Population-Based HIV Prevalence, Anti-Trans Stigma and HIV Risk Among Trans Women in Nepal

Abstract

Background: Transgender women in Nepal are underserved in the HIV response. Research is needed to determine the HIV prevalence disaggregated from MSM and the impact of stigma on HIV risk to inform trans-specific interventions. Methods: In 2019, we conducted the first population-based HIV behavioral surveillance study of trans women using respondent driven sampling (RDS). We estimated the HIV prevalence for trans women and conducted bivariate and multivariate logistic regression modeling to examine the relationship between HIV risk and stigma. Findings: Trans women participants (N=200) had a mean age of 33 years old. We found a weighted HIV prevalence of 11.3% (95% CI 6·82% - 18·13). We found that depression (OR 0·19, 95% CI 0·07–0·53; p = 0·002) and current engagement in sex work (OR 6·79; 95% CI 1·39–33·22; p = 0·018) were significantly associated with greater odds of condomless receptive anal intercourse. We also found that internalized stigma in hiding gender identity from family (OR 4·41, 95% CI 1·00–19·54; p = 0·051) and enacted stigma of being arrested for being trans (OR 3·63, 95% CI 1·02–12·91; p = 0·047) were significantly associated with greater odds of condomless receptive anal sex in the last 6 months. Felt stigma of believing they were seen by Nepali society as a criminal because of trans identity (OR 4·57; 95% CI 1·67–12·55; p = 0·003) was significantly associated with greater odds of having depression and anxiety. Enacted stigma of ever being sexually abused due to gender identity (OR 13.00; 95% CI 2·63–64·25; p = 0·002) was significantly associated with engaging in sex work. Interpretation: Trans women women are highly impacted by HIV in Nepal, and stigma is an important correlate to HIV-related risk behavior. HIV prevention interventions are needed that address the economic and mental health impacts of stigma towards trans women in Nepal. Funding Statement: National Institutes of Health, Fogarty International Center grant# R21TW011056 Declaration of Interests: All authors declare no competing interests. Ethics Approval Statement: Our study received human subject approval from the University of California, San Francisco, Baldwin Wallace University and the Nepal Health Research Council.