Using mixed methods to understand barriers to PrEP use among Black and Latinx transgender and gender-expansive youth and emerging adults: The impact of gender minority stress and gender affirmation.

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PROJECT SUMMARY. Gender minority individuals 13-24 years of age experience disproportionate risk for HIV, yet their rates of preexposure prophylaxis (PrEP) uptake to prevent HIV are the lowest of any key risk group in the United States (>10%). This population includes young transgender individuals, as well as substantial and growing numbers of those who identify as gender nonbinary, non-conforming, or genderqueer, referred to here as "gender-expansive” individuals. (We refer to the population as “YTGE”). Further, Black and Latinx (BL) YTGE individuals have higher HIV incidence, but lower PrEP use rates, than White YTGE. Yet, the specific factors that influence engagement in the PrEP care continuum among BL-YTGE, and their causes and meanings, are not well understood. The proposed study is grounded in the gender minority stress and gender affirmative models and examines salient proximal and distal stressors, their effects (e.g., substance use), and resilience factors, including gender affirmation, i.e., support for living in one’s gender identity/expression in social, psychological, medical, and legal domains. Yet, because gender affirmation is a new area of research, we know little about its relationship to engagement along the PrEP care continuum. The proposed study uses an explanatory sequential mixed methods design to advance knowledge about specific factors that promote or impede PrEP outcomes among BL-YTGE. The primary outcome is PrEP intentions, and PrEP awareness, use, and persistence are secondary outcomes. The study aims to: examine the effects of gender minority stress, including proximal and distal stressors, and behavioral responses to stress (substance use) on PrEP outcomes among diverse YTGE who evidence HIV risk (Aim 1a); examine whether resilience (e.g., gender affirmation), race/ethnicity or other sociodemographic factors heighten or buffer the effects of gender minority stress on substance use and PrEP outcomes (Aim 1b); explore BL-YTGE’s perspectives on factors identified in Aim 1 that promote or impede PrEP outcomes and their meanings (e.g., substance use, discrimination), with a focus on various types of gender affirmation, as well as emergent factors (Aim 2); and integrate findings from Aims 1 and 2 to determine how diverse YTGE experience the PrEP continuum and identify differences and similarities across sociodemographic characteristics that impede or support PrEP uptake (Aim 3). Aim 1 will use a moderated mediation structural equation modeling approach to analyze a racially/ethnically diverse (54% non- White) national sample of N=1029 YTGE who engaged in a cross-sectional survey (CDC START study). Aim 2 will rely upon semi-structured interviews with BL-YTGE from the local NYC community (N=30, half prescribed PrEP). For Aim 3 all results will be compared, contrasted, and integrated using the joint display method, to contextualize and interpret findings. Statistical and research methods training will be a key component of this study. If funded, this F31 will give the applicant protected time and will comprise the first stages of a program of research to decrease HIV incidence in this population at high-risk for HIV but with serious barriers to PrEP.