Trends in HIV Prevalence, Sexual Behavior, and Pre-Exposure Prophylaxis Willingness Among Transgender Women: An Analysis of Three Cross-Sectional Studies Conducted Mainly in Shenyang, China, 2014–2019

Purpose: Although transgender women (TGW) bear the highest HIV burden worldwide, routine surveillance of this group is rare. We aimed to evaluate the trends in health characteristics of Chinese TGW. Methods: Three cross-sectional studies using snowball sampling were conducted in 2014, 2017, and 2019, primarily in Shenyang, China. A questionnaire and voluntary HIV testing were used to obtain information on background characteristics, sexual behaviors, pre-exposure prophylaxis (PrEP) willingness, and HIV status. Results: There were 220 respondents in 2014, 198 in 2017, and 247 in 2019 (average age 31.1±7.6 to 33.5±9.6 years). HIV prevalence significantly decreased from 29.5% (95% confidence interval [CI]: 25.3–38.4%) in 2014 to 19.4% (95% CI: 14.7–24.9%) in 2019 (p<0.05). The proportion of participants reporting condomless anal intercourse (CAI) with any partner fluctuated from 30.8% (95% CI: 25.1–36.1%) to 53.0% (95% CI: 45.8–60.1%). The proportion of participants willing to use PrEP decreased from 86.4% (95% CI: 81.1–90.6%) in 2014 to 62.8% (95% CI: 56.4–68.8%) in 2019. Factors significantly associated with HIV infection were CAI with any partner (multivariate odds ratio [ORm]: 3.58, 95% CI: 1.55–8.29 in 2017; ORm: 3.18, 95% CI: 1.56–6.46 in 2019) and PrEP willingness (ORm: 0.26, 95% CI: 0.12–0.58 in 2017). Conclusion: HIV prevalence and associated risk factors remain substantial among Chinese TGW. There is an urgent need to strengthen HIV surveillance in this population, and develop trans-friendly and effective interventions to minimize HIV prevalence and transmission.