HIV Burden and Acquisition Risks Among Transfeminine Persons Who Have Sex with Men in Nairobi

Background: Global evidence suggests that transgender persons (TG) are disproportionately affected by HIV and other STIs, 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, research evidence to document transgender sexual health needs and inform service development is lacking. Methods: We recruited adult men and transgender persons who reported reporting sex with men through respondent driven sampling. Gender identity, sociodemographics, sexual behaviour and HIV prevention and care uptake were assessed by self-completed computer-assisted survey. Participants undertook testing for HIV, syphilis and anogenital gonorrhoea and chlamydia. Differences in the prevalence of sexual health outcomes, risk behaviour and service uptake between transfeminine and cisgender participants were assessed using multivariable Poisson regression. Findings: Among 618 recruits, 86.1% identified as cisgender, 11.5% transfeminine and 0.7% transmasculine. Transfeminine persons were more likely to be HIV positive (41.4 v 24.6%: p =0.001) and report symptoms suggesting a rectal STI. Transfeminine persons reported higher recent male partner counts and were more likely to report recent condomless anal intercourse, receptive anal intercourse, transactional sex with men and experience of sexual assault. Utilisation of existing biomedical prevention was low for all groups despite availability in Kenya. Interpretation: Transfeminine persons who have sex with men have a higher burden of HIV and associated HIV acquisition behaviours compared to cisgender MSM in the same context, yet uptake of prevention and care services is low. Policies should acknowledge the specific needs of transfeminine persons as distinct from men who have sex with men, and support providers to address these. Funding Statement: This study was funded through the Evidence for HIV prevention in Southern Africa (EHPSA) programme, funded by UK aid from the Department for International Development, and Sweden, through the Swedish International Development Agency (SIDA), mandated to represent the Norwegian Agency for Development Cooperation (Norad), and managed by Mott Macdonald. Declaration of Interests: No author has conflicts of interest to declare. Ethics Approval Statement: This study was approved by the Kenya Medical Research Institute Scientific and Ethics Review Unit (KERMI/SERU/CGMR-C/CSC 044/3334), the University of Oxford, Oxford Tropical Research Ethics Committee (OxTREC 47-16) and London School of Hygiene & Tropical Medicine Human Research Ethics Committee (REF: 14144). All participants provided separate written informed consent to the questionnaire, sample collection and sample storage, and were able to withdraw from any portion of the study.