95% CI, 1.05-1.55), college-educated (PR, 1.28; 95% CI, 1.04-1.57), food insecure (PR, 1.19; 95% CI, 1.00-1.41), and had PrEP indications (PR, 1.44; 95% CI, 1.21-1.71) respondents.
• LAI PrEP interest was more common among adherent PrEP users or those who had discontinued the medication than among PrEP-naïve people.

While the study’s strengths included its diverse cohort and focus on an at-risk group, the authors acknowledged its limitations. The participants completed the surveys before responding to a hypothetical scenario that omitted cost and other real-world concerns. The participants were “highly engaged in healthcare,” so the results may not be generalizable to transgender women who are less engaged, and the sample included a relatively small number of Black and Latina participants.

Dr. Cooney and transgender activist Marissa Miller talked with Physician’s Weekly (PW) about trans women’s interest in LAI PrEP and ways to increase their access to it.

PW: Why was it important to do this study? 

Dr. Cooney: From an implementation science perspective, we are always looking to see how innovations may impact existing health inequities. A highly efficacious product that is not consistent with the values and preferences of end users may have minimized the real-world impact or existing inequities may have been exacerbated. Conversely, end users who stand to benefit most and are interested in and willing to use a highly efficacious, widely available, equitably distributed product may demonstrate its potential for real-world impact.

Were the results surprising?  

These results did not surprise us because they are consistent with literature that shows transgender women in the U.S. generally have a high level of interest in and willingness to use various HIV prevention products and strategies. What is surprising—and an area to address—is the high interest in long-acting PrEP in the context of low uptake of daily oral PrEP. Inequities in uptake of and adherence to these interventions are typically explained by access issues and social and structural barriers rather than lack of interest.

What barriers do transgender women encounter in accessing PrEP?

Miller: To help ensure widespread LAI PrEP availability, professionals first need to understand that transgender women face barriers to treatment with this highly effective medication. 

Improving their access to LAI PrEP, particularly for trans women of color, requires addressing barriers to healthcare as well as social barriers. Clinicians MUST prioritize culturally competent, gender-affirming care that recognizes the unique challenges trans women face. This involves creating a welcoming healthcare environment, using correct pronouns, and integrating PrEP into broader gender-affirming services, like hormone therapy. 

Many transgender women of color have experienced medical discrimination, and professionals need to build their trust. Partnering with community organizations and trans-led groups can help bridge this gap and ensure that care is accessible and respectful.

Economic barriers need to be addressed. Many trans women of color face financial insecurity and limited healthcare access. Clinicians should connect patients with financial assistance programs to cover PrEP costs. To overcome logistical barriers, clinicians should consider providing care through mobile clinics or community-based services.

How could the results improve transgender women’s access to LAI PrEP? 

Dr. Cooney: Not all clinics offer the treatment, possibly partially due to uncertainty about client interest levels. We hope that by showing moderately high interest among transgender women, with higher interest among those who are Black and those with PrEP indications, clinics that serve transgender women will offer LAI PrEP to all clients who may benefit.

What questions remain unanswered?

Dr. Cooney: This research addressed interest in LAI PrEP in the pre-FDA approval period. Now that the treatment has been approved and is becoming more widely available, it is important to monitor uptake and adherence among transgender women and to assess for clinic-level and structural factors that may impact uptake and adherence. We are currently looking at these data in a nationwide cohort of 2,500 transgender women.

Is there anything else you would like to mention?

Dr. Cooney: As a community of scientists, clinicians, advocates, and public health practitioners, we must ensure that innovations in HIV prevention are available to those who can most benefit from them. The more options we can provide, the more likely we will be to meet the HIV prevention needs of the communities we work with.

Miller: Outreach efforts should focus on reducing the stigma surrounding PrEP by presenting it as a part of general wellness. Peer-led education and outreach can be highly effective ways to raise awareness and encourage uptake, especially when trusted community voices are involved in the conversation.