HIV Exposure and Infection Correlates in Transfeminins and Cisgender Men Having Sex with Men in Nairobi, Kenya: an Observational Study
Transgender people are disproportionately affected by HIV and other sexually transmitted infections (STIs) around the world, and culturally competent prevention and treatment services are often unavailable or inaccessible. Despite recent improvements in national HIV responses for many key populations in East Africa, there is little evidence of effective responses based on transgender sexual health needs. We wanted to assess the gender identity of men and transgender people who have sex with men in Kenya and examine their associations with sexual health outcomes, risk behavior, and uptake of HIV prevention and care interventions.
We conducted a cross-sectional study in Nairobi, Kenya, and recruited adult cisgender men and transfeminine individuals who reported having sex with men through interviewed samples. Inclusion criteria were possession of a valid study coupon who was at least 18 years old, had a male gender assignment or gender identification at birth, lived within 50 km of Nairobi, and had consensual anal or oral sexual activity with a man in the United States previous 12 months. The seed participants were identified by three community organizations providing targeted health services to gay, bisexual or other men who have sex with men (MSM) in Nairobi. We assessed gender identity, sociodemography, sexual behavior, HIV prevention and care utilization through a self-completed survey. Participants were tested for HIV, syphilis, and rectal and urethral gonorrhea and chlamydia. We compared the prevalence of sexual health outcomes, risk behavior, and uptake of HIV prevention and care services among transfeminine and cisgender participants using multivariable robust Poisson regression models with gender identity as an independent variable.
Between May 4th and December 8th 2017 we enrolled 618 participants. Six participants did not answer the questions about gender and gender identity at birth and were therefore excluded from the analyzes. 522 (sample-weighted percentage 86%) of 612 participants were classified as cisgender men, 70 (11%) as transfeminin and three (<1%) as transmasculin. 17 participants (2%) did not identify as male, female or transgender. Transfeminins were more likely to be HIV positive when compared to cisgender men (28) [41%] of 70 transfeminine vs 151 [25%] of 521 cisgender men; p = 0x0009) and to report current symptoms consistent with a rectal STI (eight [16%] of 67 vs 38 [7%] of 518; p = 0.014). Transfeminines reported a higher number of male sexual partners recently (22 [27%] Out of 70 transfeminine people reported having four or more male sexual partners in the last 3 months, versus 112 [13%] of 522 cisgender men; p = 0.042) and were more likely to report condom-free anal intercourse with men (43) [62%] of 70 vs 208 [39%] of 522; p = 0.0009) and receptive anal intercourse (54 [76%] of 70 vs 252 [46%] of 522; p <0.0001) in the last 3 months and transactional sex with men (42 [57%] of 69 vs 240 [42%] of 518; p = 0.023) and experience of sexual assault (16 [23%] of 69 vs 65 [11%] of 520; p = 0.019) in the last 12 months. The use of pre-exposure prophylaxis and post-exposure prophylaxis was low in both groups.
Transfeminine people who have sex with men have higher levels of HIV exposure and associated risk behavior than cisgender MSM in the same context, but their use of prevention and care services is low. The guidelines should take into account the specific needs of transfeminines as distinct from cisgender MSM and help healthcare providers meet these needs.
Evidence for HIV Prevention in Southern Africa (EHPSA), UK Aid.