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HIV prevention intervention in young transgender women results in safer sex

Robert Garofalo



An intervention to reduce the sexual risk for HIV in young transgender women resulted in a nearly 40% reduction of condomless sex acts at 1-year follow-up compared with participants who received standard of care, according to study results published today in JAMA Pediatrics.

“For transgender women in the United States, evidence suggests that the prevalence of HIV is very high, including among young transgender women (YTW) aged 16 through 29 years,” Robert Garofalo MD, MPH, division chief of adolescent medicine and director of the Center for Gender, Sexuality and HIV Prevention at Ann & Robert H. Lurie Children’s Hospital of Chicago, and colleagues wrote.

Garofalo told Infectious Disease News that “the intervention was developed by and for transgender women based on their social realities. It was a community participatory project from start to finish, with YTW being part of every aspect of the study — from study design, to intervention development, to recruitment and study implementation.”

Garofalo and colleagues conducted a randomized clinical trial of Project LifeSkills, a group-delivered behavioral HIV prevention intervention, comparing it with standard of care. They enrolled 190 sexually active YTW from March 26, 2012, to Aug. 15, 2016, in Boston and Chicago. The study participants were born male but self-identified as female, transgender women or on the transfeminine spectrum and reported sexual risk in the preceding 4 months. They were randomly assigned 2:1 to receive LifeSkills intervention (n = 116) or standard of care only (n = 74). The LifeSkills intervention was delivered in 2-hour small group sessions twice a week for 3 consecutive weeks and used approaches recommended by a workgroup of the NIH Health Behavior Change Consortium.

The primary outcome was change in number of self-reported condomless anal or vaginal sex acts in 4 months before baseline and at 4-, 8- and 12-month visits.

The participants had a mean age of 23.4 years; 24.7% were white, 43.7% were black and 13.2% were Hispanic or Latina. Forty participants (21.1%) were HIV infected at baseline, including 35 with previous diagnoses and five participants with newly diagnosed HIV.

At 4 months, the LifeSkills cohort had a 30.8% greater mean reduction in condomless sex acts compared with the standard of care group (2.26 at baseline vs. 1.22 at 4 months, 2.69 at baseline vs. 2.10 at 4 months, respectively; RR = 0.69; 95% CI, 0.60-0.80). At 1 year, the LifeSkills cohort had a 39.8% greater mean reduction in condomless sex acts compared with the standard of care cohort (0.71 vs. 1.40; RR = 0.60; 95% CI, 0.50-0.72).

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“Thirty-plus years into this epidemic, it is somewhat appalling that to date there has not been an intervention that has been shown to be effective with trans women — a demographic group well known to be if not at the highest risk for acquiring HIV, certainly a very high-risk group based largely upon sexual behavior,” Garofalo said. “This study changes that. Grounded in the social realities of the study population, it is the first study shown to have efficacy in reducing sexual risk for acquiring HIV among young trans women.

“Our hope is that LifeSkills can now be used by agencies all across the country that serve transwomen. And that it can be used coordination with other prevention strategies like [pre-exposure prophylaxis] as part of more holistic approached to curb the epidemic.”

In an accompanying editorial, Brittany J. Allen, MD, assistant professor of general pediatrics and adolescent medicine at the University of Wisconsin School of Medicine and Public Health, wrote, “To say that the burden of HIV among transgender women is disproportionately high greatly understates this inequity: transgender women have an estimated 48.8-fold increased odds of contracting HIV compared with other adults of reproductive age globally. Prevalence rates of HIV in transgender women are 21.7% and 19.1% in the United States and worldwide, respectively.”

She added that “Despite the limits and challenges of researching HIV in transgender women, both in this study and others, action to improve HIV prevention in this population is imperative. Perhaps most striking in this study is the high rate of HIV infection (21.1%) of this young group of participants at baseline, suggesting that prevention methods should target transgender women even younger than 16 to 29 years of age.” – by Bruce Thiel

Disclosure: The authors report no relevant financial disclosures.