Introduction of gain-framed pre-exposure prophylaxis counseling increased uptake among transgender women at the Tangerine Clinic, Bangkok, Thailand

BACKGROUND: Transgender women continue to be disproportionally affected by HIV in Thailand. Pre-exposure prophylaxis (PrEP) remains underutilized by transgender women despite its efficacy and availability due to several barriers, including stigma related to sexual behaviors and to taking PrEP. Loss-framing counseling, in which risk behavior is emphasized, further exacerbates PrEP stigma and can impede PrEP uptake. In June 2020, Tangerine Clinic in Bangkok, Thailand, introduced gain-framed PrEP counseling to encourage clients to focus on protection and healthy behavior and ultimately increase PrEP uptake. Here we assess PrEP uptake before and after implementation of gain-framed PrEP counseling.
METHODS: We analyzed data from transgender women visiting Tangerine Clinic from June 2020 through July 2021, including demographic and sexual behavioral characteristics from self-administered questionnaires, data related to HIV and sexually transmitted infections (STIs) (syphilis, gonorrhea, chlamydia). Although not the focus of counseling messages, HIV risk was determined by asking about self-perceived HIV risk and through self-reported behavioral risk factors. PrEP uptake during this period was compared to uptake before implementation of gain-framed counseling (June 2019'May 2020).
RESULTS: From June 2020 to July 2021, 1,149 transgender women not on PrEP visited Tangerine, of whom 398 (34.6%) accepted PrEP after gain-framed counseling. Median age was 26.2 years. A total of 319 (80.2%) were new initiations, and 79 (19.8%) restarted PrEP after previous discontinuation. Among the 398 transgender women accepting PrEP, 106 (26.6%) did not perceive themselves to be at risk for HIV, while 41/106 (38.7%) reported risk behaviors and 26/106 (24.5%) were diagnosed with an STI. In the year before gain-framed counseling implementation, PrEP uptake was 161/1,191 transgender women (13.5%), with 13 transgender women having no self-perceived risk accounting for 8.1% of initiations, indicating an increase in PrEP uptake of 147% overall, and a 715% increase among transgender women without self-perceived HIV risk.
CONCLUSIONS: Replacing traditional risk-based counseling with empowering messages focusing on health improved PrEP uptake overall, particularly among transgender women without self-perceived risk, despite a discrepancy between self-perceived and actual HIV risk. Gain-framed messages should be integrated with PrEP counseling to optimize PrEP use and its impact on the HIV epidemic.