Research in context
Evidence before this study
Before doing this study, the authors considered multiple sources of information about pre-exposure prophylaxis (PrEP) among transgender women in South Africa. We read the South African National Strategic Plan for HIV, Tuberculosis, and Sexually Transmitted Infections and examined the AVAC: Global Advocacy for HIV Prevention website to identify existing PrEP demonstration and implementation studies in South Africa. We reviewed the published literature on PrEP among transgender women up to March 31, 2018, by searching PubMed, PsycINFO, and CINAHL using MESH terms for transgender and PrEP. We did not limit by language or time period, and we excluded any studies that did not provide disaggregated information specific to transgender women and PrEP. The published literature indicated a high HIV burden in the general population in the region (20·4% in South Africa) and even higher among transgender women in sub-Saharan Africa (25%) but estimates of HIV prevalence among transgender women in South Africa were not available. We found that South Africa was the first sub-Saharan country to approve PrEP fully and had explicit plans to scale up PrEP for priority populations, including transgender women. Multiple demonstration projects had been implemented but none solely focused on transgender populations. We were unable to find any data on PrEP engagement, barriers, or facilitators of PrEP among transgender women in South Africa.
Added value of this study
This study fills an important gap in knowledge about HIV and PrEP among transgender women in South Africa, a priority population for PrEP implementation. In addition to providing information on the proportion of transgender women who are aware of PrEP and engagement in the PrEP continuum, this study provides qualitative and quantitative data on factors associated with PrEP awareness, barriers and facilitators to PrEP uptake and adherence, and community-derived recommendations for improving PrEP access and uptake for transgender women in South Africa. These data are particularly timely given the planned initiation of dedicated transgender health-care clinics in the three cities where data were collected.
Implications of all the available evidence
PrEP awareness, willingness, and uptake are low among transgender women in South Africa. Transgender women who felt connected to a transgender community were less likely to be willing to take PrEP, indicating a need to address specific barriers within transgender women communities. Additionally, misunderstandings about PrEP's mechanism of action, side-effects, and difference from post-exposure prophylaxis highlight the need to disseminate accurate information to transgender women. In addition to raising awareness about PrEP, it will be important to address structural barriers to access such as cost, stigma against transgender people, and distance to health-care facilities. Networks for transgender women can be leveraged in innovative ways to support accurate PrEP knowledge dissemination, uptake, and adherence. Future research specifically with transgender women is needed to evaluate effectiveness and acceptability of new and pipeline PrEP interventions for this population.