Background: Transgender women face one of the highest HIV burdens worldwide. In Malaysia, HIV prevalence in transgender women is more than thirty-fold higher than in the general population. Pre- exposure prophylaxis (PrEP) for HIV prevention may be an effective intervention for reducing HIV transmission. This study examined factors associated with willingness to use PrEP among transgender women in Malaysia.
Methods: Between June and August 2017, 374 transgender women from seven cities in four Malaysian completed a survey on willingness to use PrEP. PrEP willingness was measured using a five-item scale. Other measures include socio-demographics, substance abuse, healthcare engagement, and criminal justice involvement. Bivariate and multivariable linear regression was used to identify correlates of PrEP willingness.
Results: Participants were mostly ethnic Malay (75.1%), single (67.6%), and had at least a high school education (69.3%). Willingness to use PrEP was high (82.0%), despite only 22% having been previously aware of PrEP. Bivariate associations with willingness to use PrEP included having a high school education (B=0.375;p< 0.001), having more sex work customers (B=0.027;p=0.008), use of mobile phone apps to find sex work customers (B=0.265;p=0.024), hormone use across the lifetime (B=0.639,p=0.003) and last 90 days (B=0.283;p=0.013), having seen a doctor in the last year (B=0.339,p=0.037), willingness to pay for PrEP (B=1.554;p< 0.001), prior post-exposure prophylaxis (PEP) use (B=0.273,p=0.050), and being concerned about cost (B=0.250;p=0.036). Willingness was lower for ethnic Chinese (B=-1.378,p< 0.001), older participants (B=-0.029,p< 0.001), amphetamine use (B=-0.519,p< 0.01), injection drug use (B=-1.165,p< 0.001), previous incarceration (B=0.035,p=0.015), and prior knowledge of PrEP (B=-0.378;p=0.009). In the multivariate model, lifetime hormone use (B=0.490;p=0.016), prior PEP use (B=0.253;p=0.026;), and having a high school education (B=0.281;p=0.054) were associated with higher willingness to use PrEP, while injection drug use (B=-0.686;p=0.041), older participants (B=-0.019;p =0.002), and Chinese ethnicity (B=-1.076;p=0.002) were associated with lower PrEP willingness.
Conclusions: This is the first-ever study to evaluate PrEP willingness among transgender women in Malaysia. Results suggest that PrEP is a highly acceptable HIV prevention tool for transgender women. Differences in PrEP willingness by education, ethnicity, substance abuse, and age suggest different strategies may be needed to scale-up PrEP for this diverse community of transgender women.