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Evaluation of syndemics in transgender women (TGW) using pre-exposure prophylaxis (PrEP) for HIV prevention: preliminary findings
Michelle Ramos¹, Emilia Jalil¹, Flavia Lessa¹, Cristiane Castro¹, Cristina Jalil¹, Eduardo Carvalheira¹, Laylla Monteiro¹, Cléo Souza¹, Biancka Fernandes¹, Luciana Kamel¹, Ronaldo I. Moreira¹, Vinicius Pacheco¹, Valdilea Veloso¹, Beatriz Grinsztejn¹, Raquel B. De Boni¹.
1 LAPCLIN-AIDS, Instituto Nacional de Infectologia Evandro Chagas (INI)
FIOCRUZ, Rio de Janeiro, Brazil
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3. BACKGROUND What is syndemic? Transgender women (TGW)
The cluster of ≥2 health/social conditions that interact and increase the occurrence of other health problems.
Transgender women (TGW)
Key- population for HIV infection
19.1% of HIV prevalence worldwide ²
Brazil : 31.2% population estimates by Transcender³, 30.0% by DIVAS (12 Brazilian cities)
Limited academic literature on syndemics among TGW
PrEP : Available at no cost at Brazilian public health system (SUS) since 2017
¹Singer M, 1994;²Baral et al., 2013; ³ GRINSZTEJN et al., 2018; (BASTOS et al., 2018)

4. OBJECTIVE
To assess syndemics prevalence and its associated factors among TGW screened for the PrEParadas Study – first Brazilian trans-specific PrEP demonstration project (initial primary findings presented at IAS 2019 session: TUAC0302 – Start stop restart: Supporting effective PrEP use)

5. METHODS
Secondary cross-sectional analysis of PrEParadas study
Inclusion criteria for PrEParadas: being TGW, living at Rio de Janeiro or metropolitan area, 18+ years, at risk for HIV infection
All TGW with valid results for the primary outomes at screening were included in this analysis
Data collection at screening visit
Measures
OUTCOME: Syndemic
Standardized and validated questionnaires screening for:
Polysubstance use (ASSIST)¹
Binge drinking²
Depression(PHQ-9)³
Sexual compulsive behavior (SCB)
Intimate partner violence (IPV)
Syndemic ≥ 2
¹ASSIST (WHO), ² Binge drinking (NIAAA,2004), ³ PHQ-9(KROENKE et. al, 2001,  SCB(PARSONS, 2016)

6. METHODS Study variables
Sociodemographics (age, race/color, education, employment status, marital status)
Sexual risk : condomless anal sex, sexually transmitted infections (STI), sex with a HIV positive partner, transactional sex, post-exposure prophylaxis (PEP), HIV testing, perceived likelihood of getting HIV
Mental health: anxiety (GAD-7)*, high impulsivity (Barrat Impulsiveness Scale-11)*², substance abuse/dependence, suicide risk
Vulnerabilities: physical/ sexual violence, child abuse, school dropout
Gender discrimination
Statistical Analysis
Bivariate analysis: Chi-square, Fisher’s exact test and Mann–Whitney U test
Multiple logistic regression including variables with p<0.2 at bivariate
*SPITZER RL, et al, 2006;*²PATTON JH, 1995

7. 147 TGW screened and 143 had valid results for outcome variables.
Prevalence of syndemic conditions among 143 TGW screened for PrEPARADAS study. Rio de Janeiro, Brazil, 2018 

8. NUMBER OF SYNDEMIC CONDITIONS AMONG TGW SCREENED FOR PrEPARADAS STUDY, RIO DE JANEIRO, 2017-2018
Syndemics prevalence
49.7% (n=71)
N=143

9. DEMOGRAPHIC CHARACTERISTICS OF TGW SCREENED FOR PrEPARADAS STUDY ACCORDING TO SYNDEMICS, RIO DE JANEIRO, BRAZIL,
Total
(N = 143)
No Syndemics
(N = 72)
Syndemics
(N = 71)
p-value*
Age – median (IQR)
30 (24,36)
32 (26.8,40)
27 (23,34)
0.003
Self-declared color/Race
<0.001
White
38 (26.6)
28 (38.9)
10 (14.1)
Non- White
105 (73.4)
44 (61.1)
61 (85.9)
Years of schooling
0.811
< 8
39 (27.3)
19 (26.4)
20 (28.2)
≥ 8
104 (72.7)
53 (73.6)
51 (71.8)
Employment status
0.053
Employed
66 (46.2)
39 (54.2)
27 (38)
Not Employed
77 (53.8)
33 (45.8)
44 (62)
Marital Status
0.127
Married
109 (76.2)
51 (70.8)
58 (81.7)
Single or other
34 (23.8)
21 (29.2)
13 (18.3)
Monthy individual income (US$) - median (IQR) ꝉ
206.7 (99,333.3)
236.7 (125,360)
200 (66.7,270)
0.152
ꝉ Categories with missing data.*chi-square, Fisher's or Mann–Whitney U test.1U$ = R$3.75

10. SEXUAL RISK BEHAVIOR AND RISK PERCEPTION AMONG TGW SCREENED FOR PrEPARADAS’ STUDY ACCORDING TO SYNDEMICS, RIO DE JANEIRO, BRAZIL,
Total
(N = 143)
No Syndemics
(N = 72)
Syndemics
(N = 71)
p-value*
Condomless anal sex (6 months)
116 (81.1)
54 (75)
62 (87.3)
0.06
HIV-positive partner
7 (4.9)
3 (4.2)
4 (5.6)
0.719
STI (6 months)
36 (25.2)
18 (25)
18 (25.4)
0.961
Transactional sex (ever)
106 (74.1)
50 (69.4)
56 (78.9)
0.198
PEP (12 months)
31 (21.7)
14 (19.4)
17 (23.9)
0.514
HIV testing (12 months)
130 (90.9)
67 (93.1)
63 (88.7)
0.369
Perceived likelihood of getting HIV (next 12 months) (High)¹
40 (28.2)
22 (31.4)
0.395
*Chi-square or Fisher's exact test;¹ missing data(n=1)

11. Substance use (3 months)
SUBSTANCE USE AMONG TGW SCREENED FOR PrEPARADAS STUDY ACCORDING TO SYNDEMICS, RIO DE JANEIRO, BRAZIL,
Substance use (3 months)
Total
(N = 143)
No Syndemics
(N = 72)
Syndemics
(N = 71)
p-value*
Tobacco
72 (50.3)
24 (33.3)
48 (67.6)
< 0.001
Alcohol
116 (81.1)
50 (69.4)
66 (93)
Marijuana
48 (33.6)
12 (16.7)
36 (50.7)
Cocaine
29 (20.3)
6 (8.3)
23 (32.4)
Amphetamine²
5 (3.5)
0 (0)
5 (7)
0.028
Inhalants²
10 (7)
10 (14.1)
Hypnotic
11 (7.7)
3 (4.2)
8 (11.3)
0.111
Hallucinogen²
3 (2.1)
1 (1.4)
2 (2.8)
0.62
*Chi-square ;2Fisher's exact test.aASSIST score≥4; bASSIST score ≥10; There were no cases of hypnotic abuse and opioid use or abuse

12. Substance abuse/dependence
SUBSTANCE ABUSE/DEPENDENCE AMONG TGW SCREENED FOR PrEPARADAS STUDY ACCORDING TO SYNDEMICS, RIO DE JANEIRO, BRAZIL,
Substance abuse/dependence
Total
(N = 143)
No Syndemics
(N = 72)
Syndemics
(N = 71)
p-value *
Any substance abuse, except alcohol
82 (57.3)
33 (45.8)
49 (69)
0.005
Tobaccoa
62 (43.4)
20 (27.8)
42 (59.2)
< 0.001
Alcoholb
18 (12.6)
1 (1.4)
17 (23.9)
Marijuanaa
39 (27.3)
10 (13.9)
29 (40.8)
Cocainea
24 (16.8)
6 (8.3)
18 (25.4)
0.006
Amphetaminea ²
1 (0.7)
0 (0)
0.497
Inhalanta ²
3 (2.1)
3 (4.2)
0.12
Hallucinogena 2
2 (1.4) 1
*Chi-square ;2Fisher's exact test.aASSIST score≥4; bASSIST score ≥10; There were no cases of hypnotic abuse and opioid use or abuse

13. MENTAL HEALTH, VULNERABILITIES AND DISCRIMINATION AMONG TGW SCREENED FOR PrEPARADAS STUDY ACCORDING TO SYNDEMICS, RIO DE JANEIRO, BRAZIL,
Mental Health
Total
(N = 143)
No Syndemics
(N = 72)
Syndemics
(N = 71)
p-value*
High Impulsivity (BIS11 > 77)
34 (23.8)
6 (8.3)
28 (39.4)
< 0.001
Anxiety (GAD7 > 9)
40 (28)
9 (12.5)
31 (43.7)
Suicide risk
23 (16.1)
3 (4.2)
20 (28.2)
Vulnerabilities
School dropout
61 (42.7)
24 (33.3)
37 (52.1)
0.023
Child abuse
44 (30.8)
18 (25)
26 (36.6)
0.132
Sexual/physical violence
81 (56.6)
27 (37.5)
54 (76.1)
< 0.001
Gender discrimination
93 (65)
44 (61.1)
49 (69)
0.322
*Chi-square test

14. Independent variables
MULTIPLE LOGISTIC REGRESSION MODEL EVALUATING FACTORS ASSOCIATED WITH SYNDEMICS AMONG TGW SCREENED FOR PrEPARADAS STUDY, RIO DE JANEIRO, BRAZIL,
Independent variables
aOR(95%CI)
P(LR-test)
Age (per one year increase)
0.96 (0.9,1.0)
0.191
Non-white self-declared race/color: (ref. white)
4.1 (1.5,11.5)
0.005
Any isubstance abuse , except alcohol (ref. No)
2.0 (0.83,4.9)
0.12
Anxiety
2.8 (0.96,8.3)
0.056
High Impulsivity
3.8 (1.1,12.0)
0.021
Suicide risk
4.0 (0.9,18.3)
0.051
Sexual/physical violence
6.0 (2.4,15.0)
<0.001
Note: Most parcimounious model was selected including only variables p<0.05 or those found to be counfunders. Missing income cases (n=15) were imputed with median income. Anxiety (GAD7 >10); High impulsiveness = BIS11 >77)

15. CONCLUSIONS High prevalence of syndemics (49.7%) among Brazilian TGW
More likely to occur among non-white, those reporting history of sexual/physical violence and high impulsivity
History of sexual/physical violence + anxiety symptoms Post–Traumatic Stress Disorder?
No association between syndemics and sexual risk behavior
Due to high prevalence in both groups as sexual risk behavior was an inclusion criteria
High demand of mental health treatment vs. low availability in LMIC
PrEP is an opportunity to screen and treat mental health and substance use disorders in this vulnerable and stigmatized population

16. ACKNOWLEDMENTS Study participants
PrEPARADAS Demonstration Project team
Community educators: Laylla Monteiro, Cléo Souza, Biancka Fernandes, Toni dos Santos, and Josias Freitas
LAPCLIN-AIDS, INI, FIOCRUZ, Rio de Janeiro, Brazil
Brazilian National Department of Surveillance, Prevention and Control of sexually transmitted diseases (STIs), HIV/AIDS and Viral Hepatitis, Brazilian Ministry of Health
CNPq
FAPERJ
Gilead
Dep. Jean Wyllys