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After years of campaigning and controversy, the Department of Health recently announced that they will begin routine commissioning of pre-exposure prophylaxis (PrEP) in England, meaning that free at the point of access PrEP is available in all regions of the UK. This is an important step forward in the UK’s aim to reach zero transmissions by 2030. Global data have shown that transgender women (TGW) are disproportionately affected by HIV.1 This can be attributed to a plethora of intersecting risk factors and vulnerabilities, many of which stem from the systemic and enacted discrimination, stigma and marginalisation that TGW experience.2 Given their increased risk, PrEP could be a valuable tool for TGW, especially given that risk factors such as involvement in sex work, sexual violence, and diminished sexual agency often preclude condom use.2 However, analysis of data from the iPrEx study, the only PrEP efficacy trial to include TGW, reported low adherence among TGW.3 With PrEP implementation being in the relatively early stages, the UK has the opportunity to identify and address the needs of a high-risk but often neglected population. However, there is currently no published literature on the acceptability of PrEP among TGW in the UK.
Worldwide, there are a considerable number of PrEP acceptability studies containing TGW within a combined sample of men who have sex with men (MSM) and TGW. However, in many of these studies, TGW are only included in very small numbers and/or their data have not been disaggregated from that of MSM, making it impossible to draw meaningful conclusions about TGW specifically. There are a limited number of studies that include significant numbers of TGW, where their data are disaggregated if other groups are included in the sample. A 2019 systematic review on PrEP awareness and acceptability among TGW by Pacífico de Carvalho et al found that commonly cited barriers to uptake and use of PrEP include cost, concerns surrounding side effects, reluctance to visit medical professionals due to previous experiences of transphobia, a lack of trans-inclusive marketing, and concerns about PrEP–hormone interactions.4 Other studies, not included in Pacífico de Carvalho et al’s review, have also noted that the service provider plays a key role in PrEP acceptability, with TGW in these studies expressing a wish to access PrEP from their current medical provider, with whom they have an established relationship, or from a service that specialises in transgender health.5 6 Additionally, TGW in Klein and Golub’s research discuss the importance of community mobilisation and the value in hearing about other TGW’s experience with PrEP.7
Many of these factors are applicable to the UK context and need to be addressed by policymakers to enhance uptake. Steps to improve PrEP acceptability among TGW in the UK should include: to review current anti-discrimination policies in medical settings to ensure that they are effective in protecting TGW accessing healthcare against transphobia; to ensure that training on providing trans-inclusive care is included in workplace equality and diversity training; to ensure that marketing of PrEP is trans-inclusive; to encourage education and uptake of PrEP via community strategies by engaging with members of the transgender community; to disaggregate TGW from other demographics in future research and service provision; to increase the range of doctors and facilities that can prescribe PrEP; and to expand and develop transgender-specific healthcare services.
Further, it is vital that UK-based research into PrEP acceptability among TGW is carried out, in order to fully understand the specific barriers that TGW face in accessing PrEP in the UK and what can be done to remove these.
Contributors EB wrote the manuscript. KD was involved in planning, supervision, and critical revision of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.