Intergenerational sex and early sexual debut are associated with HIV infection among transgender women in Paraguay

Introduction: HIV prevalence among transgender women is high worldwide. The objectives of the present study were to estimate the current prevalence of HIV and identify factors associated with high HIV burden among transgender women in Paraguay.Methods: Transgender women aged =15 years in four regions of Paraguay were recruited by Starfish sampling between February and March 2021.Results: In total, 322 transgender women were included. Mean age was 31 years (range 15-67), and 102 had positive HIV test results (31.7%, 95% confi-dence interval [CI] 26.6-37.1). In multivariable analysis, factors associated with HIV infection were age at first intercourse =17 years (adjusted odds ratio [aOR] 5.47; 95% CI 1.05-28.42), >10 years difference in age with the last sexual partner (aOR 1.60; 95% CI 1.04-2.46), substance use (mostly cocaine) (aOR 3.00; 95% CI 1.47-6.12), higher risk perception (aOR 3.08; 95% CI 1.53-6.17), not testing for HIV (aOR 1.23; 95% CI 1.09-1.39), and accessed by a peer edu-cator (aOR 3.86; 95% CI 1.77-8.38).Conclusions: Sexual debut as a minor and a large age difference with sexual partners are associated with high burden of HIV among transgender women in Paraguay. Our study corroborates the finding of cocaine use during sex as a risk factor for HIV. Prevention programmes must address structural and social vulnerabilities to stem the tragically high burden of HIV among transgender women.