BACKGROUND: Transgender women (TGW) are approximately 66 times more at risk of HIV acquisition than the general population. Designing appealing pre-exposure prophylaxis (PrEP) programs for TGW is urgently needed. We evaluated the drivers of choice for PrEP among TGW living in 11 Asian countries and forecasted their PrEP uptake given different PrEP program configurations.

METHODS: An online discrete choice experiment (DCE) survey was delivered through trans-networks in each country between May-November 2022. Participants who identified as TGW, age > 18 years and had no prior HIV diagnosis were included. Final attributes included: 1)type of PrEP; 2)service location; 3)cost; 4)side effects; 5)visit frequency; and 6)extra services. We calculated the relative importance of each attribute and PrEP uptake prediction using random parameters logit (RPL) models.
RESULTS: Overall, 1,522 TGW were included, with a mean age of 28.1 (±7.0), 63% (956/1,522) reported multiple partners, 38% (581/1,522) had condomless vaginal sex and 16% (249/1,522) were diagnosed with an sexually transmitted infection (STI) in the last six months. The biggest drivers of PrEP uptake were cost (62% relative importance), type of PrEP (10%), location (8%), extra services (8%), visit frequency (7%) and side effects (5%). The most wanted PrEP service (with a predicted uptake of 87%) was: free injectable PrEP with no side effects, accessing PrEP from a peer-led community clinic that provided STI testing, and requiring 6-12 monthly visits. The least preferred PrEP service (with a predicted uptake of 50%) was: PrEP implant with out-of-pocket fees and a rare chance of kidney problems, accessing PrEP from a hospital, no extra services, and requiring 2-monthly visits.

CONCLUSIONS: Our study, the largest DCE for TGW globally, emphasizes the importance of measuring and incorporating preferences for PrEP services to accelerate the scale-up of PrEP among TGW in Asia.