Prevalence and associated risk factors of HIV infections in a representative transgender and non-binary population in Flanders and Brussels (Belgium): Protocol for a community-based, cross-sectional study using time-location sampling

Niels De Brier, Judith Van Schuylenbergh, Hans Van Remoortel, Dorien Van den Bossche, Steffen Fieuws, Geert Molenberghs, Emmy De Buck, Guy T'Sjoen, Veerle Compernolle, Tom Platteau, Joz Motmans, Niels De Brier, Judith Van Schuylenbergh, Hans Van Remoortel, Dorien Van den Bossche, Steffen Fieuws, Geert Molenberghs, Emmy De Buck, Guy T'Sjoen, Veerle Compernolle, Tom Platteau, Joz Motmans

Abstract

Introduction: HIV prevalence and sexual risk have been estimated very high for transgender people. However, the limited sampling and data collection methods used in current research on transgender people potentially led to overrepresentation and generalisation of people at risk for HIV. Current HIV prevalence estimates in transgender populations are generalised from studies mainly focusing on transgender women engaging in sex work. Moreover, studies focusing on non-binary people, who identify with a broad range of identities beyond the traditional male and female gender identities, are scarce.

Objectives: To estimate the HIV prevalence rate in the Flemish and Brussels (Belgium) transgender population, including transgender women, transgender men and non-binary people, and to identify the associated risk factors.

Methods: In this community-based cross-sectional study, self-identified transgender and non-binary (TGNB) people will be recruited through a two-stage time-location sampling approach. First, community settings in which TGNB people gather will be mapped to develop an accurate sampling frame. Secondly, a multistage sampling design is applied involving a stratification based on setting type (healthcare facilities vs outreach events), a selection of clusters by systematic sampling and a simple random selection of TGNB people within each cluster. Participants will complete an electronic self-reported survey to measure sociological, sexual and drug-using behaviors (risk factors) and oral fluid aliquots will be collected and tested for HIV antibodies. Logistic regression models will be used to evaluate risk factors independently associated with HIV infection. The presented study is registered at ClinicalTrials.gov (NCT04930614).

Discussion: This study will be the first to investigate the HIV prevalence rates and associated risk behaviors in an accurate representation of the TGNB population in a Western European country. The findings will globally serve as a knowledge base for identifying subgroups at risk for becoming infected with HIV within TGNB people and to set up targeted prevention programs.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Schedule of enrolment and assessments.
Fig 1. Schedule of enrolment and assessments.
*Because of recruitment taking place in a variety of non-research settings, a relatively short questionnaire needs to be completed at enrolment, and a follow-up questionnaire with additional questions will be sent to the participants by email (cfr. PART II).
Fig 2. Sampling scheme for the selection…
Fig 2. Sampling scheme for the selection of clusters in which each cluster is represented by a segment proportional to its expected number of attendees with k the sampling interval, p the number of subjects per sample group and n the required sample size.
The sum of the segments represents the total population (N).

References

    1. World Health Organization [Internet]. Prevalence of HIV among adults aged 15 to 49; 2019. [cited 2020 August 3]. Available from .
    1. Sasse A, Deblonde J, De Rouck M, Montourcy M, Van Beckhoven D [Internet]. Epidemiologie van AIDS en HIV-infectie in België. Toestand op 31 december 2018; 2019. [cited 2020 August 3]. Available from .
    1. World Health Organization [Internet]. Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations; 2014. [cited 2020 August 3]. Available from .
    1. Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: A systematic review and meta-analysis. Lancet Infect Dis. 2013;13(3): 214–22. doi: 10.1016/S1473-3099(12)70315-8
    1. Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N, et al.. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS Behav. 2008;12(1): 1–17. doi: 10.1007/s10461-007-9299-3
    1. Becasen JS, Denard CL, Mullins MM, Higa DH, Sipe TA. Estimating the prevalence of HIV and sexual behaviors among the US transgender population: A systematic review and meta-analysis, 2006–2017. Am J Public Health. 2019;109(1): e1–e8. doi: 10.2105/AJPH.2018.304727
    1. Nadal KL, Davidoff KC, Fujii-Doe W. Transgender women and the sex work industry: roots in systemic, institutional, and interpersonal discrimination. J Trauma Dissociation. 2014;15(2): 169–83. doi: 10.1080/15299732.2014.867572
    1. Rood BA, Kochaver JJ, McConnell EA, Ott MQ, Pantalone DW. Minority stressors associated with sexual risk behaviors and HIV testing in a US sample of transgender individuals. AIDS Behav. 2018;22(9): 3111–6.
    1. Williamson C. Providing care to transgender persons: A clinical approach to primary care, hormones, and HIV management. J Assoc Nurse AIDS C. 2010;21(3): 221–9.
    1. Van Gerwen OT, Jani A, Long DM, Austin EL, Musgrove K, Muzny CA. Prevalence of sexually transmitted infections and human immunodeficiency virus in transgender persons: A systematic review. Transgender Health. 2020;5(2): 90–103. doi: 10.1089/trgh.2019.0053
    1. Van Schuylenbergh J, Motmans J, Coene G. Transgender and non-binary persons and sexual risk: A critical review of 10 years of research from a feminist intersectional perspective. Crit Soc Policy. 2018;38(1): 121–42.
    1. MacCarthy S, Poteat T, Xia ZY, Roque NL, Kim A, Baral S, et al.. Current research gaps: A global systematic review of HIV and sexually transmissible infections among transgender populations. Sex Health. 2017;14(5): 456–68. doi: 10.1071/SH17096
    1. Zhang Q, Goodman M, Adams N, Corneil T, Hashemi L, Kreukels B, et al.. Epidemiological considerations in transgender health: A systematic review with focus on higher quality data. Int J Transgend Health. 2020;21(2): 125–37. doi: 10.1080/26895269.2020.1753136
    1. Euopean Union Agency for Fundamental Rights. A long way to go for LGBTI equality. Luxembourg: Publication Office of the European Union; 2020.
    1. Owen-Smith AA, Woodyatt C, Sineath RC, Hunkeler EM, Barnwell LT, Graham A, et al.. Perceptions of barriers to and facilitators of participation in health research among transgender people. Transgender Health. 2016;1(1): 187–96. doi: 10.1089/trgh.2016.0023
    1. Gates GJ. How many people are lesbian, gay, bisexual and transgender? Los Angeles, CA: The Williams Institute; 2011.
    1. Brown TN, Herman JL, Park AS. Exploring international priorities & best practices for collecting data on gender minorities, report of meeting. Los Angeles, CA: The Williams Institute, 2017.
    1. Bauer GR. Incorporating intersectionality theory into population health research methodology: challenges and the potential to advance health equity. Soc Sci Med. 2014;110: 10–7. doi: 10.1016/j.socscimed.2014.03.022
    1. Feldman J, Romine RS, Bockting WO. HIV risk behaviors in the U.S. transgender population: Prevalence and predictors in a large internet sample. J Homosex. 2014;61(11): 1558–88. doi: 10.1080/00918369.2014.944048
    1. Bauer GR, Redman N, Bradley K, Scheim AIJIJoT. Sexual health of trans men who are gay, bisexual, or who have sex with men: results from Ontario, Canada. Int J Transgend. 2013;14(2): 66–74.
    1. Nuttbrock LA, Hwahng SJ. Ethnicity, sex work, and incident HIV/STI among transgender women in New York City: A three year prospective study. AIDS Behav. 2017;21(12): 3328–35.
    1. Vincent BW. Studying trans: recommendations for ethical recruitment and collaboration with transgender participants in academic research. Psychol Sex. 2018;9(2): 102–16.
    1. Harrison J, Grant J, Herman JL. A gender not listed here: Genderqueers, gender rebels, and otherwise in the National Transgender Discrimination Survey. LGBTQ Public Policy Journal at the Harvard Kennedy School. 2012;2(1): 13.
    1. Reisner SL, Chaudhry A, Cooney E, Garrison-Desany H, Juarez-Chavez E, Wirtz AL. ‘It all dials back to safety’: A qualitative study of social and economic vulnerabilities among transgender women participating in HIV research in the USA. BMJ Open. 2020;10(1). doi: 10.1136/bmjopen-2019-029852
    1. Adams N, Pearce R, Veale J, Radix A, Castro D, Sarkar A, et al.. Guidance and ethical considerations for undertaking transgender health research and institutional review boards adjudicating this research. Transgender Health. 2017;2(1): 165–75. doi: 10.1089/trgh.2017.0012
    1. T’Sjoen G, Motmans J, Arcelus J, Bouman W. The need of patient involvement in transgender health care research. J Sex Med. 2017;14(12): 1494–5. doi: 10.1016/j.jsxm.2017.09.019
    1. T’Sjoen G, Radix A, Motmans J. Language & ethics in transgender health. J Sex Med. 2020;17(9): 1585–6. doi: 10.1016/j.jsxm.2020.05.017
    1. Van Schuylenbergh J, Motmans J, T’Sjoen G. HIV and sex work in a large sample of European transgender and non-binary persons. European Professional Association for Transgender Health (EPATH) 2019 Rome, Italy; 2019.
    1. Magnani R, Sabin K, Saidel T, Heckathorn D. Review of sampling hard-to-reach and hidden populations for HIV surveillance. Aids. 2005;19: S67–S72. doi: 10.1097/01.aids.0000172879.20628.e1
    1. Kendall C, Kerr LR, Gondim RC, Werneck GL, Macena RHM, Pontes MK, et al.. An empirical comparison of respondent-driven sampling, time location sampling, and snowball sampling for behavioral surveillance in men who have sex with men, Fortaleza, Brazil. AIDS Behav. 2008;12(1): 97.
    1. Muhib F, Lin L, Stueve A, Miller R, Ford W, Johnson W, et al.. A venue-based method for sampling hard-to-reach populations. Public Health Rep. 2001: 216–22. doi: 10.1093/phr/116.S1.216
    1. Statbel [Internet]. Structuur van de bevolking; 2020. [cited 2020 August 3]. Available from .
    1. Weir SS, Pailman C, Mahlalela X, Coetzee N, Meidany F, Boerma JT. From people to places: focusing AIDS prevention efforts where it matters most. Aids. 2003;17(6): 895–903. doi: 10.1097/01.aids.0000050809.06065.e0
    1. MacKellar DA, Gallagher KM, Finlayson T, Sanchez T, Lansky A, Sullivan PS. Surveillance of HIV risk and prevention behaviors of men who have sex with men—a national application of venue-based, time-space sampling. Public Health Rep. 2007;122(1_suppl): 39–47. doi: 10.1177/00333549071220S107
    1. Kuyper L, Wijsen C. Gender identities and gender dysphoria in the Netherlands. Arch Sex Behav. 2014;43(2): 377–85. doi: 10.1007/s10508-013-0140-y
    1. Van Caenegem E, Wierckx K, Elaut E, Buysse A, Dewaele A, Van Nieuwerburgh F, et al.. Prevalence of gender nonconformity in Flanders, Belgium. Archives Sex Behav. 2015;44(5): 1281–7. doi: 10.1007/s10508-014-0452-6
    1. Motmans J, Wyverkens E, Defreyne J [Internet]. Being transgender in Belgium: ten years later. Instituut voor de Gelijkheid van Vrouwen en Mannen, Brussel; 2018. [cited 2022 February 9]. Available from .
    1. Loos J, Nöstlinger C, Vuylsteke B, Deblonde J, Ndungu M, Kint I, et al.. First HIV prevalence estimates of a representative sample of adult sub-Saharan African migrants in a European city. Results of a community-based, cross-sectional study in Antwerp, Belgium. PloS One. 2017;12(4): e0174677. doi: 10.1371/journal.pone.0174677
    1. Hamers F, Phillips A. Diagnosed and undiagnosed HIV‐infected populations in Europe. HIV Med. 2008;9: 6–12. doi: 10.1111/j.1468-1293.2008.00584.x
    1. Karon JM, Wejnert C. Statistical methods for the analysis of time–location sampling data. J Urban Health. 2012;89(3): 565–86. doi: 10.1007/s11524-012-9676-8
    1. Kieser M, Friede T. Simple procedures for blinded sample size adjustment that do not affect the type I error rate. Stat Med. 2003;22(23): 3571–81. doi: 10.1002/sim.1585
    1. Demarest S, Van der Heyden J, Charafeddine R, Drieskens S, Gisle L, Tafforeau J. Methodological basics and evolution of the Belgian health interview survey 1997–2008. Arch Public Health. 2013;71(1): 1–10. doi: 10.1186/0778-7367-71-1
    1. Tibaldi F, Demarest S, Van Oyen H, Tafforeau J, Bruckers L, Molenberghs G, et al.. Changing strategies in the organization of the Belgian Health Interview Survey 2001. Arch Public Health. 2002;60: 275–94.
    1. Platteau T, Fransen K, Apers L, Kenyon C, Albers L, Vermoesen T, et al.. Swab2know: an HIV-testing strategy using oral fluid samples and online communication of test results for men who have sex with men in Belgium. JMIR. 2015;17(9): e213. doi: 10.2196/jmir.4384
    1. Beelaert G, Van Heddegem L, Van Frankenhuijsen M, Vandewalle G, Compernolle V, Florence E, et al.. Evaluation of the intercept oral specimen collection device with HIV assays versus paired serum/plasma specimens. J Virol Methods. 2016;234: 164–8. doi: 10.1016/j.jviromet.2016.04.014
    1. World Health Organization [Internet]. Prequalification assessment and change assessment target deadlines: Prequalification of in vitro diagnostics; 2017. [cited 2020 August 3]. Available from .
    1. Iribarren SJ, Ghazzawi A, Sheinfil AZ, Frasca T, Brown W, Lopez-Rios J, et al.. Mixed-method evaluation of social media-based tools and traditional strategies to recruit high-risk and hard-to-reach populations into an HIV prevention intervention study. AIDS Behav. 2018;22(1): 347–57. doi: 10.1007/s10461-017-1956-6
    1. Althubaiti A. Information bias in health research: definition, pitfalls, and adjustment methods. J Multidiscip Healthc. 2016;9: 211–7. doi: 10.2147/JMDH.S104807
    1. Mosha NR, Aluko OS, Todd J, Machekano R, Young T. Analytical methods used in estimating the prevalence of HIV/AIDS from demographic and cross-sectional surveys with missing data: A systematic review. BMC Med Res Methodol. 2020;20(1): 1–10. doi: 10.1186/s12874-020-00944-w
    1. Nöstlinger C, Loos J. Involving lay community researchers in epidemiological research: experiences from a seroprevalence study among sub-Saharan African migrants. AIDS care. 2016;28(sup1): 119–23. doi: 10.1080/09540121.2016.1146398
    1. Loos J, Vuylsteke B, Manirankunda L, Deblonde J, Kint I, Namanya F, et al.. Together project to increase understanding of the HIV epidemic among Sub-Saharan African migrants: Protocol of community-based participatory mixed-method studies. JMIR Res Protoc. 2016;5(1): e48. doi: 10.2196/resprot.5162

Source: PubMed

Patrocinadores e Colaboradores

Condições médicas

Intervenções de drogas

3
Se inscrever