# HIV Preexposure Prophylaxis Utilization and Reasons for Never Using Preexposure Prophylaxis Among Transfeminine Persons in the United States: Findings From the Transgender Women’s Internet Survey and Testing (TWIST) Study

## TL;DR

A national survey found low HIV preexposure prophylaxis (PrEP) use among transfeminine people in the U.S., with age-specific barriers like insurance concerns and transportation issues.

## Contribution

This study provides the first national data on PrEP use and barriers among transfeminine persons in the U.S., highlighting age-specific differences.

## Key findings

- Only 6% of transfeminine participants were currently using PrEP, with most using oral PrEP and a small percentage using long-acting injectable PrEP.
- Younger participants (15–24 years) cited privacy and transportation concerns as barriers to PrEP use, while older participants cited insurance loss and side-effect worries.
- Long-acting injectable PrEP may help address adherence and disclosure challenges, particularly among younger individuals.

## Abstract

Transfeminine persons in the United States face a high burden of human immunodeficiency virus (HIV), yet national data on preexposure prophylaxis (PrEP) use remain limited. We examined PrEP utilization, adherence, and persistence and reasons for never using PrEP among a national sample of transfeminine persons.

Sexually active transfeminine persons aged ≥15 years without HIV were recruited online through the Transgender Women's Internet Survey and Testing (TWIST) Study, a national cross-sectional survey conducted between June 2023 and October 2024. Multivariable Poisson regression was used to estimate adjusted prevalence ratios for characteristics associated with current PrEP use. Reasons for never using PrEP were examined descriptively by age group.

Among 1656 participants, 6% were currently using PrEP and 86% had never used PrEP. Among current users (n = 96), 94% used oral PrEP and 6% used long-acting injectable (LA) PrEP. Among the 32 participants who reported using <30 daily PrEP doses in the past 30 days, 25% indicated that they were using event-driven (on-demand) PrEP, taking it only when they anticipated having sex. In multivariable models, current PrEP use was higher among participants aged ≥40 years, Black participants, and participants reporting a sexually transmitted infection diagnosis, multiple sexual partners, illicit drug use, or prescribed medication use. Common reasons for never using PrEP among participants aged 15–24 years included insurance-related privacy and disclosure concerns and transportation barriers, while among participants aged ≥25 years, reasons included loss of insurance, side-effect concerns, and monogamous partnerships.

PrEP uptake among transfeminine persons remains low, with distinct age-specific barriers. Tailored interventions are needed. LA PrEP may help address challenges related to adherence and disclosure, particularly among younger individuals.

In a national survey of transfeminine persons without HIV, preexposure prophylaxis (PrEP) use was low (6%), with age-specific barriers including insurance concerns, transportation, and side-effect worries. Long-acting injectable PrEP may improve uptake and adherence.