Preference for long-acting injectable pre-exposure prophylaxis among transgender women clients of the Tangerine Clinic in Bangkok, Thailand

BACKGROUND: Long-acting injectable (LAI) cabotegravir demonstrated superior efficacy to oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) when used as pre-exposure prophylaxis (PrEP) among men who have sex with men and transgender women (TGW). Alternative PrEP options are crucial for TGW as low uptake and retention have been seen in oral PrEP programs. We explored preference of LAI PrEP among Thai TGW clients who had ever used oral PrEP.
METHODS: Tangerine Clinic is a trans-led, integrated gender-affirming care and sexual health clinic in Bangkok, Thailand. Between August and December 2020, we conducted a cross-sectional study, recruiting consecutive HIV-negative TGW clients at Tangerine who reported ever using oral PrEP. Participants completed a self-administered questionnaire on demographics and risk behaviors, oral PrEP adherence, perceived PrEP benefits, and preference for LAI PrEP. Logistic regression analysis was conducted to identify factors associated with LAI PrEP preference.
RESULTS: Of 173 TGW who completed the survey, 94.2% were currently undergoing feminizing hormone therapy (FHT) and 24.2% had undergone gender-affirming surgery. In the past six months, 86.1% had practiced receptive anal sex, 18.4% receptive neovaginal sex, 26.0% insertive anal sex, and 67.2% reported inconsistent condom use. Sexually transmitted infections (STIs) were diagnosed among 30.7% of respondents during the past six months. Median age was 27 (IQR 24'29) years. Of all TGW, 76.3% were current PrEP users with a mean of 6.2 PrEP pills (SD=0.8, min=4 max=7) taken per week, while 23.7% TGW had already discontinued PrEP. 123 of 166 (74.1%) who responded indicated a preference for LAI PrEP; 74.0% among current PrEP users and 74.3% among those who discontinued PrEP. Perceived benefits of PrEP (aOR 4.4, 95%CI 1.2-16.9, p=0.021) and recent STI diagnosis (aOR 3.8, 95%CI 1.2-12.1, p=0.020) were associated with preference for LAI PrEP.
CONCLUSIONS: Around three-quarters of Thai TGW who had used oral PrEP reported a preference for LAI PrEP. Perceived benefit of PrEP and awareness of risk through STI diagnosis increased LAI PrEP preference. Future studies exploring LAI PrEP acceptability among TGW who have never used PrEP, potential interactions between FHT and LAI PrEP, and alternative injection sites for TGW with buttock implants, are urgently needed.