Acceptability of venue-based HIV testing and prevention interventions for men who have sex with transgender women and transgender women in Lima, Perú: a formative, qualitative study

Abstract

Background

Despite being at elevated risk for HIV, men who have sex with transgender women (MSTW) are an overlooked population in the global HIV response. Venue-based HIV interventions have previously had success reaching other HIV priority populations, including transgender women (TW). Similar approaches could be applied for MSTW.

Objective

To evaluate the prospective acceptability of venue-based HIV testing and prevention interventions for MSTW and TW in Lima, Peru.

Methods

In this exploratory qualitative study, we conducted in-depth interviews (IDI) and focus group discussions (FGD) with three types of participants: MSTW (7 IDIs, 1 FGD), TW (1 FGD), and owners of social venues frequented by MSTW/TW in Lima (2 IDIs). We elicited participants’ attitudes and perceptions related to the following four hypothetical interventions delivered at social venues in Lima: rapid HIV testing; HIV self-test distribution; condom/lubricant distribution; and enrolment in a mobile app supporting HIV prevention. We performed a mixed deductive-inductive thematic analysis using the framework method, then applied the Theoretical Framework of Acceptability to classify the overall acceptability of each intervention.

Results

Condom/lubricant distribution and app-based HIV prevention information were highly acceptable among all participant types. The two HIV testing interventions had relatively lower acceptability; however, participants suggested this could be overcome if such interventions focused on ensuring discretion, providing access to healthcare professionals, and offering appropriate incentives.

Conclusions

Overall, MSTW and TW shared similar favourable attitudes towards venue-based HIV interventions. Venue-based outreach warrants further exploration as a strategy for engaging MSTW and TW in HIV prevention activities.

Keywords:

• HIV testing
• HIV prevention
• implementation science
• acceptability
• transgender women
• men who have sex with transgender women
• Latin America

Introduction

Globally, transgender women (TW) are disproportionately impacted by HIV and considered a priority population in the HIV response [1]. Less attention has focused on their sexual partners – cisgender men who have sex with transgender women (MSTW) – a heterogeneous group with complex HIV-related vulnerabilities and behaviors that distinguish them from traditionally defined key populations, namely men who have sex with men (MSM) and TW [2]. While MSTW also face substantial risk of HIV acquisition and transmission [3,4], they do not fit neatly within the conventional HIV risk categories that underpin targeted outreach strategies, and therefore may be missed by HIV prevention programmes [2,5]. To support the development and implementation of future interventions for MSTW, information is needed about their attitudes and preferences related to HIV testing and prevention services.

Throughout Latin America, TW experience particularly high HIV burden [6]. In Peru, it is estimated roughly one third of TW are living with HIV [7,8]. While few robust estimates exist for MSTW in this setting, available evidence suggests HIV prevalence is high [4,9], and that MSTW play an important role in local HIV transmission networks [10]. Additionally, recent studies from Lima found that MSTW, compared with MSM or TW, reported lower rates of condom use and were less likely to know their HIV status [9,11], highlighting an important need for access to HIV testing and prevention services in this population.

In recent years, a growing number of targeted HIV prevention and care interventions have been evaluated for TW [12,13], including in Peru [14,15]. In contrast, few evidence-based interventions exist for MSTW [16], and these have focused mainly on MSTW in a relationship with a primary TW partner [17,18] – potentially missing a substantial segment of the MSTW population who only have intermittent casual or transactional TW sex partners. One potential strategy for engaging MSTW in HIV interventions is outreach at social venues where MSTW and TW go to meet and interact. Venue-based interventions have been implemented successfully in a variety of settings to reach priority populations with HIV testing, prevention, and sexual health services [19–23]. Previous studies in Peru have found venue-based HIV testing to be acceptable among MSM and TW [24–26]; however, less is known about the acceptability of such interventions among MSTW [27]. Therefore, we sought to explore the attitudes of MSTW and key interested parties (TW, venue owners) towards potential venue-based HIV testing/prevention interventions, including barriers and facilitators for their implementation at social venues in Lima, Peru.

Material and methods

Study design

We conducted an exploratory qualitative study to evaluate the acceptability of HIV testing and prevention interventions delivered at social venues frequented by MSTW and TW in Lima, Peru. Focus group discussions (FGD) and individual in-depth interviews (IDI) explored attitudes and preferences of MSTW, TW, and venue owners regarding four hypothetical venue-based interventions: (1) rapid HIV testing, (2) HIV self-test distribution, (3) free condoms/lubricant distribution, and (4) a mobile phone app supporting HIV prevention.

Setting

Lima is home to over 10 million residents and a third of Peru’s population [28], including an estimated 20,000 TW [29]. New HIV cases have increased in the last decade [7]. This research was implemented by Epicentro [30], a community-based organisation focusing on LGBTQ+ health promotion, and Vía Libre [31], a non-government organisation and HIV clinic serving vulnerable populations in central Lima, an area with many social venues and hourly hotels attended by TW.

Participant selection

Participants were purposively sampled to reflect the diversity of age, education, and socioeconomic status of MSTW/TW who attend social venues in Lima. Recruitment was via informal street- and venue-based outreach and word of mouth. MSTW were eligible if they identified as male and reported at least one TW sexual partner in the last year. TW were eligible if they identified as a transgender woman and reported attending a social venue in Lima at least once in the last three months. Venue owners were eligible if they oversaw a nightclub or hourly hotel frequented by MSTW/TW in Lima. Participant recruitment and data collection were led by members of the research team at Epicentro.

Data collection

Semi-structured FGD/IDI guides were developed in Spanish and used to conduct two FGDs (one with TW and one with MSTW) and nine IDIs (seven with MSTW and two with venue owners) from May 2019 to April 2020. FGDs and MSTW IDIs were done in-person. Venue owners were interviewed by telephone. Sessions were audio recorded and transcribed in Spanish. Participants completed a brief demographic questionnaire.

Data analysis

We performed thematic analysis using a hybrid deductive-inductive coding approach that included five pre-specified codes based on core topics from IDIs/FGDs. Two research team members independently coded each transcript in Microsoft Word (Redmond, WA), adding new codes to develop the full codebook. Coded transcripts were then reviewed and discussed, in conjunction with the researcher who conducted the FGDs/IDIs, and discrepancies were reconciled until the group came to consensus. The final codebook and coded transcripts were translated into English for analysis, and the framework method was applied to summarise and synthesise findings [32]. We then identified key themes from review of the framework matrix, matching findings from the thematic analysis to domains in the Theoretical Framework of Acceptability (TFA) – affective attitude, ethicality, intervention coherence, perceived effectiveness, self-efficacy, opportunity costs, and burden – to qualitatively assess and summarise overall acceptability of each intervention [33].

Ethical review

This study was approved by the University of Washington IRB (STUDY00005823) and Vía Libre Comité Institucional de Bioética (3876 [2018a]). MSTW and TW participants provided written informed consent. Venue owners verbally consented via telephone.

Results

Participants

Twenty-six people were included in this study (Table 1). MSTW participants in IDIs (n = 7) and FGDs (n = 9) shared similar demographics: they predominantly identified as heterosexual or bisexual, were between 21 and 39 years, and the majority reported a monthly income of <1000 Peruvian Nuevos Soles (∼$300 USD). Number of sexual partners ranged widely among interviewed MSTW (data not shown). At least four interviewees reported >30 sexual partners in the last year; only one reported being in a committed relationship. Participants in the TW focus group (n = 8) had similar age and education status to MSTW, but higher incomes. Venue owner interviewees represented an hourly hotel serving ∼200 couples/weekend and a nightclub serving 800–1000 people/weekend, both located in central Lima.

Table 1. Participant characteristics.

	MSTW interviews n = 7	MSTW focus group n = 9	TW focus group n = 8	Venue owner interviews n = 2
Age (years)
Mean (SD)	28 (4.9)	30 (5.5)	28 (8.3)	63 (1.0)
Range	21–36	21–39	19–41	62–64
Sexual orientation, n (%)
Heterosexual	4 (57%)	1 (11%)	–	–
Bisexual	3 (43%)	6 (67%)	–	–
Homosexual/Gay	–	1 (11%)	–	2 (100%)
Not reported	–	1 (11%)	–	–
Monthly income (PEN)*
Mean (SD)	789 (604)	985 (552)	1467 (320)	–
Range	300–2000	300–1800	1000–1800	–
Not reported	0	2	2	2
Highest education, n (%)
All of secondary school	5 (71%)	6 (67%)	5 (63%)	0
Technical school	0	1 (22%)	1 (13%)	0
At least some university	2 (29%)	2 (11%)	2 (25%)	2 (100%)

MSTW: men who have sex with transgender women; TW: transgender women; SD; standard deviation

* At the time of this study, 1000 PEN (Peruvian Nuevos Soles) was approximately $300 USD, and the minimum full-time monthly wage in Peru was 850 PEN.

Venues

FGDs/IDIs highlighted three venue types where MSTW and TW commonly interact: public plazas, nightclubs, and hourly hotels. Key considerations for implementing HIV interventions differed by venue type (Supplementary Table 1).

Acceptability of venue-based interventions

Discussions with MSTW, TW, and venue owners explored the acceptability of four hypothetical venue-based HIV testing/prevention interventions (Table 2), and suggested barriers and facilitators for their successful implementation (Table 3). Rapid HIV testing and HIV self-test distribution were judged as having moderate and low acceptability, respectively, while condom/lube distribution and a mobile phone app delivering information about HIV prevention were highly acceptable. Overall, MSTW and TW shared similar sentiments towards interventions (Supplementary Table 2). Both groups preferred clinic-based, over venue-based, HIV testing. Among the venue types discussed as potential sites of HIV testing, MSTW indicated a preference for open outdoor spaces (e.g. public plazas), while TW preferred more private, enclosed spaces.

Table 2. Acceptability of venue-based HIV interventions for MSTW and TW in Lima, Peru.

Intervention	Theoretical Framework of Acceptability (TFA) domain*							Overall acceptability
	Affective attitude	Ethicality	Intervention coherence	Perceived effectiveness	Self-efficacy	Opportunity costs	Burden
	How an individual feels about intervention	Extent to which intervention has a good fit with individual’s value system	Extent to which participant understands intervention and how it works	Extent to which intervention is perceived as likely to achieve its purpose	Participant’s confidence that they can perform behavior to participate	Extent to which benefits, profits, or values must be given up engaging in intervention	The perceived amount of effort required to participate	–
	Higher = greater acceptability					Lower = greater acceptability
Rapid HIV testing	Low Incongruent with venue environment	High Value free testing by professionals	Moderate Familiar with HIV testing (via blood draw), more sceptical of rapid tests	Moderate Variable uptake in the past; depends on location, incentives, perceived privacy	Low Inability to handle learning results at venue	High Act of testing or positive result could derail night’s plans/business	Low Easy to access test (no need to travel to clinic)	Moderate
HIV self-test distribution	Low Incongruent with venue environment	Moderate Value free testing but not without professionals	Low Little understanding of self-tests	Low Low trust in self-tests	Low Concern about receiving results in the absence of professional support	High Act of testing or positive result could derail night’s plans	High Navigating result in the absence of health provider would be a heavy burden	Low
Condom/lube distribution	High People like receiving free things	High People like activities that help prevent HIV	High Straightforward intervention	Low Motivation to use condom, not access, is main barrier	High People know how to use condoms	Low No cost to individual	Low Free distribution of condoms	High
Mobile app supporting HIV prevention	High Most very interested in receiving information	High Most value easier access to quality health information	High Most people very familiar with navigating apps	Moderate May increase knowledge, but unsure if would lead to behaviour change	Moderate Familiarity with apps; may need to accommodate low literacy	Low Minimal financial cost for data; little time required	Moderate Some concern about privacy	High

MSTW: men who have sex with transgender women; TW: transgender women

* Adapted from Sekhon et al. [33] The synthesis presented here considers all interviews and focus groups included in this study (participants: MSTW, TW, venue owners). It is subject to the authors’ interpretation of the themes and other salient points from interviews and focus group discussions.

Table 3. Facilitators and barriers for acceptable implementation of venue-based HIV testing and prevention interventions among MSTW and TW in Lima, Peru.

Intervention	Facilitators	Barriers
Rapid HIV testing	Trust in professionally-administered HIV tests Experiences healthcare professional available on-site for post-test counseling Convenience of not having to travel to clinic for test Precedent for venue-based HIV testing Incentives provided (free test, gifts/money given)	Fear of testing positive Purpose/atmosphere of some venues (e.g. nightclubs) incongruent with potentially life-altering outcome of HIV testing Alcohol intoxication impedes ability to cope with results Limited privacy available for testing Perception of non-clinical sites as unsanitary for medical procedures Precedent necessitates incentives
HIV self-test distribution	Ability to receive testing kit discreetly Ability to test at home or other private location Flexibility to determine when the test is performed Convenience of not having to travel to clinic for test No judgment from healthcare providers (TW specifically)	Less familiarity and trust with this type of HIV test Low confidence in ability to self-administer test Low self-efficacy to handle result without professionals Fear of testing positive Intoxication impedes ability to cope with results, especially if healthcare professionals not present
Condom/lube distribution	No stigma around providing condoms/lube Can be integrated into existing entertainment at venues Can be distributed discreetly	Low motivation to use condoms among many MSTW Intoxication further reduces motivation to use condoms TW lack agency over condom use
Mobile app supporting HIV prevention	Existing motivation to learn Strong interest in receiving timely and trustworthy updates on health information Connection and ability to have dialogue with professionals	Low digital technology literacy (especially among TW) Potential privacy concerns Redundancy with information that can be found easily on web

MSTW: men who have sex with transgender women; TW: transgender women

The following key themes emerged from our analysis and informed our assessment of acceptability for the proposed interventions.

Theme 1: Interventions should align with venue atmosphere

The predominant theme was that interventions should align with the atmosphere of the venue where they are offered. Notably, MSTW and TW perceived HIV testing as antithetical to the party atmosphere of nightclubs (TFA: low affective attitude), indicating that HIV testing had potential to negate an otherwise fun night out (TFA: high opportunity cost).

‘People go there to drink so it’s difficult. [HIV testing] wouldn’t have logic. It would cancel the girl.’ – IDI-MSTW-2

In contrast, nightclubs were viewed as excellent places to disseminate condoms, lubricant, and information about HIV prevention services, partly because these could be offered in concert with existing entertainment at venues (TFA: high affective attitude).

‘They come bringing condoms, and sometimes they have come and put on a show, that’s good; it attracts attention.’ – Nightclub Owner

MSTW and TW were also concerned about their ability to process the psychological shock of a positive HIV test at a nightclub, given the chaotic and alcohol-fuelled environment at these venues (TFA: low perceived self-efficacy).

‘In night clubs, you complicate everything; you go dancing, drinking and then let’s say you discover [that you are positive], you are probably going to take it really bad.’ – FGD-MSTW-3

Similarly, participants described the nightclub atmosphere as incompatible with the privacy required for HIV testing. Concerns about privacy were also raised in the context of hourly hotels, where the provision of HIV testing was viewed as intruding on clients’ privacy.

‘The clients don’t receive [HIV testing] well because they seek privacy.’ – Hotel Owner

Theme 2: ‘how’ is more important than ‘where’

Although participants expressed strong opinions about the suitability of certain venues for HIV testing, they were also adamant that how testing was provided – rather than where – would be more important in influencing uptake. Specifically, MSTW were more inclined to accept HIV testing if it appeared professional, suggesting affective attitude towards interventions could change under different implementation scenarios.

‘…for people to see that it’s sanitary, to see how they change the needle, the gloves. Of course, they need to change all of these in front of the people so they can trust in them. More than the place it would be the way they do it.’ – IDI-MSTW-1

Similarly, there was universal sentiment that HIV testing should be provided for free in the context of such interventions, and that having appropriate incentives was more important than where it was offered.

‘…If you give something, I know people will go…The place wouldn’t be a problem, it would be how you can encourage them…’ – IDI-MSTW-5

Participants also highlighted the assurance of privacy and confidentiality as a key driver of the acceptability of interventions. For example, the nightclub owner described hosting an HIV testing event that was made successful by conducting HIV testing in a discrete, outdoor garden within the club. Likewise, MSTW recalled that past venue-based testing events were successful because they were conducted discretely.

‘Let people approach [the testers], do not approach them.’ – IDI-MSTW-4

Discretion was also a top concern for MSTW when it came to sharing information about HIV testing/prevention. Participants voiced enthusiasm for using a mobile phone app to convey such information, assuming it could be shared and accessed confidentially.

‘The most important benefit is that the app is confidential.’ – IDI-MSTW-1

Theme 3: Desire to connect with health professionals for information and services

Participants consistently described a desire for interventions to be delivered by, and connect them to, health professionals. Almost all said they wanted a professional to be present when taking an HIV test – including self-tests – because they doubted their ability to cope if they tested positive (TFA: low perceived self-efficacy). Home HIV self-testing was perceived as particularly problematic due to the absence of immediate access to a healthcare provider for emotional support and counselling.

‘Sometimes you don’t know the reaction people are going to have when doing it so it’s better to have a specialist doing it.’ – IDI-MSTW-3

‘If you do it alone, and you test positive, who is going to give you that strength? It would be better with a specialized person.’ – FGD-TW-1

Regarding provision of HIV-related information, both MSTW and TW emphasised their desire to connect with professionals. Participants demonstrated interest in using a mobile phone app that would allow them to connect with, and learn from, experienced professionals about HIV and other health-related topics. Information delivered without a personal connection was viewed as unappealing (e.g. getting only a brochure was a ‘cold gesture’ – IDI-MSTW-1).

‘Yes, if it wasn’t a recorded message, of course I’d be interested. I mean, that there’s a person who answers you and it’s real.’ – IDI-MSTW-5

Theme 4: Conflicting attitudes towards condoms

MSTW, TW, and venue owners were enthusiastic about interventions involving free condom and lubricant distribution at venues (TFA: high affective attitude). However, they expressed skepticism that this alone would lead to increased condom use, particularly in the context of alcohol consumption (TFA: low perceived effectiveness).

‘Sometimes those from the NGOs come to distribute [condoms] and some take them but also many throw them away…’ – Nightclub Owner

‘Alcohol makes you forget about lots of stuff, it makes you not think about stuff [like wearing condoms].’ – IDI-MSTW-5

Moreover, while MSTW/TW described having ready access to condoms, TW explained many MSTW were resistant to using them.

‘TW-1: Everyone wants sex without a condom, and that is how they catch him…

TW-2: …The risk is wherever you go, the client might not want a condom…

TW-3: They already leave and look for another girl who accepts them without a condom and there they go.’ – FGD-TW

Discussion

In this exploratory study, MSTW and TW shared similar perspectives on the acceptability of four venue-based HIV testing/prevention interventions that could potentially be implemented at social venues attended by these populations in Lima, Peru. Among the interventions we evaluated, MSTW and TW were most accepting of condom/lubricant distribution and mobile app-based provision of information about HIV prevention and sexual health. Although acceptability was comparatively lower for HIV testing interventions (on-site rapid testing, self-test distribution for home use), participants’ views of these were flexible, indicating that acceptability could be enhanced by certain factors related to how HIV testing was provided – specifically, by prioritising privacy, discretion, and professionalism, offering incentives, and ensuring an experienced healthcare provider is available for support and counselling. This aligns with implementation science theory, which posits that the intricacies of how an intervention is implemented – not just where – are most critical to its success [34]. The similarity in MSTW and TW perspectives towards these interventions also suggests that future venue-based HIV prevention and testing interventions could be designed to reach both populations simultaneously – under the auspices of a single intervention – through implementation at social venues where MSTW and TW interact.

Our results echo those of the one other study to date examining attitudes towards HIV prevention interventions among Peruvian MSTW, which found relatively low enthusiasm for venue-based HIV testing but higher interest receiving condoms or informational brochures at venues [27]. In contrast, studies with MSM in Peru have demonstrated broader support for venue-based HIV testing [25,26]. This might be explained by differences in HIV risk perception among MSTW compared with traditional HIV priority populations such as MSM. Given that MSTW most often identify as bisexual or heterosexual, they may be missed by HIV prevention programmes in Peru and similar epidemic contexts where HIV-related public health messaging and community outreach efforts are targeted primarily towards gay-identifying MSM [2,9,35]. Without this same degree of community sensitisation, MSTW may be less likely to perceive themselves as at risk for HIV and less comfortable accessing public HIV testing [27]. However, venue-based HIV testing could still be successful for MSTW, as it has been for MSM in Peru, if it considers the drivers for acceptance: privacy, incentives, and connection to health professionals. A discrete choice experiment may be useful to better understand the relative importance of these drivers and inform the design of future tailored interventions for MSTW.

Despite the high acceptability of interventions involving free condom/lube distribution at venues, our findings suggest this is unlikely to ultimately result in greater condom use among MSTW. Like past studies, we found low self-reported condom use amongst MSTW [3,4,9], but participants in our study explain why use is low: motivation, not access, is the main barrier to condom use. While condom distribution alone does not address this barrier, experience from other settings suggests condom distribution may be more effective if bundled as part of a larger intervention [36]. In Lima, this could be done by providing condoms/lube as an incentive for venue-based HIV testing (a suggestion by study participants).

Finally, our study reveals an opportunity to engage MSTW in HIV prevention education through interactive mobile phone apps. Bidirectional text messaging apps have been effective in supporting HIV self-testing [37] and pre-exposure prophylaxis (PrEP) use [38,39], but their role in knowledge dissemination is less clear. The enthusiasm expressed by MSTW in our study for health-related mobile apps suggests this could be an innovative and targeted approach to reach MSTW, connecting members of this overlooked population with information and services that might otherwise elude them if delivered only via traditional HIV outreach campaigns. Mobile apps that support direct communication with a healthcare professional could also be an effective tool to support uptake and appropriate use of HIV self-testing in this population.

Limitations

The primary limitation of this study was its small sample size, limiting generalizability. However, we reached saturation during data collection, and we included multiple participant types (TW, MSTW, and venue owners), whose responses generally aligned during data triangulation. Participant recruitment was also conducted by a single individual using a convenience sampling approach, which could have introduced some degree of selection bias. Another limitation is the potential for social desirability bias. We aimed to mitigate this by having a highly experienced researcher from Lima conduct interviews, but participants may have nonetheless been influenced by social norms or desire to obtain favour with the implementing organisations, which provide reduced-cost medical services to sexual and gender minority communities.

Conclusion

MSTW and TW in Peru shared similar sentiments towards hypothetical, venue-based HIV prevention interventions, suggesting it may be feasible to engage these two vulnerable groups simultaneously by delivering interventions at community venues where MSTW and TW meet and socialise. We found high acceptability of interventions involving the dissemination of free condoms/lubricant and app-based HIV prevention information, but lower acceptability of venue-based HIV testing (including HIV self-test distribution). However, by leveraging certain factors – discretion, provision of incentives, and access to health providers – it may be possible to overcome barriers to acceptance and enable successful implementation of interventions, including HIV testing. Further research is needed to understand the relative importance of key intervention attributes so that future venue-based HIV interventions can be optimally tailored for MSTW and TW.

Geolocation

This study was conducted in Lima, Peru.

Disclosure statement

The authors report there are no competing interests to declare.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Additional information

Funding

This work was supported by the Division of Allergy & Infectious Diseases at University of Washington under the Walter E. Stamm Award; the University of Washington/Fred Hutch Center for AIDS Research, an NIH funded programme under award number AI027757; and the University of Washington STD/AIDS Research Training Fellowship Programme, an NIH funded program under award number T32 AI07140.