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Further, PrEP provides those who experience elevated HIV risk increased autonomy compared to other prevention strategies such as condoms [ 2 ]. Transgender women defined as people who identify as women and were assigned a male sex at birth experience disproportionately elevated HIV incidence rates and can benefit from PrEP.
Engagement in sex work can further elevate social and structural vulnerabilities, thereby increasing vulnerability to HIV [ 38 ]. A growing body of literature has focused on identifying factors impacting PrEP continuum engagement amongst transgender populations [ 30 , 37 , 46 ].
Findings include: concerns around medication side effects, in particular interactions with hormones [ 17 ], health provider distrust due to enacted and anticipated transphobia [ 10 , 35 ], PrEP stigma and its intersection with HIV stigma [ 6 , 11 ], exclusion of trans people in PrEP marketing [ 35 ], structural instability due to economic marginalization and homelessness [ 46 ].
Conversely, potential facilitators to PrEP engagement include individual self-perceived HIV risk [ 9 ], interpersonal peer influence and social support and access to gender affirming PrEP service sites [ 20 ]. In Baltimore City, despite efforts by the Health Department to prioritize PrEP awareness and uptake among identified priority populations including transgender women through social innovation projects, recent studies indicate important PrEP continuum gaps and suboptimal PrEP uptake.
