AIDS and Behavior

, Volume 21, Issue 12, pp 3287–3298 | Cite as

Acceptability of Daily Use of Free Oral Pre-exposure Prophylaxis (PrEP) Among Transgender Women Sex Workers in Shenyang, China

  • Zixin Wang
  • Joseph T. F. Lau
  • Xueying Yang
  • Yong Cai
  • Danielle L. Gross
  • Tiecheng Ma
  • Yan Liu
Original Paper


This study investigated the acceptability of daily use of free oral pre-exposure prophylaxis (PrEP) and associated factors among transgender women sex workers in Shenyang, China, following a briefing on PrEP. A total of 183 HIV negative or sero-status unknown participants completed the cross-sectional survey. The prevalence of acceptability of daily use of free oral PrEP was 61.2%. Adjusting for education level and monthly income, variables on negative attitudes toward PrEP (i.e., having concerns about the side-effects of PrEP) [Adjusted odds ratios (AOR): 0.26], perceived subjective norms (i.e., perceiving support from male partners to take PrEP) (AOR: 2.08), and perceived behavioral control (e.g., perceiving complete control over using PrEP) (AOR: 2.10–16.72) were significantly associated with acceptability of daily use of free oral PrEP. In addition, experiencing violence during sex work, perceived risk of contracting HIV from clients and probable anxiety were also significant. Future PrEP promotion campaigns should consider these factors.


Acceptability Pre-exposure prophylaxis Transgender women sex workers Theory of planned behavior China 



Adjusted odds ratios


Confidence interval


Condomless receptive anal intercourse


Exploratory factor analysis


Female sex workers




Human immunodeficiency virus


Men who have sex with men


Male sex workers


Non-governmental organization


Non-regular sex partner


Univariate odds ratios


Multivariate odds ratios


Pre-exposure prophylaxis


Regular sex partner


Standard deviation


Sexually transmitted diseases


Tenofovir disoproxil fumarate


Theory of planned behavior


World Health Organization


Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Research Involving Human Participants

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Survey and Behavioural Research Ethics Committee, the Chinese University of Hong Kong and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Nemoto T, Iwamoto M, Perngparn U, Areesantichai C, Kamitani E, Sakata M. HIV-related risk behaviors among kathoey (male-to-female transgender) sex workers in Bangkok, Thailand. AIDS Care. 2012;24(2):210–9.PubMedGoogle Scholar
  2. 2.
    Center for AIDS Prevention Studies. What are the prevention needs of male-to-female transgender persons (MTFs)? San Francisco, CA: University of California, San Francisco. 2001.
  3. 3.
    Poteat T, Wirtz AL, Radix A, Borquez A, Silva-Santisteban A, Deutsch MB, et al. HIV risk and preventive interventions in transgender women sex workers. Lancet. 2015;385(9964):274–86.CrossRefPubMedGoogle Scholar
  4. 4.
    Roche K, Keith C. How stigma affects healthcare access for transgender sex workers. Br J Nurs. 2014;23(21):1147–52.CrossRefPubMedGoogle Scholar
  5. 5.
    Operario D, Soma T, Underhill K. Sex work and HIV status among transgender women: systematic review and meta-analysis. J Acquir Immune Defic Syndr. 2008;48(1):97–103.CrossRefPubMedGoogle Scholar
  6. 6.
    Cai Y, Wang Z, Lau JT, Li J, Ma T, Liu Y. Prevalence and associated factors of condomless receptive anal intercourse with male clients among transgender women sex workers in Shenyang, China. J Int AIDS Soc. 2016;19(3 Suppl 2):20800.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Richter ML, Chersich M, Temmerman M, Luchters S. Characteristics, sexual behaviour and risk factors of female, male and transgender sex workers in South Africa. S Afr Med J. 2013;103(4):246–51.CrossRefPubMedGoogle Scholar
  8. 8.
    Hawkes S, Collumbien M, Platt L, Lalji N, Rizvi N, Andreasen A, et al. HIV and other sexually transmitted infections among men, transgenders and women selling sex in two cities in Pakistan: a cross-sectional prevalence survey. Sex Transm Infect. 2009;85(Suppl 2):ii8–16.CrossRefPubMedGoogle Scholar
  9. 9.
    Taylor RD, Bimbi DS, Joseph HA, Margolis AD, Parsons JT. Girlfriends: evaluation of an HIV-risk reduction intervention for adult transgender women. AIDS Educ Prev. 2011;23(5):469–78.CrossRefPubMedGoogle Scholar
  10. 10.
    Longfield K, Panyanouvong X, Chen J, Kays MB. Increasing safer sexual behavior among Lao kathoy through an integrated social marketing approach. BMC Public Health. 2011;11:872.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Lipsitz MC, Segura ER, Castro JL, Smith E, Medrano C, Clark JL, et al. Bringing testing to the people—benefits of mobile unit HIV/syphilis testing in Lima, Peru, 2007-2009. Int J STD AIDS. 2014;25(5):325–31.CrossRefPubMedGoogle Scholar
  12. 12.
    Pawa D, Firestone R, Ratchasi S, Dowling O, Jittakoat Y, Duke A, et al. Reducing HIV risk among transgender women in Thailand: a quasi-experimental evaluation of the sisters program. PLoS ONE. 2013;8(10):e77113.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Goswami P, Rachakulla HK, Ramakrishnan L, Mathew S, Ramanathan S, George B, et al. An assessment of a large-scale HIV prevention programme for high-risk men who have sex with men and transgenders in Andhra Pradesh, India: using data from routine programme monitoring and repeated cross-sectional surveys. BMJ Open. 2013;3(4):e002183.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Subramanian T, Ramakrishnan L, Aridoss S, Goswami P, Kanguswami B, Shajan M, et al. Increasing condom use and declining STI prevalence in high-risk MSM and TGs: evaluation of a large-scale prevention program in Tamil Nadu, India. BMC Public Health. 2013;13:857.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587–99.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Deutsch MB, Glidden DV, Sevelius J, Keatley J, McMahan V, Guanira J, et al. HIV pre-exposure prophylaxis in transgender women: a subgroup analysis of the iPrEx trial. Lancet HIV. 2015;2(12):e512–9.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Abdool Karim Q, Abdool Karim SS, Frohlich JA, Grobler AC, Baxter C, Mansoor LE, et al. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science. 2010;329(5996):1168–74.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Baeten J, Celum C. Antiretroviral pre-exposure prophylaxis for HIV-1 prevention among heterosexual African men and women: the Partners PrEP Study. In: 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention. Rome. 2011.Google Scholar
  19. 19.
    Choopanya K, Martin M, Suntharasamai P, Sangkum U, Mock PA, Leethochawalit M, et al. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet. 2013;381(9883):2083–90.CrossRefPubMedGoogle Scholar
  20. 20.
    Gomez GB, Borquez A, Caceres CF, Segura ER, Grant RM, Garnett GP, et al. The potential impact of pre-exposure prophylaxis for HIV prevention among men who have sex with men and transwomen in Lima, Peru: a mathematical modelling study. PLoS Med. 2012;9(10):e1001323.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    World Health Organization. Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. 2014.
  22. 22.
    Yang D, Chariyalertsak C, Wongthanee A, Kawichai S, Yotruean K, Saokhieo P, et al. Acceptability of pre-exposure prophylaxis among men who have sex with men and transgender women in Northern Thailand. PLoS ONE. 2013;8(10):e76650.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Hoagland B, De Boni RB, Moreira RI, Madruga JV, Kallas EG, Goulart SP, et al. Awareness and willingness to use pre-exposure prophylaxis (PrEP) among men who have sex with men and transgender women in Brazil. AIDS Behav. 2016.Google Scholar
  24. 24.
    Oldenburg CE, Le B, Toan T, Thien DD, Huyen HT, Friedman MR, et al. HIV pre-exposure prophylaxis indication and readiness among HIV-uninfected transgender women in Ho Chi Minh City, Vietnam. AIDS Behav. 2016.Google Scholar
  25. 25.
    Wilson EC, Jin H, Liu A, Raymond HF. Knowledge, indications and willingness to take pre-exposure prophylaxis among transwomen in San Francisco, 2013. PLoS ONE. 2015;10(6):e0128971.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Golub SA, Gamarel KE, Rendina HJ, Surace A, Lelutiu-Weinberger CL. From efficacy to effectiveness: facilitators and barriers to PrEP acceptability and motivations for adherence among MSM and transgender women in New York City. AIDS Patient Care STDs. 2013;27(4):248–54.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Peinado J, Lama JR, Galea JT, Segura P, Casapia M, Ortiz A, et al. Acceptability of oral versus rectal HIV preexposure prophylaxis among men who have sex with men and transgender women in Peru. J Int Assoc Provid AIDS Care. 2013;12(4):278–83.CrossRefPubMedGoogle Scholar
  28. 28.
    Wheelock A, Eisingerich AB, Ananworanich J, Gomez GB, Hallett TB, Dybul MR, et al. Are Thai MSM willing to take PrEP for HIV prevention? An analysis of attitudes, preferences and acceptance. PLoS ONE. 2013;8(1):e54288.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Mimiaga MJ, Closson EF, Kothary V, Mitty JA. Sexual partnerships and considerations for HIV antiretroviral pre-exposure prophylaxis utilization among high-risk substance using men who have sex with men. Arch Sex Behav. 2014;43(1):99–106.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Baeten JM, Haberer JE, Liu AY, Sista N. Preexposure prophylaxis for HIV prevention: where have we been and where are we going? J Acquir Immune Defic Syndr. 2013;63(Suppl 2):S122–9.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Nemoto T, Bodeker B, Iwamoto M. Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work. Am J Public Health. 2011;101(10):1980–8.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Cohan D, Lutnick A, Davidson P, Cloniger C, Herlyn A, Breyer J, et al. Sex worker health: San Francisco style. Sex Transm Infect. 2006;82(5):418–22.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Boles J, Elifson KW. The social organization of transvestite prostitution and AIDS. Soc Sci Med. 1994;39(1):85–93.CrossRefPubMedGoogle Scholar
  34. 34.
    Ye L, Wei S, Zou Y, Yang X, Abdullah AS, Zhong X, et al. HIV pre-exposure prophylaxis interest among female sex workers in Guangxi, China. PLoS ONE. 2014;9(1):e86200.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Peacock E, Andrinopoulos K, Hembling J. Binge drinking among men who have sex with men and transgender women in san salvador: correlates and sexual health implications. J Urban Health. 2015;92(4):701–16.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Flentje A, Heck NC, Sorensen JL. Characteristics of transgender individuals entering substance abuse treatment. Addict Behav. 2014;39(5):969–75.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Zhou F, Gao L, Li S, Li D, Zhang L, Fan W, et al. Willingness to accept HIV pre-exposure prophylaxis among Chinese men who have sex with men. PLoS ONE. 2012;7(3):e32329.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    McEachana RRC, Conner M, Taylor NJ, Lawton RJ. Prospective prediction of health-related behaviours with the theory of planned behaviour: a meta-analysis. Health Psychol Rev. 2011;5(2):97–144.CrossRefGoogle Scholar
  39. 39.
    Brooks RA, Landovitz RJ, Regan R, Lee SJ, Allen VC Jr. Perceptions of and intentions to adopt HIV pre-exposure prophylaxis among black men who have sex with men in Los Angeles. Int J STD AIDS. 2015;26(14):1040–8.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Veloso VG, Mesquita F, Grinsztejn B. Pre-exposure prophylaxis for men and transgender women who have sex with men in Brazil: opportunities and challenges. J Int AIDS Soc. 2015;18(4 Suppl 3):20010.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Zhang Y, Peng B, She Y, Liang H, Peng HB, Qian HZ, et al. Attitudes toward HIV pre-exposure prophylaxis among men who have sex with men in western China. AIDS Patient Care STDs. 2013;27(3):137–41.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Michie S, Johnston M, Francis J, Hardeman W, Eccle M. From theory to intervention: mapping theoretically derived behaviorual determinants to behaviour change techniques. Appl Psychol. 2008;57:660–80.CrossRefGoogle Scholar
  43. 43.
    Ajzen I. The theory of planned behaivor. Organ Behav Hum Decis. 1991;50(2):179–211.CrossRefGoogle Scholar
  44. 44.
    Wang Z, Feng T, Lau JT. Needs assessment and theory-based promotion of voluntary medical male circumcision (VMMC) among male sexually transmitted diseases patients (MSTDP) in China. AIDS Behav. 2015.Google Scholar
  45. 45.
    Lau JT, Zhang J, Yan H, Lin C, Choi KC, Wang Z, et al. Acceptability of circumcision as a means of HIV prevention among men who have sex with men in China. AIDS Care. 2011;23(11):1472–82.CrossRefPubMedGoogle Scholar
  46. 46.
    Ko NY, Yeh SH, Tsay SL, Ma HJ, Chen CH, Pan SM, et al. Intention to comply with post-exposure management among nurses exposed to blood and body fluids in Taiwan: application of the theory of planned behaviour. J Hosp Infect. 2011;77(4):321–6.CrossRefPubMedGoogle Scholar
  47. 47.
    Song Y, Huang Y, Liu D, Kwan JS, Zhang F, Sham PC, et al. Depression in college: depressive symptoms and personality factors in Beijing and Hong Kong college freshmen. Compr Psychiatry. 2008;49(5):496–502.CrossRefPubMedGoogle Scholar
  48. 48.
    Cheung CK, Bagley C. Validating an American scale in Hong Kong: the center for epidemiological studies depression scale (CES-D). J Psychol. 1998;132(2):169–86.CrossRefPubMedGoogle Scholar
  49. 49.
    Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7.CrossRefPubMedGoogle Scholar
  50. 50.
    Guidance for the use of pre-exposure prophylaxis (PrEP) to prevent HIV transmission. 2016.
  51. 51.
    Hail-Jares K, Chang RC, Choi S, Zheng H, He N, Huang ZJ. Intimate-partner and client-initiated violence among female street-based sex workers in China: does a support network help? PLoS ONE. 2015;10(9):e0139161.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Richens J, Imrie J, Copas A. Condoms and seat belts: the parallels and the lessons. Lancet. 2000;355(9201):400–3.CrossRefPubMedGoogle Scholar
  53. 53.
    Wilde GJS. Target risk: dealing with danger of death, disease, and damage in everday decisions. Ontario: PDE Publications; 1994.Google Scholar
  54. 54.
    Li D, Li C, Wang Z, Lau JT. Prevalence and associated factors of unprotected anal intercourse with regular male sex partners among HIV negative men who have sex with men in China: a cross-sectional survey. PLoS ONE. 2015;10(3):e0119977.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    O’Cleirigh C, Skeer M, Mayer KH, Safren SA. Functional impairment and health care utilization among HIV-infected men who have sex with men: the relationship with depression and post-traumatic stress. J Behav Med. 2009;32(5):466–77.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Best J, Tang W, Zhang Y, Han L, Liu F, Huang S, et al. Sexual behaviors and HIV/syphilis testing among transgender individuals in China: implications for expanding HIV testing services. Sex Transm Dis. 2015;42(5):281–5.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Nemoto T, Operario D, Keatley J, Han L, Soma T. HIV risk behaviors among male-to-female transgender persons of color in San Francisco. Am J Public Health. 2004;94(7):1193–9.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Nemoto T, Operario D, Keatley J, Villegas D. Social context of HIV risk behaviours among male-to-female transgenders of colour. AIDS Care. 2004;16(6):724–35.CrossRefPubMedGoogle Scholar
  59. 59.
    Bockting WO, Robinson BE, Rosser BR. Transgender HIV prevention: a qualitative needs assessment. AIDS Care. 1998;10(4):505–25.CrossRefPubMedGoogle Scholar
  60. 60.
    Bianchi FT, Reisen CA, Zea MC, Vidal-Ortiz S, Gonzales FA, Betancourt F, et al. Sex work among men who have sex with men and transgender women in Bogota. Arch Sex Behav. 2014;43(8):1637–50.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Zixin Wang
    • 1
    • 2
  • Joseph T. F. Lau
    • 1
    • 2
  • Xueying Yang
    • 1
  • Yong Cai
    • 3
  • Danielle L. Gross
    • 1
  • Tiecheng Ma
    • 4
  • Yan Liu
    • 4
  1. 1.Centre for Health Behaviours Research, JC School of Public Health and Primary CareThe Chinese University of Hong KongHong KongChina
  2. 2.Shenzhen Research InstituteThe Chinese University of Hong KongShenzhenChina
  3. 3.Department of Community Health and Family Medicine, School of Public HealthShanghai Jiao Tong UniversityShanghaiChina
  4. 4.Shenyang Consultation Centre of AIDS Aid and Health ServiceShenyangChina

Personalised recommendations