# Social and structural drivers of HIV vulnerability among a respondent‐driven sample of feminine and non‐feminine presenting transgender women who have sex with men in Zimbabwe

## TL;DR

This study explores how social and structural factors increase HIV risk for transgender women in Zimbabwe, especially those who present as feminine.

## Contribution

The study identifies specific social and structural inequities faced by feminine-presenting transgender women in Zimbabwe, contributing to their heightened HIV vulnerability.

## Key findings

- Feminine-presenting transgender women experienced higher rates of arrest, rejection, and harassment compared to non-feminine presenting individuals.
- Feminine-presenting transgender women were more likely to engage in transactional sex and non-injection drug use, which may increase HIV risk.
- The study highlights the need for gender-affirming and psychosocial support services to mitigate HIV vulnerability among transgender women in Zimbabwe.

## Abstract

We sought to characterize social and structural drivers of HIV vulnerability for transgender women (TGW) in Zimbabwe, where TGW are not legally recognized, and explore differences in vulnerability by feminine presentation.

A secondary analysis was conducted with a sub‐sample of participants recruited from a 2019 respondent‐driven sampling survey that comprised men who have sex with men, TGW and genderqueer individuals assigned male sex at birth, from two cities in Zimbabwe. Survey questionnaires captured information related to socio‐demographics, sexual and substance use behaviours, and social and structural barriers to HIV services. Secondary analyses were restricted to participants who identified as female, transfemale or transwomen (236/1538) and were unweighted. Descriptive statistics were used to calculate sample estimates and chi‐square and Fisher's exact tests were used to assess differences in vulnerability by feminine presentation.

Among 236 TGW, almost half (45.3%) presented as feminine in the 6 months preceding the survey and 8.5% had ever used hormones to affirm their gender identities. Median age among TGW was 23 years (interquartile range: 20–26). Feminine presenting TGW in our sample had higher prevalence of arrest (15.9% vs. 3.9%), rejection by family/friends (38.3% vs. 14.0%), employment termination (11.2% vs. 3.9%), employment refusal (14.0% vs. 3.9%), denial of healthcare (16.8% vs. 2.3%), physical, sexual or verbal harassment or abuse (59.8% vs. 34.1%), alcohol dependence (32.7% vs. 12.4%), recent transactional sex with a male or TGW partner (30.8% vs. 13.3%) and recent non‐injection drug use (38.3% vs. 20.2%) than non‐feminine presenting TGW (all p‐value <0.05).

Findings suggest that TGW, particularly feminine presenting TGW, experience social and structural inequities which may contribute to HIV vulnerability. Interventions aimed at addressing inequities, including trans competency training for providers and gender‐affirming, psychosocial and legal support services for TGW, might mitigate risk.