Low awareness of HIV status and high proportion of recent infections among young travestis and trans women in Brazil

Abstract

Introduction  This study examined correlates of new HIV diagnosis (i.e., no prior awareness of HIV-positive status and HIV diagnosis at study entry) and identified factors associated with HIV vulnerability among Brazilian young trans women.

Material and methods  Baseline assessment of Brilhar e Transcender (BeT [“Shine and Transcend” in English]), an HIV status-neutral intervention single-center study using peer-led digital and in-person systems navigation, between February‒July 2022, in Rio de Janeiro, Brazil. Trans women aged 18‒24 years, living in Rio de Janeiro city or the metropolitan area, were eligible if they were not currently on HIV Pre-Exposure Prophylaxis (PrEP) for those who were HIV-negative, or if they were not on antiretroviral therapy, had a detectable viral load, or were not linked to HIV care for those living with HIV.

Results  Among 170 potential participants, 164 young trans women were eligible and enrolled. Among these, 13% (n = 22) were living with HIV, 68% of them (n = 15) were unaware of their HIV status and diagnosed with HIV; 33% (n = 4 of 12) had a recent HIV infection. Overall, 23.1% had current syphilis, 15% rectal chlamydia, and 13% rectal gonorrhea. Younger age (18‒19 years) (adjusted Odds Ratio [aOR=5.62], 95% Confidence Interval [95% CI 1.36‒27.22]), lower educational attainment (aOR = 7.99, 95% CI 1.78‒47.85), and moderate/high risk of crack/cocaine use (aOR = 8.6, 95% CI 1.44‒54.91) were associated with a higher odds of a new HIV diagnosis.

Conclusions  HIV disparities among young trans women in Brazil reflect persistent structural and social inequities shaping vulnerability and access. Tailored interventions must extend prevention efforts beyond individual behaviors to address these broader determinants.

Keywords
Brazil; HIV care; HIV prevention; Peer-led digital intervention; Trans women; Youth

Introduction

Trans women face extraordinary risk for HIV, with prevalence reaching levels as high as 49.6%.¹ A critical public health challenge is how to prevent new infections among adult and young trans women. Longitudinal research measuring the HIV incidence of trans women in the U.S found young age was a predictor, suggesting that current efforts are insufficient to eradicate HIV in the next generation of young trans women.² Increasing attacks on transgender populations, particularly regarding access to gender-affirming care and HIV prevention, risk worsening existing health disparities as health access and prioritization is affected.³

Since 2000, Latin America has made important gains in expanding access to HIV prevention and treatment. Brazil is the largest country in the region and offers effective HIV prevention and care at no direct cost to users through its National Public Health System (SUS). Despite advancements, the region has seen limited progress in reducing new HIV acquisitions.⁴ From 2010 to 2023, the number of new HIV infections in Brazil increased by 9%. Persistent challenges in reducing new HIV acquisitions in key populations like young sexual and gender minority communities, including trans women, are part of why new infections are on the rise.⁴ Prior research conducted in Rio de Janeiro, Brazil found that one-third-of trans women were living with HIV, and 25% of young trans women were already living with HIV by age 24.⁵ Although oral Pre-Exposure Prophylaxis (PrEP) has been available in the country since 2017, only 4.5% of those currently using it are transgender people, predominantly those aged 30-years or older.⁶ Low PrEP utilization and poor outcomes along the PrEP continuum in Brazil⁷,⁸ highlight the urgent need to identify factors associated with new HIV infections among young trans women.

Discrimination and violence are key drivers of mental health disorders and sexual risk behaviors among trans women,⁵,⁹ contributing to HIV vulnerability through syndemic conditions such as depression, substance use, and social marginalization.¹⁰,¹¹ Research in the US has found that experiences of bullying, trauma, mental distress and parental rejection are correlated with engagement in sexual risk behaviors and HIV status among trans youth.¹² However, few studies have been conducted in Latin America with young trans women to explore their elevated vulnerability to HIV and determine factors most closely associated with risk for acquiring HIV.

In this study, we examined the correlates of new HIV diagnosis and identified factors associated with vulnerability to HIV among young trans women aged 18‒24 years in Rio de Janeiro, Brazil. The goal of this analysis was to uncover factors to target interventions tailored to young trans women to curb the ever-growing epidemic in the population and region.

Material and methods

Study design and participants

We analyzed data from the baseline assessment of Brilhar e Transcender (BeT [“Shine and Transcend” in English]) study, an adapted evidence-based, HIV status-neutral intervention study using peer-led digital and in-person systems navigation, conducted in the Instituto Nacional de Infectologia Evandro Chagas ‒ Fiocruz (INI-Fiocruz), in Rio de Janeiro, Brazil, between February‒July 2022. Study procedures have been described elsewhere.¹³ The study was part of eight sponsored research projects chosen to be a part of a Eunice Kennedy Shriver National Institute of Child Health and Human Development ‒ funded Prevention and Treatment through a Comprehensive Care Continuum for HIV-affected Adolescents in Resource Constrained Settings (PATC3H) consortium. This trial was registered at ClinicalTrials.gov NCT05299645; https://clinicaltrials.gov/ct2/show/NCT05299645.

Our site at INI-Fiocruz is a referral center that provides comprehensive, gender-affirming, and stigma-sensitive care for transgender individuals within a multidisciplinary HIV framework. Participants were recruited from those receiving HIV care or prevention at our clinical site or were referred by our Community Education Team, partners from non-governmental organizations and other health units. Eligibility criteria were: 1) Male sex assigned at birth and self-identification as travesti, transgender woman, or within the trans feminine spectrum, 2) Ages between 18- and 24-years, 3) Living in Rio de Janeiro city or its metropolitan area, and 4) Sexually active. Throughout this manuscript, we use the term “trans women” to refer to participants of all gender identities included in the study. Additional criteria for young trans women not living with HIV were 1) No current PrEP use, 2) PrEP indication according to the Brazilian recommendations at the time of the study, and 3) No PrEP contraindication. For participants living with HIV, additional inclusion criteria were 1) Confirmed HIV diagnosis, 2) No current Antiretroviral Therapy (ART) use or a detectable Viral Load (VL) or not linked to HIV care. Exclusion criteria were: 1) Participation in any HIV prevention or care intervention study in the last year, 2) Refusal to undergo HIV testing, or 3) Having any health condition that, in the opinion of the investigator, precludes participation in the study or may lead to harm to the participant. After eligibility assessment, participants were enrolled and followed for 48-weeks.

Procedures

At study entry, participants responded to trained interviewer-administered surveys, including a screening questionnaire and demographic information after providing written consent. Participants were tested for HIV, syphilis, rectal Chlamydia Trachomatis (CT), and rectal Neisseria Gonorrhea (NG). Participants reporting recent anal condomless sex (<30-days) with a negative HIV rapid test were screened for acute HIV infection through VL testing. Recent HIV acquisitions were identified using the Maxim HIV-1 Lag-Avidity EIA assay as part of Recent Infection Testing Algorithm (RITA), following previous studies.¹⁴–¹⁶ Syphilis screening was conducted using treponemal testing, followed by Venereal Disease Laboratory Testing (VDRL) if the former test yielded a positive result. Hepatitis B and C were first screened using rapid tests followed by serology assessments, if needed.

Study outcomes and definitions

Data were analyzed by grouping participants into three categories: HIV-negative, with a known HIV diagnosis, and with a new HIV diagnosis (i.e., participants who were previously unaware of their HIV status and received an HIV diagnosis at study entry). We collected information on education as a continuous variable and categorized educational attainment into: “up to 8-years” (incomplete elementary school), “9‒11 years” (incomplete secondary school), and “12-years or more” (complete secondary school or more). Unstable housing was defined as living in a shelter or institution, transitional housing, as a guest in someone else's home, at a workplace, in a motel/hotel/inn, or other temporary arrangements. Food insecurity was assessed using an adapted version of the Food and Agriculture Organization of the United Nations questions.¹⁷ Ever syphilis was defined as a positive treponemal test at study entry. Current syphilis was defined as a positive treponemal test with a reactive VDRL, subsequently confirmed as active syphilis by clinical adjudication performed by a study physician. We assessed crack/cocaine use through the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) scale and classified into ‘low risk’ and ‘moderate/high risk’ use.¹⁸ HIV knowledge was assessed using an adapted HIV Knowledge Questionnaire-10 with 8-items.¹⁹,²⁰ We used the Alcohol Use Disorders Identification Test for alcohol consumption (3-items) to assess alcohol use.²¹ Substance use was defined as use of any illicit substance as marijuana, cocaine (powder, crack, or paste), ecstasy, LSD, MDMA, methamphetamine, ketamine, poppers or other inhalants. Social support was assessed using Multidimensional Scale of Perceived Social Support, and evaluated overall, from friends, from family, and from partner.²² We screened the following mental health issues: 1) Posttraumatic Stress Disorder (PTSD) using the Primary Care PTSD scale (positive screening: score ≥ 4),²³ 2) Depression and anxiety using the Patient Health Questionnaire for Depression and Anxiety scale (positive screening: positive if scores ≥ 3).²⁴ Participants were considered with HIV recent acquisition if the final LAg ODn of the avidity assay was ≤ 1.5, VL > 400 copies/mL, CD4 count >200 cells/mm³, and absence or no history of an AIDS-defining illness, all according to data obtained from Brazilian national information systems.

Statistical analysis

Descriptive statistics included median with Interquartile Ranges (IQRs), and absolute and relative frequencies, overall and according to HIV status. Univariable and multivariable logistic regression models were used to assess factors associated with new HIV diagnosis, using HIV-negative participants as the reference group. All variables with p-value <0.25 in the univariable analysis were included in the initial multivariable model, adjusted for race, transactional sex, fillers, and binge drinking. Model fit was assessed using the Hosmer-Lemeshow test, and residual normality was evaluated with the Shapiro-Wilk test. The final model was selected based on overall fit quality. All analyses were performed on the R project version 4.2.3.

Ethical considerations

This study was approved by the Institutional Review Board at the INI-Fiocruz; CAAE #05018818.0.0000.5262) and the University of California, San Francisco Committee on Human Research (#18-26770) in accordance with all applicable regulations. All participants provided written informed consent prior to any study procedure.

Results

Among 170 potential participants, 164 young trans women were eligible and enrolled in the study, and six were ineligible. Among those enrolled, 13% (n = 22) were living with HIV. Among these, 68% (n = 15) were unaware of their HIV status and were diagnosed with HIV at enrollment. We evaluated HIV recency in 12 out of the 15 participants with new HIV diagnosis (3 had no sample available); 33% of them (n = 4 of 12) had a recent HIV acquisition. Overall, median age was 21-years (interquartile range: 19‒22), most participants identified as Black (38%) or Pardo/mixed (26%), and 59% reported food insecurity (Table 1). Median age of identifying a gender different than assigned at birth was 13-years, while the median age of gender transition was 18-years. A large majority of participants had used Gender-Affirming Hormone Therapy (GAHT) at some point (85%), with most using non-prescribed hormones (92%). While none had undergone gender-affirming bottom surgery, 38% expressed a desire to have it in the future. A small percentage (9.8%) reported using industrial fillers (Table 2).

Table 1
Sociodemographics, sexual behavior, and HIV knowledge among young trans women in BeT study, Rio de Janeiro, Brazil, 2022.

	Total (n = 164)	HIV new diagnosis, n = 15 (9.1%)	HIV negative, n = 142 (86.6%)	HIV known diagnosis, n = 7 (4.3%)
Age, years (median [IQR])	21 (19; 23)	21 (19; 22)	21 (20; 23)	23 (21; 24)
Age category, years (%)
18‒19	43 (26.2%)	6 (40.0%)	35 (24.6%)	2 (28.6%)
20‒22	74 (45.1%)	6 (40.0%)	68 (47.9%)	0 (0.0%)
23‒24	47 (28.7%)	3 (20.0%)	39 (27.5%)	5 (71.4%)
Gender identity
Travesti	34 (20.7%)	0 (0.0%)	33 (23.2%)	1 (14.3%)
Transgender women	123 (75.0%)	15 (100.0%)	104 (73.2%)	4 (57.1%)
Women	4 (2.4%)	0 (0.0%)	2 (1.4%)	2 (28.6%)
Other identities	3 (1.8%)	0 (0.0%)	3 (2.1%)	0 (0.0%)
Race
Black	63 (38.7%)	6 (40.0%)	57 (40.1%)	0 (0.0%)
Pardo/Mixed	42 (25.8%)	4 (26.7%)	35 (24.6%)	3 (42.9%)
White	55 (33.7%)	5 (33.3%)	46 (32.4%)	4 (57.1%)
Indigenous	1 (0.6%)	0 (0.0%)	1 (0.7%)	0 (0.0%)
Asian	2 (1.2%)	0 (0.0%)	2 (1.4%)	0 (0.0%)
Missing	1	0	1	0
City
Rio de Janeiro	121 (73.8%)	8 (53.3%)	109 (76.8%)	4 (57.1%)
Other	43 (26.2%)	7 (46.7%)	33 (23.2%)	3 (42.9%)
Schooling (complete years)
Up to 8-years	18 (11.0%)	5 (33.3%)	11 (7.7%)	2 (28.6%)
9‒11 years	37 (22.7%)	4 (26.7%)	31 (21.8%)	2 (28.6%)
12+ years	108 (66.3%)	6 (40.0%)	99 (69.7%)	3 (42.9%)
Missing	1	0	1	0
Currently studying	61 (37.2%)	3 (20.0%)	57 (40.1%)	1 (14.3%)
Currently working	66 (40.2%)	7 (46.7%)	56 (39.4%)	3 (42.9%)
Living with: a
Alone	42 (25.6%)	3 (20.0%)	36 (25.4%)	3 (42.9%)
Parents	68 (41.5%)	7 (46.7%)	60 (42.3%)	1 (14.3%)
Family	29 (17.7%)	4 (26.7%)	25 (17.6%)	0 (0.0%)
Partner	9 (5.5%)	1 (6.7%)	8 (5.6%)	0 (0.0%)
Friends	15 (9.1%)	0 (0.0%)	14 (9.9%)	1 (14.3%)
Other	8 (4.9%)	1 (6.7%)	5 (3.5%)	2 (28.6%)
Housing
Stable	148 (90.2%)	15 (100.0%)	129 (90.81%)	4 (57.1%)
Unstable	16 (9.8%)	0 (0.0%)	13 (9.2%)	3 (42.9%)
Concern with housing situation b
Yes	45 (27.4%)	4 (26.7%)	38 (26.8%)	3 (42.9%)
No	119 (72.6%)	11 (73.3%)	104 (73.2%)	4 (57.1%)
Food insecurity c
Yes	97 (59.1%)	7 (46.7%)	87 (61.3%)	3 (42.9%)
No	67 (40.9%)	8 (53.3%)	55 (38.7%)	4 (57.1%)

• IQR, Interquartile Range, TGW, Trans Women.
• ^a
  Participants could report more than one category.
• ^b
  In prior 6-months.
• ^c
  In prior 3-months.

Table 2
Gender transition characteristics among young trans women in BeT study in Rio de Janeiro, Brazil, 2022.

	Total (n = 164)	HIV new diagnosis n = 15 (9.1%)	HIV negative, n = 142 (86.6%)	HIV known diagnosis, n = 7 (4.3%)
Age of identifying with gender different from that assigned at birth (median [IQR])	13 (10‒16)	11 (10‒15)	14 (10‒16)	12 (8‒14)
Age of gender transition (median [IQR])	18 (15‒19)	17 (15‒19)	18 (15‒19)	16 (15‒18)
Ever GAHT use	139 (84.8%)	13 (86.7%)	120 (84.5%)	6 (85.7%)
Non-prescribed hormone use a	129 (92.8%)	13 (100.0%)	110 (91.7%)	6 (100.0%)
Current GAHT use a	95 (68.3%)	9 (69.2%)	85 (70.8%)	1 (16.7%)
Gender-affirming bottom surgery
Already performed it	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Want to perform it	63 (38.4%)	5 (33.3%)	56 (39.4%)	2 (28.6%)
Don’t want to perform it	97 (59.1%)	10 (66.7%)	82 (57.7%)	5 (71.4%)
Refused to answer	4 (2.4%)	0 (0.0%)	4 (2.8%)	0 (0.0%)
Industrial filler	16 (9.8%)	3 (20.0%)	10 (7.0%)	3 (42.9%)

• ^a
  Among those who ever used GAHT. GAHT, Gender-Affirming Hormone Therapy; IQR, Interquartile Range.

Prevalence of bacterial Sexually Transmitted Infections (bSTI) was high, with 23.1% presenting current active syphilis, 15% with rectal CT, and 13% with rectal NG (Table 3). No participant tested positive for hepatitis B (n = 0/163) or C (n = 0/160). A total of 70% engaged in condomless receptive anal sex in the last 6-months, and 49% ever engaged in transactional sex. Binge drinking and moderate/high risk of crack/cocaine use were reported by 74% and 9.1%, respectively. The majority of participants reported experiencing discrimination due to their gender identity (99%), with 83% having experienced verbal violence. A significant proportion screened positive for anxiety (44%), depression (32%), and PTSD (17%), and 59% reported ever attempting suicide. Furthermore, 44% reported avoiding healthcare assistance due to fear of discrimination and 32% were unaware of the meaning of ‘U = U’ (Undetectable = Untransmittable).

Table 3
Health, STI, and behavior characteristics among young trans women in BeT study in Rio de Janeiro, Brazil, 2022.

	Total (n = 164)	HIV new diagnosis, n = 15 (9%)	HIV negative, n = 142 (87%)	HIV known diagnosis, n = 7 (4%)
Overall health rating
Excellent	10 (6.1%)	2 (13.3%)	8 (5.6%)	0 (0.0%)
Very good	19 (11.6%)	2 (13.3%)	16 (11.3%)	1 (14.3%)
Good	80 (48.8%)	7 (46.7%)	70 (49.3%)	3 (42.9%)
Reasonable	47 (28.7%)	3 (20.0%)	43 (30.3%)	1 (14.3%)
Bad	5 (3.0%)	0 (0.0%)	4 (2.8%)	1 (14.3%)
Don’t know	3 (1.8%)	1 (6.7%)	1 (0.7%)	1 (14.3%)
Has private health insurance
Yes	19 (11.6%)	2 (13.3%)	16 (11.3%)	1 (14.3%)
No	145 (88.4%)	13 (86.7%)	126 (88.7%)	6 (85.7%)
Ever tested for HIV
Yes	117 (78.5%)	6 (85.7%)	110 (78.0%)	1 (100.0%)
No	30 (20.1%)	1 (14.3%)	29 (20.6%)	0 (0.0%)
Don't know	2 (1.3%)	0 (0.0%)	2 (1.4%)	0 (0.0%)
Missinga	15	8	1	6
Ever syphilis	61 (37.7%)	10 (66.7%)	45 (32.1%)	6 (85.7%)
Missinga	2	0	2	0
Current active syphilis	37 (23.1%)	5 (33.3%)	27 (19.6%)	5 (71.4%)
Missinga	4	0	4	0
Rectal chlamydia	24 (15.0%)	3 (20.0%)	21 (15.2%)	0 (0.0%)
Missinga	4	0	4	0
Rectal gonorrhea	21 (13.1%)	3 (20.0%)	18 (13.0%)	0 (0.0%)
Missinga	4	0	4	0
Known number of sex partners in the last 3-months
Yes	128 (78.0%)	9 (60.0%)	115 (81.0%)	4 (57.1%)
No	21 (12.8%)	5 (33.3%)	14 (9.9%)	2 (28.6%)
Number of partners (median [IQR]) b	3 (1‒5)	5 (3‒5)	3 (1‒5)	1 (1‒4)
HIV knowledge scale c
High	121 (73.8%)	8 (53.3%)	109 (76.8%)	4 (57.1%)
Low	43 (26.2%)	7 (46.7%)	33 (23.2%)	3 (42.9%)
Had condomless receptive anal sex in the last 6-months	115 (70.1%)	12 (80.0%)	98 (69.0%)	5 (71.4%)
Transactional sex
In the last 3-months	57 (34.8%)	8 (53.3%)	45 (31.7%)	4 (57.1%)
Prior to 3-months	24 (14.6%)	2 (13.3%)	20 (14.1%)	2 (28.6%)
Never	83 (50.6%)	5 (33.3%)	77 (54.2%)	1 (14.3%)
Binge drinking	121 (73.8%)	13 (86.7%)	103 (72.5%)	5 (71.4%)
Moderate/high risk of crack/cocaine use*	15 (9.1%)	4 (26.7%)	9 (6.3%)	2 (28.6%)

• IQR, Interquartile Range; TGW, Trans Women.
• ^a
  Missing data excluded from percentages.
• ^b
  Among those who knew the number of sexual partners.
• ^c
  HIV knowledge range: 0‒8; low knowledge: <6.

Compared to young trans women not living with HIV, those with a new HIV diagnosis were younger (40%vs. 25% aged 18- to 19-years). They also more frequently lived outside the main metropolitan area of Rio de Janeiro (47%vs. 23%) and had an incomplete elementary school education (33%vs. 7.8%) (Table 1). Less utilization of GAHT was observed among young trans women with a new HIV diagnosis (17%vs. 69%) and a higher proportion of industrial fillers’ use (43%vs. 20%) (Table 2). In addition, participants with a new HIV diagnosis more often reported transactional sex (66%vs. 46%), an unknown number of sexual partners (40%vs. 19%), and had lower HIV knowledge (47%vs. 23%) compared to those not living with HIV (Table 3). Regarding the ‘U = U’ message, a higher proportion of young trans women with a new HIV diagnosis were unaware of its meaning compared to those without HIV (67%vs. 30%) (Table 4). Multivariable analysis identified that individuals aged 18‒19 years (adjusted Odds Ratio [aOR=5.62], 95% Confidence Interval [95% CI 1.36‒27.22]), with lower educational attainment (aOR=7.99, 95% CI 1.78‒47.85), and those who reported moderate/high risk of crack/cocaine use (aOR=8.6, 95% CI 1.44‒54.91) had a higher odds of a new HIV diagnosis (Table 5).

Table 4
Knowledge, stigma, and mental health characteristics among young trans women in BeT study in Rio de Janeiro, Brazil, 2022.

	Total (n = 164)	HIV new diagnosis, n = 15 (9%)	HIV negative, n = 142 (87%)	HIV known diagnosis, n = 7 (4%)
Ever disclosed gender identity	155 (94.5%)	15 (100.0%)	133 (93.7%)	7 (100.0%)
Social support
Friends
High	97 (59.1%)	6 (40.0%)	86 (60.6%)	5 (71.4%)
Medium	48 (29.3%)	7 (46.7%)	39 (27.5%)	2 (28.6%)
Low	19 (11.6%)	2 (13.3%)	17 (12.0%)	0 (0.0%)
Partner
High	110 (67.1%)	10 (66.7%)	94 (66.2%)	6 (85.7%)
Medium	44 (26.8%)	5 (33.3%)	38 (26.8%)	1 (14.3%)
Low	10 (6.1%)	0 (0.0%)	10 (7.0%)	0 (0.0%)
Family
High	60 (36.6%)	6 (40.0%)	50 (35.2%)	4 (57.1%)
Medium	64 (39.0%)	5 (33.3%)	58 (40.8%)	1 (14.3%)
Low	40 (24.4%)	4 (26.7%)	34 (23.9%)	2 (28.6%)
U = U knowledge
Don’t know what it means	53 (32.3%)	10 (66.7%)	43 (30.3%)	0 (0.0%)
Totally correct	67 (40.9%)	4 (26.7%)	60 (42.3%)	3 (42.9%)
Somewhat correct	25 (15.2%)	1 (6.7%)	21 (14.8%)	3 (42.9%)
Somewhat incorrect	12 (7.3%)	0 (0.0%)	12 (8.5%)	0 (0.0%)
Totally incorrect	7 (4.3%)	0 (0.0%)	6 (4.2%)	1 (14.3%)
Any discrimination due to gender identity	162 (98.8%)	15 (100.0%)	140 (98.6%)	7 (100.0%)
Ever physical violence due to gender identity	61 (37.2%)	6 (40.0%)	52 (36.6%)	3 (42.9%)
Ever verbal violence due to gender identity	136 (82.9%)	14 (93.3%)	117 (82.4%)	5 (71.4%)
Avoided healthcare because of fear of being discriminated	72 (43.9%)	8 (53.3%)	63 (44.4%)	1 (14.3%)
Health professionals refused to assist due to gender identity	12 (7.3%)	2 (13.3%)	10 (7.0%)	0 (0.0%)
Treated badly/unfairly by healthcare professionals due to gender identity	30 (18.3%)	1 (6.7%)	27 (19.0%)	2 (28.6%)
Healthcare professionals refused to discuss about issues of trans health	34 (20.7%)	1 (6.7%)	31 (21.8%)	2 (28.6%)
Positive depression screening	52 (32.1%)	5 (33.3%)	46 (32.9%)	1 (14.3%)
Missinga	2	0	2	0
Positive anxiety screening	69 (43.7%)	6 (40.0%)	62 (45.3%)	1 (16.7%)
Missinga	6	0	5	1
Positive PTSD screening	28 (17.1%)	1 (6.7%)	25 (17.6%)	2 (28.6%)
Ever sexual violence	58 (36.9%)	5 (33.3%)	49 (36.3%)	4 (57.1%)
Missinga	7	0	7	0
Ever sexual violence from partner	35 (22.0%)	3 (20.0%)	32 (23.4%)	0 (0.0%)
Missinga	5	0	5	0
Ever worried about safety from partner	70 (42.9%)	4 (26.7%)	65 (46.1%)	1 (14.3%)
Missing	1	0	1	0
Ever suicide attempt
In the last 30-days	35 (21.3%)	3 (20.0%)	31 (21.8%)	1 (14.3%)
Prior to 30-days	63 (38.4%)	5 (33.3%)	56 (39.4%)	2 (28.6%)
Never	64 (39.0%)	7 (46.7%)	53 (37.3%)	4 (57.1%)
Refused to answer	2 (1.2%)	0 (0.0%)	2 (1.4%)	0 (0.0%)

• IQR, Interquartile Range; PTSD, Post-Traumatic Stress Disorder.
• ^a
  Missing data excluded from percentages.

Table 5
Multivariable model of factors associated with a new HIV diagnosis among young trans women in BeT study, Rio de Janeiro, Brazil, 2022.

Variablesa	aOR	95%CI	p-value
Age 18‒19 years (ref. 20‒24 years)	5.62	1.36‒27.22	0.021
Race: Black/Mixed/Otherc (ref. white)	0.47	0.11‒1.9	0.276
Schooling ≤ 8-years (ref. 12+ years)	7.99	1.78‒47.85	0.017
Schooling 9‒11 years (ref. 12+ years)	1.60	0.33‒7.18	0.543
Moderate/high risk of crack/cocaine useb (ref. low risk)	8.60	1.44‒54.91	0.018
Low HIV knowledge (ref. high)	3.02	0.83‒11.52	0.094
Ever transactional sex: yes (ref. no)	1.05	0.25‒4.35	0.945
Use of industrial fillers: yes (ref. no)	3.40	0.56‒18.45	0.158
Binge drinking: yes (ref. no)	3.34	0.70‒25.55	0.172

• aOR, Adjusted Odds Ratio; CI, Confidence Interval.
• ^a
  Adjusted for race, transactional sex, fillers, and binge drinking.
• ^b
  Measured by the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST); score range: 0‒12, moderate/high risk > 2.
• ^c
  Includes Indigenous and Asian. Residual analysis tested by Hosmer-Lemeshow (p = 0.101) (Suppl. Fig. 1).

Discussion

More than half of young trans women living with HIV in our study were unaware of their status. Furthermore, many recently acquired HIV, suggesting ongoing incident cases that are often underestimated by prevalence studies alone.²⁵ Young trans women also had a high burden of bSTIs. Characteristics of participants with a new HIV diagnosis were younger age, residence outside Rio de Janeiro’s metropolitan core, and the presence of intersecting vulnerabilities, including industrial filler use, engagement in sex work, and low educational attainment. The multivariable models identified educational attainment and moderate/high crack/cocaine use risk as key predictors of new HIV diagnoses, with those aged 18‒19 years old exhibiting the highest risk of a new HIV infection.

To our knowledge, this is the first study of new HIV infections among young trans women in a low- and middle-income country. Brazil is the largest country in South America, which is one of few regions globally with a rising HIV epidemic, where the highest burden falls on youth. This study points to significant unmet HIV prevention need for young trans women in Brazil. Despite high rates of prior HIV testing, many remained unaware of their status and/or not engaged in HIV prevention and care. Post-test counseling and referrals may be ineffective at linking young trans women to HIV prevention and treatment. Younger age, crack/cocaine use, and lower educational attainment were key predictors of new HIV diagnosis. These factors reflect a syndemic interplay of substance use, economic instability, and structural barriers to education, all of which exacerbate HIV vulnerability among young trans women.¹¹,²⁶,²⁷ Systemic barriers, including stigma, transphobia, inadequate provider training, and limited access to gender-affirming care may further hinder engagement with HIV prevention and treatment services for young trans women.²⁸

The association between less education and new HIV diagnoses align with broader evidence linking educational disparities to HIV vulnerability among trans populations. Other Brazilian studies have found a high percentage of low educational attainment among trans women and an association with high HIV prevalence.⁵,²⁹ Low education has also been associated with low PrEP adherence in the PrEParadas study, which was a Brazilian trans-specific PrEP demonstration project.³⁰ Lower educational attainment reduces job opportunities, creating economic insecurity and reliance on informal economies such as sex work, which was prevalent among those with a new HIV diagnosis in our sample. A large Brazilian cohort study of 22.7 million low-income individuals analyzed over 9-years (2007‒2015) found that conditional cash transfers (Bolsa Família) significantly reduced AIDS-related morbidity and mortality in highly vulnerable populations.³¹ In addition, among adult men who have sex with men and trans and non-binary persons living in Brazil enrolled in a cross-sectional online study advertised on dating apps and social media from May to September 2021, there was a direct link between food insecurity and non-adherence to PrEP and ART use.³²

Brazil has a Universal Health System (SUS) that provides free and comprehensive healthcare to all people living in the country. SUS has played a crucial role in the HIV response by ensuring widespread access to HIV testing, prevention, and treatment, including universal access to ART and PrEP.³³ Yet, many people from sexual and gender minorities face significant barriers to healthcare, including discrimination, stigma, lack of culturally competent care, and fear of mistreatment, all of which ultimately impact their health and well-being.³⁴–³⁶ Geographic disparities were also present in our data as many young trans women lived far from centers of affirming healthcare, reducing access to HIV prevention and care.¹¹,³⁷ In our sample, nearly 10% of participants with a new HIV diagnosis reported industrial filler use, a marker of engagement with unregulated cosmetic providers, a practice that is usually linked to social, medical, and economic constraints, including lack of access to transitioning procedures and healthcare avoidance.³⁸,³⁹ Basic HIV and sexual health education is needed among young trans women to improve their HIV knowledge and potentially reduce their sexual risk behaviors.

This study has some limitations. Due to the cross-sectional design, we cannot infer causality and temporality. The sample size also limits statistical power and the precision of estimates, particularly for subgroup analysis, and may reduce generalizability. In addition, no formal correction for multiple testing was applied, and findings should be interpreted with caution. The study was intentionally designed to enroll young trans women not yet engaged in HIV prevention or care, which may further limit generalizability to other trans populations. Despite these limitations, a key strength of the study is that it was specifically designed to reach a population that is underrepresented in research and for whom data remain scarce in our setting. As such, these findings provide valuable evidence to inform prevention and care strategies for this population.

This study reinforces that HIV disparities among young trans women are rooted in structural inequities that shape individual risk behaviors and limit access to HIV prevention and care. Tailored interventions must address the intersection of social factors and structural needs to effectively reach this population.

Data sharing statement

A complete de-identified dataset sufficient to reproduce the primary study findings will be made available upon request to the corresponding author, following approval of a concept sheet summarizing the analyses to be done.

• Funding
  This work was supported by the National Institute of Child Health and Human Development and the National Institutes of Health as the Prevention and Treatment through a Comprehensive Care Continuum for HIV-affected Adolescents in Resource Constrained Settings sponsor (grants UG3HD096914 and UH3HD096914). The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. BG was financed in part by CNPq (#313265/2023-2) and Carlos Chagas Filho Foundation for Research Support in the State of Rio de Janeiro (FAPERJ #E.26/200.946/2022). TST was financed in part by CNPq (#304417/2025-4 and #405558/2025-2), FAPERJ (#E-26/201.270/2022). EMJ was financed in part by FAPERJ (E-26/210.072/2025) and CNPq (408880/2025-2).

Acknowledgements

We would like to thank all study participants. The BeT study team: Ana Carolina Figueiredo, Andressa Araujo, Beatriz Grinsztejn, Brenda Hoagland, Camila Mattos Santos, Carolina Ribeiro de Arsolino, Carolina Coutinho, Claudia M. da Silva, Cristina M. Jalil, Cristiane Castro, Daniel Bezerra, Daniel Waite, Eduardo Carvalheira, Eduardo Peixoto, Edilene Bastos, Emilia M. Jalil, Erin C. Wilson, Flavia Lessa, Giovanna Costa, Isabele Barbosa Moura, Jose Roberto Granjeiro, Katia S. M. Derrico, Iasmim Garrido, Laylla Monteiro, Luana Marins, Luiz Ricardo S. Camacho, Marcella Feitosa, Marcos Davi, Mayara Secco, Natalia Ibiapino Proenca, Renata Bastos, Rita de Cassia O. Cockrane, Robson Silva, Ronaldo I. Moreira, Sandra W. Cardoso, Sandro Nazer, Tania Krstic, Thaylla Warggas, Thiago da Silva Torres, Valdilea G. Veloso, Valeria Ribeiro.

Supplementary materials

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.bjid.2026.105874.

Supplementary PDF

Supplementary PDF

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Edited by

• Edited by
  Dr. Luciano Goldani

Publication Dates

• Publication in this collection
  07 Sept 2026
• Date of issue
  2026

History

• Received
  05 Feb 2026
• Accepted
  12 May 2026
• Published
  11 June 2026