https://orcid.org/0000-0003-4663-8459
Figures
Abstract
Transgender youth face disproportionately high rates of homelessness, which can increase vulnerability to HIV. In Peru, the incidence of HIV among transgender women has increased 19% since 2010 and young transgender women are a priority population for HIV prevention. We sought to estimate the proportion of young transgender women experiencing homelessness and associations between homelessness and HIV vulnerabilities. We recruited transgender women ages 16–24 years (N = 209) to participate in a biobehavioural survey and HIV and STI testing (chlamydia, syphilis, gonorrhea). Poisson regression models with robust standard errors were fit to estimate the association between past homelessness and past 6-month condomless sex, adjusted for potential confounding by age, education, sex work, non-injection drug use, post-traumatic stress disorder (PTSD), and violence. Among participants (median age 23 years), 68 (32.5%) had ever been homeless and 19 (9.1%) reported homelessness in the past 3 months. Overall, 51.5% of those who had been homeless reported past 6-month condomless sex compared to 29.1% of those who had never been homeless (p < 0.001). HIV prevalence was 44.6% among those with a history of homelessness and 39.6% among those who had never been homeless (p = 0.65); lifetime homelessness was significantly associated with increased sex work (p < 0.001), violence (p < 0.01), and PTSD (p < 0.001). In the model adjusting for age, education, and behavioural risk (sex work, non-injection drug use), participants who had been homeless had 1.43 times higher prevalence of past 6-month condomless sex (95% CI = 1.05-1.96); results were attenuated when adjusting for violence and PTSD. The high prevalence of homelessness among young transgender women sampled underscores the compounding HIV vulnerabilities faced by this population. Efforts to prevent homelessness and improve access to housing are urgently needed alongside healthcare services, including HIV prevention and treatment, to address the disproportionate HIV epidemic among young Peruvian transgender women.
Citation: Apedaile D, Silva-Santisteban A, Reisner SL, Huerta L, León SR, Perez-Brumer A (2025) Lifetime homelessness among young transgender women in Lima, Peru is associated with HIV vulnerability: Results from a cross-sectional survey. PLOS Glob Public Health 5(4): e0004351. https://doi.org/10.1371/journal.pgph.0004351
Editor: Katia Bruxvoort, University of Alabama at Birmingham, UNITED STATES OF AMERICA
Received: September 24, 2024; Accepted: January 30, 2025; Published: April 21, 2025
Copyright: © 2025 Apedaile et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The data underlying the findings in the manuscript contain potentially identifying and sensitive patient information and are not available due to ethical and legal restrictions from the research ethics board at Universidad Peruana Cayetano Heredia (UCPH). Data will be made available upon reasonable request to the corresponding author or UCPH Research Ethics Board (orvei.ciei@oficinas-upch.pe). To maintain long-term data availability and security, all data is stored by the study principle investigators on a secure, cloud-based platform that adheres to institutional and ethical data protection standards in non-proprietary formats (e.g., CSV) in addition to a secure back up by the corresponding author.
Funding: This work was funded by the National Institute of Mental Health of the National Institutes of Health (R21MH118110 to SLR and AS-S) and Canadian Institutes of Health Research (CRC-2021-00132 to AP-B). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Transgender young people ages 16–24 experience disproportionately high rates of homelessness compared to their non-transgender peers, based on studies from North America [1,2]. Both familial rejection and violence as well as systemic exclusion can contribute to high rates of homelessness among transgender youth [3,4]. While most definitions of youth homelessness focus on youth who are living independently from their parents or guardians, it is also possible for transgender youth to experience homelessness alongside members of their families [5,6]. Once homeless, transgender youth face additional barriers to accessing support services and finding new housing and this can have lasting health consequences [2,7,8]. However, limited research has investigated homelessness among transgender people outside of North America. A 2019 systematic review of the experiences and healthcare needs of homeless LGBTQ youth found only studies from Canada and the United States and few focussed on transgender youth only [7]. A review of homelessness among transgender people similarly found no studies from outside North America [9].
The lack of research about transgender youth homelessness outside North America is particularly concerning in the context of consistently high HIV incidence among youth from key populations, including transgender women [10]. Homelessness can increase vulnerability to HIV and other sexually transmitted infections (STIs) through decreased access to healthcare services as well as increased biopsychosocial vulnerabilities through sex work and violence [11–13]. People experiencing homelessness face discrimination from healthcare providers as well as logistical barriers to accessing healthcare services [14,15]. A lack of health insurance and gender-congruent identification documents can further limit access to health care, particularly for transgender people [16]. There is increasing attention to the importance of addressing homelessness to prevent HIV and improve the health and wellbeing of people living with HIV, particularly for populations that already face a high burden of HIV, such as transgender women [17,18]. Stable housing is strongly associated with better adherence to HIV treatment and improved health outcomes for people living with HIV [19]. In contrast, homelessness and housing instability are associated with decreased uptake and adherence to HIV prevention strategies, such as pre-exposure prophylaxis (PrEP) [20,21].
Homelessness can also decrease the ability to negotiate condom use with paying and non-paying sexual partners in the context of economic precarity (e.g., being offered more money to engage in condomless sex), particularly for individuals who are relying on friends, intimate partners, or sex work clients for temporary housing [22,23]. Condomless sex is a key pathway for HIV acquisition and transmission among transgender women [24]. Importantly, poor mental health, substance use, and interpersonal violence can all contribute to decreased condom use as well as increased homelessness [25,26].
In Latin America and the Caribbean, there were an estimated 11,000 new cases of HIV among adolescents ages 10-19 years in 2023 and HIV incidence in Latin America has increased 19% among transgender women since 2010 [27,28]. This rising incidence occurs in contexts where young transgender women face pervasive violence and marginalization, including harassment and discrimination from state actors (e.g., police), difficulty finding employment, high rates of poverty, and high rates of violence [16,29,30]. Further, studies conducted in Latin America have found that transgender women aged 18-24 are at a higher risk of HIV incidence and less likely to engage in HIV prevention strategies such as condom use and PrEP [31,32]. In Peru, the estimated prevalence of HIV among transgender women is 29.8%-48.8% compared to 0.4% prevalence in the general population of Peru [33,34]. Consequently, young transgender women ages 16-24 years are a critical group for primary HIV prevention efforts in Peru, and further information on their social vulnerabilities is crucial to informing efforts to reduce HIV incidence, improve health outcomes for those living with HIV, and improve health and wellbeing more broadly. The purpose of this exploratory analysis was to examine the prevalence of lifetime homelessness among young transgender women in Lima, Peru and associations between lifetime homelessness and HIV vulnerability.
Methods
Study design and participants
From February to July 2022, we conducted a cross-sectional survey and testing for HIV and bacterial STIs (gonorrhea, chlamydia, and syphilis) among transgender women ages 16-24 years in Lima, Peru. Eligibility criteria included being ages 16-24 years, being a transgender woman (assigned a male sex at birth and identifying on the transfeminine continuum [35]), and living in Lima, Peru. The study design was informed by qualitative research and consultation with Féminas, a community-based organization formed and led by transgender women [16]. Participants were recruited by peers and recruiters from a community organization and surveys were administered by peer survey interviewers. Study participants were also invited to encourage potential participants from their social networks to contact the study team. Detailed study procedures have been published elsewhere [36]. Of the 211 young transgender women who participated in the study, this analysis is restricted to the 209 participants with complete responses to the survey questions regarding homelessness.
Ethics statement
All study activities were approved by the Universidad Peruana Cayetano Heredia Institutional Committee on Research Ethics. Written informed consent (participants 18 or older) or assent (participants ages 16 to 17) was obtained from all participants prior to study participation. For participants ages 16 to 17, parental consent was waived when it would potentially result in harm to the participant.
Measures
Measures were drawn from prior research fielded with transgender populations generally or transgender women specifically [37–39].
Primary exposure: Lifetime homelessness.
The primary exposure, lifetime homelessness, was measured as a binary variable representing whether the participant had been homeless at any point. Homelessness was defined as sleeping in a shelter, on the street, in a car, in some other place not designed for sleeping, or in the home of a friend or relative for a few nights or weeks. Participants were also asked if they had been homeless in the past 30 days and 3 months as well as their current living situation.
Outcome: Past 6-month condomless sex.
The primary outcome was any condomless sex in the past 6 months with a partner living with HIV or a partner with an unknown HIV status. This binary variable was derived from survey questions where participants were asked how many times they had sex (insertive or receptive vaginal or anal sex) in the past 6 months, how many of those times were without a condom, and the HIV status of their partners.
Sociodemographics.
Age, place of birth, educational attainment, ever dropped out of school, and monthly household income were assessed. Employment status was assessed as formal employment (full time or part-time job with a salary), informal work, or unemployment. Food insecurity was defined as participants reporting they sometimes, most of the time, or almost always ran out of food or money to buy food by the end of the month.
HIV and STI vulnerability, sex work, and HIV prevention.
Sex work was defined as engaging in sex work ever and in the past 30 days. History of HIV testing was queried. Participants were asked if they had ever used PrEP and, after explaining PrEP, if they were willing to use daily oral PrEP.
Psychosocial vulnerabilities.
Gender affirmation was assessed based on lifetime hormone use. Lifetime experiences of violence were assessed by asking about physical, psychological, or sexual violence; lifetime intimate partner violence was measured using the Trans-specific Intimate Partner Violence Scale [40] (e.g., “Did your partner tell you or threaten to tell someone else that you are transgender against your will, in order to humiliate you or to make you feel unsafe?”); and past-year sexual objectification was measured using an adapted version of the Spanish-language Interpersonal Sexual Objectification Scale [41]. Participants were defined as lacking family acceptance if they disagreed or strongly disagreed that their families accepted and supported their gender identity. The questionnaire also assessed psychological distress using the validated six-item Kessler-6 psychological distress tool (score >= 13) [42], post-traumatic stress disorder using the five-item Primary Care PTSD Screen for DSM-V post-traumatic stress disorder symptoms used in prior transgender health research (score >= 4) [43], suicidal ideation and attempts, non-injection drug use (e.g., marijuana, benzodiazepines, hallucinogens) and alcohol misuse (using the AUDIT-C score >= 3 from the Spanish-language version of the AUDIT-C) [44].
Healthcare.
Health insurance, usual source of medical care, and last visit to a medical provider were measured. Health insurance options included public insurance available to individuals living in poverty; private insurance paid for by the participant, their employer, or their family member; or no health insurance. Anticipated discrimination from a healthcare provider was assessed using the healthcare item from the Intersectional Discrimination Index–Anticipated discrimination [45] and barriers to healthcare access were measured by asked participants to indicate which challenges they faced when seeking healthcare.
Laboratory procedures
After completing the survey, participants were offered testing for HIV, syphilis, chlamydia, and gonorrhea. HIV testing was performed by using two rapid HIV tests ([Alere Determine™ HIV-1/2 Ag/Ab Combo—Alere, Waltham, MA, USA] and SURE CHECK® HIV 1/2 Assay [Chembio Diagnostic Systems Inc, NY, USA]) in parallel. Pre-test counselling was provided by a certified HIV test counsellor following Peruvian guidelines. Confirmatory testing was performed via a combination of regular enzyme immunoassay and Western blot (Genscreen ULTRA HIV Ag-Ab Assay and NEW LABBLOT HIV-1, BioRad, France). Those diagnosed as HIV positive were referred to the National Antiretroviral Treatment (Programa TARGA). Syphilis testing included qualitative and quantitative Rapid Plasma Reagin (Syphilis RPR Test, Human Diagnostics, Germany) tests followed by confirmation through Treponema pallidum-Particle Agglutination test (Syphilis TPHA liquid, Human Diagnostics, Germany) using a cut-off value of 1:80; a threshold of RPR titers >1:8 was used to identify syphilis. A pharyngeal swab was also collected for chlamydia and gonorrhea testing using the Aptima Combo 2® Assay (Hologic, San>Diego, USA). Participants were classified as having a bacterial STI if they had a positive test result for chlamydia, gonorrhea, or syphilis.
Statistical analysis
Descriptive statistics were used to characterize participants overall and by lifetime experience of homelessness. Chi-square tests were used to compare young transgender women who had been homeless to those who have never been homeless for categorical variables and Kruskall-Wallis tests were used for continuous variables, excluding participants with missing data. For categorical variables with expected cell values ≤5, Fisher’s exact tests were used. Sensitivity analyses for these comparisons were conducted including the missing data level as an explicit category. Cronbach’s alpha was estimated for all continuous scales to assess reliability. Poisson regression models with robust standard errors were fit to estimate the association between lifetime homelessness and past 6-month condomless sex in unadjusted and adjusted models with covariates added in blocks [46,47]. In the first model, we adjusted for sociodemographic characteristics (age and education). In the second model, we adjusted for sociodemographic characteristics and key behavioural risks that can increase engagement in condomless sex (sex work and non-injection drug use). In the third model, we adjusted for sociodemographic characteristics, behavioural risks, and psychosocial vulnerabilities that can increase engagement in condomless sex as well as homelessness (PTSD and violence). For the regression models, participants were excluded if they were missing data on the outcome or any covariates, resulting in an analytical sample of 176 participants. A sensitivity analysis was conducted where homelessness was operationalized as a categorical variable (homeless in the past 3 months, lifetime homelessness, never homelessness). Statistical significance was pre-determined at the alpha 0.05 level. All analyses were conducted in R.
Results
Sample characteristics
A total of 209 young transgender women were included in this analysis. The median age was 23 years (IQR = 21-24) and 44.5% reported being born in Lima (Table 1). Overall, 68 (32.6%) reported experiencing homelessness in their lifetime, with 19 (9.1%) reporting homelessness in the past 3 months. Young transgender women mostly reported their current housing status as living in their own house, apartment, or room (34.9%) or living with family (27.3%). In addition, 11.5% reported living in a “casa para personas trans” (collective house for transgender women). However, those who had never been homeless were more likely to report currently living with family (31.2% vs 19.1%) and less likely to report living in their own rented house, apartment, or room (28.4% vs 48.5%). Participants reported high socioeconomic vulnerability, with 45.0% reporting less than 500 soles (~130 USD) per month in income, less than half of the monthly minimum wage, and 65.1% reporting food insecurity. While there was no difference in the highest level of education completed for participants with and without a history of homelessness, 55.9% of participants who had been homeless reported dropping out of school, compared to 28.4% of those who had never been homeless.
Homelessness, HIV and bacterial STI vulnerability, sex work, and HIV prevention
Table 2 presents HIV and STI vulnerability variables comparing young transgender women with and without experiences of homelessness. Overall, 67 (41.4%) participants tested positive for HIV and 74 (46.2%) tested positive for a bacterial STI. There were no significant differences in the prevalence of HIV among those with and without a history of homelessness. Among the 67 trans women testing HIV seropositive, 11 (16.4%) had been homeless in the past 3 months and another 14 (20.9%) had experienced homelessness more than 3 months ago (S1 Table). Young transgender women who had experienced homelessness reported a higher number of sexual partners in the past 6 months (median of 22 partners versus 3; p = 0.001) and were more likely to report lifetime and recent sex work. However, they were also more likely to have been tested for HIV and 65.1% were willing to use daily oral PrEP compared to 42.6% of those who had never been homeless (p = 0.058). Participants with a history of homelessness were more likely to report condomless sex with a partner living with HIV or status unknown partner in the past 6 months (51.5%) compared to those who had never been homeless (29.1%). Among participants with complete data on condomless sex, 43.8% of participants who had been homelessness in the past 3 months reported condomless sex in the past 6 months (Fig 1).
Note: Only participants with complete data on condomless sex (n = 180) were included in this figure.
Homelessness and psychosocial vulnerabilities
Young transgender women who had experienced homelessness reported higher rates of hormone use (Table 3). They were also significantly more likely to report lifetime physical, psychological, and sexual violence, as well as lifetime trans-specific intimate partner violence and high levels of sexual objectification in the past year. While transgender women who had previously been homeless reported similar rates of family acceptance (58.8%) to those who had never been homeless (53.9%), a history of homelessness was associated with experiencing a higher number of adverse childhood experiences (ACEs; median of 3 ACEs vs 4, p=0.03). Participants who had been homeless were more likely to endorse PTSD (35.3%) and current psychological distress (33.8%) and were also more likely to report attempting suicide and suicidal thoughts than young transgender women who had never experienced homelessness. The trans-specific intimate partner violence scale (α = 0.94), interpersonal sexual objectification scale (α = 0.95), primary care PTSD screen for DSM-V (α = 0.93) and Kessler 6-item psychological distress scale (α = 0.88) displayed good to excellent reliability while the AUDIT-C scale displayed lower reliability (α = 0.69).
Homelessness and healthcare access
Table 4 presents healthcare access among transgender women with and without a history of homelessness. Those who had been homeless were more likely to report having no health insurance (27.9% vs 18.4%) or having publicly-funded insurance (51.5% vs 43.3%). Approximately one-third of participants from both groups reported seeing a medical provider in the past year. A higher proportion of those who had been homeless reported anticipating discrimination from a healthcare provider than those without a history of homelessness (45.6% versus 24.8%; p = 0.003). Finally, participants who had been homeless were more likely to endorse logistical barriers to healthcare access, including transportation (60.3% vs 27.0%, p < 0.001), safety going to or from healthcare (47.1% vs 21.3%; p<0.001), and inconvenient hours (44.1% vs 26.2%; p = 0.013).
Regression models of homelessness and past 6-month condomless sex
The results of multivariable regression models estimating the association between past homelessness and recent HIV risk (condomless sex in the past 6 months with a partner living with HIV or a partner with unknown HIV status) are presented in Table 5. In the model adjusting for sociodemographic characteristics (age, education) and behavioural risk (sex work and non-injection drug use), participants who had previously been homeless had 1.43 times higher prevalence of recent condomless sex than those who had not been homeless (95% CI=1.05-1.96). When variables representing experiences of violence and poor mental health were added to the model, the association between homelessness and condomless sex was attenuated and no longer statistically significant (aPR = 1.19, 95% CI = 0.87-1.63). When conducting the sensitivity analysis with homelessness operationalized as a 3-level variable (recent homelessness, lifetime homelessness, never homeless), the estimates for lifetime homelessness compared to never experiencing homelessness were similar (S2 Table). Smaller effect sizes with wider confidence intervals were observed for the association between recent homelessness and recent condomless sex.
Discussion
In this cross-sectional study of young transgender women ages 16–24 years living in Lima, Peru, approximately one-third had experienced homelessness at least once in their lifetime, with more than 1 in 10 experiencing homelessness in the last 3 months. Our findings are consistent with the most recent US Trans Survey, which found one-third of transgender adults had experienced homelessness in their lifetime, and results from the 2021 National Survey on LGBTQ Mental Health, which found that 38% of young transgender women ages 13–24 years had experienced homelessness [39,48]. We also found that lifetime homelessness was significantly associated with increased HIV vulnerabilities through engagement in condomless sex with a partner living with HIV or status unknown partner in the past 6 months. This finding corroborates prior research among transgender women and extends it to young transgender women in the Peruvian setting [49]. Although these results were attenuated after adjusting for PTSD and violence, findings point to an important need to tailor HIV prevention strategies for young transgender women who experience homelessness. Young transgender women who had experienced homelessness also reported barriers to healthcare access above and beyond barriers already experienced by young transgender women, including lack of health insurance, anticipated discrimination in healthcare, and logistical barriers to care access. These results suggest that young transgender women in Peru need support to secure and maintain adequate housing, and that addressing housing and other material needs is crucial to HIV prevention efforts for young transgender women.
For transgender women in our sample, homelessness was situated alongside other vulnerabilities.
The young transgender women in this study also reported high rates of material deprivation more broadly, including very low incomes, lack of employment, and high levels of food insecurity. While there is limited research on homelessness in Peru, studies in Brazil have found higher rates of STIs among people experiencing homelessness, high rates of adverse childhood experiences among homeless children and adolescents, and increasing homelessness and food insecurity over the past decade [50–52]. While we found no significant association between lifetime homelessness and familial acceptance, it is notable that those who had experienced homelessness were significantly less likely to be currently living with family. Lack of family support in young adulthood, whether due to familial rejection or poverty, can have significant negative impacts for young transgender women [16,26].
There are very limited programs to support people experiencing homelessness in Peru, and fewer still that offer services for transgender people [53]. This is particularly concerning given recent evidence of substantial discrimination against transgender people in Peru’s rental market [54]. However, transgender people across Latin America are leading efforts to secure safe and adequate housing for their communities, particularly through “casas para personas trans,” collective dwellings shared by transgender women [55,56]. Notably, 11% of participants in this survey reported living in one of these shared homes for transgender women. These homes are especially important for young transgender women who may lack support networks in Lima, whether due to migration or rejection by their family of origin [57]. Efforts to improve housing and reduce homelessness among transgender women must acknowledge existing community social capital and social networks to build upon existing formal and informal housing solutions led by transgender women themselves.
Consistent with research in other contexts, we found that lifetime homelessness was associated with behavioural and structural vulnerability to HIV, with participants who had experienced homelessness more likely to report recent condomless anal sex, engagement in sex work (both lifetime and in the past 30 days), and experiences of violence and poor mental health [22,49,58]. For young transgender women, experiencing homelessness is both a consequence of transphobic discrimination as well as an important contributor to future poor health outcomes. Intervening to prevent homelessness early in life is critical to prevent compounding negative health and social outcomes [8]. Notably, young transgender women who had experienced homelessness were more likely to have been tested for HIV and were more likely to be willing to use PrEP, though these results were not statistically significant. As Peru works to improve access to PrEP, it is crucial to ensure transgender women, and young transgender women experiencing homelessness in particular, are not left behind in the design and implementation of these services [59].
Despite Peru’s public health insurance programs for individuals living in severe poverty, 28% of participants who had experienced homelessness reported not having health insurance, compared to 18% of those who had never been homeless. Further, this study identified several other barriers to healthcare for young transgender women with experiences of homelessness, including concerns about discrimination from healthcare providers and logistical barriers such transportation, safety traveling to the health clinic, and inconvenient hours. These findings are consistent with other, commonly cited barriers to healthcare for people experiencing homelessness [60]. The significantly higher rates of anticipated discrimination by healthcare providers indicate the transgender women who have been homeless may expect intersecting discrimination based on both their transgender identity as well as their experiences of being poor and/or homeless [61]. Given the high rates of homelessness found among this population, healthcare services for all transgender women in Peru should be attentive to the needs of individuals with experiences of homelessness to improve accessibility to needed healthcare, such as HIV prevention and care. Routinely screening for homelessness in clinical settings and offering referrals to services is recommended.
These exploratory results must be understood in the context of several limitations. First, the cross-sectional design of the study limits causal inference, particularly since participants were not asked when they first experienced homelessness. We also lacked details on participants’ experiences of homelessness, including what they understood as the cause, the type of homelessness (e.g., unsheltered homelessness, temporary accommodation), and the frequency and duration of homelessness. Housing instability is dynamic in nature and future research is needed to evaluate longitudinal patterns of homelessness among young transgender women, particularly given prior research demonstrating that young transgender women ages 18-24 years experience increased duration of homelessness compared to transgender women in older age groups [49,62]. Qualitative research is also warranted to explore the antecedents and consequences of homelessness for this study population. This study also had a small sample size, limiting the precision of the estimates and necessitating the use of lifetime homelessness rather than recent homelessness for modeling. The sample size was further reduced by participants opting out of HIV and STI testing, limiting the precision of the estimates for the associations between homelessness and HIV status. In addition, some scales (transgender-specific intimate partner violence, PC-PTSD) have not yet been validated in Spanish. Lastly, potential generalizability may be limited in this peer-recruited sample; findings may not generalize to young transgender women who are less connected to transgender peers.
Our study findings present some of the first estimates of experiences of homelessness and the associations with HIV vulnerabilities among transgender women in Latin America. Results underscore compounding HIV vulnerabilities faced by young transgender women who experience homelessness, including higher rates of sex work, violence, psychological distress, and barriers to healthcare access. Integrated social supports to prevent homelessness, housing support services, and tailored HIV prevention and care among young transgender women in Peru are urgently needed, in addition to ensuring services for transgender women are accessible to those who are currently homeless and those with a history of homelessness. Integrated strategies that combine housing assistance with HIV prevention and care service delivery represent an important next step forward to address structural vulnerability and HIV and STI morbidity for young transgender women in Peru.
Supporting information
S1 Table. HIV and STI vulnerability among young transgender women with and without experiences of homelessness (categorical homelessness).
https://doi.org/10.1371/journal.pgph.0004351.s001
(DOCX)
S2 Table. Poisson regression models with robust standard errors estimating the association between recent homelessness and past 6-month condomless sex with a partner living with HIV or status unknown partner among young transgender women in Lima, Peru.
https://doi.org/10.1371/journal.pgph.0004351.s002
(DOCX)
S1 Checklist. Inclusivity in global research questionnaire.
https://doi.org/10.1371/journal.pgph.0004351.s003
(DOCX)
Acknowledgments
We wish to thank Yahaira Chavarri, Anto Garcia, Flavia Cuenca, Mia Loarte and the young transgender women who participated in this research and shared their lived experiences with us.
References
- 1. Kidd SA, Gaetz S, O’Grady B, Schwan K, Zhao H, Lopes K, et al. The Second National Canadian Homeless Youth Survey: Mental Health and Addiction Findings: La Deuxième Enquête Nationale Auprès des Jeunes Sans Abri : Résultats en Matière De Santé Mentale et de Toxicomanie. Can J Psychiatry. 2021;66(10):897–905. pmid:33525910
- 2. Deal C, Doshi RD, Gonzales G. Gender minority youth experiencing homelessness and corresponding health disparities. J Adolesc Health. 2023;72(5):763–9. pmid:36646565
- 3. Masa R, Baca-Atlas SN, Shangani S, Forte AB, Operario D. Family rejection, socioeconomic precarity, and exchanging sex for food among young transgender adults: findings from the U.S. transgender survey. J Health Care Poor Underserved. 2023;34(2):549–68. pmid:37464517
- 4. Fraser B, Pierse N, Chisholm E, Cook H. LGBTIQ+ Homelessness: a review of the literature. Int J Environ Res Public Health. 2019;16(15):2677. pmid:31357432
- 5. UN Free & Equal. Youth homeless [Internet]. n. d. [cited 2024 Jul 29. ]. Available from: https://www.unfe.org/en/know-the-facts/challenges-solutions/youth-homelessness
- 6. Canadian Observatory on Homelessness. Definition of youth homelessness [Internet]. 2016 [cited 2023 Apr 4. ]. Available from: https://www.homelesshub.ca/sites/default/files/attachments/Definition%20of%20Youth%20Homelessness.pdf
- 7. McCann E, Brown M. Homelessness among youth who identify as LGBTQ+: a systematic review. J Clin Nurs. 2019;28(11–12):2061–72. pmid:30786099
- 8. Ormiston CK. LGBTQ youth homelessness: why we need to protect our LGBTQ youth. LGBT Health. 2022;9(4):217–21. pmid:35325559
- 9. There is no room for homelessness. Lancet Reg Health Am. 2023;26:100621. pmid:37876676
- 10. Baggaley R, Armstrong A, Dodd Z, Ngoksin E, Krug A. Young key populations and HIV: a special emphasis and consideration in the new WHO Consolidated Guidelines on HIV prevention, diagnosis, treatment and care for key populations. Journal of the International AIDS Society. 2015;18(2 Suppl 1):19438.
- 11. Arum C, Fraser H, Artenie AA, Bivegete S, Trickey A, Alary M, et al. Homelessness, unstable housing, and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis. Lancet Public Health. 2021;6(5):e309–23. pmid:33780656
- 12. Patel CG, Williams SP, Tao G. Access to healthcare and the utilization of sexually transmitted infections among homeless medicaid patients 15 to 44 years of age. J Community Health. 2022;47(5):853–61. pmid:35819549
- 13. Myles RL, Best J, Bautista G, Wright ER, LaBoy A, Demissie Z, et al. Factors associated with HIV testing among atlanta’s homeless youth. AIDS Educ Prev. 2020;32(4):325–36. pmid:32897135
- 14. Purkey E, MacKenzie M. Experience of healthcare among the homeless and vulnerably housed a qualitative study: opportunities for equity-oriented health care. Int J Equity Health. 2019;18(1):101. pmid:31262310
- 15. Omerov P, Craftman ÅG, Mattsson E, Klarare A. Homeless persons’ experiences of health- and social care: a systematic integrative review. Health Soc Care Community. 2020;28(1):1–11. pmid:31524327
- 16. Reisner SL, Aguayo-Romero RA, Perez-Brumer A, Salazar X, Nunez-Curto A, Orozco-Poore C, et al. A life course health development model of HIV vulnerabilities and resiliencies in young transgender women in Peru. Glob Health Res Policy. 2023;8(1):32. pmid:37605284
- 17. Centres for Disease Control and Prevention. Issue brief: the role of housing in ending the HIV epidemic [Internet]. 2022 [cited 2023 Jun 29. ]. Available from: https://www.cdc.gov/hiv/policies/data/role-of-housing-in-ending-the-hiv-epidemic.html
- 18. International AIDS Society. Put people first: Enabling access to quality integrated HIV services for people experiencing homelessness [Internet]. 2023 [cited 2023 Jun 2. ]. Available from: https://www.iasociety.org/sites/default/files/PCC/IAS_HIV-and-homelessness-brief.pdf
- 19. Aidala A, Wilson M, Shubert V, Gogolishvili D, Globerman J, Rueda S. Housing status, medical care, and health outcomes among people living with HIV/AIDS: a systematic review. American Journal of Public Health. 2016;106(1):e1–23.
- 20. Cooney E, Reisner S, Saleem H, Althoff K, Beckham S, Radix A. Prevention-effective adherence trajectories among transgender women indicated for PrEP in the United States: a prospective cohort study. Annals of Epidemiology. 2022;70(1):23–31.
- 21. Morris E. Characteristics associated with pre-exposure prophylaxis discussion and use among transgender women without HIV infection — National HIV behavioral surveillance among transgender women, seven urban areas, United States, 2019–2020. MMWR Suppl. 2024;73(1):9–20. pmid:38261546
- 22. Eastwood EA, Nace AJ, Hirshfield S, Birnbaum JM. Young transgender women of color: homelessness, poverty, childhood sexual abuse and implications for HIV care. AIDS Behav. 2021;25(Suppl 1):96–106. pmid:31865517
- 23. Stoner MCD, Haley DF, Golin CE, Adimora AA, Pettifor A. The relationship between economic deprivation, housing instability and transactional sex among women in North Carolina (HPTN 064). AIDS Behav. 2019 Nov 1;23(11):2946–55.
- 24. Stutterheim SE, van Dijk M, Wang H, Jonas KJ. The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis. PLoS One. 2021;16(12):e0260063. pmid:34851961
- 25. Collins P, Velloza J, Concepcion T, Oseso L, Chwastiak L, Kemp C. Intervening for HIV prevention and mental health: a review of global literature. Journal of the International AIDS Society. 2021;24(Suppl 2):e25710.
- 26. Glick JL, Lopez A, Pollock M, Theall KP. Housing insecurity and intersecting social determinants of health among transgender people in the USA: A targeted ethnography. Int J Transgend Health. 2020;21(3):337–49. pmid:34993513
- 27. UNICEF. 2023 Global Snapshot on HIV and AIDS: Progress and priorities for children, adolescents and pregnant women [Internet]. 2023 [cited 2024 Jul 30. ]. Available from: https://www.childrenandaids.org/sites/default/files/2023-11/231130%20UNCEF_HIV_Global_Snapshot_2023UPDATED_0.pdf
- 28.
Joint United Nations Programme on HIV/AIDS (UNAIDS). The urgency of now: AIDS at a Crossroads — 2024 global AIDS update. Geneva; 2024.
- 29. Nettuno L. Gender identity, labor market outcomes, and socioeconomic status: evidence from Chile. Labour Economics. 2024;87:102487.
- 30. Murphy EC, Segura ER, Lake JE, Huerta L, Perez-Brumer AG, Mayer KH. Intimate partner violence against transgender women: Prevalence and correlates in Lima, Peru (2016-2018). AIDS Behav. 2020;24(6):1743–51.
- 31. Wilson EC, Jalil EM, Moreira RI, Velasque L, Castro CV, Monteiro L, et al. High risk and low HIV prevention behaviours in a new generation of young trans women in Brazil. AIDS Care. 2021;33(8):997–1001. pmid:33191759
- 32. Veras M de SM, Saggese GS, Gomez Junior JL, Silveira P, Paiatto B, Ferreira D, et al. Brief report: young age and sex work are associated with HIV seroconversion among transgender women in São Paulo, Brazil. Journal of Acquired Immune Deficiency Syndromes. 2021;88(1):e1–4.
- 33.
Centro Nacional de Epidemiología, Prevención y Control de Enfermedades. Situación epidemiológica del VIH - Sida en el Perú: Boletín VIH 2023 II Trimestre [Internet]. Ministerio de Salud; 2023 [cited 2024 Jul 30. ]. Available from: https://www.dge.gob.pe/epipublic/uploads/vih-sida/vih-sida_202311_30_085137.pdf
- 34. Silva-Santisteban A, Raymond HF, Salazar X, Villayzan J, Leon S, McFarland W, et al. Understanding the HIV/AIDS epidemic in transgender women of Lima, Peru: results from a sero-epidemiologic study using respondent driven sampling. AIDS Behav. 2012;16(4):872–81. pmid:21983694
- 35. Harper G, Wagner R, Popoff E, Reisner S, Jadwin-Cakmak L. Psychological resilience among transfeminine adolescents and emerging adults living with HIV. AIDS. 2019;33(Suppl 1):S53–62.
- 36. Silva-Santisteban A, Apedaile D, Perez-Brumer A, Leon SR, Huerta L, Leon F, et al. HIV vulnerabilities and psychosocial health among young transgender women in Lima, Peru: results from a bio-behavioural survey. J Int AIDS Soc. 2024;27(7):e26299. pmid:39041820
- 37. Wirtz AL, Poteat T, Radix A, Althoff KN, Cannon CM, Wawrzyniak AJ, et al. American cohort to study HIV acquisition among transgender women in high-risk areas (The LITE Study): protocol for a multisite prospective cohort study in the eastern and southern United States. JMIR Res Protoc. 2019;8(10):e14704. pmid:31584005
- 38. Meyer IH, Bockting WO, Herman JL, Reisner SL, Choi SK. TransPop study questionnaire for transgender-identified adults and measure sources [Internet]. 2016. Available from: https://static1.squarespace.com/static/55958472e4b0af241ecac34f/t/5d11526fa55f6500010d130e/1561416304031/Trans+identified-TransPop+2+Questionnaire+and+Measures+sources.pdf
- 39.
James SE, Herman JL, Durso LE, Heng-Lehtinen R. Early Insights: a report of the 2022 U.S. transgender survey. National Centre for Transgender Equality; 2022.
- 40. Peitzmeier SM, Wirtz AL, Humes E, Hughto JMW, Cooney E, Reisner SL, et al. The transgender-specific intimate partner violence scale for research and practice: Validation in a sample of transgender women. Soc Sci Med. 2021;291:114495. pmid:34710821
- 41. Lozano LM, Valor-Segura I, Sáez G, Expósito F. The Spanish adaptation of the interpersonal sexual objectification scale (ISOS). Psicothema. 2015;27(2):134–40. pmid:25927693
- 42. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SLT, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med. 2002;32(6):959–76. pmid:12214795
- 43. Reisner SL, White Hughto JM, Gamarel KE, Keuroghlian AS, Mizock L, Pachankis JE. Discriminatory experiences associated with posttraumatic stress disorder symptoms among transgender adults. J Couns Psychol. 2016;63(5):509–19. pmid:26866637
- 44. Knight J, Sherritt L, Harris S, Gates E, Chang G. Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcohol Clinical and Experimental Research. 2003;27(1):67–73.
- 45. Scheim AI, Bauer GR. The Intersectional discrimination index: development and validation of measures of self-reported enacted and anticipated discrimination for intercategorical analysis. Soc Sci Med. 2019;226:225–35. pmid:30674436
- 46. Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702–6. pmid:15033648
- 47.
Allen M. Multiple Regression: Block Analysis. In: The SAGE Encyclopedia of Communication Research Methods [Internet]. SAGE Publications, Inc; 2017 [cited 2024 Dec 20. ], 1046–8. Available from: https://sk.sagepub.com/ency/edvol/the-sage-encyclopedia-of-communication-research-methods/chpt/multiple-regression-block-analysis
- 48.
The Trevor Project. National survey on LGBTQ mental health [Internet]. West Hollywood, California: The Trevor Project; 2021 [cited 2024 Jul 30. ]. Available from: https://www.TheTrevorProject.org/survey-2021/
- 49. Marcus R, Trujillo L, Olansky E, Cha S, Hershow RB, Baugher AR, et al. Transgender women experiencing homelessness — National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019–2020. MMWR Suppl. 2024 [cited 2024 Jan 27]. 73.
- 50. Hino P, Santos J, Rosa A. Pessoas que vivenciam situação de rua sob o olhar da saúde. Revista Brasileira de Enfermagem. 2018;71(suppl 1):684–92.
- 51. Raffaelli M, Santana JP, de Morais NA, Nieto CJ, Koller SH. Adverse childhood experiences and adjustment: A longitudinal study of street-involved youth in Brazil. Child Abuse Negl. 2018;85:91–100. pmid:30170923
- 52. Figueiredo TMR, Lins HCC, Cassiano CJ de M, Correia da Silva KVC, da Silva CGL, Filho MS da S, et al. The hunger and the defense of homeless in Brazil. Lancet Reg Health Am. 2022;6:100108. pmid:36777887
- 53. Moquillaza-Risco M, León E, Dongo M, Munayco C. Características sociodemográficas y de salud de los adultos mayores en situación de calle en Lima, Perú. Revista Peruana de Medicina Experimental y Salud Pública. 2015;32(4):693.
- 54. Abbate N, Berniell I, Coleff J, Laguinge L, Machelett M, Marchionni M. Discrimination against gay and transgender people in Latin America: A correspondence study in the rental housing market. Labour Economics. 2024;87(1):102486.
- 55. Hidalgo JA, Monje A. A House for Trans People [Internet].¿Y si hablamos de igualdad? 2023 [cited 2024 Jul 30. ]. Available from: https://blogs.iadb.org/igualdad/en/vivienda-personas-trans/
- 56.
Valiquette T, Cowper-Smith Y, Su Y. Casa Miga: A case of LGBT-led, transnational activism in Latin America. In: Sexualities, transnationalism, and globalisation. Routledge; 2021.
- 57. Temelkovska T, Moriarty K, Huerta L, Perez-Brumer AG, Segura ER, Passaro RC, et al. Both/And: Mixed methods analysis of network composition, communication patterns, and socio-economic support within social networks of transgender women involved in sex work in Lima, Peru. BMC Public Health. 2023;23(1):2385. pmid:38041045
- 58. Cusack M, Montgomery AE, Byrne T. Examining the intersection of housing instability and violence among LGBTQ adults. J Homosex. 2023;70(12):2943–54. pmid:35700390
- 59. Menacho L, Konda KA, Lecca L, Cabello R, Lankowski A, Benites C, et al. Optimising PrEP uptake and use in Peru: no time to lose! Lancet HIV. 2024;11(4):e204–6. pmid:38538157
- 60. Baxter AJ, Tweed EJ, Katikireddi SV, Thomson H. Effects of Housing First approaches on health and well-being of adults who are homeless or at risk of homelessness: systematic review and meta-analysis of randomised controlled trials. J Epidemiol Community Health. 2019;73(5):379–87. pmid:30777888
- 61. Baugher AR, Olansky E, Sutter L, Cha S, Lewis R, Morris E. Prevalence of discrimination and the association between employment discrimination and health care access and use — National HIV behavioral surveillance among transgender women, seven urban areas, United States, 2019–2020. MMWR Suppl. 2024;73(1):51–60.
- 62. Aubry T, Agha A, Mejia-Lancheros C, Lachaud J, Wang R, Nisenbaum R. Housing trajectories, risk factors, and resources among individuals who are homeless or precariously housed. The ANNALS of the American Academy of Political and Social Science. 2021;693(1):102–22.