Social Networks Play a Complex Role in HIV Prevention Knowledge, Attitudes, Practices, and the Uptake of PrEP Through Transgender Women Communities Centered Around Three "Casas Trans" in Lima, Peru: A Qualitative Study

The study addresses how transgender women’s (TW) social networks in Lima, Peru—particularly within communities centered around three casas trans—shape HIV prevention knowledge, attitudes, and practices and influence the uptake of pre-exposure prophylaxis (PrEP). Grounded in Diffusion of Innovations (DOI) theory and the knowledge–attitudes–practice gap (KAP-gap) framework, the study explores the mismatch between high awareness/positive attitudes and actual prevention behaviors among TW. In Peru, PrEP access is limited primarily to research studies, and TW face barriers including mistrust of medical institutions, prioritization of hormones, and structural constraints, motivating an examination of network mechanisms that could facilitate PrEP diffusion in this context.

Prior research shows TW bear a disproportionate HIV burden, and PrEP—though effective—has limited uptake among TW due to access barriers, medical mistrust, and competing priorities (e.g., feminizing hormones). Social networks are critical sources of prevention information and support, as shown among MSM and TW in various settings. DOI theory highlights homophily, opinion leadership, and perceived attributes (relative advantage, trialability, observability, complexity, compatibility) that influence diffusion of innovations. Past DOI-informed interventions (e.g., C-POL trial in Peru) did not demonstrate superior outcomes compared to robust education controls, underscoring the challenge of translating knowledge into behavior (the KAP-gap). The literature suggests that interventions must be adapted to local contexts, target behavior modeling, and address structural barriers to close the KAP-gap for HIV prevention, particularly PrEP, among TW.

Design: Qualitative study conducted in May 2018 among TW residing in or affiliated with three casas trans in the greater Lima area. Sampling and eligibility: Convenience sampling via a local TW community organization. Eligibility: age ≥18, self-reported HIV-negative or unknown serostatus, self-identified as a transgender woman (transgénero, travesti, mujer trans), and anal/oral sex within past 12 months. Of 22 screened, 20 eligible. Procedures: Written informed consent; brief demographics; standardized social network interview; semistructured in-depth interview in Spanish by two fluent interviewers (one TW community member, one cis-woman qualitative researcher). Interview guide co-developed with TW community input, piloted with three TW. Participants listed their three closest/most influential network members; probes covered relationship dynamics, support, communication, prevention knowledge/attitudes (condoms, PrEP), HIV/STI discussions, and influence on behaviors. Interviews conducted privately, 45–60 minutes, audio-recorded and transcribed; compensation: 40 Nuevos soles (~USD 13). Analysis: Quantitative demographics and network data analyzed in Stata. Qualitative analysis in Atlas.ti using immersion–crystallization. A preliminary deductive codebook (based on guide and literature) was applied line-by-line; inductive refinement added/merged codes aligned with DOI and KAP-gap frameworks. Thematic saturation determined by dual initial transcript reviews. Ethics: Approved by Asociación Civil Impacta (0014-2018-CE) and UCLA IRB (17-001538-CR-00001); procedures adhered to the Declaration of Helsinki.

Sample: N=20 TW; median age 26 (IQR 21.5–32.5); 85% living in a casa trans; most born outside Lima with median 5 years in Lima among migrants; education: 55% completed secondary school or greater; income (n=19): majority 501–1500 soles/month; sexual role: 63.2% passiva, 36.8% moderna; relationship status per table: 35% in a partnership; all engaged in sex work; condom use: 55% always; PrEP awareness: 85%; current PrEP use: 15%. Network influence on HIV prevention: - Knowledge sharing: TW networks, especially older/more experienced TW, educated younger/new arrivals about condom use and routine HIV/STI screening. Respondents often served as sources of prevention information for partners and family, and sometimes accessed testing with TW friends or brought partners for screening. - KAP-gap for condoms: Despite positive attitudes and widespread pro-condom discourse within TW and families, consistent condom use was not maintained, especially with primary partners (trust cited) and with clients due to power imbalances, economic coercion (higher pay for condomless sex), and reports of stealthing. - Routine HIV/STI screening: Positive attitudes aligned with practice; testing commonly accessed, often with network support. - PrEP attitudes and practices: PrEP discussions were less frequent within TW networks and marked by misinformation and mistrust. Network opinions strongly shaped beliefs, including concerns that PrEP was not scientifically proven, fears of side effects, and mistrust of health/research personnel. Structural barriers—limited access mainly via research studies, enrollment burden/time costs, lack of legal ID (DNI)—compounded hesitancy and impeded uptake. - Positive deviants: A minority adopted PrEP when supported by TW peers already using it, health promoters, or supportive family, illustrating potential leverage points for diffusion. Overall, high HIV prevention knowledge and generally positive attitudes coexisted with low engagement in consistent condom use and very low PrEP uptake; network dynamics amplified both supportive behaviors (testing) and barriers (condom use, PrEP).

The study demonstrates that TW social networks significantly shape HIV prevention knowledge, attitudes, and practices. A pronounced KAP-gap persists: while testing is both endorsed and practiced, condom use and especially PrEP uptake lag due to partner-driven power dynamics, economic coercion, misinformation, and structural barriers. Applying DOI theory, PrEP diffusion is hindered by low perceived compatibility (mistrust, MSM-centric messaging not tailored to TW), high perceived complexity (access primarily via research protocols), and limited trialability/observability. However, existing homophily and opinion leadership within TW networks can be leveraged: engaging trusted TW community leaders, tailoring messaging for TW, and modeling PrEP use may improve perceived compatibility and relative advantage. Structural changes—broadening access beyond research, simplifying pathways, potentially using incentives—are critical. Recognizing DOI’s limitations (underemphasis on resources/social support and institutional constraints), the findings underscore that social support within TW networks and systemic reforms must align to close the KAP-gap and enhance PrEP uptake.

TW play central roles in disseminating and reinforcing HIV prevention knowledge and norms across their networks. Interventions to promote PrEP among TW in Peru should leverage community relationships, involve TW leaders in design and delivery, tailor messaging specifically for TW (not bundled with MSM), and consider including family and partners. Policy-level changes to expand PrEP access beyond research settings and improve healthcare experiences for TW are necessary to reduce structural barriers. DOI theory can guide strategies that enhance compatibility, reduce complexity, and utilize opinion leaders to support diffusion, while centering TW input to ensure acceptability and empowerment.

- Generalizability: Findings are specific to TW affiliated with casas trans in Lima and may not generalize to other regions or contexts. - Temporal context: Data collected in 2018; PrEP access, awareness, and attitudes may have evolved since. - Sample and design: Convenience sample (N=20) limits representativeness; qualitative design precludes causal inference. - Structural constraints: Ongoing systemic barriers (e.g., limited non-research PrEP access, documentation challenges) may influence both attitudes and behaviors beyond individual agency.