Nuffield Department of Population Health, University of Oxford, Oxford, UK.
Partners for Health and Development, Nairobi, Kenya; Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
Lancet HIV. 2021 May;8(5):e274-e283. doi: 10.1016/S2352-3018(20)30310-6. Epub 2021 Feb 22.
Transgender people are disproportionately affected by HIV and other sexually transmitted infections (STIs) worldwide, and culturally competent prevention and treatment services are often unavailable or inaccessible. Despite recent improvements in national HIV responses for many key populations in east Africa, evidence of effective responses informed by transgender sexual health needs is sparse. We aimed to assess gender identity among men and transgender people who have sex with men in Kenya, and to explore its associations with sexual health-related outcomes, risk behaviours, and uptake of HIV prevention and care interventions.
We did a cross-sectional study in Nairobi, Kenya, and recruited adult cisgender men and transfeminine people who reported having sex with men, through respondent-driven sampling. Inclusion criteria were possession of a valid study coupon, being aged 18 years or older, having male sex assignment at birth or male gender identification currently, living within 50 km of Nairobi, and having had consensual anal or oral sexual activity with a man in the previous 12 months. Seed participants were identified by three community organisations that provide targeted health-care services to gay, bisexual, or other men who have sex with men (MSM) communities in Nairobi. We assessed gender identity, sociodemographics, sexual behaviour, and HIV prevention and care uptake, by self-completed survey. Participants were tested for HIV, syphilis, and rectal and urethral gonorrhoea and chlamydia. We compared prevalence of sexual health outcomes, risk behaviour, and HIV prevention and care service uptake among transfeminine and cisgender participants, using multivariable robust Poisson regression models, with gender identity as the independent variable.
Between May 4 and Dec 8, 2017, we enrolled 618 participants. Six participants did not answer the questions on sex assigned at birth and gender identity and so were excluded from the analyses. 522 (sample-weighted percentage 86%) of 612 participants were classified as cisgender men, 70 (11%) as transfeminine, and three (<1%) as transmasculine. 17 participants (2%) did not identify as male, female, or transgender. Compared with cisgender men, transfeminine people were more likely to be HIV-positive (28 [41%] of 70 transfeminine vs 151 [25%] of 521 cisgender men; p=0·0009) and to report current symptoms consistent with a rectal STI (eight [16%] of 67 vs 38 [7%] of 518; p=0·014). Transfeminine people reported higher numbers of recent male sexual partners (22 [27%] of 70 transfeminine people reported four or more male sexual partners in the past 3 months vs 112 [13%] of 522 cisgender men; p=0·042) and were more likely to report condomless anal intercourse with men (43 [62%] of 70 vs 208 [39%] of 522; p=0·0009) and receptive anal intercourse (54 [76%] of 70 vs 252 [46%] of 522; p<0·0001) in the past 3 months, and transactional sex with men (42 [57%] of 69 vs 240 [42%] of 518; p=0·023) and experience of sexual assault (16 [23%] of 69 vs 65 [11%] of 520; p=0·019) in the past 12 months. Use of pre-exposure prophylaxis and post-exposure prophylaxis was low in both groups.
Transfeminine people who have sex with men have a higher burden of HIV and associated risk behaviours compared with cisgender MSM in the same context, yet their uptake of prevention and care services is poor. Policies should acknowledge the specific needs of transfeminine people as distinct from cisgender MSM, and support health-care providers to address these needs.
Evidence for HIV Prevention in Southern Africa (EHPSA), UK Aid.
跨性别者在全球范围内受到艾滋病毒和其他性传播感染（STIs）的不成比例影响，而且文化上有能力的预防和治疗服务往往不可用或无法获得。尽管东非许多关键人群的国家艾滋病毒应对措施最近有所改善，但关于艾滋病毒预防和治疗服务需求的有效应对措施的证据仍然很少。我们旨在评估肯尼亚与男性发生性关系的男性和跨性别者的性别认同，并探讨其与性健康相关结果、风险行为以及艾滋病毒预防和护理干预措施的采用之间的关系。
我们在肯尼亚内罗毕进行了一项横断面研究，通过回应驱动抽样招募了报告与男性发生性行为的顺性别男性和跨女性人。纳入标准是拥有有效的研究优惠券、年龄在 18 岁或以上、出生时具有男性性别分配或目前具有男性性别认同、居住在内罗毕 50 公里范围内、并且在过去 12 个月内与男性进行了自愿的肛门或口腔性行为。种子参与者由三个社区组织确定，这些组织为内罗毕的同性恋、双性恋或其他与男性发生性关系的男同性恋者（MSM）社区提供有针对性的医疗保健服务。我们通过自我完成的调查评估了性别认同、社会人口统计学、性行为以及艾滋病毒预防和护理的采用情况。参与者接受了艾滋病毒、梅毒、直肠和尿道淋病和衣原体检测。我们使用多变量稳健泊松回归模型比较了跨女性和顺性别参与者之间性健康结果、风险行为和艾滋病毒预防和护理服务采用情况，以性别认同为自变量。
在 2017 年 5 月 4 日至 12 月 8 日之间，我们招募了 618 名参与者。6 名参与者未回答关于出生时性别分配和性别认同的问题，因此被排除在分析之外。612 名参与者中的 522 名（样本加权百分比 86%）被归类为顺性别男性，70 名（11%）为跨女性，3 名（<1%）为跨男性。17 名参与者（2%）没有表示自己是男性、女性或跨性别者。与顺性别男性相比，跨女性更有可能是艾滋病毒阳性（70 名跨女性中有 28 名[41%]，521 名顺性别男性中有 151 名[25%]；p=0·0009），并且报告目前与直肠 STI 一致的症状（67 名中的 8 名[16%]，518 名中的 38 名[7%]；p=0·014）。跨女性报告的近期男性性伴侣人数更多（70 名跨女性中有 22 名[27%]报告在过去 3 个月内有 4 个或更多男性性伴侣，而 522 名顺性别男性中有 112 名[13%]；p=0·042），并且更有可能报告与男性发生无保护的肛门性交（70 名中的 43 名[62%]，522 名中的 208 名[39%]；p=0·0009）和接受性肛交（70 名中的 54 名[76%]，522 名中的 252 名[46%]；p<0·0001）在过去 3 个月内，并且与男性发生易货性交易（69 名中的 42 名[57%]，518 名中的 240 名[42%]；p=0·023）和过去 12 个月内遭受性侵犯（69 名中的 16 名[23%]，520 名中的 65 名[11%]；p=0·019）。两组人群中，暴露前预防和暴露后预防的使用都很低。
与同一背景下的顺性别 MSM 相比，与男性发生性关系的跨女性者具有更高的艾滋病毒负担和相关风险行为，但他们对预防和护理服务的采用率很低。政策应承认跨女性者与顺性别 MSM 的不同需求，并支持医疗保健提供者满足这些需求。
南部非洲艾滋病毒预防证据（EHPSA），英国援助。
