AIDS and Behavior (2023) 27:992–1002

https://doi.org/10.1007/s10461-022-03836-w

ORIGINAL PAPER

HIV Risk Perception and Pre-Exposure Prophylaxis (PrEP) Awareness

Among Transgender Women from Mexico
Centli Guillen-Diaz-Barriga1 · Dulce Diaz-Sosa1 · Thiago S. Torres2 · Kelika A. Konda3 · Rebeca Robles-Garcia1 ·
Brenda Hoagland2 · Marcos Benedetti2 · Cristina Pimenta4 · Beatriz Grinsztejn2 · Carlos F. Caceres3 ·
Valdilea G. Veloso2 · Hamid Vega-Ramirez1

Accepted: 23 August 2022 / Published online: 19 September 2022

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022, corrected publication 2022

Abstract
This study aimed to identify factors associated with HIV risk perception among Mexican transgender women (TGW).
This cross-sectional survey was conducted online and at a public HIV clinic in Mexico City. Participants were ≥ 18 years
old, self-identified as TGW, and reported not living with HIV. They answered questions on sexual behavior, HIV risk
perception, and pre-exposure prophylaxis (PrEP) awareness. We performed a multivariate logistic regression to accomplish
the study’s objective. One hundred ninety-one TGW completed the survey. High HIV risk perception was associated
with > 5 sexual partners, condomless receptive anal sex, sex with a male partner(s) of unknown HIV status, and PrEP
awareness. Although most TGW reported low HIV risk perception, over half had risk sexual behavior, reflecting inaccurate
risk assessment. Future interventions to improve accurate risk perception among TGW should promote HIV transmission
and prevention knowledge and increase PrEP awareness and uptake.

Keywords  transgender women · HIV risk perception · HIV prevention · PrEP awareness · risk sexual behavior
Resumen
Este estudio tuvo como objetivo identificar los factores asociados con la percepción de riesgo al VIH entre las mujeres
trans (MT) mexicanas. El reclutamiento de esta encuesta transversal se realizó en línea y en una clínica pública de VIH
en la Ciudad de México. Las participantes tenían ≥ 18 años, se autoidentificaron como MT y reportaron no vivir con VIH.
Respondieron preguntas sobre su comportamiento sexual, percepción del riesgo al VIH y conocimiento de la profilaxis
preexposición (PrEP). Se realizó un análisis de regresión logística multivariado para cumplir con el objetivo del estudio.
Ciento noventa y uno participantes completaron la encuesta. La percepción de alto riesgo al VIH se asoció con > 5 parejas
sexuales, sexo anal receptivo sin condón, sexo con una pareja masculina de estado serológico desconocido y conocimiento
de la PrEP. Aunque la mayoría de las MT informaron baja percepción del riesgo al VIH, más de la mitad reportaron
conductas sexuales de riesgo, lo que refleja una evaluación de riesgo inexacta. Futuras intervenciones para mejorar la
percepción precisa del riesgo entre las MT deben centrarse en promover el conocimiento de transmisión y la prevención
del VIH, así como aumentar el conocimiento y la aceptación de la PrEP.

Hamid Vega-Ramirez
2
hamid.vega@gmail.com Instituto Nacional de Infectologia Evandro Chagas, Fundação
Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
1
National Institute of Psychiatry Ramon de la Fuente Muñiz, 3
Universidad Peruana Cayetano Heredia, Lima, Peru
Col. San Lorenzo Huipulco Alc. Tlalpan, 14370 Mexico City,
4
Mexico Ministry of Health, Brasilia, DF, Brazil

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AIDS and Behavior (2023) 27:992–1002
Introduction
Transgender women (TGW) experience substantial health
disparities, HIV infection being among the most significant
[1]. Globally, TGW are between 34.2 [2] and 49 times more
likely to acquire HIV than the general population [3]. In
Mexico, it is estimated that 73% of TGW living with HIV
are unaware of their serological status [4, 5]. During the first
four months of 2021, TGW accounted for 12% of newly
diagnosed HIV cases in Mexico [6]. Several factors con-
verge to make TGW a vulnerable group for HIV infection,
such as condomless anal sex with stable or casual partners
[7], transactional sex [8], and high rates of sexually trans-
mitted infections (STI) [9, 10]. TGW have limited access to
health services and experience barriers to HIV knowledge
[11], which may impact their HIV risk perception. Risk per-
ception is crucial in health behavioral change models, so
understanding and incorporation into prevention, such as
HIV infection prevention, is essential [12].
Factors associated with HIV risk perception have been
evaluated among TGW in different settings. For example, in
a study conducted in Thailand, most TGW perceived them-
selves as low-risk, even those reporting risky sexual behav-
ior [13]. In another mixed sample of Thai men who have
sex with men (MSM) and TGW, high HIV risk perception
has been associated with HIV testing, inconsistent condom
use, amphetamine use, and unknown STI history [14]. HIV
knowledge improved HIV risk perception and facilitated
preventive behaviors among TGW from different studies [9,
11, 15–18].
With the advances in biobehavioral interventions in HIV
prevention, it is essential to explore and understand the
associations between HIV risk perception and these strate-
gies [19]. Research has indicated that biobehavioral inter-
ventions (e.g., condoms, male circumcision, highly-active
antiretroviral treatment, post-exposure prophylaxis [PEP],
and pre-exposure prophylaxis [PrEP] can change risk per-
ception because individuals can perceive that HIV infection
is not dangerous in terms of morbidity and mortality [20,
21].
In Mexico, information about biobehavioral interven-
tions such as PEP and PrEP and their implications on HIV
risk perception has been mainly focused on men who have
sex with men and has left behind other key populations such
as TWG [22, 23]. This study focused on HIV risk perception
and daily oral PrEP (comprising tenofovir disoproxil fuma-
rate and emtricitabine - TDF/FTC) since it is the biobehav-
ioral intervention recently introduced to México. In 2018,
daily PrEP was available in Mexico through an implemen-
tation project (The ImPrEP Project), and in 2021 became
available through public health services (22).
993
It has been documented that willingness to use PrEP
is associated with HIV risk perception. Low HIV risk
perception is the most common reason for refusing to
participate in PrEP programs [14, 24], while having a high
HIV risk perception increases the likelihood of willingness
to use PrEP [14, 25]. Previous studies in Latin America
have found a strong association between PrEP awareness
and willingness to use it, reinforcing the importance of
awareness for PrEP scale-up [22, 26, 27]. In Brazil, 38%
[28] and 57.1% of TGW are aware of PrEP, and 76.4%
would be willing to use it [25]. Likewise, in Argentina,
89.3% of TGW would be willing to use PrEP [29].
Another factor associated with HIV risk perception and
PrEP is risk compensation. Studies show that PrEP use
can discourage condom use, thus leaving the individual
unprotected against other STIs [19]. The previous could
be explained by the fact that when receiving PrEP, a treat-
ment that offers protection against HIV, the risk perception
decreases and changes decision-making, which translates
into an increase in risk behavior [17]. Therefore, biobehav-
ioral interventions change how individuals assess their own
risk and should be considered when developing counseling
and behavioral intervention strategies. This study aimed to
identify the factors associated with high HIV risk percep-
tion, including PrEP awareness and willingness to use PrEP,
among Mexican TGW. We hypothesized that awareness and
willingness to use PrEP would be associated with high HIV
risk perception.
Methods
This study was part of a PrEP implementation project (The
ImPrEP Project) conducted in three countries in Latin Amer-
ica: Brazil, Mexico, and Peru. The ImPrEP Project aimed to
assess the feasibility, acceptability, and cost-effectiveness of
PrEP among key populations (MSM and TGW) adapted to
their local context and health systems. Under the umbrella
of ImPrEP, several studies were conducted to inform stake-
holders from each country on how to include PrEP as part of
the combined HIV prevention strategy. This study provides
additional analysis of Mexican TGW included in formative
research for ImPrEP conducted in 2018 [22].
Study Design
This was a cross-sectional study using targeted sampling.
Eligible participants were TGW, 18 years or older, and self-
reported not living with HIV. Recruitment was conducted
in two settings: online (web-based) and on-site at a public
health clinic in Mexico City that specializes in HIV testing
and care. An ethical board reviewed and approved the proto-
col and the informed consent forms (ICF). After participants
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994
signed the ICF on-site or accepted the online version of ICF,
they started to answer the questionnaire. Online recruit-
ment was performed through geosocial networking apps
mainly used by sexual and gender minorities, such as TGW
(Hornet® and Grindr®). The decision to use these contact
media was because this study was part of the first approach
to implement PrEP in Mexican territory (The ImPrEP proj-
ect) among key populations. It was assumed that TGW
would use the same dating/social apps as MSM. Online
recruitment took place during June and July 2018, concomi-
tant with the survey targeting MSM [22]. On-site recruit-
ment was conducted from October to December 2018. All
participants provided informed consent before participation,
and no incentives were provided for answering the survey.
Variables
Socio-Demographics
Age was described in median and interquartile ranges (IQR),
and it was dichotomized into 18–24 and ≥ 25 years for the
analysis. Schooling was dichotomized into ≤ secondary edu-
cation and > secondary education. Income was categorized
by the number of minimum wages earned per month (2,686
MXM = USD 141, values for Mexico in 2018), yielding the
following categories: low income (from no income to ≤ 2
minimum wages) and high income ( ≥3 minimum wages).
Recruitment was dichotomized into online and on-site.
Sexual Behavior and STI Diagnosis
We assessed sexual behavior with cisgender men in the pre-
vious six months: number of sexual partners (none, 1–5, and
> 5), condomless receptive and insertive anal sex, sex with
partners living with HIV, sex with partners with unknown
HIV status, sex under the influence of alcohol, chemsex
(sex under the influence of stimulant drugs), transactional
sex (assessed through the question “Did you receive money,
gifts, accommodation, or other goods in exchange for hav-
ing sex?”). We also evaluated self-reports of STI diagno-
sis (gonorrhea, chlamydia, and syphilis) in the previous six
months. We evaluated PrEP eligibility according to WHO
recommendations for PrEP use (in the last six months):
reporting unprotected anal sex, having an HIV-positive part-
ner, transactional sex, previous PEP use, or having an STI
[22, 30].
HIV Biobehavioral Interventions and Prevention (HIV
Testing, PrEP, PEP, and HIV Self-testing)
We asked when the last HIV test was performed, and the
options were: never, less than 12 months ago, and more than
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AIDS and Behavior (2023) 27:992–1002
12 months ago. We assessed PrEP awareness through the
question: “Have you ever heard of PrEP?” (yes/no). Then,
regardless of reported PrEP awareness, we provided a brief
explanation of PrEP and assessed willingness to use PrEP
with a dichotomized (yes/no) option of likelihood through
the statement “Would you use PrEP to prevent HIV if it were
offered to you in the health services in your neighborhood
or city?”. Participants eligible for PrEP answered questions
about concerns related to PrEP use. We also asked partici-
pants about PEP awareness and previous use (yes/no) and
awareness and willingness to use HIV self-testing (yes/no).
Anticipated risk compensation was assessed with the follow-
ing statement: “I would not use a condom if I used PrEP”
(yes/no). Concerns regarding PrEP use were provided in a
pre-existing list, and possible answers were yes/no.
Main Outcome
HIV risk perception was assessed through the question:
Considering your sexual practices, in your opinion, what
would be your risk of getting HIV in the next 12 months?
[22, 31–33]. Participants had three response options: none,
low, and high. For the analysis, responses were grouped into
low (none/low risk) and high risk.
Data Analysis
Sociodemographic characteristics, sexual behavior, and
awareness of PrEP, PEP, and HIV self-testing were described
by frequencies. Chi-square tests were subsequently used to
compare the variables by HIV risk perception (low vs. high)
with the error probability set at ˂0.05; in variables where
the cells included fewer than five cases, Fisher’s exact test
was used. The answers “I do not want to answer” or “I do
not know” were considered missing in the analysis. Logistic
regression models were used to identify variables associ-
ated with high HIV risk perception. Variables with p < 0.05
in the chi-square test were included in the model. Age, con-
domless receptive and insertive anal sex, PrEP awareness,
and willingness to use PrEP were specified as confounders
before the analysis and included in the final model regard-
less of their statistical significance. We used backward step-
wise selection and included all variables with a bivariate of
p < 0.05 in the initial multivariable model. Subsequently,
variables with p > 0.05 were excluded from the model, and
the process was repeated until a final multivariable model
was obtained with all the variables that remained statisti-
cally significant (p < 0.05). We also performed a multicol-
linearity test with the independent variables to produce
variance inflation factors (VIF), considering a VIF value ≥ 5
as an indicator of multicollinearity [34]. All data analyses
were conducted using SPSS version 21 (IBM Corporation).
AIDS and Behavior (2023) 27:992–1002 995

Fig. 1  Study flow-chart. Online and on-site recruitments from June to July 2018 and October to December 2018, respectively

Table 1  Characteristics of Mexican Transgender Women by HIV Risk

Perception
ninety-one TGW (91 recruited online and 100 on-site) were
Characteristics HIV Risk Perception included in this study (Fig. 1).
Total Low High X2 pvalue The median age was 30 years (interquartile range: 24–37).
(N = 169; (N = 22; The majority had completed secondary education or less
88.5%) 11.2%) (61.8%) and had none/low income (53.4%). Most partici-
Age (years) pants (88.5%) reported low HIV risk perception (Table 1).
median (IQR) 30 30 29 0.27 0.898 About half of the participants (52.9%) were eligible for
(24–37) (24–36) (24–38)
PrEP according to WHO recommendations. As shown in
18–24 57 (29.8) 51 (30.2) 6 (23.7)
25–35 82 (42.9) 73 (43.2) 9 (40.9)
Table 2, participants with high HIV risk perception reported
≥ 36 52 (27.2) 45 (26.6) 7 (31.8) more high-risk sexual behavior in the previous six months
Schooling than those reporting low HIV risk perception: more sexual
≤ Secondary 118 106 12 0.551 0.458 partners (68.2% vs. 15.2%, p < 0.001), condomless insertive
education (61.8) (62.7) (54.5) anal sex (33.3% vs. 9.6%, p < 0.001), sex with partners liv-
> Secondary 73 (38.2) 63 (37.3) 10 ing with HIV (27.3% vs. 2.4%, p < 0.001), sex with partners
education (45.5) with unknown HIV status (63.6% vs. 21.1%, p < 0.001),
Income (n = 178) and transactional sex (15% vs. 3.9% p < 0.001). They were
Low 95 (53.4) 85 (54.1) 10 0.317 0.574
(47.6)
also more likely to be eligible for PrEP (90.9% vs. 47.9%,
High 83 (46.6) 72 (45.9) 11 (52.4) p < 0.001), and reported greater anticipated risk compensa-
Recruitment tion (36.4% vs. 16%, X2 = 4.1; p < 0.043).
Online 91 (47.6) 77 (45.6) 14 2.54 0.110 Only 34.6%, 31.7%, and 28.9% were aware of PrEP,
(63.6) PEP, and HIV self-testing, respectively. Compared to those
On-site 100 (52.4) 92 (54.4) 8 (36.4) reporting low HIV perceived risk, TGW with high HIV risk
IQR: interquartile range perception reported more PrEP (68.2% vs. 30.2%, X2 = 12.4;
p < 0.001) and PEP (59.1% vs. 28.1%, X2 = 8.5; p = 0.003)
Results awareness (Fig. 2).
A total of 88.5% would be willing to use PrEP if available.
Of 504 individuals who accessed or were invited to complete TGW with high HIV risk perception were more willing to
the survey, 62.2% were considered ineligible. One hundred use PrEP (95.5%) and less willing to use HIV self-testing

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996 AIDS and Behavior (2023) 27:992–1002

Table 2  Sexual Behavior and Variables HIV risk perception

HIV Testing History of Mexican Total Low High X2 pvalue
Transgender Women by HIV n (%) (N = 169) (N = 22)
Risk Perception n(%) n(%)
Number of sexual partnersa (n = 187) - < 0.001*b
None 65 (34.8) 63 (38.2) 2 (9.1)
1–5 82 (43.9) 77 (46.7) 5 (22.7)
> 5 40 (21.4) 25 (15.2) 15 (68.2)
Condomless receptive anal sexa (n = 190) 1.7 0.279
Yes 79 (41.9) 67 (39.9) 12 (54.5)
No 111(58.4) 101 (60.1) 10 (45.5)
Condomless insertive anal sexa (n = 187) - < 0.001* b
Yes 24 (12.8) 16 (9.6) 8 (33.3)
No 163 (87.2) 151 (90.4) 12 (60.0)
Sex with partners living with HIV a (n = 188) - < 0.001*b
Yes 10 (5.3) 4 (2.4) 6 (27.3)
No 178 (94.7) 162 (97.6) 16 (72.7)
Sex with partners with unknown HIV statusa 18.2 < 0.001*
(n = 188)
Yes 49 (26.1) 35 (21.1) 14 (63.6)
No 139 (73.9) 131 (78.9) 8 (36.4)
Sex under the influence of alcohola 8.8 0.007*
(n = 190)
Yes 53 (27.9) 41 (24.4) 12 (54.4)
No 137 (72.1) 127 (75.6) 10 (45.5)
Chemsexa,c - 0.202 b
(n = 190)
Yes 23 (12.1) 18 (10.7) 5 (22.7)
No 167 (87.9) 150 (89.3) 17 (77.3)
Transactional sexa,d (n = 189) - < 0.001* b
Yes 39 (20.6) 25 (15) 14 (63.6)
No 150 (79.4) 142 (85) 8 (36.4)
STI diagnosisa,e (n = 147) - 0.070 b
Yes 8 (5.4) 5 (3.9) 3 (15.0)
No 139 (94.6) 122 (96.1) 17 (85.0)
PrEP elegibilityf 14.43 < 0.001*
*p ≤ 0.05 aPrevious 6 months Yes 101 (52.9) 81 (47.9) 20 (90.9)
with cisgender men; b Fisher’s No 90 (47.1) 88 (52.1) 2 (9.1)
exact test was used; cChemsex
Last HIV test - 0.119 b
was defined as sex under the
influence of stimulant drugs; Never 30 (15.7) 29 (17.2) 1 (4.5)
d
Transactional sex was assessed Previous 3 months 54 (28.3) 42 (24.9) 12 (54.5)
with the question “Did you Previous 6 months 42 (22) 2 (9.1) 40 (23.7)
receive money, gifts, accom- Previous 12 months 37 (19.4) 36 (21.3) 1 (4.5)
modation, or other goods in More than 12 months 28 (14.7) 22 (13) 6 (27.3)
exchange for having sex?”; Anticipated risk compensation 4.1 0.043*
e
Syphilis, gonorrhea, or chla- (n = 185), n(%)
mydia based of self-report;
f Yes 34 (18.4) 26 (16) 8 (36.4)
Based on WHO criteria for
PrEP use (28) No 151 (81.6) 137 (84) 14 (63.6)

(81.8%), but neither difference was statistically significant
(Fig. 3). Previous PEP use was reported only in 5.2% of the
total sample, with no differences between groups.
The most frequent concerns among those eligible for
PrEP were side effects (76%), interaction with hormones
(71%), and the efficacy against HIV (72.7%). Compared to
TGW with high HIV risk perception, those with low HIV
risk perception reported more significant concern about the
potential interaction between PrEP and hormones (76.3%
vs. 52.6%, X2 = 5.7; p = 0.040; Table 3).
In the final multivariate logistic model, having more
than five sexual partners (aOR  = 6.00 [95%CI:1.1–31.2],
p = 0.033), condomless receptive anal sex (aOR  = 0.15
[95%IC: 0.3–0.8], p = 0.031), sex with partners with unknown

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AIDS and Behavior (2023) 27:992–1002 997

Table 3  Self-reported concerns related to PrEP among Mexican trans-

gender women eligible for PrEP by HIV risk perception
Would you be HIV risk perception
concerned about/ Total Low Risk High Risk X2 Pvalue
that… (n%) Perception Perception
N = 80 N = 19
n(%) n(%)
Possible PrEP 2.9 0.180
side effects?
(n = 96), n(%)
Yes 73 62 (79.5) 11 (61.1)
(76)
No 23 16 (20.5) 7 (38.9)
(24)
PrEP doesn’t 1.7 0.557
Fig. 2 PrEP, PEP, and HIV self-testing awareness among Mexican protect you
transgender women. * indicates p < 0.01 100% against
HIV?
(n = 99), n (%)
Yes 72 59 (74.7) 13 (65)
(72.7)
No 27 20 (25.3) 7 (35)
(27.3)
PrEP would 5.7 0.040*
interfere with
your hormone
treatment?
(n = 99), n(%)
Yes 71 61 (76.3) 10 (52.6)
(71.7)
No 28 19 (23.8) 9 (47.4)
(28.3)
Fig. 3  Willingness to use PrEP and HIV self-testing among Mexican People thinking - - .487a
transgender women you had HIV if
they saw you
taking PrEP?
HIV status (aOR = 8.9 [95%CI: 2.0-38.5], p = 0.004), and (n = 101), n(%)
PrEP awareness (aOR = 6.4 [95%CI: 1.3–31.2], p = 0.001) Yes 18 16 (19.8) 2 (10)
were associated with high HIV risk perception (Table 4). (17.8)
The VIF values were less than 5 (range: 1.014–1.613); No 83 65 (80.2) 18 (90)
(82.2)
therefore, no adjustments were necessary to the model.
Taking PrEP - .654a
every day?
(n = 98), n(%)
Discussion Yes 10 9 (11.5) 1 (5)
(10.2)
This study shows that PrEP awareness is associated with No 88 69 (88.5) 19 (95)
(89.8)
high HIV risk perception among TGW in Mexico. In the
Going to the - .674a
present study, only 11.5% of TGW had a high HIV risk per- doctor every
ception, similar to other studies [11, 35, 36]. Our data show three months to
the discrepancy between HIV risk perception and actual get tested for
HIV?
HIV risk since nearly half the participants would be eligible
(n = 99), n(%)
to use PrEP based on the WHO criteria. This discrepancy Yes 7 (7.1) 6 (7.6) 1 (7.1)
has also been observed for MSM [13, 31], suggesting that No 92 73 (92.4) 19 (95)
populations vulnerable to HIV may be unaware of their (92.9)
actual HIV risk. *p ≤ 0.05; aFisher’s exact test was used
In our adjusted multivariate model, PrEP awareness
had the highest odds for high HIV risk perception, HIV risk perception. For example, PrEP awareness can
suggesting that PrEP awareness could help increase high promote willingness to use it [26], and the individual can

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998 AIDS and Behavior (2023) 27:992–1002

Table 4  Factors associated with Bivariate Models Multivariate Modela

high HIV risk perception among a
Variable OR(95% CI) p-value aOR(95% p-value
Mexican transgender women
CI)
Age group
18–24 Ref. 0.780 -
≥ 25 0.86 (0.32–2.34)
Number of sexual partners
≤ 5 Ref. < 0.001* Ref. 0.033*
> 5 12 (4.4–32.4) 6.00
(1.1–31.2)
Condomless receptive anal sex
Yes 1.0 (0.9-1.0) 0.826 0.15 0.031*
(0.3–0.8)
No Ref.
Condomless insertive anal sex -
Yes 6.3 (2.2–17.7) < 0.001*
No Ref.
Sex with partners living with HIV
Yes 15.2 (3.9–59.5) < 0.001* -
No Ref.
Sex with partners with unknown HIV status
Yes 6.5 (2.5–16.9) < 0.001* 8.9 (2.0-38.5) 0.004*
No Ref. Ref.
Transactional sex
Yes 9.9 (3.8–26.1) < 0.001* 6.4 0.020*
(1.3–31.2)
No Ref.
Sex under the influence
of alcohol
Yes 3.7 (1.5–9.2) 0.005* -
No Ref.
PrEP elegibility
Yes 10.9 (2.5–47.9) 0.002* -
No Ref.
Anticipated risk compensation
Yes 3.0 (1.5–7.9) 0.025* -
No Ref.
OR: odds ratio; aOR: adjusted
PrEP awareness
odds ratio. a Variables with
p < 0.05 in the chi-square test and Yes 4.9 (1.9–12.9) < 0.001* 35.9 0.001*
those previously established by (3.9–32.4)
theoretical relevance (age, con- No Ref. Ref.
domless anal sex [receptive and PrEP willingness
insertive]), PrEP awareness, and Yes 2.9 (0.4–23.3) 0.298 -
PrEP willingness were included No
in the initial multivariable PEP awareness
model. Variables with p < 0.05
Yes 3.9 (1.5–9.2) 0.005* -
were kept in the final multivari-
able. *p ≤ 0.05 No Ref.

seek a better understanding and knowledge of preventive
measures. Knowledge can encourage better self-assessment
of risk [37]. Other factors found to be related to HIV risk
perception were similar to other studies conducted among
MSM, in which a high number of sexual partners [31, 32,
38] and transactional sex [39] have been associated with
high HIV risk perception [13].
Our study also noted that condomless receptive anal
sex decreases the probability of perceiving oneself at
high risk. This is contrary to what was reported in other
investigations where condomless receptive anal sex
increases high HIV risk perception [14]. It is important to
understand risk perception from different perspectives since
the characteristics of the disease are combined with social
norms and the context in which they develop [19]. In this

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AIDS and Behavior (2023) 27:992–1002
sense, it has been widely documented that in relationships
known as stable or formal, condom use decreases [40].
Condom use comes with a meaning where feelings of trust
towards the partner and the partner’s sexual behavior have a
central role in HIV risk perception, and ultimately condom
use is not an individual choice [17]. We can hypothesize
that the women who participated in this study could have
been in a stable relationship or had feelings of trust, so they
chose to stop using the condom. Being part of a formal
relationship decreases HIV risk perception, even if condoms
are not used regularly. Another explanation may lie in
understanding the relationship between stress, coping, and
unprotected anal intercourse [41]. For example, TGW who
perceive themselves as without resources to face a demand
(i.e., condom use) to prevent HIV usually choose avoidance
(i.e., they do not negotiate their use). Due to the above, it
is essential to provide interventions that provide counseling
free of prejudice and promote safe sex practices, even when
it comes to individuals with partners defined as stable [42].
For the Mexican TGW population, our findings support
the evidence that when this population seeks prevention for
HIV is an opportunity to increase awareness and change
HIV risk perception if in dissonance with risky behaviors.
For example, when people go to an STI clinic is an excel-
lent opportunity to raise awareness about HIV [9], so it can
also be seen as a chance to promote PrEP literacy. Another
viable option for the TGW community is to leverage peer
advocacy so that more individuals know about strategies
such as PrEP and its implications for the actual risk of HIV
infection. Health providers remain responsible for provid-
ing PrEP information using techniques to encourage change
[43] and strategies to increase self-efficacy in preventive
behaviors [44].
PrEP awareness was low among our participants
compared with Mexican MSM [22] and Brazilian TGW [25,
28]. Conversely, willingness to use PrEP was higher than
TGW from Brazil [25] and Argentina [29]. PrEP has been
provided in Brazil as part of demonstration initiatives since
2013 [45] and as a public policy since 2017 [46]. In contrast,
since mid-2021, PrEP availability has officially increased
through Mexico’s public health services. Still, by the time
of study conduction, PrEP was only available through the
ImPrEP project [47], which promotion campaign only
began in late 2018 [48]. Making a population aware of
new preventive strategies is the first step toward gaining
recognition among individuals and creating demand for
biobehavioral interventions [23]. Promoting and improving
HIV risk perception among TGW could increase motivation
to use PrEP, which may reduce new HIV infections [49].
However, it is critical to consider the job conditions of TGW
in Mexico, as most of the time, their options are restricted
to beauty salons, nightclubs, and transactional sex due to
999
discrimination and stigma [50]. As a result, their income
is limited or non-existent, impacting their access to health
care. Public policies must be aligned with TGW needs, and
PrEP promotion campaigns should be tailored to reach them,
ensuring access to health free of discrimination and stigma.
As observed in previous studies, most reported concerns
related to PrEP referred to side effects [3, 25, 36, 51, 52]
and hormone therapy interaction [53–55]. These concerns
can be reduced by providing adequate information, as TDF/
FTC does not influence the level of hormones in the blood.
On the contrary, the hormones taken can slightly decrease
the serum level of PrEP [56, 57]. Campaigns, peer educa-
tion, and promotion should be used to debunk the myths
about PrEP.
Even though it was not within our main objectives,
we consider essential to highlight the PEP and HIV test-
ing results since they represent another type of biobehav-
ioral intervention. Awareness of PEP was less than 20%,
although non-occupational PEP for populations vulnerable
to HIV has been included in the Mexican National Guide-
lines for Antiretroviral Treatment since 2014[58]. How-
ever, there has been evidence that the implementation of
non-occupational PEP faces at least two main obstacles in
Mexico. First, PEP services are centralized in a single clinic
specializing in HIV prevention in Mexico City, making it
difficult for people outside the country’s capital to access
this prevention strategy. Second, information dissemination
has not been universal, so it is restricted to people who have
access to the Internet or engage with non-profit organiza-
tions [23]. Due to social vulnerabilities, TGW fail to obtain
information on PEP, so they cannot use it.
HIV testing history was similar to that observed for TGW
in Brazil [25] but higher than Peruvian TGW [33]. Part of
our sample was obtained on-site, where regular HIV testing
is part of their follow-up protocol to receive hormonal treat-
ment, so we expected a high proportion of recent HIV test-
ing. Surprisingly, the high proportion of TGW willing to use
HIV self-testing proves that this strategy should be offered
to this population. This may be explained by the anonym-
ity and intimacy provided by HIV self-testing, preventing
discrimination and stigma experienced by this population
when they seek or use public health services [59].
This study has limitations. First, we got wide confidence
intervals due to the small sample with the variables of
interest, so these results do not precisely represent all TGW
in Mexico. We could improve the parameter by expanding
the sample in future research; however, despite the difficulty
of getting TGW involved in previous studies, we had almost
two hundred participants. For future research, it should
be noted that the ImPrEP communication team found that
social networks are not the primary communication channel
for the trans population in Mexico. They must be contacted
13
1000
in community scenarios [60]. Our sample had access to the
internet connection and public health services, meaning that
populations with other needs have been excluded. In addition,
a portion of the sample was recruited at a specialized clinic
where patients are constantly monitored, and the ImPrEP
study was promoted. In addition, this clinic is a referral
in Mexico City for HIV prevention and care among the
TGW community (23), limiting the generalization of other
Mexican cities. Second, the research was based on self-
reported HIV, which cannot be guaranteed since desirability
bias could be present. Third, because this is a cross-sectional
study, causalities cannot be inferred. However, this study
can guide further longitudinal studies [61]. Fourth, only
one element of HIV risk perception (risk probability)
was accessed, which should be complemented with the
inclusion of risk severity, emotional risk (risk concern), and
comparative risk (more or less risk than their peers) [62],
or the use of risk perception scales in future studies [39,
63]. Finally, risk perception is multifactorial, and the study
did not incorporate the life experiences of TGW related to
discrimination and stigma [33], which could mediate risk
perception from a social perspective.
Conclusion
This study strengthens information on TGW and their HIV
risk perception in populations from Latin America, specifi-
cally Mexico. High reports of low HIV risk perception were
inconsistent with risky sexual behaviors. PrEP awareness
was associated with high HIV risk perception. Access to
PrEP information may be translated into better risk assess-
ment and correct HIV perceived risk. Health providers
should help TGW develop accurate HIV risk perception
based on their sexual behavior and provide PrEP users inter-
ventions based on self-efficacy or motivation to change.
Acknowledgements We want to thank the Ministry of Health of
Mexico and all the participants who helped with this survey. We are
also grateful to Clinica Especializada Condesa and the staff: Erica
González, MD, and María Guadalupe Martínez, RN, who facilitated
contact with the participants and encouraged them to participate; and
research assistant Lorena Hernández-Cariño. Also, thanks to UNFPA
Mexico for coordinating the allocation of funds in Mexico to under-
take this research.
Authors’ Contributions HVR, TST, and KAK developed the survey
and designed the study. CGDB and DDS conducted the fieldwork
in Mexico. CGDB, HVR, and DDS conducted the data analysis and
wrote the manuscript. TST, KAK, and RRG reviewed the results and
the draft. BH, MB, CP, BG, CFC, and VGV reviewed, contributed in-
tellectually, and approved the final version.
Funding This project was made possible by Unitaid’s funding and
support. Unitaid is a hosted partnership of the WHO. Unitaid expe-
dites access to innovative health products and lays the foundations for
13
AIDS and Behavior (2023) 27:992–1002
their scale-up by countries and partners. Thiago S. Torres acknowl-
edge funding from Conselho Nacional de Desenvolvimento Científico
e Tecnológico (CNPq) and Fundação de Amparo a Pesquisa do Estado
do Rio de Janeiro (FAPERJ).
Data Availability  The authors ensure that all data reflects published
statements. The datasets analyzed during the current study are avail-
able from the corresponding author on reasonable request.
Code Availability  Not applicable.
Declarations
Conflict of Interest  The authors declare no conflict of interest. Kelika
A. Konda reports employment at Universidad Peruana Cayetano Here-
dia and University of California, Los Angeles.
Ethics Approval This study was approved by the Research Ethics
Committee of the National Institute of Psychiatry Ramón de la Fuente
Muñiz (#CEI/C/038/2018) of Mexico City.
Consent to Participate  Informed consent was obtained from all indi-
vidual participants included in the study.
Consent for Publication  Not applicable.
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