ABSTRACT

Objective

To describe HIV prevention strategies and gender-based discrimination among adolescent travestis and transgender women.

Methods

This was a cross-sectional study involving 148 adolescent travestis and transgender women aged 15 to 19 years in Salvador, Bahia state, São Paulo, São Paulo state, and Belo Horizonte, Minas Gerais state, conducted between February 2019 and March 2023. Fisher’s exact test was performed to assess differences between prevention strategies and gender-based discrimination within healthcare services.

Results

18.9 % reported engaging in receptive anal sex using condom in the past 6 months; 62.2% had undergone HIV test at least once in their lifetime; and 88.5% had started pre-exposure prophylaxis (PrEP) for HIV. Adolescents aged 15 to 17 years with previous experiences of discrimination in healthcare services had undergone fewer HIV tests in their lifetime or had started PrEP less frequently.

Conclusion

There is an urgent need for the implementation of public policies that eradicate gender-based discrimination and expand access to HIV prevention.

Palabras clave
Adolescente; Travestis; Mujeres Trans; VIH; Discriminación de Género

Study contributions

Main results

The primary experiences of discrimination occurred in school and family environments as well as in public spaces. Discrimination within healthcare services was associated with limited condom use and resistance to initiating pre-exposure prophylaxis (PrEP).

Implications for services

Expand access to prevention strategies in this population and develop strategies to combat gender-based discrimination within healthcare services, as well as in family and school environments and in public spaces.

Perspectives

Strategies to provide access to health services must be prioritized, focusing on demand creation and establishing a connection between adolescent travestis and transgender women and healthcare services.

Palabras clave
Adolescente; Travestis; Mujeres Trans; VIH; Discriminación de Género

RESUMEN

Objetivo

Describir las prácticas de prevención del VIH y la discriminación de género entre adolescentes travestis y mujeres trans

Métodos

Estudio transversal con 148 adolescentes travestis y mujeres trans de 15 a 19 años de edad en Salvador, São Paulo y Belo Horizonte entre febrero de 2019 y marzo de 2023. Se utilizó la prueba exacta de Fisher para verificar diferencias entre las prácticas de prevención y la discriminación de género en los servicios de salud

Resultados

El 18,9% informó haber tenido relaciones sexuales anales con preservativo en los últimos 6 meses; el 62,2% se había realizado la prueba de VIH alguna vez en la vida; y el 88,5% había iniciado la profilaxis previa a la exposición (PrEP) para el VIH. Las adolescentes de entre 15 y 17 años con experiencias previas de discriminación en los servicios habían realizado menos pruebas de VIH en su vida o habían iniciado PrEP con menor frecuencia

Conclusión

Se enfatiza la urgencia de implementar políticas públicas que erradiquen la discriminación de género y amplíen el acceso a la prevención del VIH.

Palabras clave
Adolescente; Travestis; Mujeres Trans; VIH; Discriminación de Género

INTRODUCTION

Brazil is the country with the highest number of homicides among the transgender population worldwide.¹1 TGEU. Transgender Europe. 2023 [cited 2024 Jan 28]. Transgender Europe. Trans Murder Monitoring 2023 Global Update. Available from: https://tgeu.org/trans-murder-monitoring-2023/
https://tgeu.org/trans-murder-monitoring... Over the 15 years of data reported on this issue, since the first report carried out in 2009 to the most recent one in 2023, Brazil continues to lead the ranking of deaths among this population.¹1 TGEU. Transgender Europe. 2023 [cited 2024 Jan 28]. Transgender Europe. Trans Murder Monitoring 2023 Global Update. Available from: https://tgeu.org/trans-murder-monitoring-2023/
https://tgeu.org/trans-murder-monitoring... The majority of these deaths are due to homicide, with victims generally being transgender women (TGW) and travestis aged between 18 and 29 years, of Black or mixed-race/skin color, and in situations of high vulnerability.²2 Benevides BG. Dossiê: assassinatos e violências contra travestis e transexuais brasileiras em 2023. Brasília, DF: Distrito Drag, ANTRA; 2024.

Violence against travestis and TGW can be explained by the stigma and gender-based discrimination (GBD) prevalent throughout society, culturally rooted in cis-heteronormativity.²2 Benevides BG. Dossiê: assassinatos e violências contra travestis e transexuais brasileiras em 2023. Brasília, DF: Distrito Drag, ANTRA; 2024. Although transphobia has been classified as a crime by the Supreme Federal Court since 2019,³3 BRASIL. Supremo Tribunal Federal. Ação Direta de Inconstitucionalidade por Omissão (ADO) no 26. Relator: Ministro Celso de Mello [Internet]. Supremo Tribunal Federal. 2019 [ citado em 28 de janeiro de 2024]. Disponível em: https://redir.stf.jus.br/paginadorpub/paginador.jsp?docTP=TP&docID=754019240
https://redir.stf.jus.br/paginadorpub/pa... discrimination still persists in various contexts: individual, interpersonal and institutional.⁴4 Magno L, Silva LAV, Veras MA, Pereira-Santos M, Dourado I. Stigma and discrimination related to gender identity and vulnerability to HIV/AIDS among transgender women: a systematic review. Cad Saude Publica [Internet]. 2019 Apr 8 [cited 2021 Feb 4];35(4):e00112718. doi: 10.1590/0102-311X00112718
https://doi.org/10.1590/0102-311X0011271... ,⁵5 Monteiro S, Brigeiro M. Experiências de acesso de mulheres trans/travestis aos serviços de saúde: avanços, limites e tensões. Cad Saude Publica. 2019;35(4):e00111318. doi: https://doi.org/10.1590/0102-311XER111318
https://doi.org/https://doi.org/10.1590/...

Transphobia is reported in numerous situations, such as disrespect for social names, discrimination in healthcare services or by healthcare professionals, breakdown of family ties, and physical, verbal, or sexual aggression in Brazil⁴4 Magno L, Silva LAV, Veras MA, Pereira-Santos M, Dourado I. Stigma and discrimination related to gender identity and vulnerability to HIV/AIDS among transgender women: a systematic review. Cad Saude Publica [Internet]. 2019 Apr 8 [cited 2021 Feb 4];35(4):e00112718. doi: 10.1590/0102-311X00112718
https://doi.org/10.1590/0102-311X0011271... ,⁵5 Monteiro S, Brigeiro M. Experiências de acesso de mulheres trans/travestis aos serviços de saúde: avanços, limites e tensões. Cad Saude Publica. 2019;35(4):e00111318. doi: https://doi.org/10.1590/0102-311XER111318
https://doi.org/https://doi.org/10.1590/... and other countries.⁶6 King WM, Hughto JMW, Operario D. Transgender stigma: A critical scoping review of definitions, domains, and measures used in empirical research. Soc Sci Med. 2020;250:112867. doi: 10.1016/j.socscimed.2020.112867
https://doi.org/10.1016/j.socscimed.2020... ,⁷7 Lelutiu-Weinberger C, English D, Sandanapitchai P. The Roles of Gender Affirmation and Discrimination in the Resilience of Transgender Individuals in the US. Behav Med. 2020;46(3-4):175-88. doi: 10.1080/08964289.2020.1725414
https://doi.org/10.1080/08964289.2020.17... Travestis and TGW are at a higher risk of sexually transmitted infections, especially HIV.⁸8 Poteat T, Scheim A, Xavier J, Reisner S, Baral S. Global Epidemiology of HIV Infection and Related Syndemics Affecting Transgender People. J Acquir Immune Defic Syndr [Internet]. 2016 Aug 15;72 Suppl 3(Suppl 3):S210-9. Available from: https://pubmed.ncbi.nlm.nih.gov/27429185
https://pubmed.ncbi.nlm.nih.gov/27429185...

Globally, HIV prevalence among travestis and TGW was 19.1%,⁹9 Stutterheim SE, van Dijk M, Wang H, Jonas KJ. The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis. PLoS One [Internet]. 2021 Dec 1 [cited 2022 Jun 19];16(12):e0260063. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0260063 while in Brazil the prevalence ranged between 9% and 40% across different municipalities.⁹9 Stutterheim SE, van Dijk M, Wang H, Jonas KJ. The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis. PLoS One [Internet]. 2021 Dec 1 [cited 2022 Jun 19];16(12):e0260063. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0260063,¹⁰10 Leite BO, Magno L, Soares F, MacCarthy S, Brignol S, Bastos FI, et al. HIV prevalence among transgender women in Northeast Brazil - Findings from two Respondent Driven Sampling studies. BMC Public Health [Internet]. 2022 Dec 1 [cited 2023 Feb 22];22(1):2120. Available from: https://pubmed.ncbi.nlm.nih.gov/36401261/ Vulnerability to HIV can be attributed to behavioral factors (unprotected sex),¹¹11 Magno L, Dourado I, Silva LAV, Brignol S, Amorim L, MacCarthy S. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: A mixed methods study. PLos One. 2018 [cited 2019 Jun 6];13(4):e0194306 doi: 10.1371/journal.pone.0194306
https://doi.org/10.1371/journal.pone.019... programmatic factors (limited access to services, prevention strategies and technologies)⁵5 Monteiro S, Brigeiro M. Experiências de acesso de mulheres trans/travestis aos serviços de saúde: avanços, limites e tensões. Cad Saude Publica. 2019;35(4):e00111318. doi: https://doi.org/10.1590/0102-311XER111318
https://doi.org/https://doi.org/10.1590/... and socio-structural factors (stigma and discrimination).⁴4 Magno L, Silva LAV, Veras MA, Pereira-Santos M, Dourado I. Stigma and discrimination related to gender identity and vulnerability to HIV/AIDS among transgender women: a systematic review. Cad Saude Publica [Internet]. 2019 Apr 8 [cited 2021 Feb 4];35(4):e00112718. doi: 10.1590/0102-311X00112718
https://doi.org/10.1590/0102-311X0011271... ,¹²12 Leite BO, Medeiros DS, Magno L, Bastos FI, Coutinho C, Brito AM, et al. Association between gender-based discrimination and medical visits and HIV testing in a large sample of transgender women in northeast Brazil. Int J Equity Health [Internet]. 2021;20(199):1-11. doi: 10.1186/s12939-021-01541-z
https://doi.org/10.1186/s12939-021-01541...

The association between discrimination and HIV infection with HIV prevention strategies, such as HIV testing and condom use, has been described in the literature;¹¹11 Magno L, Dourado I, Silva LAV, Brignol S, Amorim L, MacCarthy S. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: A mixed methods study. PLos One. 2018 [cited 2019 Jun 6];13(4):e0194306 doi: 10.1371/journal.pone.0194306
https://doi.org/10.1371/journal.pone.019... ,¹²12 Leite BO, Medeiros DS, Magno L, Bastos FI, Coutinho C, Brito AM, et al. Association between gender-based discrimination and medical visits and HIV testing in a large sample of transgender women in northeast Brazil. Int J Equity Health [Internet]. 2021;20(199):1-11. doi: 10.1186/s12939-021-01541-z
https://doi.org/10.1186/s12939-021-01541... however, the focus of these studies has been on the adult travestis and TGW. Regarding travestis and adolescent TGW, there is a knowledge gap concerning these outcomes.

Adolescence is a phase marked by the onset of biopsychosocial changes. This is a crucial time for health interventions, as behaviors learned during this time may persist into adulthood.¹³13 Kar SK, Choudhury A, Singh AP. Understanding normal development of adolescent sexuality: A bumpy ride. J Hum Reprod Sci [Internet]. 2015 Apr 1 [cited 2024 Feb 27];8(2):70-4. Available from: https://journals.lww.com/jhrs/fulltext/2015/08020/understanding_normal_development_of_adolescent.3.aspx For adolescent travestis and TGW, this can also be a critical time, often marked by the beginning of social transition, the use of hormones or other body modification strategies, fragile or broken family ties, and experiences of gender-based discrimination.¹⁴14 Medeiros DS, Magno L, Guimarães MDC, Grangeiro A, Eustorgio Filho M, Soares F, et al. Violence, Discrimination, and High Levels of Symptoms of Depression Among Adolescent Men Who Have Sex With Men and Transgender Women in Brazil. J Adolesc Health. 2023 Dec 1;73(6S):S19-S25. doi: 10.1016/j.jadohealth.2023.08.020

Access for adolescent travestis and TGW to healthcare services or HIV prevention strategies and other sexually transmitted infections may be hindered by: i) a lack of strategies to engage adolescents with services, qualified professionals to support this population, or a lack of ongoing educational actions for prevention;¹⁵15 Dourado I, Magno L, Greco DB, Zucchi EM, Ferraz D, Westin MR, et al. Interdisciplinarity in HIV prevention research: the experience of the PrEP1519 study protocol among adolescent MSM and TGW in Brazil. Cad Saude Publica [Internet]. 2023 Mar 27 [cited 2024 Feb 27];39:e00143221. Available from: https://www.scielo.br/j/csp/a/WSysCnFn5SgfrSB6FNfrZWn/?lang=en or ii) GBD that can operate both interpersonally among healthcare professionals and institutionally through services.¹²12 Leite BO, Medeiros DS, Magno L, Bastos FI, Coutinho C, Brito AM, et al. Association between gender-based discrimination and medical visits and HIV testing in a large sample of transgender women in northeast Brazil. Int J Equity Health [Internet]. 2021;20(199):1-11. doi: 10.1186/s12939-021-01541-z
https://doi.org/10.1186/s12939-021-01541... ,¹⁶16 Monteiro S, Brigeiro M, Barbosa RM. Saúde e direitos da população trans. Cad Saude Publica. 2019 Apr 8;35(4):e00047119. doi: 10.1590/0102-311X00047119
https://doi.org/10.1590/0102-311X0004711... This study aimed to investigate the prevalence of HIV, experiences of GBD, and HIV prevention strategies among adolescent travestis and TGW in three Brazilian capitals from 2019 to 2023.

METHODS

Study design

The PrEP15-19 study is the first cohort study in Latin America aimed at demonstrating the effectiveness of HIV pre-exposure prophylaxis (PrEP) among adolescent men who have sex with men and adolescent travestis and TGW, aged 15 to 19, residing in three major Brazilian capitals: Salvador, Bahia state, São Paulo, São Paulo state, and Belo Horizonte, Minas Gerais, state. This is a cross-sectional analysis using baseline data from adolescent travesti and TGW recruited between February 2019 and March 2023 in these three capitals.

Population

Eligible adolescent travestis and TGW were those who met the following criteria: self-identified as a travesti or TGW; aged 15 to 19 years; residing in one of the cities where the study was conducted; and reported sexual relations with cisgender men, travestis or TGW. The exclusion criteria were: being under the influence of alcohol or other drugs at the time of the study or having a mental disorder that could impair participation.

Data collection

Initial formative research was conducted to identify the social settings for adolescent travestis and TGW, and strategies for online and in-person demand generation were developed to reach and recruit this population.¹⁷17 Zucchi EM, Couto MT, Castellanos M, Dumont-Pena É, Ferraz D, Pinheiro TF, et al. Acceptability of daily pre-exposure prophylaxis among adolescent men who have sex with men, travestis and transgender women in Brazil: A qualitative study. PLoS One. 2021 May 4;16(5):e0249293. doi: 10.1371/journal.pone.0249293
https://doi.org/10.1371/journal.pone.024... Eligible participants were referred to the project clinics at each site, or received by spontaneous creation. All participants completed a standard questionnaire administered by a trained researcher to collect sociodemographic and sexual behavior information, in a private setting dedicated to this purpose. Third- and fourth-generation rapid HIV-1/2 tests were performed. All participants received pre- and post-test counseling, and were informed of their results. If the first fourth-generation rapid test result was reactive, a second third-generation rapid test was performed following the Ministry of Health’s HIV testing algorithm. If HIV infection was confirmed, participants were immediately referred for clinical follow-up and treatment initiation. More details can be found in the paper by Dourado et al.¹⁵15 Dourado I, Magno L, Greco DB, Zucchi EM, Ferraz D, Westin MR, et al. Interdisciplinarity in HIV prevention research: the experience of the PrEP1519 study protocol among adolescent MSM and TGW in Brazil. Cad Saude Publica [Internet]. 2023 Mar 27 [cited 2024 Feb 27];39:e00143221. Available from: https://www.scielo.br/j/csp/a/WSysCnFn5SgfrSB6FNfrZWn/?lang=en

Study variables

The variables described in this study were selected from the questionnaires and organized into the following blocks.

• Sociobehavioral: age (15-17 years , 18-19 years); race/skin color (white, black, brown, indigenous, asian); schooling (elementary education, high school, higher education); housing (lives with parents or guardians, does not live with parents or guardians); employment status (unemployed or unpaid work, paid employment); participation in a civil society organization (never participated, has participated); and age at first sexual intercourse (up to 15 years old, 15 years or older).

• HIV prevention strategies: receptive anal sex using a condom in the past 6 months (no, yes); had undergone HIV test at least once in their lifetime; (no, yes); and initiation of PrEP during the study (no, yes).

• Reports of GBD in the 6 months prior to cohort entry: not selected or dismissed from employment; was poorly served or prevented from entering commercial/leisure establishments; mistreated in healthcare services or by healthcare professionals; mistreated or marginalized by teachers at school/university/course; mistreated or marginalized by peers at school/university/course; excluded or marginalized by friends; excluded or marginalized by neighbors; excluded or marginalized within the family; excluded or marginalized in religious settings; mistreated by police or poorly attended in police stations; mistreated in public services (shelters, local government offices, transport); blackmailed or extorted; felt unsafe walking in public spaces; harassed on social media or other virtual environments; mistreated/discriminated against at work. For each of these situations, responses were “sometimes” or “once,” categorized as “once or more,” and “never.” Responses of “I do not wish to answer” or “not applicable” were disregarded.

Data analysis

Absolute and relative frequencies were calculated for each variable, stratified by age groups of younger (15-17 years) and older (18-19 years) adolescent travestis and TGW. Differences in proportions of HIV prevention strategies were investigated according to reports of discrimination in healthcare services or by healthcare professionals, also stratified by age group. Fisher’s exact test was performed to verify the differences between the proportions considering a descriptive level of statistical significance of the alpha error of 5%. All analyses were performed using R version 4.3.2.

Ethical aspects

The study was conducted in accordance with Resolution of the National Research Ethics Committee No. 466/2012 and approved by the Research Ethics Committee of the World Health Organization, and by the committees of the Universidade Federal da Bahia on 26/03/2019 (No. 3,224,384/ Certificate of Submission for Ethical Appraisal (CAAE): 89993018.9.3002.5030), Universidade de São Paulo on 12/13/2024 (No. 4,229,488/CAAE: 89993018.9.0000.0065) and Universidade Federal de Minas Gerais on 06/05/2024 (No. 2,027,889/CAAE: 89993018.9.3003.5149). All adolescent travestis and TGW aged 18 or over who agreed to participate in the study signed a free and informed consent form. For adolescent travestis and TGW under 18 years old, each site followed different procedures. In São Paulo, parental or guardian consent was waived; requiring only the adolescent’s signed assent form. In Salvador, parents or guardians signed the informed consent, but in cases of broken family ties or evidence of violence, the consent requirement was waived. In Belo Horizonte, the signing of the informed consent form by parents or guardians was mandatory in all cases.

RESULTS

In this study, a total of 148 adolescent travestis and TGW were recruited, 29.0% (43) in Salvador, 51.4% (76) in São Paulo and 19.6% (19) in Belo Horizonte. Of these, 31.8% (47) were aged 15 to 17 years, while 68.2% (101) were aged 18 to 19 years (Table 1). The prevalence of HIV in this sample was 2.7% (4/148).

The majority of adolescent travestis and younger TGW (15-17 years old) self-identified as Black (50.0%), were either attending or had completed high school (61.7%), lived with parents or guardians (66.7%), were unemployed or engaged in unpaid work (66.7%), had never participated in a civil society organization (86.7%), had their first sexual intercourse at 15 years or older (51.1%), had never undergone an HIV test (51.1%) and initiated PrEP use during the study (80.0%). In the last 6 months, 17% reported engaging in receptive anal sex using a condom (Table 1).

Among adolescent travestis and older TGW (18-19 years old) the majority self-identified as Black (40.0%), were either attending or had completed high school (75.3%), lived with parents or guardians (61.1%), were unemployed or engaged in unpaid work (65.6%), had never participated in a civil society organization (82.2%) and initiated PrEP use during the study (92.2%). Most of them had their first sexual intercourse before the age of 15 (68.9%), 31.1% had never undergone an HIV test and 19.8% engaged in receptive anal sex using a condom in the last 6 months (Table 1).

Table 2 highlights the reports of discrimination by school/college/course peers (53%) and within the family environment (51.1%) and fear of walking in public spaces (71.9%), which were reported by more than half of all adolescent travestis and TGW, especially among those aged 18 to 19 (the oldest group): 53.9%, 60.0% and 76.7%. Previous history of discrimination at any time in health services or by healthcare professionals before entering the cohort was reported by 31.8% of the total adolescent travesti and TGW, 26.7% among the youngest group and 34.4% among the oldest group (Table 2).

It is noteworthy that, among travesti adolescents and TGW who had undergone HIV test at least once in their lifetime (p-value 0.003), or initiated PrEP use (p-value 0.004), experiences of discrimination in healthcare services or by health professionals prior to cohort entry was greater among the oldest group (87.1% and 78.6%) compared to the youngest group (33.3% and 40.0%) (Figure 1).

DISCUSSION

This study identified a high prevalence of HIV among adolescent travestis and TGW (2.7%) when compared to the cisgender female population (0.4%).¹⁸18 BRAZIL. Ministry of Health. Health Surveillance Secretary. Department of STI Aids and Viral Hepatitis. The Brazilian Response to HIV and AIDS. Global AIDS Response Report (GARPR). Brasília, DF; 2015. Notably, nearly half of the adolescent travestis and TGW reported never having undergone an HIV test, particularly the youngest participants, when evaluating sexual prevention strategies.

The prevalence among travestis and TGW reached 25.0% in Porto Alegre,¹⁹19 Costa AB, Fontanari AMV, Jacinto MM, Silva DC, Lorencetti EK, da Rosa Filho HT, et al. Population-Based HIV Prevalence and Associated Factors in Male-to-Female Transsexuals from Southern Brazil. Arch Sex Behav. 2015;44:521-4. 31.2% in Rio de Janeiro²⁰20 Grinsztejn B, Jalil EM, Monteiro L, Velasque L, Moreira RI, Garcia ACF, et al. Unveiling of HIV dynamics among transgender women: a respondent-driven sampling study in Rio de Janeiro, Brazil. Lancet HIV [Internet]. 2017 Apr 1 [cited 2023 Feb 22];4(4):e169-e176. Available from: http://www.thelancet.com/article/S2352301817300152/fulltext and 24.3% in Salvador.¹⁰10 Leite BO, Magno L, Soares F, MacCarthy S, Brignol S, Bastos FI, et al. HIV prevalence among transgender women in Northeast Brazil - Findings from two Respondent Driven Sampling studies. BMC Public Health [Internet]. 2022 Dec 1 [cited 2023 Feb 22];22(1):2120. Available from: https://pubmed.ncbi.nlm.nih.gov/36401261/ The prevalence of HIV among adolescent travestis and TGW observed in this study is relatively low when compared to the adult group. This may be related to the fact that adolescents may have had little time between the onset of sexual activity and potential exposure to the risk of infection. It is noteworthy that, during the study period (February 2019 to March 2023), the COVID-19 pandemic led to a reduction in the number of sexual contacts observed in this population.²¹21 Ferraz D, Rossi TA, Zucchi EM, Deus LFA, Mabire X, Ferguson L, et al. “I Can’t Take This Shitty Quarantine Anymore”: Sexual Behavior and PrEP Use Among Young Men Who Have Sex with Men and Transgender Women in Brazil During the COVID-19 Pandemic. Arch Sex Behav [Internet]. 2023 Feb 1 [cited 2024 Aug 19];52(2):689-702. Available from: https://pubmed.ncbi.nlm.nih.gov/35881251/

In Brazil, a study conducted in Rio de Janeiro revealed that younger travestis and TGW, aged 18 to 24 years, were less likely to have ever undergone an HIV test (OR 0.4; 95%CI 0.2;0.7) compared to those older than 24 years.²⁴24 Wilson EC, Jalil EM, Moreira RI, Velasque L, Castro CV, Monteiro L, et al. High risk and low HIV prevention behaviours in a new generation of young trans women in Brazil. AIDS Care. 2021;33(8):997-1001. doi: 10.1080/09540121.2020.1844859
https://doi.org/10.1080/09540121.2020.18...

Access to HIV testing remains inadequate for the trans population. Despite the expansion of HIV testing services in primary healthcare, not all services and healthcare professionals are prepared to comprehensively attend to travestis and TGW.⁵5 Monteiro S, Brigeiro M. Experiências de acesso de mulheres trans/travestis aos serviços de saúde: avanços, limites e tensões. Cad Saude Publica. 2019;35(4):e00111318. doi: https://doi.org/10.1590/0102-311XER111318
https://doi.org/https://doi.org/10.1590/... ,¹⁶16 Monteiro S, Brigeiro M, Barbosa RM. Saúde e direitos da população trans. Cad Saude Publica. 2019 Apr 8;35(4):e00047119. doi: 10.1590/0102-311X00047119
https://doi.org/10.1590/0102-311X0004711... HIV testing is still largely concentrated in specialized services, which are few and do not provide effective and adequate access to this population.²⁵25 Pereira LBC, Chazan ACS. O Acesso das Pessoas Transexuais e Travestis à Atenção Primária à Saúde: uma revisão integrativa. Rev Bras Med Fam Comunidade. 2019 May 14;14(41):1795.

Receptive anal sex using a condom was rarely observed in this study. In Salvador, the prevalence of receptive anal sex using a condom in the last 6 months in 2016 and in the last 30 days in 2017 was 30.7% among travestis and TGW aged 18 years or older and 25.2% among travestis and TGW aged 15 years or older.¹²12 Leite BO, Medeiros DS, Magno L, Bastos FI, Coutinho C, Brito AM, et al. Association between gender-based discrimination and medical visits and HIV testing in a large sample of transgender women in northeast Brazil. Int J Equity Health [Internet]. 2021;20(199):1-11. doi: 10.1186/s12939-021-01541-z
https://doi.org/10.1186/s12939-021-01541... In Rio de Janeiro, the frequency of receptive anal sex using a condom with the last 3 partners among travestis and TGW aged 18 years or older was 31.8%.²⁰20 Grinsztejn B, Jalil EM, Monteiro L, Velasque L, Moreira RI, Garcia ACF, et al. Unveiling of HIV dynamics among transgender women: a respondent-driven sampling study in Rio de Janeiro, Brazil. Lancet HIV [Internet]. 2017 Apr 1 [cited 2023 Feb 22];4(4):e169-e176. Available from: http://www.thelancet.com/article/S2352301817300152/fulltext For young travestis and TGW aged 18 to 24 years old, there was a higher likelihood of engaging in condomless receptive anal sex with the last three partners compared to those older than 24 years (OR 1.8; 95%CI 1.1;3.0).²⁴24 Wilson EC, Jalil EM, Moreira RI, Velasque L, Castro CV, Monteiro L, et al. High risk and low HIV prevention behaviours in a new generation of young trans women in Brazil. AIDS Care. 2021;33(8):997-1001. doi: 10.1080/09540121.2020.1844859
https://doi.org/10.1080/09540121.2020.18...

Several factors may explain the low frequency of condom use during receptive anal sex among adolescent travestis and TGW compared to the general population: gender-based discrimination and limited access to healthcare services, which includes HIV prevention and care services;¹¹11 Magno L, Dourado I, Silva LAV, Brignol S, Amorim L, MacCarthy S. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: A mixed methods study. PLos One. 2018 [cited 2019 Jun 6];13(4):e0194306 doi: 10.1371/journal.pone.0194306
https://doi.org/10.1371/journal.pone.019... ,¹²12 Leite BO, Medeiros DS, Magno L, Bastos FI, Coutinho C, Brito AM, et al. Association between gender-based discrimination and medical visits and HIV testing in a large sample of transgender women in northeast Brazil. Int J Equity Health [Internet]. 2021;20(199):1-11. doi: 10.1186/s12939-021-01541-z
https://doi.org/10.1186/s12939-021-01541... lack of guidance or counseling on sexual education;⁵5 Monteiro S, Brigeiro M. Experiências de acesso de mulheres trans/travestis aos serviços de saúde: avanços, limites e tensões. Cad Saude Publica. 2019;35(4):e00111318. doi: https://doi.org/10.1590/0102-311XER111318
https://doi.org/https://doi.org/10.1590/... ,¹⁶16 Monteiro S, Brigeiro M, Barbosa RM. Saúde e direitos da população trans. Cad Saude Publica. 2019 Apr 8;35(4):e00047119. doi: 10.1590/0102-311X00047119
https://doi.org/10.1590/0102-311X0004711... involvement in sex work;⁴4 Magno L, Silva LAV, Veras MA, Pereira-Santos M, Dourado I. Stigma and discrimination related to gender identity and vulnerability to HIV/AIDS among transgender women: a systematic review. Cad Saude Publica [Internet]. 2019 Apr 8 [cited 2021 Feb 4];35(4):e00112718. doi: 10.1590/0102-311X00112718
https://doi.org/10.1590/0102-311X0011271... low self-esteem; and limited or no autonomy in deciding to use a condom during sexual intercourses.²⁶26 Xia D, Chen Y, Chang R, Xu C, Yu X, Liu Y, et al. Psychosocial Problems and Condomless Anal Sex among Transgender Women in Two Cities of China: Study Based on the Syndemic Framework. Int J Environ Res Public Health. 2022 Dec 1;19(23):16161. doi: 10.3390/ijerph192316161
https://doi.org/10.3390/ijerph192316161...

Despite the low frequencies of lifetime HIV testing and condom use during receptive anal sex among travesti adolescents and TGW, the initiation of daily oral PrEP use in this cohort was high, especially when compared to initiation rates among travestis and trans women. In Rio de Janeiro, a study involving travestis and adult TGW revealed a PrEP initiation rate of 48%.²⁷27 Jalil EM, Torres TS, Luz PM, Monteiro L, Moreira RI, Castro CRV, et al. Low PrEP adherence despite high retention among transgender women in Brazil: the PrEParadas study. J Int AIDS Soc [Internet]. 2022 Mar 1 [cited 2024 Jan 29];25(3):e25896. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/jia2.25896 The high frequency of initiation of PrEP use among adolescent travesti and TGW can be explained by their motivation for prevention due to their vulnerability. Additionally, the provision of youth-friendly services staffed by professionals trained to offer effective counseling may have contributed to this result. This may indicate that PrEP may be a valuable strategy for protection which is already highly vulnerable to HIV infection.²⁷27 Jalil EM, Torres TS, Luz PM, Monteiro L, Moreira RI, Castro CRV, et al. Low PrEP adherence despite high retention among transgender women in Brazil: the PrEParadas study. J Int AIDS Soc [Internet]. 2022 Mar 1 [cited 2024 Jan 29];25(3):e25896. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/jia2.25896,²⁸28 Moncayo JE, Pérez-Arizabaleta MDM, Villegas-Trujillo LM, Rodríguez-Ortiz A. Adherence to Oral Pre-Exposure Prophylaxis Intervention by Transgender Women: A Systematic Review. AIDS Educ Prev. 2023 Oct;35(5):362-75. doi: 10.1521/aeap.2023.35.5.362
https://doi.org/10.1521/aeap.2023.35.5.3... In 2022, the update of the Clinical Protocols and Therapeutic Guidelines for PrEP use were updated to expand access to adolescents aged 15 years and older.²⁹29 BRASIL. Ministério da Saúde. Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde. Secretaria de Vigilância em Saúde. Protocolo Clínico e Diretrizes Terapêuticas para Profilaxia Pré-Exposição (PrEP) de Risco à Infecção pelo HIV [Internet]. Brasília - DF; 2022 [ citado em 29 de Janeiro de 2024]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/protocolo_clinico_profilaxia_prep_1ed.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...

It is important emphasizing that the experience of gender-based discrimination reported by adolescent travesti and TGW in health services or by professionals in these services pose a barrier to access and adherence to combined prevention strategies, such as HIV testing and the use of PrEP. Even though the present study created welcoming services specifically aimed at the young transgender participants, previous experiences of discrimination in other services may hinder the breaking of internalized barriers among adolescent TGW in establishing trust with healthcare professionals or the service itself.¹²12 Leite BO, Medeiros DS, Magno L, Bastos FI, Coutinho C, Brito AM, et al. Association between gender-based discrimination and medical visits and HIV testing in a large sample of transgender women in northeast Brazil. Int J Equity Health [Internet]. 2021;20(199):1-11. doi: 10.1186/s12939-021-01541-z
https://doi.org/10.1186/s12939-021-01541... ,²⁷27 Jalil EM, Torres TS, Luz PM, Monteiro L, Moreira RI, Castro CRV, et al. Low PrEP adherence despite high retention among transgender women in Brazil: the PrEParadas study. J Int AIDS Soc [Internet]. 2022 Mar 1 [cited 2024 Jan 29];25(3):e25896. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/jia2.25896,³⁰30 Magno L, Medeiros DS, Soares F, Grangeiro A, Caires P, Fonseca T, et al. Factors associated to HIV prevalence among adolescent men who have sex with men in Salvador, Bahia State, Brazil: baseline data from the PrEP1519 cohort. Cad Saude Publica [Internet]. 2023 [cited 2023 Jun 17];39Suppl 1(Suppl 1):e00154021. Available from: https://pubmed.ncbi.nlm.nih.gov/36995866/
https://pubmed.ncbi.nlm.nih.gov/36995866...

This study had some limitations. The sample size and convenience sampling hinder the application of more robust methodologies for determining the magnitude of effects between the variables studied. However, the sample size did not pose a barrier, as the study’s intent is descriptive, and its findings align with those reported in the literature.

While there is motivation to seek prevention strategies, gender-based discrimination, especially in the context of health care for adolescent transgender women, is one of the main obstacles for establishing effective and ethical health care. As a result, access to HIV prevention, such as regular testing, early diagnosis or the use of preventive methods, such as access to condoms or PrEP, are limited. For adolescents, the absence of preventive behaviors and attitudes may persist throughout their lives.

It is necessary to eradicate gender-based discrimination in healthcare and ensure adequate access for the transgender population from adolescence onwards. Key actions include: expanding healthcare coverage for adolescent TGW within the Brazilian National Health System beyond specialized outpatient clinics; investing in demand creation through initiatives that attract younger populations; and ensuring service linkage by establishing welcoming spaces within the Brazilian National Health System.

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