Examining the Interplay Between Preexposure Prophylaxis (PrEP) and Gender-Related Stigmas as Barriers for PrEP Uptake Among Transgender Women in Tijuana, Mexico: A Mixed-Methods Study.

HIV prevalence among transgender women (TW) in Tijuana, Mexico is estimated at 22%. Pre-exposure prophylaxis (PrEP) reduces the risk of HIV acquisition by > 90%, though uptake in Tijuana has been low due to limited availability. The interplay between PrEP and gender stigmas may also serve as a barrier to PrEP uptake among TW in Tijuana. Experiences of gender- and PrEP- stigmas were assessed quantitatively (Quan) among 110 HIV-negative TW and qualitatively (Qual) among 17 TW through semi-structured interviews guide by the Health Stigma and Discrimination Framework. Qual findings were triangulated with Quant data to identify factors that may support gender affirmation and reduce PrEP stigma in an explanatory sequential Quan → Qual fashion. Most participants were < 40 years of age (80%), while approximately half had at least a high school education (48.2%) and were accessing gender-affirming hormone therapy (56.4%). Mean expectations of gender stigma were greatest for endorsing negative future expectations from others (M = 17.69; possible range 0-36). PrEP stigma was prominent among those who associated negative stereotypes with PrEP users, such as poor judgment (M = 45.91; possible range 14-70) and high personal risk attributes (M = 28.61; possible range 12-60). While PrEP knowledge was low among the qualitative sample, participants identified gender-, PrEP-, and intersectional- stigmas as potential barriers to PrEP uptake. Participants suggested that resilience strategies used to combat gender stigma could also mitigate PrEP stigma. Enhancing resilience skills at the intersection of gender and PrEP stigma may reduce these barriers, facilitating greater PrEP uptake as it becomes more available in Mexico.

Social, economic, and physical side effects impact PrEP uptake and persistence among transgender women in Peru.

INTRODUCTION: Oral pre-exposure prophylaxis (PrEP) for HIV-1 infection is over 99% effective in protecting against HIV acquisition when used consistently and appropriately. However, PrEP uptake and persistent use remains suboptimal, with a substantial gap in utilization among key populations who could most benefit from PrEP. In Latin America specifically, there is poor understanding of barriers to PrEP uptake and persistence among transgender (trans) women. METHODS: In April-May 2018, we conducted qualitative interviews lasting 25-45 min as part of an end-of-project evaluation of TransPrEP, a pilot RCT that examined the impact of a social network-based peer support intervention on PrEP adherence among trans women in Lima, Peru. Participants in the qualitative evaluation, all adult trans women, included individuals who either (1) screened eligible to participate in the TransPrEP pilot, but opted not to enroll (n = 8), (2) enrolled, but later withdrew (n = 6), (3) were still actively enrolled at the time of interview and/or successfully completed the study (n = 16), or (4) were study staff (n = 4). Interviews were audio recorded and transcribed verbatim. Codebook development followed an immersion/crystallization approach, and coding was completed using Dedoose. RESULTS: Evaluation participants had a mean age of 28.2 years (range 19-47). When describing experiences taking PrEP, participant narratives highlighted side effects that spanned three domains: physical side effects, such as prolonged symptoms of gastrointestinal distress or somnolence; economic challenges, including lost income due to inability to work; and social concerns, including interpersonal conflicts due to HIV-related stigma. Participants described PrEP use within a broader context of social and economic marginalization, with a focus on daily survival, and how PrEP side effects negatively contributed to these stressors. Persistence was, in some cases, supported through the intervention's educational workshops. CONCLUSION: This research highlights the ways that physical, economic, and social side effects of PrEP can impact acceptability and persistence among trans women in Peru, amplifying and layering onto existing stressors including economic precarity. Understanding the unique experiences of trans women taking PrEP is crucial to informing tailored interventions to improve uptake and persistence.

HIV vulnerabilities and psychosocial health among young transgender women in Lima, Peru: results from a bio-behavioural survey.

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.

Social reintegration of cisgender and transgender women post-incarceration in Brazil: policies and challenges.

BACKGROUND: Social reintegration relies on the support given to prisoners not only during their reentry into society but also throughout their imprisonment. Our goal was to analyze the expectations reported by cisgender and transgender women returning to society and of the justice and social welfare professionals from the Brazilian prison system. METHODS: A qualitative analysis using saturation sampling was conducted. The participants were selected through a non-probabilistic sampling technique. Data was collected through semi-structured interviews with professionals involved in the management of the prison system and female former inmates. Interviews were transcribed and analyzed using an open and focused coding process. Textual data was stored, organized, and coded using Atlas software according to emerging themes. RESULTS: The study involved 15 professionals and 13 female former inmates, five of them identified as transgender women. Among the professionals, the age range went from 38 to 65 years old; they reported a work history in their respective fields, from 10 to 35 years, with an equal distribution across genders. As for the female former inmates, their ages ranged from 24 to 42 years old, and the most reported crime was drug trafficking. Their incarceration time varied from 1 to 8 years. Female inmates were vulnerable to abuse and violence, including physical, sexual, and emotional violence. Women in situations of prior vulnerability faced additional challenges during their sentences. Transgender women were even more neglected and discriminated against by the system. Despite the professionals being aware and concerned about vulnerabilities and the need to improve the reintegration process, in general, they were not sensitive to the gender perspective. There were no specific policies able to support social integration for this public. CONCLUSIONS: Data showed multifaceted challenges faced by female former inmates within the Brazilian prison system, highlighting the insufficient policies for both cisgender and transgender women. Additionally, the results revealed a lack of sensitivity among professionals regarding gender issues and their particularities in the prison system and social reintegration. These findings emphasize the need for a more comprehensive and intersectional approach that addresses the diverse socio-economic backgrounds of these individuals.

Influence of Stigma on Engagement in HIV Care and Adherence to Antiretroviral Therapy in Specialized HIV Clinics Targeting Men Who Have Sex with Men and Transgender Women in Lima, Peru.

HIV stigma is a social determinant of health that can influence multiple health outcomes, including adherence to antiretroviral therapy (ART), engagement in HIV care, and viral suppression levels in people with HIV (PWH). In Peru, where the HIV epidemic is concentrated in men who have sex with men (MSM) and transgender women (TGW), stigma may play an important role in healthcare engagement. To understand the relationship between stigma and two outcome variables, ART adherence and engagement in HIV care in 400 MSM and TGW, we assessed factors from the Behavioral Model for Vulnerable Populations at two HIV clinics that tailor services for sexual and gender minorities. While some predisposing, need, and enabling resource factors were associated with optimal (≥ 90%) ART adherence or engagement in HIV care, none of the stigma subscales were correlated, suggesting that when LGBTQ-affirming care is provided to MSM/TGW, stigma may not influence HIV-related outcomes.

RESUMEN: El estigma hacia el VIH es un determinante social de la salud que puede influir en múltiples desenlaces, incluyendo la adherencia a la terapia antirretroviral (TAR), el compromiso con la atención del VIH y los niveles de supresión viral en personas viviendo con VIH (PVV). En el Perú, donde la epidemia del VIH se concentra en hombres que tienen sexo con hombres (HSH) y mujeres transgénero (MT), el estigma puede desempeñar un papel importante en el compromiso con la atención médica. Para comprender la relación entre el estigma y dos variables de resultado, la adherencia al TAR y el compromiso con la atención del VIH en 400 HSH y MT, evaluamos factores del Modelo de Comportamiento para Poblaciones Vulnerables en dos clínicas de VIH que adaptan sus servicios para minorías sexuales y de género. Si bien algunos factores predisponentes, de necesidad y de recursos habilitantes se asociaron con una adherencia óptima (≥ 90%) al TAR o al compromiso con la atención del VIH, ninguna de las sub-escalas de estigma estuvieron correlacionadas, sugiriendo que cuando se brinda atención que afirma a la comunidad LGBTQ a HSH/MT, el estigma puede no influir en los desenlaces relacionados con el VIH.

HPTN 083-02: factors influencing adherence to injectable PrEP and retention in an injectable PrEP study.

INTRODUCTION: HPTN 083 demonstrated the superiority of long-acting cabotegravir (CAB-LA) versus daily oral emtricitabine/tenofovir disoproxil fumarate (TDF/FTC) as pre-exposure prophylaxis (PrEP) among cisgender men and transgender women who have sex with men (MSM/TGW). HPTN 083 provided the first opportunity to understand experiences with injectable PrEP in a clinical trial. METHODS: Participants from two US sites (Chicago, IL and Atlanta, GA) and one international site (Rio de Janeiro, Brazil) were purposively sampled for individual qualitative interviews (N = 40), between November 2019 and March 2020, to explore trial experiences, barriers to adherence and other factors that may have impacted study implementation or outcomes. The blinded phase ended early due to efficacy; this analysis includes interviews conducted prior to unblinding with three groups defined by adherence (i.e. injection visit attendance): adherent (n = 27), non-adherent (n = 12) and early discontinuers (n = 1). Data were organized using NVivo software and analysed using content analysis. RESULTS: Participants (mean age: 27) were primarily cisgender MSM (90%) and Black/African American (60%). Reasons for trial enrolment and PrEP use included a preference for using HIV prevention medication versus treatment in the event of HIV acquisition; the ability to enhance health via study-related education and services; access to a novel, convenient HIV prevention product at no cost; and contributing to MSM/TGW communities through research. Participants contrasted positive experiences with study staff with their routine clinical care, and emphasized increased scheduling flexibility, thorough communication, non-judgemental counselling and open, affirming environments (e.g. compassion, less stigma) as adherence facilitators. Injection experiences were positive overall; some described early injection-related anxiety, which abated with time and when given some measure of control (e.g. pre-injection countdown), and minimal injection site discomfort. Some concerns and misperceptions about injectable PrEP were reported. Barriers to adherence, across all adherence categories, included structural factors (e.g. financial constraints, travel) and competing demands (e.g. work schedules). CONCLUSIONS: Respondents viewed injectable PrEP trial participation as a positive experience and a means of enhancing wellbeing. Study site flexibility and affirming clinic environments, inclusive of non-judgemental counselling, were key facilitators of adherence. To support injection persistence, interventions that address structural barriers and promote flexible means of injection delivery may be most effective.

HIV Risk Behaviors and the Use of Geosocial Networking Dating Apps among Men Who have Sex with Men and Transgender Women in Lima, Peru: a Cross-Sectional Study.

Geosocial networking dating apps (GSN apps) are an increasingly widespread technology used by populations throughout the world to facilitate sexual encounters. Studies from a variety of settings suggest a possible association between GSN app use and HIV risk behaviors, including among sexual and gender minority populations such as men who have sex with men (MSM) and transgender women (TW). However, it remains unclear to what extent GSN apps play a causal role. We explored the relationship between GSN app use and sexual risk behaviors among MSM and TW in Lima, Peru by analyzing data from a multi-site cross-sectional survey assessing both general and partner-specific sexual behaviors. We performed bivariate analysis to estimate the association of GSN app use with different individual and partner-specific factors, then fit multivariable regression models adjusting for age and education. Among 741 total participants (698 MSM, 43 TW), 64% met at least one sex partner in the prior three months using a GSN app. GSN app users were significantly more likely to report engaging in HIV risk behaviors in general, including condomless receptive anal sex, group sex, transactional sex, and sex under the influence of alcohol or drugs. Having condomless anal sex with a given partner was not associated with meeting that partner via GSN app. These findings highlight GSN app users as a particularly vulnerable subpopulation among MSM and TW in Lima. GSN apps could provide a useful vehicle for targeted HIV prevention efforts for priority populations in Peru.

RESUMEN: Las aplicaciones de citas de redes geosociales (aplicaciones GSN) son una tecnología con creciente alcance en todo el mundo usadas para facilitar encuentros sexuales. Diferentes estudios sugieren una posible relación entre uso de aplicaciones GSN y comportamientos de riesgo para VIH entre hombres que tienen sexo con hombres (HSH) y mujeres transgénero (MT). No es claro hasta qué punto aplicaciones GSN tendrían un papel causal directo. Exploramos la relación entre uso de aplicaciones GSN y comportamientos sexuales de riesgo entre HSH y MT en Lima, Perú, analizando datos de una encuesta transversal que evaluó comportamientos sexuales en general y en parejas específicas. Realizamos análisis bivariable para estimar la asociación del uso de aplicaciones GSN con diferentes factores individuales y específicos de la pareja. También aplicamos modelos de regresión multivariables ajustados por edad y educación. Entre 741 participantes totales (698 HSH, 43 MT), 64% conoció al menos a una pareja sexual en los últimos tres meses mediante una aplicación GSN. Los usuarios de aplicaciones GSN fueron significativamente más propensos a reportar comportamientos de riesgo de VIH en general, incluyendo sexo anal receptivo sin condón, y sexo grupal, transaccional y bajo influencia de alcohol o drogas. Tener sexo anal sin condón con una pareja determinada no se asoció con conocer a esa pareja mediante aplicación GSN. Estos hallazgos muestran a usuarios de aplicaciones GSN como una subpoblación particularmente vulnerable entre HSH y MT en Lima. Aplicaciones GSN podrían ser útiles para iniciativas de prevención del VIH en poblaciones prioritarias en Perú.

Gender affirming hormone therapy and transgender women fertility: Histologic predictors of germ cell presence.

Objective: Evaluate histological changes in testicular parameters after hormone treatment in transgender women. Methods: Cross-section study with patients who underwent gonadectomy at Hospital de Clínicas de Porto Alegre from 2011 to 2019. Hormone treatment type, route of administration, age at initiation and duration were recorded. Atrophy parameters were observed: testicular volume, tubular diameter, basal membrane length, presence of spermatogonia and spermatids (diploid and haploid spermatozoid precursors). Results: Eighty-six patients were included. Duration of hormone treatment is associated with testicular atrophy and spermatogenesis arrest. Other characteristics of hormone treatment such as age of initiation, route of administration and type of treatment were not associated with testicular histological changes. Testicular volume may predict spermatogenesis arrest. Basal membrane length and tubular diameter ratio is an interesting predictor of germ cell presence. Conclusion: Cross-sex hormone treatment affects testicular germ cell presence. Basal membrane length and tubular diameter ratio reduces inter variability of measurements and better exemplify how atrophic seminiferous tubules are. Fertility preservation should be addressed by healthcare providers in order to recognize gender affirming treatment impact on transgender health.

A Contextualization of Transgender Women and Condom Use Using the HIV Syndemic Framework: Scoping Review.

Objective: To contextualize condom use in the transgender women population utilizing the HIV syndemic framework. Methods: Studies reporting condom use frequency and syndemic factors associated with HIV risk in transgender women were systematically searched. We followed the Scoping Reviews (PRISMA-ScR) checklist. Results: Social factors have a proven relationship with using condoms and HIV among transgender women. Syndemic factors, defined as co-occurring adverse factors that interact to contribute to risk behaviors, deserve a specific analysis to develop strategies to face HIV among transgender women. Conclusions: A syndemic perspective allows to generate specific health intervention and prevention policies to protect transgender women.

Acceptability of venue-based HIV testing and prevention interventions for men who have sex with transgender women and transgender women in Lima, Perú: a formative, qualitative study.

BACKGROUND: Despite being at elevated risk for HIV, men who have sex with transgender women (MSTW) are an overlooked population in the global HIV response. Venue-based HIV interventions have previously had success reaching other HIV priority populations, including transgender women (TW). Similar approaches could be applied for MSTW. OBJECTIVE: To evaluate the prospective acceptability of venue-based HIV testing and prevention interventions for MSTW and TW in Lima, Peru. METHODS: In this exploratory qualitative study, we conducted in-depth interviews (IDI) and focus group discussions (FGD) with three types of participants: MSTW (7 IDIs, 1 FGD), TW (1 FGD), and owners of social venues frequented by MSTW/TW in Lima (2 IDIs). We elicited participants' attitudes and perceptions related to the following four hypothetical interventions delivered at social venues in Lima: rapid HIV testing; HIV self-test distribution; condom/lubricant distribution; and enrolment in a mobile app supporting HIV prevention. We performed a mixed deductive-inductive thematic analysis using the framework method, then applied the Theoretical Framework of Acceptability to classify the overall acceptability of each intervention. RESULTS: Condom/lubricant distribution and app-based HIV prevention information were highly acceptable among all participant types. The two HIV testing interventions had relatively lower acceptability; however, participants suggested this could be overcome if such interventions focused on ensuring discretion, providing access to healthcare professionals, and offering appropriate incentives. CONCLUSIONS: Overall, MSTW and TW shared similar favourable attitudes towards venue-based HIV interventions. Venue-based outreach warrants further exploration as a strategy for engaging MSTW and TW in HIV prevention activities.

Association between in-country migration and HIV infection among transgender women from northeastern Brazil: a respondent-driven sampling survey.

BACKGROUND: Migration is common among transgender women (TGW), often driven by the desire to escape stigma, find acceptance, establish new connections, access body modifications, or enter new avenues of sex work. Given the heightened mobility of TGW, they are mostly vulnerable to human immunodeficiency virus (HIV) due to migration. This study aimed to evaluate the association between in-country migration and HIV infection among TGW in Northeast Brazil. METHODS: The DIVAS was a cross-sectional, multicity study investigating risk behaviors and sexually transmitted infections (STI) among TGW in 2016-2017. A total of 864 TGW were recruited through respondent-driven sampling from three capital cities in Northeast Brazil. Logistic regression estimating odds ratios (OR) and 95% confidence intervals (CI) was used to assess the relationship between in-country migration and HIV infection. RESULTS: The prevalence of HIV among TGW was 24.5%, 21.4% among those aged 18-34 and 36.1% among those ≥ 35 years old. In-country migration increased the odds of HIV infection among TGW aged 18-34 years (OR = 1.84; 95%CI:1.04-3.27) and even higher among those aged ≥ 35y old (OR = 3.08; 95%CI:1.18-8.04). CONCLUSIONS: These data reinforce the pressing need for public health policies that provide comprehensive access and strategies for demand creation for HIV/AIDS prevention and care for TGW who are already highly vulnerable to infection.

Alarming patterns of moderate and high-risk alcohol use among transgender women in Goiás, Central Brazil.

Background: Scant studies have examined alcohol consumption among transgender women in Latin America. This cross-sectional study estimated the prevalence and associated factors of risky alcohol use among transgender women in Goiás, a state located in the center of Brazil. Methods: Participants were 440 transgender women (median age = 35 years, interquartile range = 9) recruited through respondent-driven sampling. All participants were interviewed about sociodemographic characteristics, violence, and risk behavior. Alcohol use was assessed using the alcohol use disorders identification test (AUDIT). An AUDIT score greater than or equal to eight was considered as risky alcohol consumption. Logistic regression analysis was used to examine predictors of risky alcohol use, and p-values <0.05 were considered significant. Results: The majority were young, single, sex workers. Most transgender women had used alcohol in the previous year (85.7%), and more than half (56.6%) reported binge drinking and risky alcohol consumption (60.2%). There was a high overlap between sexual behavior, drugs, and alcohol use. Using alcohol during sex (adjusted odds ratio [aOR]: 2.9; 95% confidence interval [CI]: 1.7-4.8), cocaine/crack use (aOR: 2.3; 95% CI: 1.5-3.7) and having a drug user as a sexual partner (aOR: 2.9; 95% CI: 1.5-5.9) were independently associated with risky alcohol consumption. Conclusion: Alcohol consumption was highly prevalent, and drugs seem to play an important role in risky alcohol consumption among transgender women Goiás. These findings support stakeholders to promote intervention strategies to reduce this pattern of alcohol consumption and reduce the burden of substance use disorders among transgender women.

Anticipated Stigma and Social Barriers to Communication Between Transgender Women Newly Diagnosed with HIV and Health Care Providers: A Mediation Analysis.

Purpose: We assessed whether anticipated stigma (i.e., fear of public mistreatment due to gender identity) impacts communication between transgender women (TGW) living with HIV and health care providers. Methods: This is a secondary analysis of baseline data from Trans Amigas, a study conducted in Brazil, 2018. The study population consisted of TGW living with HIV, older than 18 years, residing in the São Paulo metropolitan area. We used multivariable logistic regression (α = 0.05), mediation, and bootstrapping for the analysis. Results: One hundred and thirteen participants completed the study. Fear of public mistreatment had an adjusted odds ratio (aOR) of 7.42 (p = 0.003) for difficulty reporting new symptoms to providers. Concerning fear of public mistreatment, we found that unemployment had an aOR of 3.62 (p = 0.036); sex work, an aOR of 2.95 (p = 0.041); and issues related to name change in documents, an aOR of 2.71 (p = 0.033). For the indirect effect on difficulty reporting new symptoms, mediated by fear of public mistreatment, unemployment had an aOR of 1.52 (confidence interval [CI] = 0.88-2.24); sex work, an aOR of 1.48 (CI = 0.81-2.52); and name change issues, an aOR of 1.47 (CI = 0.96-2.43). Conclusions: Anticipated stigma was associated with communication difficulties between TGW living with HIV and providers. Our data suggest that structural factors associated with anticipated stigma could indirectly impact on difficulty reporting new symptoms. These findings indicate the importance of considering social contexts that intersect with individual experiences when analyzing communication barriers between providers and patients, and the need to strengthen social policies for TGW in Brazil. Clinical Trial Registration number: R34MH112177.

Bodies of desire: use of nonprescribed hormones among transgender women and travestis in five brazilian capitals (2019–2021) / Corpos do desejo: uso de hormônios sem prescrição médica entre mulheres trans e travestis em cinco capitais brasileiras (2019–2021)

Objective: To analyze the experiences of transgender women and travestis regarding the use of hormones for body changes without a medical prescription. Methods: This is a cross-sectional, quantitative and qualitative study, using data from “TransOdara”, which estimated the prevalence of Sexually Transmitted Infections in transgender women and travestis recruited through Respondent-Driven Sampling, between December 2019 and July 2021, in São Paulo, Campo Grande, Manaus, Porto Alegre, and Salvador, Brazil. The main outcome was: use of hormones without medical prescription and associated risk factors. Descriptive analysis, mixed univariate logistic regression models, and semi-structured interviews were carried out. Results: Of the 1,317 recruited participants, 85.9% had already used hormones. The current use of hormones was reported by 40.7% (536) of them. Of those who were able to inform the place where they obtained them, 72.6% (381/525) used them without a medical prescription. The variables associated with the outcome were: current full-time sex work (OR 4.59; 95%CI 1.90–11.06) or in the past (OR 1.92; 95%CI 1.10–3.34), not having changed their name (OR 3.59; 95%CI 2.23–5.76), not currently studying (OR 1.83; 95%CI 1.07–3.13), being younger (OR 2.16; 95%CI 1.31–3.56), and having suffered discrimination at some point in life for being a transgender women and travestis (OR 0.40; 95%CI 0.20–0.81). Conclusion: The use of nonprescribed hormones is high among transgender women and travestis, especially among those who are younger, did not study, have not changed their name, and with a history of sex work. This use is related to the urgency for gender transition, with excessive use and damage to health.

Objetivo: Analisar experiências de mulheres trans e travestis com o uso de hormônios para mudança corporal sem prescrição médica. Métodos: Estudo de corte transversal, quantitativo e qualitativo, utilizando um recorte do TransOdara, que estimou prevalência de Infecções Sexualmente Transmissíveis em mulheres trans e travestis, recrutadas por meio de Respondent-Driven Sampling, entre dezembro de 2019 e julho de 2021, em São Paulo, Campo Grande, Manaus, Porto Alegre e Salvador. Principal desfecho: uso de hormônios sem prescrição médica e fatores associados. Foram realizados análise descritiva e modelos de regressão logísticos univariados mistos e entrevistas semiestruturadas. Resultados: Das 1.317 participantes recrutadas, 85,9% já haviam usado hormônios. O uso atual de hormônios foi referido por 40,7% (536) delas. Das que souberam informar o local onde os conseguiram, 72,6% (381/525) faziam uso sem prescrição médica. As variáveis associadas ao uso sem prescrição foram: exercer trabalho sexual em tempo integral (OR 4,59; IC95% 1,90–11,06) ou no passado (OR 1,92; IC95% 1,10–3,34); não ter retificado o nome (OR 3,59; IC95% 2,23–5,76); não estar estudando (OR 1,83; IC95% 1,07–3,13); ser mais jovem (OR 2,16; IC95% 1,31–3,56); ter sofrido discriminação em algum momento na vida por ser mulheres trans e travestis (OR 0,40 – IC95% 0,20–0,81). Conclusão: O uso de hormônios não prescritos é alto entre mulheres trans e travestis, principalmente entre as mais jovens, as que não estudavam, as que não retificaram o nome e as com histórico de trabalho sexual. Está relacionado à urgência para a transição de gênero, com uso exagerado e danos à saúde.

Lifetime sexual violence among transgender women and travestis (TGW) in Brazil: Prevalence and associated factors / Violência sexual durante a vida em mulheres trans e travestis (MTT) no Brasil: Prevalência e fatores associados

ABSTRACT Objective To describe the prevalence, characteristics, and factors associated with sexual violence in transgender women and travestis (TGW) in Brazil. Methods This cross-sectional study was conducted in five Brazilian cities (Campo Grande, Manaus, Porto Alegre, Salvador, and São Paulo) between 2019 and 2021. Participants were recruited using the respondent-driven sampling (RDS) technique. The outcome of interest is the self-reported experience of sexual violence throughout the respondents' lifetime. We evaluated the actions taken by victims of sexual violence and how they dealt with the experience. Logistic regression analysis was employed to examine the associations between sociodemographic and behavioral factors (such as race, income, drug use, sex work, and access to healthcare) and the outcome. Results A total of 1,317 TGW were interviewed. Among them, 53% (n=698) reported experiencing sexual violence. For 64.4% (n=419) of the respondents, sexual violence occurred on more than one occasion. The majority of TGW did not seek health services (93.2%, n=648), disclose the violence (93.9%, n=653), nor seek support from family or friends (86.5%, n=601). A higher prevalence of sexual violence was associated with homelessness (adjusted prevalence ratio — aPR=1.69, 95% confidence interval — 95%CI 1.01-2.84), a history of engaging in sex work (aPR=2.04, 95%CI 1.46-2.85), self-reporting regular, bad, or very bad emotional health (aPR=1.67, 95%CI 1.28-2.19), and experiencing difficulties accessing health services in the previous year (aPR=2.78, 95%CI 1.74-4.43). Conclusion The high prevalence of sexual violence, analyzed together with the actions of the victims, indicates a context of high vulnerability and low institutional support. In this scenario, violence can be exacerbated, resulting in severe health consequences.

RESUMO Objetivo Descrever a prevalência, características e fatores associados à violência sexual em mulheres trans e travestis (MTT) no Brasil. Métodos Estudo transversal conduzido em cinco cidades brasileiras (Campo Grande, Manaus, Porto Alegre, Salvador e São Paulo) entre 2019 e 2021. As participantes foram recrutadas usando a técnica respondent-driven sampling (RDS). O desfecho é a experiência de violência sexual ao longo da vida. As ações tomadas pelas vítimas e como elas lidaram com a experiência foram avaliadas. Análise de regressão logística foi empregada para examinar as associações entre fatores sociodemográficos e comportamentais (como raça, renda, trabalho sexual e acesso aos serviços de saúde) e o desfecho. Resultados Um total de 1.317 MTT foram entrevistadas. Entre elas, 53% (n=698) relataram violência sexual. Para 64,4% (n=419) destas, a violência sexual ocorreu em mais de uma ocasião. A maioria das MTT não procurou serviços de saúde (93,2%, n=648), não denunciou (93,9%, n=653) nem buscou apoio de familiares ou amigos (86,5%, n=601). A maior prevalência de violência sexual foi associada à falta de moradia (razão de prevalência ajustada — RPa=1,69, IC 95% 1,01-2,84), histórico de envolvimento em trabalho sexual (RPa=2,04, IC 95% 1,46-2,85), relato de saúde emocional regular, ruim ou muito ruim (RPa=1,67, IC 95% 1,28-2,19) e experiência de dificuldades de acesso aos serviços de saúde (RPa=2,78, IC 95% 1,74-4,43). Conclusão A alta prevalência de violência sexual, analisada em conjunto com as ações das vítimas, indica um contexto de alta vulnerabilidade e baixo suporte institucional. Nesse cenário, a violência pode ser exacerbada, resultando em graves consequências para a saúde.

Multiple substance use and associated factors in transgender women and travestis: findings from the TransOdara Study, Brazil / Uso de múltiplas substâncias e fatores associados em mulheres trans e travestis: resultados do estudo TransOdara, Brasil

ABSTRACT Objective To estimate the prevalence of concomitant substance consumption and analyze associated risk factors in a non-probabilistic sample of the Brazilian population of transgender women and travestis. Methods A cross-sectional study was conducted with recruitment via respondent-driven sampling. The sample included transgender women and travestis residing in São Paulo, Porto Alegre, Salvador, Manaus, and Campo Grande, aged 18 years or older, between 2019 and 2021. The outcome was the concomitant use of licit and illicit substances. The association between sociodemographic/behavioral factors and the outcome was analyzed through Poisson regression with mixed effects. Adjusted prevalence ratios (confidence interval of 95% — 95%CI) were estimated. Results The prevalence in the last 12 months of multiple substance use was 49.3%, of which 65.5% were alcohol, 52.9% tobacco, and 40.1% marijuana. Transgender women and travestis who use multiple substances face more violence (1.71; 95%CI 1.14-2.55), unemployment (1.58; 95%CI 1.05-2.37) and pervasive unstable work status (1.52; 95%CI 1.08-2.14), transactional sex (1.51; 95%CI 1.21-1.88) which can be their sole option to make a living, and are aged 18 to 24 years (1.37; 95%CI 1.14-1.65). Conclusion The use of multiple substances may be an attempt to cope with distress and marginalization. Substance use has been associated with multiple harms and medical conditions. Comprehensive management and care should be provided, as defined by the key principles of the Brazilian Unified Health System. Health care should be integrated into structural interventions.

RESUMO Objetivo Estimar a prevalência do consumo concomitante de substâncias e analisar fatores de risco associados em uma amostra não probabilística da população brasileira de mulheres trans e travestis. Métodos Estudo transversal, com recrutamento por meio da metodologia respondent-driven sampling. A amostra incluiu mulheres trans e travestis residentes em São Paulo, Porto Alegre, Salvador, Manaus e Campo Grande, maiores de 18 anos, entre 2019 e 2021. O desfecho foi o uso concomitante de substâncias lícitas e ilícitas. A associação entre fatores sociodemográficos/comportamentais e o desfecho foi analisada com regressão de Poisson com efeitos mistos, estimando-se razões de prevalência ajustadas (intervalo de confiança de 95% - IC95%). Resultados A prevalência nos últimos 12 meses de uso de múltiplas substâncias foi de 49,3%, sendo 65,5% álcool, 52,9% tabaco e 40,1% maconha. Mulheres trans e travestis que usam múltiplas substâncias enfrentam mais violência (1,71; IC95% 1,14-2,55), desemprego (1,58; IC95% 1,05-2,37) e trabalho instável (1,52; IC95% 1,08-2,14), sexo transacional (1,51; IC95% 1,21-1,88), que pode ser a única opção de sustento, e têm de 18 a 24 anos (1,37; IC95% 1,14-1,65). Conclusão O uso de múltiplas substâncias pode ser uma tentativa de lidar com o sofrimento e a marginalização. O uso de substâncias tem sido associado a múltiplos danos e condições médicas. Uma gestão integral e cuidados abrangentes devem ser providenciados, conforme definido pelos princípios-chave do Sistema Único de Saúde do Brasil. Os cuidados de saúde devem ser integrados em intervenções estruturais.

Prevalence of syphilis in transgender women and travestis in Brazil: results from a national cross-sectional study / Prevalência de sífilis em mulheres trans e travestis no Brasil: resultados de um estudo multicêntrico nacional

ABSTRACT Objective: The study aimed to estimate the prevalence of acquired syphilis and associated factors in a national survey. Methods: TransOdara was a cross-sectional study comprising transgender women and travestis (TGW) in five major cities in Brazil during December of 2019 and July of 2021. The sample was recruited using the respondent-driven sampling (RDS) method. The outcome "active syphilis" was defined as a positive treponemal test and Venereal-Disease-Research-Laboratory (VDRL) title greater than∕ equal to ⅛. Sociodemographic variables were described. Bivariate and multiple logistic regression were performed, and odds ratios (OR) and 95% confidence intervals (95%CI) were estimated. All analyses were performed in R, 4.3.1. Results: A total of 1,317 TGW were recruited, with 1,291 being tested for syphilis, and 294 (22.8%) meeting the criteria for active syphilis. In bivariate analysis, black/mixed race (OR=1.41, 95%CI 1.01-1.97), basic level of education (OR=2.44, 95%CI 1.17-5.06), no name change in documents (OR=1.39, 95%CI 1.00-1.91) and sex work (past only OR= 2.22, 95%CI 1.47-3.32; partial OR=2.75, 95%CI 1.78-4.25; full time OR=3.62, 95%CI 2.36-5.53) were associated with active syphilis. In the multivariate analysis, sex work was the only associated factor, 2.07 (95%CI 1.37-3.13) past sex work, 2.59 (95%CI 1.66-4.05) part-time sex work and 3.16 (95%CI 2.04-4.92) sex work as the main source of income. Conclusion: The prevalence of active syphilis in this study was elevated compared with other countries in Latin America. Sex work was an important associated factor with active syphilis, highlighting the impact that this condition of vulnerability may have in the health of TGW, as members of a key, marginalized population.

RESUMO Objetivo: O estudo teve como objetivo estimar a prevalência de sífilis adquirida e fatores associados em uma pesquisa nacional. Métodos: "TransOdara" foi um estudo transversal compreendendo mulheres trans e travestis (MTT) em cinco grandes cidades do Brasil durante dezembro-2019 e julho-2021. A amostra foi recrutada usando o método respondente-driven sampling (RDS). O desfecho "sífilis ativa" foi definido como um teste treponêmico positivo e título do Venereal-Disease-Research-Laboratory (VDRL) maior ou igual a ⅛. Variáveis sociodemográficas foram descritas. Análises bi- e multivariadas foram realizadas, e odds ratio (OR) e IC95% foram estimados. Todas as análises foram realizadas no R,4.3.1. Resultados: Um total de 1.317 MTT foram recrutadas, com 1.291 sendo testadas para sífilis, das quais 294 (22,8%) preencheram os critérios para sífilis ativa. Na análise bivariada, raça negra/parda (OR=1,41; IC95% 1,01-1,97), nível básico de educação (OR=2,44; IC95% 1,17-5,06), não alteração do nome nos documentos (OR=1,39; IC95% 1,00-1,91) e trabalho sexual (pregresso OR=2,22; IC95% 1,47-3,32; parcial OR=2,75; IC95% 1,78-4,25; período integral OR=3,62; IC95%: 2,36-5,53) foram associados à sífilis ativa. Na análise multivariada, o trabalho sexual foi o único fator associado, 2,07 (IC95%: 1,37-3,13) trabalho sexual passado, 2,59 (IC95% 1,66-4,05) trabalho sexual em tempo parcial e 3,16 (IC95% 2,04-4,92) trabalho sexual como principal fonte de renda. Conclusão: A prevalência de sífilis ativa neste estudo foi elevada em comparação com outros países da América Latina. O trabalho sexual foi um fator associado importante com sífilis ativa, destacando o impacto que essa condição de vulnerabilidade pode ter na saúde das MTT, como membros de uma população-chave marginalizada.

Bodies of desire: use of nonprescribed hormones among transgender women and travestis in five Brazilian capitals (2019-2021) / Corpos do desejo: uso de hormônios sem prescrição médica entre mulheres trans e travestis em cinco capitais brasileiras (2019-2021)

ABSTRACT Objective: To analyze the experiences of transgender women and travestis regarding the use of hormones for body changes without a medical prescription. Methods: This is a cross-sectional, quantitative and qualitative study, using data from "TransOdara", which estimated the prevalence of Sexually Transmitted Infections in transgender women and travestis recruited through Respondent-Driven Sampling, between December 2019 and July 2021, in São Paulo, Campo Grande, Manaus, Porto Alegre, and Salvador, Brazil. The main outcome was: use of hormones without medical prescription and associated risk factors. Descriptive analysis, mixed univariate logistic regression models, and semi-structured interviews were carried out. Results: Of the 1,317 recruited participants, 85.9% had already used hormones. The current use of hormones was reported by 40.7% (536) of them. Of those who were able to inform the place where they obtained them, 72.6% (381/525) used them without a medical prescription. The variables associated with the outcome were: current full-time sex work (OR 4.59; 95%CI 1.90-11.06) or in the past (OR 1.92; 95%CI 1.10-3.34), not having changed their name (OR 3.59; 95%CI 2.23-5.76), not currently studying (OR 1.83; 95%CI 1.07-3.13), being younger (OR 2.16; 95%CI 1.31-3.56), and having suffered discrimination at some point in life for being a transgender women and travestis (OR 0.40; 95%CI 0.20-0.81). Conclusion: The use of nonprescribed hormones is high among transgender women and travestis, especially among those who are younger, did not study, have not changed their name, and with a history of sex work. This use is related to the urgency for gender transition, with excessive use and damage to health.

RESUMO Objective Analisar experiências de mulheres trans e travestis com o uso de hormônios para mudança corporal sem prescrição médica. Métodos: Estudo de corte transversal, quantitativo e qualitativo, utilizando um recorte do TransOdara, que estimou prevalência de Infecções Sexualmente Transmissíveis em mulheres trans e travestis, recrutadas por meio de Respondent-Driven Sampling, entre dezembro de 2019 e julho de 2021, em São Paulo, Campo Grande, Manaus, Porto Alegre e Salvador. Principal desfecho: uso de hormônios sem prescrição médica e fatores associados. Foram realizados análise descritiva e modelos de regressão logísticos univariados mistos e entrevistas semiestruturadas. Resultados: Das 1.317 participantes recrutadas, 85,9% já haviam usado hormônios. O uso atual de hormônios foi referido por 40,7% (536) delas. Das que souberam informar o local onde os conseguiram, 72,6% (381/525) faziam uso sem prescrição médica. As variáveis associadas ao uso sem prescrição foram: exercer trabalho sexual em tempo integral (OR 4,59; IC95% 1,90-11,06) ou no passado (OR 1,92; IC95% 1,10-3,34); não ter retificado o nome (OR 3,59; IC95% 2,23-5,76); não estar estudando (OR 1,83; IC95% 1,07-3,13); ser mais jovem (OR 2,16; IC95% 1,31-3,56); ter sofrido discriminação em algum momento na vida por ser mulheres trans e travestis (OR 0,40 - IC95% 0,20-0,81). Conclusão: O uso de hormônios não prescritos é alto entre mulheres trans e travestis, principalmente entre as mais jovens, as que não estudavam, as que não retificaram o nome e as com histórico de trabalho sexual. Está relacionado à urgência para a transição de gênero, com uso exagerado e danos à saúde.

Hepatitis A, B and C prevalence among transgender women and travestis in five Brazilian capitals between 2019-2021 / Prevalência das hepatites A, B e C entre mulheres trans e travestis em cinco capitais brasileiras entre 2019-2021

ABSTRACT Objective: To estimate the prevalence and factors associated with hepatitis A, B, and C in transgender women and travestis's networks, in 5 regions of Brazil. Methods: This cross-sectional study includedtransgender women and travestis in five Brazilian capitals (Campo Grande, Manaus, Porto Alegre, Salvador, and São Paulo), between December/2019 and July/2021. All samples were subjected to detection of serological markers of hepatitis virus A (HAV), B (HBV), and C (HCV) infections through rapid tests and chemiluminescent microparticle immunoassays. Positive samples in the screening tests were submitted to detect HBV DNA and HCV-RNA by real-time PCR and genotyped by Sanger sequencing. Results: Analysis of 1,317 samples showed network prevalence rates of 69.1%, 25.1%, and 1.5% for HAV, HBV, and HCV exposure, respectively. A high susceptibility rate to HBV infection (35.7%) and low prevalence of vaccine response markers (40%) were also observed. Age greater than 26 years, self-declared black/brown skin color, having only primary education, history of incarceration, and use of a condom in the last sexual intercourse with a casual partner were associated with total anti-HAV. Exposure to HBV was associated with age greater than 26 years, self-declared black/brown, history of being a sex worker, and incarceration. Age > 37 years, history of sexual abuse, and frequent alcohol consumption were associated with hepatitis C infection. Conclusion: The highest prevalence of HAV in this population was found in the North and Northeast regions, and the prevalence found was higher than that in the general population, suggesting greater vulnerability. The prevalence of HCV infection in our study was similar to that observed in the general population.

RESUMO Objetivo: Estimar as prevalências e fatores associados com as hepatites A, B e C em mulheres trans e travestis em cinco regiões do Brasil. Métodos: Estudo transversal com mulheres trans e travestis em cinco capitais brasileiras (Campo Grande, Manaus, Porto Alegre, Salvador e São Paulo), entre dezembro/2019 e julho/2021. As amostras foram submetidas à detecção de marcadores das infecções pelos vírus das hepatites A (HAV), B (HBV) e C (HCV), utilizando-se testes rápidos e quimioluminescência. Amostras positivas foram submetidas à detecção de HBV-DNA e HCV-RNA por PCR em tempo real e genotipadas por sequenciamento de Sanger. Resultados: As análises de 1.317 amostras indicaram taxas de prevalências nas mulheres trans e travestis recrutadas de 69,1%, 24,4% e 1,5% para exposição ao HAV, HBV e HCV, respectivamente. Elevada taxa de suscetibilidade ao HBV (35,7%) e baixa prevalência do marcador vacinal (40,0%) foram observadas. Mostraram-se associadas à presença de anti-HAV: idade maior que 26 anos, autodeclarar-se preta-parda, ter apenas educação básica, história de encarceramento e uso de preservativo na última relação sexual com parceiro casual. Quanto à exposição ao HBV, foi associada a idade maior que 26 anos, cor da pele preto-parda, ter sido profissional do sexo e história de encarceramento. Idade maior de 37 anos, história de abuso sexual e consumo frequente de álcool foram associadas ao HCV. Conclusão: As maiores prevalências de HAV nessa população encontram-se nas regiões Norte e Nordeste. Com relação ao HBV, a prevalência encontrada foi superior à encontrada na população geral, sugerindo maior vulnerabilidade. A prevalência do HCV foi semelhante à encontrada na população geral.

Discrimination based on gender identity against transgender women and travestis in Brazil: a latent class analysis and associated factors / Discriminação por identidade de gênero entre mulheres trans e travestis no Brasil: uma análise de classes latentes e fatores associados

ABSTRACT Objective To identify groups of transgender women and travestis (TGW) with specific patterns of gender-based discrimination (GBD) and analyze the factors associated with GBD. Methods A cross-sectional study was conducted with TGW recruited through respondent-driven sampling in five Brazilian cities (2019-2021). Latent class analysis was used to characterize GBD (low, medium, and high) using 14 observable variables. Descriptive analysis was performed, and associations between predictor variables and GBD were estimated by adjusted odds ratios (aOR) using ordinal logistic regression. Results Out of a total of 1,317 TGW, 906 (68.8%) answered questions about GBD. Most were under 34 years old, single, and had a Brown race/skin color. GBD was classified as "low," "medium," and "high," with estimates of 41.7, 44.5, and 13.8%, respectively. Variables positively associated with higher intensity of GBD included living in Manaus compared to São Paulo, being ≤34 years old compared to >34, being homeless compared to living in one's own house or rented apartment, not having legally changed one's name compared to those who had, and reporting physical or sexual violence compared to those who did not report. Variables negatively associated with higher intensity of GBD included having a Brown or Asian race/skin color compared to White and a monthly income ≥1 minimum wage compared to ³1. Conclusion A high proportion of GBD was observed in Brazilian TGW, with this outcome associated with more vulnerable sociodemographic characteristics and a history of violence.

RESUMO Objetivo Identificar grupos de mulheres trans e travestis (MTT) com padrões específicos de discriminação por identidade de gênero (DIG) e analisar os fatores associados à DIG. Métodos Estudo transversal com MTT recrutadas por respondent-driven sampling em cinco capitais brasileiras (2019-2021). Análise de classes latentes foi usada para caracterizar a DIG (em baixa, média e alta) usando 14 variáveis observáveis. Análise descritiva foi realizada e as associações entre variáveis preditoras e DIG foram estimadas por odds ratio ajustados (ORaj), usando regressão logística ordinal. Resultados Do total de 1.317 MTT, 906 (68,8%) responderam perguntas sobre DIG. A maioria apresentava idade ≤34 anos, solteiras e com raça/cor de pele parda. DIG foi classificada em "baixa", "média" e "alta", com estimativas de 41,7, 44,5, 13,8%, respectivamente. As variáveis positivamente associadas à maior intensidade de DIG foram: morar em Manaus em comparação com São Paulo; possuir idade £34 anos em comparação com idade >34; estar em situação de rua em comparação com quem mora em casa ou apartamento próprio ou alugado; não ter retificado o nome em documento em comparação com quem retificou; e relato de violência física ou sexual em comparação com quem não relatou. As variáveis negativamente associadas à maior intensidade de DIG foram: raça/cor de pele parda ou amarela em comparação com branca; e renda média mensal <1 salário mínimo em comparação com ≥1 salários. Conclusão Observaram-se alta proporção de DIG em MTT brasileiras e associação desse desfecho com características sociodemográficas mais vulneráveis e histórico de violência.