Canada needs to improve PrEP awareness among transgender and nonbinary people

— Researchers surveyed more than 1,900 trans and nonbinary people in Canada about PrEP
— PrEP awareness, lifetime PrEP use and current PrEP use figures were low
— Improved PrEP awareness and access are needed for transgender and nonbinary people

Pre-exposure prophylaxis, or PrEP, is a medication that people without HIV can take to protect themselves against HIV. When taken as directed, PrEP greatly reduces the risk of acquiring HIV. PrEP, a pill that consists of a combination of the drugs tenofovir + FTC, is taken orally. However, recently a new formulation of PrEP given via injection every two months has been approved in Canada. It will likely take at least a year before this injectable long-lasting formulation of PrEP, which is sold under the brand name Apretude (cabotegravir), is subsidized by provincial and territorial ministries of health.

Although PrEP is highly effective at preventing HIV, there are disparities in who has access to or even knows about it. Though anyone can take PrEP, it is especially recommended for gay or bisexual men and transgender women who report having sex without a condom in the last six months. Despite transgender people being recognized worldwide as being disproportionately affected by HIV, the limited data available on PrEP awareness and usage in this population (much of it from the United States) shows low PrEP usage.

Previous studies attribute low PrEP usage among transgender people to several factors, including marketing that focuses on gay and bisexual men, a lack of access to trans-inclusive medical care, as well as cost, stigma and concerns about potential side effects.

A health survey of transgender and nonbinary people

Canadian researchers analyzed data from the Trans PULSE Canada survey, which was conducted between July and October 2019. This comprehensive survey collected health-related and behavioural information from transgender and nonbinary people across Canada. The sample of responses that researchers analyzed included people 16 years and older. Participants indicated that they had either tested negative for HIV or had never been tested.

A brief average profile of the 1,965 participants upon study entry was as follows:

• age – most participants were younger than 35
• 25% were transgender women and 24% were transgender men
• approximately half of the sample was nonbinary, with 42% assigned female at birth and 9% assigned male at birth

Results

PrEP awareness

The survey defined PrEP and asked participants if they had heard of it. Out of all the participants, 71% had ever heard of PrEP. The lowest level of PrEP awareness was among transgender women (61%); the highest was among nonbinary people assigned female at birth (78%).

PrEP use

Of the 1,965 participants, only 43 people had ever used PrEP, while only 18 were currently using PrEP. The percentage of people who had ever used PrEP was highest among nonbinary people assigned male at birth (7%), and current PrEP use was highest among transgender men (2%). Both lifetime (1%) and current PrEP use (0.4%) were lowest among transgender women.

Results were slightly better in a subgroup of people who had condomless anal sex in the past six months, with 7% reporting having used PrEP at some point and 4% currently taking PrEP.

Those more likely to be aware of PrEP included people with the following characteristics:

• age 25-34
• transgender men
• nonbinary people assigned female at birth
• White people
• a graduate or professional degree
• single
• in a non-monogamous relationship
• tested for HIV in the last year
• having a trans-aware primary care physician or service provider
• getting gender-affirming medical care
• engaging in sex work

Those less likely to be aware of PrEP included people with the following characteristics:

• older than 45
• transgender women
• Indigenous
• a high school degree or less
• in a monogamous relationship
• not getting gender-affirming medical care

Overall, researchers found that one in five transgender and nonbinary people who are eligible for PrEP in Canada were completely unaware that it existed. What’s more, the percentage of people in this group who knew about PrEP lagged behind awareness among gay and bisexual Canadian men.

Inequities in PrEP uptake and awareness 

Though researchers suggest that PrEP uptake has most likely increased since the survey was conducted in 2019, they stressed that the number of people taking PrEP in the survey was low—with less than 4% of people who could benefit from PrEP taking it.

To address these inequities, researchers stated that certain groups with low PrEP awareness should be targeted, including:

• people over 45
• transfeminine people
• Indigenous people
• people living in Quebec or Atlantic Canada
• people with a high school degree or less
• people who are not currently receiving gender-affirming care

For the future

Researchers called for more public health initiatives specifically aimed at transgender and nonbinary Canadians to address the inequities in PrEP awareness and use. In particular, they called for campaigns focusing on the groups mentioned in the list above.

By Mathew Rodriguez

Resources

Trans Pulse Canada

What are the barriers and facilitators to HIV PrEP use among transgender people? – CATIE

Long-acting cabotegravir – focus on transgender women – CATIE 

Awareness, accessibility and uptake of pre-exposure prophylaxis (PrEP) among cisgender and transgender women at risk of HIV infection – Ontario HIV Treatment Network

HIV pre-exposure prophylaxis (PrEP) resource page  – CATIE

REFERENCE:

Hallarn J, Scheim AI, Bauer GR. Pre-exposure prophylaxis awareness and use among transgender and nonbinary individuals in Canada. JAIDS. 2024 Aug 1;96(4):341-349.