Introduction
Transgender women are the population most vulnerable to HIV in Latin America, with prevalence between 18 and 38%. Although the region has improved antiretroviral coverage, there is an ...urgent need to strengthen HIV prevention for key populations to meet regional targets set by governments. We conducted an assessment on the state of HIV prevention among transgender women in Latin America.
Methods
We conducted a desk review of Global AIDS Response Progress Reports, national strategic plans, technical reports and peer‐reviewed articles from 17 Latin American countries published through January 2015. The review was preceded by 12 semi‐structured interviews with UNAIDS and Pan American Health Organization officers and a discussion group with transgender women regional leaders, to guide the identification of documents. We assessed access to, implementation and coverage of programmes; legal frameworks; community participation; inclusion of new strategies; and alignment with international recommendations.
Results and discussion
Overall, prevention activities in the region focus on condom distribution, diagnosis of sexually transmitted infections and peer education, mostly delivered at health facilities, with limited community involvement. Argentina and Uruguay have implemented structural interventions to address social inclusion. Argentina, Brazil and Mexico have adopted early initiation of antiretroviral therapy and treatment as prevention strategies. The other countries do not have substantial tailored interventions and consider the trans population a sub‐population of men who have sex with men in data collection and programme implementation. Limited coverage of services, discrimination and a deep‐seated mistrust of the health system among transgender women are the main barriers to accessing HIV prevention services. Promising interventions include health services adapted to transgender women in Mexico; LGBT‐friendly clinics in Argentina that incorporate community and health workers in mixed teams; task‐shifting to community‐based organizations; mobile HIV testing; and gender identity laws.
Conclusions
Transgender women in Latin America continue to have limited access to HIV prevention services, which presents a bottleneck for reaching prevention goals and incorporating new prevention interventions. Prevention programmes should be rights‐based; offer tailored, holistic interventions; and involve transgender women in their design and implementation.
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FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Introduction: In Peru, transgender women (TW) experience unique vulnerabilities for HIV infection due to factors that limit access to, and quality of, HIV prevention, treatment and care services. ...Yet, despite recent advances in understanding factors associated with HIV vulnerability among TW globally, limited scholarship has examined how Peruvian TW cope with this reality and how existing community‐level resilience strategies are enacted despite pervasive social and economic exclusion facing the community. Addressing this need, our study applies the understanding of social capital as a social determinant of health and examines its relationship to HIV vulnerabilities to TW in Peru.
Methods: Using qualitative methodology to provide an in‐depth portrait, we assessed (1) intersections between social marginalization, social capital and HIV vulnerabilities; and (2) community‐level resilience strategies employed by TW to buffer against social marginalization and to link to needed HIV‐related services in Peru. Between January and February 2015, 48 TW participated (mean age = 29, range = 18–44) in this study that included focus group discussions and demographic surveys. Analyses were guided by an immersion crystallization approach and all coding was conducted using Dedoose Version 6.1.18.
Results: Themes associated with HIV vulnerability included experiences of multilevel stigma and limited occupational opportunities that placed TW at risk for, and limited their engagement with, existing HIV services. Emergent resiliency‐based strategies included peer‐to‐peer and intergenerational knowledge sharing, supportive clinical services (e.g. group‐based clinic attendance) and emotional support through social cohesion (i.e. feeling part of a community).
Conclusion: This study highlights the importance of TW communities as support structures that create and deploy social resiliency‐based strategies aimed at deterring and mitigating the impact of social vulnerabilities to discrimination, marginalization and HIV risk for individual TW in Peru. Public health strategies seeking to provide HIV prevention, treatment and care for this population will benefit from recognizing existing social capital within TW communities and incorporating its strengths within HIV prevention interventions. At the intersection of HIV vulnerabilities and collective agency, dimensions of bridging and bonding social capital emerged as resiliency strategies used by TW to access needed healthcare services in Peru. Fostering TW solidarity and peer support are key components to ensure acceptability and sustainability of HIV prevention and promotion efforts.
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FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Introduction
Among men who have sex with men (MSM) and transgender women (TW), stimulant use is high and has been associated with an increased risk of HIV infection, suicide and cardiovascular ...disease (CVD) mortality. We used epidemic modelling to investigate these intersecting health harms among MSM/TW in Lima, Peru and assess whether they could be mitigated by prioritizing HIV pre‐exposure prophylaxis (PrEP) and harm reduction interventions among MSM/TW who use stimulants.
Methods
We adapted a dynamic model of HIV transmission among MSM/TW in Lima to incorporate stimulant use and increased HIV risk, suicide and CVD mortality. Among 6% to 24% of MSM/TW using stimulants (mostly cocaine), we modelled an increased risk of unprotected anal sex (RR = 1.35 95%CI: 1.17 to 1.57) obtained from local data, and increased risk of suicide (SMR = 6.26 95%CI: 2.84 to 13.80) and CVD (SMR = 1.83 95%CI: 0.39 to 8.57) mortality associated with cocaine use based on a global systematic review. We estimated the proportion of health harms occurring among MSM/TW who use stimulants in the next year (01‐2020/01‐2021). We also investigated the 10‐year impact (01‐2020/01‐2030) of: (1) PrEP prioritization for stimulant‐using MSM/TW compared to random allocation, and (2) integrating PrEP with a theoretical intervention halving stimulant‐associated risk.
Results
MSM/TW in Lima will experience high HIV incidence, suicide mortality and CVD mortality (1.6/100 py, and 0.018/100 py, 0.13/100 py respectively) in 2020. Despite stimulant using MSM/TW comprising an estimated 9.5% (95%CI: 7.8 to 11.5) of all MSM/TW, in the next year, 11% 95%CI (i.e. 2.5% to 97.5% percentile) 10% to 13%) of new HIV infections, 39% (95%CI: 18% to 60%) of suicides and 15% (95%CI: 3% to 44%) of CVD deaths could occur among this group. Scaling up PrEP among all stimulant using MSM/TW could prevent 19% (95%CI: 11% to 31%) more HIV infections over 10 years compared to random allocation. Integrating PrEP and an intervention to halve stimulant‐associated risks could reduce new HIV infections by 20% (95%CI: 10% to 37%), suicide deaths by 14% (95%CI: 5% to 27%) and CVD deaths by 3% (95%CI: 0% to 16%) over a decade.
Conclusions
MSM/TW who use stimulants experience a disproportionate burden of health harms. Prioritizing PrEP based on stimulant use, in addition to sexual behaviour/gender identity criteria, could increase its impact. Integrated substance use, harm reduction, mental health and HIV care among MSM/TW is needed.
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FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Introduction
Peruvian young transgender women (YTW) ages 16−24 years are a critical but understudied group for primary HIV prevention efforts, due to sharp increases in HIV prevalence among TW ages ...25 years and older.
Methods
Between February and July 2022, a cross‐sectional quantitative study with YTW ages 16−24 years in Peru (N = 211) was conducted consisting of a bio‐behavioural survey accompanied by laboratory‐based testing for HIV and sexually transmitted infections (STIs). Bivariate and multivariable Poisson regression models were used to estimate prevalence ratios between socio‐demographic and behavioural characteristics and HIV status.
Results
HIV prevalence was 41.5% (95% CI: 33.9−49.4%), recent syphilis acquisition 19.4% (95% CI: 12.7−28.4), chlamydia 6.3% (95% CI: 3.1−11.1) and gonorrhoea 12.3% (95% CI: 7.9−18.7). Almost half (47.9%) reported condomless anal sex in the past 6 months, 50.7% reported sex work in the past 30 days and 13.7% reported accepting more money for condomless sex. There were no significant differences in reported sexual behaviours by HIV status. Only 60.8% of participants reported ever having been tested for HIV, and 25.6% reported a past 6‐month STI test. More than two‐thirds (67.8%) had not heard of antiretroviral pre‐exposure prophylaxis (PrEP) and only 4.7% had taken PrEP in the past month. Current moderate‐to‐severe psychological distress was endorsed by 20.3%, 10.0% reported attempting suicide in the past 6 months and 85.4% reported alcohol misuse.
Conclusions
Findings show that the HIV epidemic for YTW in Lima, Peru is situated in the context of widespread social exclusion, including economic vulnerabilities, violence victimization and the mental health sequelae of transphobic stigma that starts early in life. Future research should aim to further understand the intersection of these vulnerabilities. Moreover, there is an urgent necessity to design and evaluate HIV prevention programmes that address the root systems driving HIV vulnerabilities in YTW and that focus on developmentally specific clusters of stigma‐related conditions.
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FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Introduction
Although pre‐exposure prophylaxis (PrEP) is a remarkable biomedical advance to prevent HIV, ongoing research on PrEP contributes to and interacts with a legacy of HIV experimentation on ...marginalized communities in resource‐limited settings. This paper explores the complexity of PrEP research mistrust among Peruvian transgender (trans) women who completed a PrEP adherence intervention and those who refused participation (i.e. declined to enrol, voluntarily withdrew, and/or were lost to follow‐up).
Methods
Data were derived from 86 trans women (mean age 29 years) participants in the formative (four focus groups (n = 32), 20 interviews) and the evaluation stages (34 interviews) of a social network‐based PrEP intervention for trans women in Lima, Peru. The formative stage took place from May to July 2015, while the evaluative stage took place from April to May 2018. Audio files were transcribed verbatim and analysed via an immersion crystallization approach using Dedoose (v.6.1.18).
Results
Three paradoxes of trans women’s participation in PrEP science as a “key” population emerged as amplifying mistrust: (1) increases in PrEP research targeting trans women but limited perceived improvements in HIV outcomes; (2) routine dismissal by research physicians and staff of PrEP‐related side effects and the social realities of taking PrEP, resulting in questions about who PrEP research is really for and (3) persistent limitations on PrEP access for trans women despite increasing involvement in clinical trials, fostering feelings of being a “guinea pig” to advance PrEP science.
Conclusions
Findings highlight the wisdom inherent in PrEP mistrust as a reflection of trans women’s experiences that underscore the broken bonds of trust between communities, researchers and the research enterprise. PrEP mistrust is amplified through perceived paradoxes that suggest to trans women that they are key experimental participants but not target PrEP users outside of research settings. Findings highlight the urgent need to reframe mistrust not as a characteristic of trans women to be addressed through education and outreach, but as a systemic institutional‐ and industry‐level problem replicated, manifested and ultimately to be corrected, through global HIV science.
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FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Summary Worldwide, transgender women who engage in sex work have a disproportionate risk for HIV compared with natal male and female sex workers. We reviewed recent epidemiological research on HIV in ...transgender women and show that transgender women sex workers (TSW) face unique structural, interpersonal, and individual vulnerabilities that contribute to risk for HIV. Only six studies of evidence-based prevention interventions were identified, none of which focused exclusively on TSW. We developed a deterministic model based on findings related to HIV risks and interventions. The model examines HIV prevention approaches in TSW in two settings (Lima, Peru and San Francisco, CA, USA) to identify which interventions would probably achieve the UN goal of 50% reduction in HIV incidence in 10 years. A combination of interventions that achieves small changes in behaviour and low coverage of biomedical interventions was promising in both settings, suggesting that the expansion of prevention services in TSW would be highly effective. However, this expansion needs appropriate sustainable interventions to tackle the upstream drivers of HIV risk and successfully reach this population. Case studies of six countries show context-specific issues that should inform development and implementation of key interventions across heterogeneous settings. We summarise the evidence and knowledge gaps that affect the HIV epidemic in TSW, and propose a research agenda to improve HIV services and policies for this population.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
The health of transgender men (trans men)-individuals who identify as men and were assigned a female sex assigned at birth-is overlooked globally. This mixed-methods exploratory study sought to ...understand the lived experiences, health, and social needs of trans men in Lima, Peru to bring visibility to specific health needs and inform responsive and holistic public health efforts.
Between July 2016-January 2017, 46 trans men in Lima, Peru participated in a mixed-methods study. Four focus group discussions were conducted, complemented with 10 one-on-one interviews to explore in-depth issues that arose in groups. Two individuals participated in both a focus group and an interview. All participants completed a brief survey assessing sociodemographic characteristics and experiences with healthcare, mental health, and stigma. Audio files were transcribed verbatim and analyzed using an immersion crystallization approach to identify themes.
Participants had a mean age of 24 years (range 18-48). Trans men reported a lack of awareness and information among medical providers, avoidance of healthcare due to discrimination and maltreatment, an absence of public services for medical gender affirmation (hormones, surgeries), and unmet mental health needs. Trans men described health as multidimensional and influenced by social, economic, and legal contexts including family, school, employment and work, legal identity recognition, discrimination in public spaces, and peer support. Violence, stigma, and intersecting forms of oppression were described as limiting social and legal recognition of trans identity a central dimension of health. Peer support, often in an online environment, was described as important to resistance and well-being.
Findings demonstrate that the physical and mental health of trans men, as well as unmet needs for healthcare services, are influenced by a complex set of social, economic, and legal challenges due to the social exclusion of trans people in Peruvian society. Results are a call to action for stakeholders in Peru to guarantee the rights, health, and wellbeing of this community.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Legal gender affirmation - legal name and gender marker change - is an important health-promoting health determinant for transgender people. In Peru, the state's failure to universally recognize ...transgender people's legal identity limits standardized legal affirmation procedures, including the paucity of government officials trained in gender affirmation strategies. This project, in partnership with Registro Nacional de Identificación y Estado Civil (RENIEC) and transgender communities, designed and piloted a group-based intervention to sensitize government officers to the importance of gender-concordant identity documents. Between August 2017 and February 2018, three in-person group intervention sessions were held (each 3-4 hours) with 51 government officers. Guided by Gender Affirmation and Structural Violence Frameworks, the intervention utilized Adult Learning Theory and applied storytelling and testimonials as pedagogy. Pre-/post-test surveys were administered (19 true/false items, summed to create an index score measuring knowledge and attitudes toward transgender people). Within-person changes in pre-/post-intervention scores were evaluated using paired t-tests. Pre-/post-test data were available for 41 participants. After the intervention, there were improvements in knowledge and more favorable attitudes toward transgender people (pre-test mean = 14.09, SD = 2.33 vs. post-test mean = 15.62, SD = 1.82; difference = 1.53, 95% CL = 0.60, 2.67; t-test = 3.30 df = 46; p = 0.002). The intervention was feasible to conduct and garnered high acceptability. The results suggest the promise of this brief intervention for future research and testing before potential later implementation and scale-up to increase the capacity of government officers to address legal gender affirmation for transgender people in Peru.Legal gender affirmation - legal name and gender marker change - is an important health-promoting health determinant for transgender people. In Peru, the state's failure to universally recognize transgender people's legal identity limits standardized legal affirmation procedures, including the paucity of government officials trained in gender affirmation strategies. This project, in partnership with Registro Nacional de Identificación y Estado Civil (RENIEC) and transgender communities, designed and piloted a group-based intervention to sensitize government officers to the importance of gender-concordant identity documents. Between August 2017 and February 2018, three in-person group intervention sessions were held (each 3-4 hours) with 51 government officers. Guided by Gender Affirmation and Structural Violence Frameworks, the intervention utilized Adult Learning Theory and applied storytelling and testimonials as pedagogy. Pre-/post-test surveys were administered (19 true/false items, summed to create an index score measuring knowledge and attitudes toward transgender people). Within-person changes in pre-/post-intervention scores were evaluated using paired t-tests. Pre-/post-test data were available for 41 participants. After the intervention, there were improvements in knowledge and more favorable attitudes toward transgender people (pre-test mean = 14.09, SD = 2.33 vs. post-test mean = 15.62, SD = 1.82; difference = 1.53, 95% CL = 0.60, 2.67; t-test = 3.30 df = 46; p = 0.002). The intervention was feasible to conduct and garnered high acceptability. The results suggest the promise of this brief intervention for future research and testing before potential later implementation and scale-up to increase the capacity of government officers to address legal gender affirmation for transgender people in Peru.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Human Papilloma Virus (HPV) infection is the most common sexually transmitted viral infection worldwide. HPV is highly prevalent in sexually active men who have sex with men (MSM) and has been ...associated with anal cancer, penile cancer, and oropharyngeal cancer.
From March to September 2011, we conducted a cross-sectional study of HPV prevalence among MSM above age 18 years. Participants were recruited using respondent driven sampling at Clinica Cayetano Heredia. All participants provided anal, genital, and oral samples for HPV DNA testing, and blood for HIV and HPV antibody testing.
A total of 200 MSM were recruited in the study. The mean age was 34 years (range 18-59 years, SD = 9.4) and101 participants were HIV negative (99 HIV positive). HPV 6/11/16/18 or quadrivalent HPV vaccine (HPV4) genotype seroprevalence among HIV negative and positive MSM was 64.3% (55%-75.9%) and 93.8% (87.6%-99.2%) respectively (p<0.001). HIV positivity was associated with a higher prevalence of HPV4 and HPV 16/18 DNA at external genital sites and the anal canal. HPV4 DNA prevalence at external genital sites among HIV negative and positive MSM was 14.9% and 28.7% (p = 0.02) respectively, at anal canal was 50.9% and 79.0% (p = 0.001), and at the oral cavity was 9.9% and 8.5% (p = 0.6).
HPV4 seroprevalence was high in our study among both HIV positives and negatives, with HPV DNA prevalence much lower, and the anal canal being the anatomical site with the highest HPV DNA prevalence. HPV prevention interventions are needed among MSM at high-risk for HIV infection.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Migration is recognized as a key determinant of health. Yet, limited research addresses the arc of intranational migration and, even less, the experiences of transgender (trans) adolescents and women ...migrants and the associated health vulnerabilities. Using intersectional stigma as a theoretical frame, this study seeks to better understand the sexual health vulnerabilities and needs of trans women migrants in Peru.
Between October and November 2016, in-depth interviews (n = 14) and two focus groups (n = 20) were conducted in Spanish with trans women in three Peruvian cities. To explore pre- and during migration experiences, focus groups were conducted in Pucallpa and Iquitos, key cities in the Amazon where trajectories often originate. To assess during migration and post-migration experiences, we conducted interviews in Pucallpa, Iquitos, and Lima to better understand processes of relocation. Audio files were transcribed verbatim and analysed via an immersion crystallization approach, an inductive and iterative process, using Dedoose (v.6.1.18).
Participants described migration as an arc and, thus, results are presented in three phases: pre-migration; during migration; and post-migration. Intersectional stigma was identified as a transversal theme throughout the three stages of migration. The pre-migration stage was characterized by poverty, transphobia, and violence frequently motivating the decision to migrate to a larger city. Exploitation was also described as pervasive during migration and in relocation. Many participants spoke of their introduction to sex work during migration, as key to economic earning and associated violence (police, clients).
Findings advance understandings of intranational migration and forced displacement as key determinants of trans women's health. Dimensions of violence at the intersection of classism and cisgenderism render trans women highly vulnerable at every step of their migratory journeys. Experiences of intranational mobility and relocation were described as uniquely tied to age, intersectional transphobic stigma, engagement in sex work, and multiple forms of violence, which impact and can magnify sexual health vulnerabilities for transgender women in Peru who migrated intranationally.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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