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.

Design and pilot evaluation of a brief intervention to reduce transphobia and improve attitudes of government officials to address legal gender affirmation needs of 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.

Main findings: A brief group-based theoretically informed intervention designed and piloted by a multidisciplinary cross-sector team in partnership with transgender communities was feasible to conduct, garnered high levels of acceptability, and significantly increased knowledge and favorable attitudes toward transgender people for government officers responsible for identity documents in Peru.Added knowledge: Legal gender affirmation is an important determinant of mental health and wellbeing for transgender people; this evidence-based intervention increased the capacity of government officers to meet health-harming legal gender affirmation needs, specifically legal name and gender marker change, addressing a structural barrier to legal gender affirmation for transgender people in Peru.Global health impact for policy and action: Findings underscore the promise of this intervention for future research and testing before potential later implementation and scale-up in Peru, and for adaptation in other countries and contexts to address the training and capacity of government officials to effectively process and implement legal gender affirmation, a structural barrier to legal gender affirmation for transgender people.

A life course health development model of HIV vulnerabilities and resiliencies in young transgender women in Peru.

BACKGROUND: Globally transgender women (TW) are at heightened vulnerability for HIV infection. In Lima Peru, sharp increases in HIV prevalence are seen among TW ages 25 years and older highlighting the need for early HIV prevention efforts for young TW. This study conducted in-depth qualitative interviews to elucidate the social and developmental contexts of HIV vulnerability for young TW in Lima Peru. METHODS: Between November 2019 and February 2020, young TW ages 16-24 years (n = 21) in Lima Peru were purposively sampled using in-person (e.g., face-to-face outreach) and online (e.g., social media, networking websites) social network-based methods. Interviews were conducted in Spanish and a rapid qualitative analysis was conducted using a modified immersion crystallization methodology to identify themes. RESULTS: Five themes emerged, informing the conceptualization of a Life Course Health Development Model of HIV Vulnerabilities and Resiliencies: (1) interpersonal contexts (family, school, partners, sexual debut, trans mothers); (2) structural vulnerabilities (poverty, educational constraints, migration, hostile environments, sex work, police violence); (3) concomitant mental health and psychosocial factors (discrimination, violence, depression, suicidality, substance use, life hopes/dreams/future expectations); (4) gender affirmation processes (gender identity development, hormones, surgery, legal name/gender marker change); (5) HIV prevention and treatment barriers (PrEP uptake, HIV care, condom use, risk reduction). CONCLUSIONS: Young TW experience formidable developmental challenges associated with transphobia, violence, and pre-maturely facing accelerated milestones. Developmentally and culturally appropriate interventions to mitigate HIV vulnerability in Peru are needed, including those that consider co-occurring stigma-related conditions in adolescence and young adulthood.

Intersectional stigma and the arc of intranational migration: experiences of transgender adolescents and women who migrate within Peru.

BACKGROUND: 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. METHODS: 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). RESULTS: 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). CONCLUSION: 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.

Exploring Contextual Differences for Sexual Role Strain Among Transgender Women and Men Who Have Sex with Men in Lima, Peru.

Sexual and gender politics inform relational expectations surrounding sexual experiences of Peruvian transgender women (TW) and men who have sex with men (MSM). We used the framework of sexual role strain, or incongruence between preferred sexual role and actual sexual practices, to explore potential conflicts between personally articulated identities and externally defined norms of gender and sexuality and its potential to increase HIV/STI risk. Cross-sectional individual- and dyad-level data from 766 TW and MSM in Lima, Peru were used to assess the partnership contexts within which insertive anal intercourse was practiced despite receptive role preference (receptive role strain), and receptive anal intercourse practiced despite insertive role preference (insertive role strain). Sexual role strain for TW was more common with non-primary partners, while for MSM it occurred more frequently in the context of a primary partnership. Receptive role strain was more prevalent for TW with unknown HIV status (reference: without HIV) or pre-sex drug use (reference: no pre-sex drug use). For homosexual MSM, receptive role strain was more prevalent during condomless anal intercourse (reference: condom-protected) and with receptive or versatile partners (reference: insertive). Among heterosexual or bisexual MSM, insertive role strain was more prevalent with insertive or versatile partners (reference: receptive), and less prevalent with casual partners (reference: primary). Our findings suggest TW and MSM experience different vulnerabilities during sexual role negotiation with different partner-types. Future studies should explore the impact of sexual role strain on condom use agency, HIV/STI risk, and discordances between public and private presentations of gender and sexual orientation.

HIV transmission patterns among transgender women, their cisgender male partners, and cisgender MSM in Lima, Peru: A molecular epidemiologic and phylodynamic analysis.

BACKGROUND: Transgender women (TW) in Peru are disproportionately affected by HIV. The role that cisgender men who have sex with TW (MSTW) and their sexual networks play in TW's risk of acquiring HIV is not well understood. We used HIV sequences from TW, MSTW, and cisgender men who have sex with men (MSM) to examine transmission dynamics between these groups. METHODS: We used HIV-1 pol sequences and epidemiologic data collected through three Lima-based studies from 2013 to 2018 (n = 139 TW, n = 25 MSTW, n = 303 MSM). We identified molecular clusters based on pairwise genetic distance and used structured coalescent phylodynamic modeling to estimate transmission patterns between groups. FINDINGS: Among 200 participants (43%) found in 62 clusters, the probability of clustering did not differ by group. Both MSM and TW were more likely to cluster with members of their own group than would be expected based on random mixing. Phylodynamic modeling estimated that there was frequent transmission from MSTW to TW (67·9% of transmission from MSTW; 95%CI = 52·8-83·2%) and from TW to MSTW (76·5% of transmissions from TW; 95%CI = 65·5-90·3%). HIV transmission between MSM and TW was estimated to comprise a small proportion of overall transmissions (4·9% of transmissions from MSM, and 11·8% of transmissions from TW), as were transmissions between MSM and MSTW (7·2% of transmissions from MSM, and 32·0% of transmissions from MSTW). INTERPRETATION: These results provide quantitative evidence that MSTW play an important role in TW's HIV vulnerability and that MSTW have an HIV transmission network that is largely distinct from MSM.

Decision-Making at the Intersection of Risk and Pleasure: A Qualitative Inquiry with Trans Women Engaged in Sex Work in Lima, Peru.

To inform culturally relevant HIV prevention interventions, we explore the complexity of sex work among Peruvian transgender women. In 2015, we conducted twenty in-depth interviews and demographic surveys with transgender women in Lima, Peru to examine how transgender women enact individual- and community-level resistance strategies within a context of pervasive marginalization. Although 40% self-identified as "sex workers," 70% recently exchanged sex for money. Participants described nuanced risk-benefit analyses surrounding paid sexual encounters. Classification of clients as "risky" or "rewarding" incorporated issues of health, violence, and pleasure. Interviews highlighted context-informed decision-making (rejecting disrespectful clients, asserting condom use with specific partner types) demonstrating that motivations were not limited to HIV prevention or economic renumeration, but considered safety, health, attraction, gender validation, hygiene, and convenience. These findings underscore the complex risk assessments employed by Peruvian trans women. These individual-level decision-making and context-specific health promotion strategies represent critical frameworks for HIV prevention efforts.

The wisdom of mistrust: qualitative insights from transgender women who participated in PrEP research in Lima, Peru.

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.

"Existimos": Health and social needs of transgender men in Lima, Peru.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Intimate Partner Violence Against Transgender Women: Prevalence and Correlates in Lima, Peru (2016-2018).

Limited data exists on intimate partner violence (IPV) among transgender women (TW), though global trends suggest IPV is associated with HIV risk in this population. We describe the prevalence of verbal, physical, and/or sexual violence as well as participant- and partner-level correlates of IPV among TW in Lima, Peru. Among 389 respondents, 15.2% reported IPV with one or more of their last three sexual partners: 9.2% verbal, 8.2% physical, and 2.3% sexual violence. Physical and verbal violence were more common with stable partners (aPR 3.46, 95% CI 1.17-10.25, aPR 2.46, 95% CI 1.14-5.28, respectively). Physical violence was associated with condomless receptive anal intercourse (cRAI) (aPR 2.22, 95% CI 1.19-4.13) and partner alcohol use (aPR 4.38, 95% CI 1.56-12.33) while verbal violence correlated with participant inebriation (aPR 4.86, 95% CI 1.63-14.46). Our results link IPV with stable partnerships, alcohol use, and cRAI, suggesting TW in Peru may benefit from multidimensional IPV prevention strategies to foster supportive relationships and reduce HIV transmission.

HIV pretreatment drug resistance among cisgender MSM and transgender women from Lima, Peru.

INTRODUCTION: Transmitted, or any pretreatment drug resistance (TDR, PDR) can compromise efficacy of first-line antiretroviral therapy (ART). In Peru, genotypic resistance testing is not routinely performed before ART initiation, and estimated PDR prevalence prior to 2012 ranged from 1.0% to 4.7%. We aimed to update estimates of PDR prevalence in men who have sex with men (cis-MSM) and transgender women (TW). METHODS: We obtained HIV sequences from three studies of ART-naïve cisgender-MSM and TW (n = 470) in Lima, Peru from 2013 to 2017, almost two-thirds of whom had acute or recent infections. Sanger sequences of HIV pol were interrogated for surveillance drug resistance mutations (SDRM) using the Stanford Calibrated Population Resistance (CPR) tool and scored for resistance to nucleoside reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) with the HIVdb programme. We calculated binomial proportions and 95% confidence intervals. χ2 and exact or trend tests were used to examine predictors of PDR. RESULTS: Seventy-seven (16.4%) individuals had PDR (95% CI: 13.2 to 20.0); most resistance was likely TDR since 63% were incident infections. SDRM were present in 9.8% (7.3 to 12.9). Resistance to any NRTI was present in <1% of individuals, while efavirenz resistance was present in 10% (6.9% to 12.4%). TW were not statistically more likely than cis-MSM to have PDR (11.4% vs. 9.1%, p = 0.54). Age, incident versus prevalent infection, or residence district did not predict PDR. Prevalence of SDRM increased from 3% in 2013 to 21% 2017 within incident infections (p = 0.04), but not when including prevalent infections. CONCLUSIONS: Prevalence of NNRTI resistance in three studies of ART-naïve MSM and TW in Lima, Peru reaches 10%. Because our study reports PDR in a population in which most acquired HIV recently, the overall prevalence of PDR, including previously treated persons, is likely underestimated. These results underscore the need for a nationally representative survey of PDR in Peru and consideration of non-NNRTI anchored first-line ART options. This study also represents the first evaluation of PDR in cis-MSM versus TW in South America, and demonstrates that, although TW are at higher risk of acquiring HIV, they are at similar risk of acquiring a virus with resistance mutations.

Integration of Gender-Affirming Primary Care and Peer Navigation With HIV Prevention and Treatment Services to Improve the Health of Transgender Women: Protocol for a Prospective Longitudinal Cohort Study.

BACKGROUND: Public health strategies are urgently needed to improve HIV disparities among transgender women, including holistic intervention approaches that address those health needs prioritized by the community. Hormone therapy is the primary method by which many transgender women medically achieve gender affirmation. Peer navigation has been shown to be effective to engage and retain underserved populations living with HIV in stable primary medical care. OBJECTIVE: This study aims to assess the feasibility and acceptability of an integrated innovative HIV service delivery model designed to improve HIV prevention and care by combining gender-affirming primary care and peer navigation with HIV prevention and treatment services. METHODS: A 12-month, nonrandomized, single-arm cohort study was implemented in Lima, Peru, among adult individuals, assigned a male sex at birth, who identified themselves as transgender women, regardless of initiation or completion of medical gender affirmation, and who were unaware of their HIV serostatus or were living with HIV but not engaged in HIV treatment. HIV-negative participants received quarterly HIV testing and were offered to initiate pre-exposure prophylaxis. HIV-positive participants were offered to initiate antiretroviral treatment and underwent quarterly plasma HIV-1 RNA and peripheral CD4+ lymphocyte cell count monitoring. All participants received feminizing hormone therapy and adherence counseling and education on their use. Peer health navigation facilitated retention in care by visiting participants at home, work, or socialization venues, or by contacting them by social media and phone. RESULTS: Patient recruitment started in October 2016 and finished in March 2017. The cohort ended follow-up on March 2018. Data analysis is currently underway. CONCLUSIONS: Innovative and culturally sensitive strategies to improve access to HIV prevention and treatment services for transgender women are vital to curb the burden of HIV epidemic for this key population. Findings of this intervention will inform future policies and research, including evaluation of its efficacy in a randomized controlled trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT03757117; https://clinicaltrials.gov/ct2/show/NCT03757117. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/14091.

Perceived Barriers and Facilitators to Integrating HIV Prevention and Treatment with Cross-Sex Hormone Therapy for Transgender Women in Lima, Peru.

Transgender women (TW) represent a vulnerable population at increased risk for HIV infection in Peru. A mixed-methods study with 48 TW and 19 healthcare professionals was conducted between January and February 2015 to explore barriers and facilitators to implementing a model of care that integrates HIV services with gender-affirmative medical care (i.e., hormone therapy) in Lima, Peru. Perceived acceptability of the integrated care model was high among TW and healthcare professionals alike. Barriers included stigma, lack of provider training or Peruvian guidelines regarding optimal TW care, and service delivery obstacles (e.g., legal documents, spatial placement of clinics, hours of operation). The hiring of TW staff was identified as a key facilitator for engagement in health care. Working in partnership with local TW and healthcare provider organizations is critical to overcoming existing barriers to successful implementation of an integrated HIV services and gender-affirmative medical care model for this key population in Peru.

Leveraging social capital: multilevel stigma, associated HIV vulnerabilities, and social resilience strategies among transgender women in Lima, Peru.

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.

Potential impact and acceptability of Internet partner notification for men who have sex with men and transgender women recently diagnosed as having sexually transmitted disease in Lima, Peru.

We assessed the potential impact of Internet partner notification among men who have sex with men and transgender women in Peru recently diagnosed as having sexually transmitted disease. Use of Internet partner notification was anticipated for 55.9% of recent partners, including 43.0% of partners not currently expected to be notified, a 20.6% increase in anticipated notification outcomes.