key: cord-0286954-jknb1kvk authors: Carosella, E. A.; Huerta, L.; Galea, J. T.; Lecca, L.; Ramos, K.; Hernandez, G.; Franke, M. F.; Peinado, J. title: Towards increasing equity in healthcare among transgender women: a cross-sectional analysis of self-reported needs and health service utilization in Lima, Peru date: 2022-02-02 journal: nan DOI: 10.1101/2022.02.01.22270281 sha: 41da724d090d615ce91b7eb347d4bf9ee0a17bb5 doc_id: 286954 cord_uid: jknb1kvk Globally, transgender women experience wide-ranging barriers to health and care, with disproportionately high risks of infectious and chronic diseases, mental illness, violence, and substance abuse. Despite these vulnerabilities, research on transgender populations in low- and middle-income countries is extremely limited. Furthermore, existing studies have primarily focused on HIV/AIDS, with less emphasis on transgender women's broader health needs. This cross-sectional study conducted in Lima, Peru aimed to analyze patterns of morbidity and health service uptake to identify subgroups that be especially in need of health interventions to improve access. We identified suboptimal levels of health coverage and access to care, with less education and older age as important risk factors for self-reported illness and HIV and tuberculosis (TB) testing, and differential HIV testing and pre-exposure prophylaxis (PrEP) usage among gender identity subgroups within Peru's broader community of transgender women. Both awareness of and interest in PrEP were suboptimal, and usage was low among those who were interested in taking PrEP. Future public health efforts should be tailored to the diverse needs of transgender women, bridge the gap between PrEP interest and use, and increase insurance coverage and access to trans-friendly services to promote improved health outcomes and equity. stigma leads to marginalization and vulnerability, which undermine transgender women's educational attainment, safe employment, and access to and utilization of healthcare. 1 As a result, transgender women suffer disproportionately high rates of sexually transmitted infections (STIs), substance abuse, physical violence and injury, mental illness, and chronic diseases. 2 3 4 Latin America is one of the least hospitable places for transgender women in the world, with nearly 80% of reported murders of transgender people globally occurring in the region. 5 Transphobia accompanies cultural conservativism and pervasive machismo, 6,7 a concept of masculinity that is characterized by traditional beliefs about gender roles and men's superior status in society and associated with controlling, aggressive attitudes and behaviors. Despite recent regulatory improvements in some countries, most Latin American countries deny transgender women legal recognition of their gender identity, access to gender affirming care, and a host of other benefits and protections. 8 Transgender women experience widespread discrimination and abuse, including at health facilities, where providers may refuse treatment or give inadequate care. 9 Transgender women are often forced to leave home after experiencing physical, sexual, and/or verbal violence and family rejection, 10 11 with many migrating to cities where they have few resources and support networks. 12 High prevalence of sex work, often one of the only livelihood options available, 13 14 is linked with risky behaviors 15 and increases risks for STIs and other infectious diseases. 16 13 While the evidence base around sexual health and HIV/AIDS among transgender women has grown, their broader health needs and healthcare utilization remain understudied. 4 17 Data on transgender populations are scarce, in part, because until recently it was common practice to combine this population with MSM. Indeed, less than 0.01% of published articles in PubMed focus on transgender populations, with the majority from the United States and other high-income countries. 18 A limitation to existing epidemiologic research of transgender women is that it largely assesses them as a single, homogenous group. However, there are diverse gender identities within the broader transgender community that impact social perceptions, lived experiences, and behavior trends. 19 In Peru, commonly used terminology ascribes different individual characteristics: "travesti," refers to transgender women who "utilize female dress full time," while "transformistas," alternate between masculine and feminine appearance, often presenting as male in public places or places of work. 19 The umbrella term "trans," on the other hand, is not consistently applied in the literature or in practice. 4 There is also a lack of quantitative research on sub-groups within Peru's transgender women community to understand which groups may be at higher risk of poor health or barriers to healthcare utilization. Our research sought to improve understanding and promote visibility of the health inequities facing Peru's transgender women. Specifically, this cross-sectional study aimed to identify risk factors and patterns of morbidity and health service uptake to identify the most vulnerable subgroups within this population, and to inform future public health outreach and interventions. Féminas is the oldest organization of its kind in Peru and has one of the most extensive networks of transgender women in the country. Participants and recruitment: The recruitment process occurred in two steps: first, all Féminas members in participating districts were contacted by phone and invited to participate, after which peer enumerators -transgender women affiliated with Féminas -made in-person visits with each respondent to administer the survey. Inclusion criteria were that respondents be at least 18 years of age, identify as transgender women, and reside in a district of metropolitan Lima, with confirmation by a Féminas peer enumerator. Participants were excluded if they lacked capacity to consent or complete the survey, or reported active SARS-CoV-2 symptoms. Each participant who met the criteria gave informed consent. Of All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 2, 2022. ; https://doi.org/10.1101/2022.02.01.22270281 doi: medRxiv preprint a total of 311 transgender women who were invited to participate, 10 either refused to participate or did not respond to phone calls, leaving a total of 301 people completed the survey. Participants were drawn from Féminas de Lima's extensive network, with near even participation of transgender women who were originally from Lima (46.5%) as those originally from other regions of the country (53.5%). Data collection: Respondents filled out paper surveys, which took approximately 40 minutes to complete. These were then digitized by study staff and uploaded to a central database. The objective of the survey was to understand the broader health profile, including service utilization, of transgender women in Lima with the ultimate aim of informing future public health outreach and interventions. Survey questions addressed demographics, stigma, discrimination, drug and alcohol consumption, access to health services, TB and HIV testing, PrEP knowledge and usage, and mental health. Sample characteristics (i.e., age group, education, department of origin, employment, and gender identity) were described by frequencies and percentages. Age was examined as a categorical variable (i.e., younger than 27 years, 27 -36, and 36 and older), with the upper and lower thresholds corresponding to the highest and lowest quartiles of the distribution. For analyses of gender identity, the self-reported categories of "trans" and "transgender" were pooled into the "trans" category, as Féminas leadership confirmed that these terms are understood synonymously. Next, we evaluated whether these characteristics predicted binary outcomes of insurance coverage, self-reported illness, regular clinic attendance, TB and HIV testing, and PrEP usage. Bivariate Poisson regression models with robust error variance were fitted to calculate unadjusted prevalence ratios (PRs) and 95% confidence intervals. We All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 2, 2022. ; https://doi.org/10.1101/2022.02.01.22270281 doi: medRxiv preprint then fitted multivariable models to report prevalence ratios (aPRs) and 95% confidence intervals, adjusted for the other predictors of interest, some of which may confound one another. Socio-demographic characteristics among 301 transgender women participants are shown in had completed higher than secondary education. The vast majority were currently working (79.1%), and sex work was the most common livelihood reported (48.2%). More than half were originally from outside of Lima (53.5%). Many reported living in shared spaces or communal homes: 38.2% reported renting a single room and another 10.6% lived in hostels. Trans or transgender (58.5%) was the most common gender identity, followed by women (15.3%), transformistas (9.0%), transsexuals (8.3%), and travestis (7.0%). Insurance: As described in Table 2 , more than a third (35.2%) of the respondents were uninsured. Of those with insurance, the subsidized public health insurance Seguro Integral de Salud (SIS) (translated as "Comprehensive Health Insurance") was the most common (53.8%), followed by the contributory public social health insurance (EsSalud) (7%), private insurance (3.7%), and supplementary private insurance (EPS) (0.3%). All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. CI: 0.10, 0.72). Older transgender women were relatively more likely to report illness and clinic All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 2, 2022. ; https://doi.org/10.1101/2022.02.01.22270281 doi: medRxiv preprint attendance, though confidence intervals for these estimands were wider and included one ( Table 3) . Older age was also significantly associated with reduced prevalence of sex work (aPR for 27 -36 years: 0.69 (95% CI: 0.55, 0.87); aPR for those > 36 years: 0.44 (95% CI: 0.31, 0.64)). Education: Compared with respondents who had higher than secondary education, transgender women with primary education or less had a higher prevalence of being uninsured (aPR = 1.77, 95% CI: 1.04, 3.03) and reporting illness (aPR =2.61, 95% CI: 1.07, 6.40). They also were less likely to report TB testing (aPR=0.29, 95% CI: 0.05, 1.89), HIV testing (aPR =0.71, 95% CI: 0.40, 1.24), and PrEP utilization (aPR =0.44, 95% CI: 0.08, 2.54), though confidence intervals were wide around some estimates. Origin: We did not find strong evidence that origin outside of Lima predicted the outcomes under study. Employment: Employed transgender women had a significantly lower relative prevalence of selfreported illness (aPR=0.48, 95% CI: 0.27, 0.85) and were less likely to report clinic attendance (aPR=0.88, 95% CI: 076, 1.02).The relationship between employment and illness or clinic attendance did not appear to depend on whether that employment was sex work (p-value for interaction = 0.31). Employment did not appear to impact TB testing (aPR=1.01, 95% CI: 0.47, 2.18) or HIV testing (aPR=0.95, 95% CI: 0.66, 1.37). Gender Identity: Transgender women who identified as women were more likely to test for HIV (aPR=1.49, 95% CI: 1.16, 1.91) and TB (aPR=1.69, 95% CI: 0.89, 3.22), and to use PrEP (aPR=2.36, 95% CI: 1.15, 4.80) compared to those who identified as trans or transgender. Self-identified women also had a higher relative prevalence of surgical procedures: PR: 1.73 (0.92, 3.24). Those who indicated their gender identity as "other" were significantly more likely to use PrEP (aPR=5.64, 95% CI: 2.75, 11.58). All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This study identified a diverse population with varying health needs and service utilization patterns. Overall, we found suboptimal levels of health coverage and care among transgender women, while education and age emerged as important risk factors for many outcomes. In the first study to quantitatively examine health utilization by gender identity subgroups in Peru, we also found that transgender women who identify as women had higher HIV testing and PrEP uptake compared to those who identify as trans or transgender. Nearly one in five respondents did not receive healthcare through a health clinic. This may be due to a combination of factors that contribute to poor linkages to and retention in healthcare. 32 Over one third of our sample did not have health insurance of any kind, with younger and less educated transgender women least likely to be insured. In Peru, national ID cards typically do not reflect transgender women's true gender identity, 33 which can obstruct administrative processes or elicit harassment from authorities. Many transgender women either lack ID cards entirely or do not use them for fear of being subjected to ridicule or abuse, including in health centers. 33 Because national ID cards are required for Peruvians to enroll in coverage through the SIS, despite regulatory changes in recent years to loosen restrictions for changing gender on national IDs, this remains a barrier to healthcare access. The lack of differentiated services or trans-friendly spaces within Peru's health system is likely another important barrier. 26 Gender affirming healthcare is rarely provided in public facilities and we found high prevalence of non-surgical gender enhancement practices-mainly, hormone injections and silicone implants, which are often obtained outside the health system without medical supervision. 13 19 12 Previous studies found that many transgender women self-administer treatments or rely on medicallyunqualified acquaintances. 13 19 Medical providers and staff may lack training and cultural competency to provide quality health services to transgender women, 34 26 and the expectation of hostile, discriminatory, or substandard treatment may deter even those transgender women who have public health insurance from seeking facility-based care. To date most scholarship has focused on patient perspectives, however, and All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 2, 2022. ; https://doi.org/10.1101/2022.02.01.22270281 doi: medRxiv preprint there is a need for more research on providers' knowledge, attitudes, and other supply-side barriers to care facing transgender women. Though HIV testing rates were generally high, we identified disparities by age and education level, with older and less educated transgender women less likely to have been tested. Older transgender women may have had less exposure or access to preventive testing, free anti-retroviral treatment, and informational and anti-stigma campaigns, which have become more common over time. In addition, though nearly half of respondents engage in sex work, putting them at increased risks for HIV, HIVassociated TB, and other STIs, 15 increasing age was associated with a decline in sex work. Older women may have a reduced HIV risk or perception of risk, leading them to test less frequently. We also found that transgender women who identify as women were 54% more likely to have been tested for HIV. A sub analysis found that self-identified women had nearly twice the rate of surgical procedures compared to those who identified as trans or transgender. Together with findings on testing rates, this might reflect that having a physical appearance that aligns with a traditional binary gender reduces some friction in transgender womens' interaction with the health system. It could be that identifying as a woman is a marker of access to care. More qualitative research on how different gender identities impact the testing and broader healthcare utilization could better illuminate this finding. We also note that this research exclusively studied transgender women, and that there is little research available on Peruvian transgender men or non-binary populations. About two in five transgender women (39.9%) had never heard of PrEP, and there was a large gap between those who expressed interest in PrEP (55.8%) and, among those who had heard of PrEP, reported using it (21.0%). Among the overall sample, prevalence of PrEP usage was just 12.6%. Prior research found that anticipated out-of-pocket costs over time greatly reduced acceptability of PrEP and also documented concerns among transgender women that PrEP would disincentivize condom usage among PrEP users. 35 Another factor is the mistrust of medical institutions, including widespread doubts about safety and efficacy and suspected ulterior motives of international actors offering free PrEP, All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 2, 2022. ; https://doi.org/10.1101/2022.02.01.22270281 doi: medRxiv preprint reduced acceptance. 27 Perez-Brumer et al. found that limited perceived benefits, research clinicians' disregard of PrEP-related side effects, and feelings of exploitation in the face of persistent barriers to PrEP access outside of research environments fueled mistrust. Further qualitative research among those who reported interest but not uptake could help to disentangle supply-versus demand-side factors and inform communication strategies to improve knowledge and increase demand for PrEP. It is also unclear why participants who selected "other" as their gender identity group had significantly greater PrEP usage. This group may include transgender women in transition or who have not embraced a single gender identity label. 36 Looking forward, long-acting injectable PrEP, cabotegravir (CAB -LA) 37, 38 and was approved by the US FDA in December 2021, 39 may reduce barriers related to the stigma of daily oral medication, dosing, and adherence. TB testing was low with over a third of the sample never tested and another 4 in 10 transgender women reporting that they had not been tested for at least a year. TB is an important public health concern in Peru, which has the second highest TB incidence in the western hemisphere and is the only Latin American country on the WHO's top 30 high multi-drug resistant TB (MDR-TB) burden countries. 40 In addition to the high national burden of TB and its well-established circular relationship with HIV/AIDS, many transgender women in Lima cluster together in communal homes, which can speed TB transmission from infected housemates. Because stigma and discrimination is so extreme, transgender women are not accepted in most neighborhoods: among our sample, nearly half live in shared housing or hostels in the few districts where they can secure housing 31, 41 . Thus, transgender women likely are at a disproportionately high risk of TB infection. However, to our knowledge, there is no published data on TB incidence or prevalence among transgender women in Peru. Research in other countries suggests that TB poses a significant risk to transgender women's health: a recent study found pulmonary TB infection among 52.6% of sampled transgender women in Papua New Guinea. 42 Whereas public health efforts to expand HIV testing have explicitly targeted transgender women throughout Peru, there is wide variation in TB knowledge and testing levels. Among our sample in Lima, All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 2, 2022. ; https://doi.org/10.1101/2022.02.01.22270281 doi: medRxiv preprint we saw a major drop in testing among older transgender women -those 36 and over were 70% less likely to have ever been tested. Although our sample included a broad range of ages and was relatively young -the vast majority can be categorized according to current MeSH classifications 43 as adult or middle aged (45 -64), Negin et al. identified a growing disease burden among older adults in Latin America. Targeted outreach to these groups is important to connect them to TB testing and treatment. Along with existing HIV programs, there may also be opportunities to build on recent strategies and infrastructure for COVID-19 testing. This was an exploratory analysis aiming to identify subgroups of transgender women who could be targeted for interventions to improve access to care. As such, we examined a number of correlates and outcomes. We did not adjust for multiple comparisons because sample size was variable and we sought to identify disparities based on patterns of utilization rather than one-off associations. There is potential for selection bias; however, we expect that this is limited given Féminas' extensive network and the high participation rate. The study relied on self-reporting rather than structured diagnostic interviews or verification of medical records, which could result in misclassification of some exposure or outcome variables, thereby introducing bias, the direction of which may be difficult to predict. Finally, meanings associated with gender identity labels are consistently evolving: certain terms, like "transsexual," become less commonly used and others like "trans" begin to subsume previous catch-all terms like "travesti." This may limit interpretation or generalizability of associations with specific gender identity labels presented in this paper. Our findings highlight continuing barriers to health coverage and services among Peruvian transgender women. Public health outreach and interventions should aim to expand insurance coverage and extend access to trans-friendly services for transgender women who do not seek care through the All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 2, 2022. ; https://doi.org/10.1101/2022.02.01.22270281 doi: medRxiv preprint formal health system, particularly younger transgender women. While HIV testing rates are high, PrEP uptake remains suboptimal among this high-risk population, and further efforts are needed to bridge the gap between interest and usage. Finally, TB research and testing must dramatically increase, though there may be synergies with existing HIV and COVID-19 programs that can be leveraged. (2.75, 11.58)* * Significantly different than zero at 95% confidence. ◊ Adjusted for age group, education level (primary or less, secondary, or higher than secondary), department of origin (Lima or other), current employment (yes/no), sex work (yes/no), and gender identity. 2. 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(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted Blueprint for the Provision of Comprehensive Care for Trans Persons and Their Communities in the Caribbean and Other Anglophone Countries. Pan American Health Organization Need for more research on and health interventions for transgender people You should build yourself up as a whole product The Gender Identity in U.S. Surveillance (GenIUSS) Group. Best Practices for Asking Questions to Identify Transgender and Other Gender Minority Respondents on Population-Based Surveys. The Williams Institute Perceived Barriers and Facilitators to Integrating HIV Prevention and Treatment with Cross-Sex Hormone Therapy for Transgender Women in Lima Increasing PrEP Uptake and Adherence among MSM and TW Sex Workers in Lima, Perú: What and Whom Do Different Patients Trust? AIDS Care Peru's HIV care continuum among men who have sex with men and transgender women: opportunities to optimize treatment and prevention Acceptability of pre-exposure prophylaxis as an HIV prevention strategy: barriers and facilitators to pre-exposure prophylaxis uptake among at-risk Peruvian populations Centro Comunitario y Albergue para Personas Transgénero en el Distrito de la Victoria Long-Acting Injectable Form of HIV Prevention Outperforms Daily Pill in NIH Study. NIH National Institute of Allergy and Infectious Diseases Ni empleadas ni ciudadanas: no hay tregua para las mujeres trans High prevalence of pulmonary tuberculosis among female sex workers, men who have sex with men, and transgender women in Papua New Guinea We are grateful to the study participants for sharing their experiences. Socios En Salud Peru developed the survey, collected the data and analyzed findings. Féminas co-designed the survey, supplied peer community health workers, and contributed to the analysis. All authors declare no conflict of interest.All rights reserved. No reuse allowed without permission.(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.