In the ongoing battle against HIV, a recent study sheds light on a critical yet often overlooked aspect of prevention: the unique needs and preferences of transgender and nonbinary adults. This research, focusing on long-acting injectable pre-exposure prophylaxis (LA-PrEP), offers valuable insights into how we can better serve a community disproportionately affected by HIV. It underscores a broader imperative in healthcare: the need to design interventions with, not just for, the communities they aim to serve (Restar et al., 2024).

The Study: Summary of Key Findings

The research used a Discrete Choice Experiment (DCE), a preference-elicitation method commonly used in marketing research and health economics, to assess which attributes of a gender-affirming LA-PrEP program are most important to participants. Transgender adults in Washington State (n=366) were asked to choose between hypothetical program profiles, each with different combinations of attributes related to: duration of LA-PrEP protection, type of healthcare provider, site of LA-PrEP injection, care facility type, and type of hormone prescriptions available through the program. Key findings were that:

• Gender-affirming care providers were preferred for LA-PrEP administration over HIV or primary care providers.
• Participants valued the convenience of integrating both oral and injectable hormone therapy with HIV prevention services.
• Longer durations of PrEP protection (e.g., 12 months) and injection in the upper arm were strongly preferred (Restar et al., 2024).

The study underscores that transgender adults want comprehensive care that combines both HIV prevention and gender-affirming services. This holistic approach addresses both their medical needs (HIV prevention) and personal gender goals, which often involve hormone therapy (Restar et al., 2024).

The Broader Context: Addressing Disparities and Promoting Inclusivity

HIV continues to disproportionately affect transgender communities. For example, HIV prevalence in the United States is under 0.5% in the general population but skyrockets to over 14% among transgender women, with the highest rates seen in Black and Latina transgender women (Becasen et al., 2019). Despite this, PrEP uptake remains low in trans communities. A national survey showed that only 32-35% of transgender women were using PrEP by 2021, even though it is a key tool in preventing new infections (Centers for Disease Control and Prevention, 2021).

Why is this happening? The barriers to PrEP uptake are multi-faceted:

• Stigma and discrimination: Transgender individuals often face hostility or discomfort in healthcare settings, making them less likely to engage with preventative health services (Feldman et al., 2021).
• Misinformation: There is confusion around drug interactions, particularly between hormone therapy and PrEP, even though studies show no significant interactions (Hiransuthikul et al., 2019).
• Access and affordability: Many trans people are uninsured or underinsured, limiting their access to consistent care (Restar et al., 2024).

Health Equity and Choice Architecture

The Restar et al., 2024 study illuminates how public health programs can use insights from behavioral economics to design interventions that align with the preferences of the communities they serve (Galárraga et al., 2023). Applying the insight of choice architecture, programs can be structured in a way that makes health-promoting decisions easy and appealing for the end user (Thaler & Sunstein, 2021). For instance, in the case of LA-PrEP, transgender adults value receiving care in environments where they feel respected and affirmed in their gender identity. Ensuring that LA-PrEP is delivered in gender-affirming clinics, or by providers trained in culturally competent care, is crucial to improving uptake. Additionally, simplifying care by combining PrEP appointments with hormone therapy (a service many trans individuals already access regularly) meets participants’ preference for convenience and integrated care (Restar et al., 2024).

Lessons for Policymakers: Structural Barriers Need to be Addressed

While this study is centered on preferences, it also raises broader questions about the structural and systemic issues that impede access to health services. Tackling these problems requires more than just better program design—it also demands policy-level changes:

• Training and sensitization: Healthcare providers must be trained to offer gender-affirming care, not just in specialized clinics but in all healthcare settings. This ensures that transgender individuals can access services like PrEP without facing discrimination or hostility (Lelutiu-Weinberger et al., 2020).
• Financial incentives and coverage: Given that many transgender individuals face economic hardships, policymakers need to consider financial incentives or subsidies to support PrEP uptake (Galárraga & Sosa-Rubí, 2019). Medicaid and other public insurance programs should cover LA-PrEP and hormone therapy as routine, essential services.
• Community engagement: Public health initiatives must involve transgender individuals in the design and delivery of services. This creates programs that are more likely to meet their needs and be seen as trustworthy (Restar et al., 2024).

Looking Ahead: Implications for HIV Prevention and Beyond

This study is just one piece of a broader movement toward creating inclusive, patient-centered healthcare for marginalized populations. The findings have implications not only for HIV prevention but for how we design health services for diverse communities. The principle of offering care that addresses the whole person—not just a single health issue—can be extended to other areas. For instance, combining mental health services, substance use support, and preventative care could be beneficial for other populations facing multiple health disparities, such as Black and Indigenous communities, sex workers, and people experiencing homelessness (Restar et al., 2024). Moreover, the use of stated preference methods like DCEs offer a low-cost way for public health practitioners to gather actionable insights. As the healthcare landscape continues to evolve, involving the people we serve in decision-making will be key to designing effective, accessible, and equitable services (Clark et al., 2014).

Conclusion: A Call to Action

This study shows that integrating HIV prevention with gender-affirming care is not just preferred by trans communities—it’s essential. When designing public health programs, especially for marginalized populations, inclusivity, convenience, and respect for the individual’s lived experience are non-negotiable. As healthcare systems look to expand LA-PrEP access, they must do so in a way that centers the needs of trans individuals. Public health professionals and policymakers alike have a duty to ensure that effective HIV prevention strategies are not just available, but accessible and affirming for everyone.

References

• Becasen, J. S., Denard, C. L., Mullins, M. M., Higa, D. H., & Sipe, T. A. (2019). Estimating the prevalence of HIV and sexual behaviors among the U.S. transgender population: A systematic review and meta-analysis. American Journal of Public Health, 109(E1-E8). https://doi.org/10.2105/Ajph.2018.304727
• Centers for Disease Control and Prevention. (2021). HIV infection, risk, prevention, and testing behaviors among transgender women—National HIV Behavioral Surveillance, 7 U.S. cities, 2019–2020. HIV Surveillance Special Report 27.
• Clark, M. D., Determann, D., Petrou, S., Moro, D., & de Bekker-Grob, E. W. (2014). Discrete choice experiments in health economics: A review of the literature. Pharmacoeconomics, 32(9), 883–902.
• Feldman, J. L., Luhur, W. E., Herman, J. L., Poteat, T., & Meyer, I. H. (2021). Health and healthcare access in the U.S. transgender population health (TransPop) survey. Andrology, 9(11), 1707-1718.
• Galárraga, O., Linnemayr S., McCoy S.I., Thirumurthy H., Gordon C., Vorkoper S. (2023). We must invest in behavioural economics for the HIV response. Nat Hum Behav. Aug;7(8):1241-1244. doi: 10.1038/s41562-023-01664-z.
• Galárraga, O., & Sosa-Rubí, S. G. (2019). Conditional economic incentives to improve HIV prevention and treatment in low- and middle-income countries. Lancet HIV, 6(12), e705-e714.
• Hiransuthikul, A., Janamnuaysook, R., Himmad, K., et al. (2019). Drug-drug interactions between feminizing hormone therapy and pre-exposure prophylaxis among transgender women: The iFACT study. Journal of the International AIDS Society, 22(4), e25338.
• Lelutiu-Weinberger, C., English, D., & Sandanapitchai, P. (2020). The roles of gender affirmation and discrimination in the resilience of transgender individuals in the U.S. Behavioral Medicine, 46(3), 175-188.
• Restar, A., Wilson-Barthes, M. G., Dusic, E., Operario, D., & Galárraga, O. (2024). Using stated preference methods to design gender-affirming long-acting PrEP programs for transgender and nonbinary adults. Scientific Reports.
• Thaler, R. H., & Sunstein, C. R. (2021). Nudge: The Final Edition. Yale University Press.