Only a small proportion of participants in PrEP studies have been transgender (trans) or gender diverse people (2, 3, 4). As a result, limited data are available for these populations. Incorrect assumptions can be made about trans people and their sexual practices, as they may practice vaginal/neovaginal and anal intercourse, both insertive and receptive. Trans and gender-diverse people who are at risk of acquiring HIV on the basis of their sexual history are eligible to access PrEP. It is essential for clinicians to take a sexual history using appropriate and sensitive language to assess risk. Box 4.2
Box 4.2 PrEP suitability criteria for trans and gender diverse people
HIV risk in the previous 3 months and the future 3 months
The clinician should prescribe PrEP if the patient describes a history of any of the following HIV acquisition risks in the previous 3 months and if the patient foresees that there are likely to be similar acquisition risks in the next 3 months:
- At least one episode of condomless anal intercourse (insertive or receptive) with a regular HIV-positive partner who is either not on treatment, or who is on treatment but has a detectable HIV viral load
- At least one episode of receptive condomless anal intercourse with any with any casual bisexual male partner of unknown status
- More than one episode of anal or vaginal intercourse where a condom slipped off or broke where the HIV serostatus of the partner was not known, or where the partner was HIV positive and not on treatment or had a detectable viral load on treatment
- One or more episodes of engaging in sexualised drug use, sometimes referred to as ‘chemsex’. In the Australian context this typically involves the use of crystal methamphetamine (Ice) but can also include the use of gamma hydroxybutyrate (GHB)
- One or more episodes of rectal gonorrhoea, rectal chlamydia or infectious syphilis including any STIs diagnosed at screening for PrEP.
HIV risk in the future 3 months
The clinician should prescribe PrEP if the patient foresees that they will have HIV acquisition risk in the upcoming 3 months, despite not having had HIV acquisition risk in the previous 3 months:
- When a person plans to travel during which time they anticipate that they will be having condomless sex with casual partners
- When a person plans to return home to an overseas country which has a high HIV prevalence during which time they anticipate that they will be having condomless sex with casual partners
- When a person reports that they have recently left a monogamous relationship and will be having condomless sex with casual partners in the future
- When a person reports that they will be entering or leaving institutional or correctional facilities in the near future where they may have condomless sex with casual partners in the future
- When a person presents with concerns of deteriorating mental health and a history of having previously increased their HIV acquisition risk behaviour in this setting
- When a person presents with a history of intermittent binge drinking of alcohol or recreational drug use and a history of having had increased their HIV acquisition risk behaviour in this setting.
The clinician should consider prescribing PrEP also in the following circumstances:
- When an HIV serodiscordant couple experience undue suffering and anxiety about inter-couple HIV transmission despite the positive partner being virologically suppressed on treatment
- When a person reports being so anxious about HIV infection that it may prevent them from having regular HIV testing or engaging in any form of anal or vaginal sex
- When a person presents with a history of recurrent genital ulceration or dermatoses (e.g. psoriasis), as this increases the potential risk of HIV transmission.