Her Voice: Role of Shared Decision Making for Prep in African American Transgender Women

Background: Shared decision making (SDM), comprised of information exchange, deliberation, and decision-making, is a patient-centered strategy to reduce healthcare disparities by improving patient-provider communication and subsequent health outcomes. SDM has been infrequently studied in patients with intersectional identities such as trans women of color. We identified individual, community, and healthcare factors that impact SDM between African American transgender women and their providers around HIV pre-exposure prophylaxis (PrEP).

Methods: 24 semi-structured, in-person interviews and two focus groups were conducted from 2016-2017. Participants were eligible if ≥18 years of age, identified as an African American transgender woman, and reported having sex with men within the past two years. Interview transcripts were thematically coded and analyzed using qualitative data analysis software.

Results: 38 individuals completed the study; the majority (n=25, 65.8%) were <30 years of age and had public health insurance. Several participants described positive experiences related to their intersectional identity, however many experienced transphobia and racism leading to avoidance of healthcare. Passing privilege was seen as a way to avoid transphobia, both in the community and healthcare settings. Disclosure of gender and sexual identities as well as sexual practices depended on clinical setting and level of trust in the provider. Sexual practices were the most sensitive to disclose to providers. 28 (73.7%) participants reported a previous conversation about PrEP with a provider. Participants advised that providers raise the subject of PrEP at each visit. Participants emphasized provider training in trans-affirming care and peer education about PrEP within the African American trans community.

Conclusions: SDM has potential to reduce HIV-related healthcare disparities for African American transgender women. SDM about PrEP can only be effective if bi-directional information exchange occurs, since transgender identity and sexual practices are central to the conversation about risk of HIV acquisition. Information sharing is affected by trust in the provider and intersectional experiences of the patient. Providers need to establish trans-culturally competent practices to facilitate information sharing. Participants recommended delivering information about HIV and PrEP through face-to-face interactions with their provider, written information in the form of decision aids, and peer education. In addition, providers should recognize that deliberation about PrEP frequently occurs longitudinally over recurring visits; thus repeatedly discussing PrEP can facilitate deliberation and decision-making. These methods can help empower engagement in SDM for African American transgender women.