HIV burden and correlates of infection among transfeminine persons and cisgender men who have sex with men in Nairobi: an observational study

Background: Globally transgender persons are disproportionately affected by HIV and other sexually transmitted infections (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, evidence of transgender sexual health needs to inform effective responses is sparse. We aimed to assess gender identity among men and transgender persons who have sex with men in Nairobi and explore associations with sexual health related outcomes, risk behaviour and uptake of HIV interventions. Methods: We recruited adult men and transgender persons who reported sex with men through respondent driven sampling during 2017 in Nairobi. We assessed gender identity, sociodemographics, sexual behaviour and HIV prevention and care uptake by self-completed survey. Participants tested for HIV, syphilis, rectal and urethral gonorrhoea and chlamydia. We compared prevalence of sexual health outcomes, risk behaviour and service uptake among transfeminine and cisgender participants using multivariable robust Poisson regression models with gender identity as the independent variable. Findings: 18 Among 618 recruits, 522 (86.1%) identified as cisgender, 70 (11.5%) transfeminine and 3 (0.7%) transmasculine. Compared to cisgender participants, transfeminine persons were more likely to be HIV positive (41.4% (28/70) v 24.6% (151/521) p=0.00087) and report rectal symptoms consistent with a current STI (16.3% (88/67) v 7.0% (38/518) p=0.014). Transfeminine persons reported higher recent male partner counts and were more likely to report recent condomless anal intercourse (62.1% (43/70) v 38.6% (208/522) p=0.00085), receptive anal intercourse (76.5% (54/70) v 45.5% (252/522) p Interpretation: Transfeminine persons who have sex with men have a higher burden of HIV and associated risk behaviours compared to cisgender MSM in the same context, yet uptake of prevention and care services is poor. Policies should acknowledge the specific needs of transfeminine persons as distinct from men who have sex with men, and support providers to address these.