Abstract

Background

Transgender women (TGWs) constitute one of the key populations for HIV prevention and control and constitute a high-risk group due to a lack of health services. The aim of this study was to investigate knowledge, attitudes and practices (KAPs) related to HIV and knowledge access and needs amongst transgender women in Chongqing, China.

Methods

A cross-sectional study was conducted from October 2022 to March 2023. A total of 128 self-identified TGWs were recruited in Chongqing, China, via snowball sampling, and a KAP-related questionnaire was completed via Questionnaire Star.

Results

For the 128 TGWs surveyed effectively, the total knowledge of AIDS-related knowledge was 82.03%, with significant differences in age, education level, marital status, occupation and average monthly income (p < 0.05). Significant differences were obtained in terms of personal attitudes toward AIDS and place of domicile and literacy (p < 0.05) and subjective norms in terms of literacy (p < 0.05). No significant difference was observed between the groups in terms of HIV-related practices. The corresponding values were assigned to knowledge, attitudes or practices. The total scores of the three aspects were 6.77 ± 1.47 (95% confidence interval [CI]: 3.89–9.65) (range: 0–8), 14.22 ± 2.37 (95% CI: 9.57–18.87) (range: 0–18) and 6.66 ± 1.79 (95% CI: 3.16–10.17) (range: 0–9), respectively. The main approaches for TGWs to acquire AIDS knowledge are ‘Internet/smartphone’ (81.68%), ‘TV/radio’ (49.62%) and ‘special education on AIDS prevention in schools’ (48.09%). TGW is more inclined to accept promotional activities such as ‘WeChat push’ (58.02%), ‘peer education’ (44.27%) and ‘mobile app management’ (37.40%). AIDS knowledge indicates that TGW needs to strengthen publicity, including ‘transmission routes’ (71.76%), ‘voluntary counselling and testing knowledge’ (67.94%) and ‘virus-related knowledge’ (64.89%).

Conclusions

First, the knowledge rate of AIDS amongst TGWs in Chongqing, China, still has room for improvement, and there is a gap between knowledge and behavior. Second, TGWs are tolerant of AIDS and people living with AIDS and have a strong awareness of AIDS prevention. Third, the health department should attach importance to the group of TGW over 35 years old, low-income, and low-educated, and promote social organizations and network platforms to further strengthen the health education and publicity of AIDS from the perspectives of knowledge acquisition and needs.

Background

‘Transgender women’ (TGWs) are people whose biological sex is male and whose psychological sex is female. In 2016, the World Health Organization (WHO) listed TGW as one of the priority populations for HIV prevention and control and one of the populations at high risk of a lack of access to health services [1]. According to an updated systematic evaluation and meta-analysis [2], the standardised HIV prevalence amongst TGWs was 29.9% (95% confidence interval [CI]: 22.5–37.3%) in sub-Saharan Africa; 25.9% (95% CI: 20.0–31.8%) in Latin America; 13.5% (95% CI: 2.3–17.7%) in Asia; and 17.1% (95% CI: 13.1–21.1%) in the global North, namely, Australia, Europe and North America. The global prevalence of TGW HIV infection is approximately 19.1% [3], which is double the prevalence amongst men who have sex with men (MSM) [4].

Some studies have noted that the presence of multiple genders, including male, female and transgender [1], amongst the sexual partners of TGWs increases the risk of HIV infection and transmission in this population. Given the traditional attitudes in China, sexual minorities in China are often hidden and undisclosed, and TGWs are excluded from routine HIV surveillance. The HIV tests and related studies on this population are relatively few. Currently, studies on TGW populations have been conducted only in Shenyang [4], Shanghai [5], Jiangsu [6] and Kunming [7]. Currently, Southwest China and Northwest China are regions with high mortality rates of AIDS [8]. As the only municipality directly under the central government in Southwest China, Chongqing is an important economic and cultural centre and transportation hub in Southwest China; coupled with its unique sociocultural characteristics, openness and inclusiveness, the transgender population in this region is relatively active [9, 10]. Moreover, Chongqing ranks amongst the top 5 cities in the country in terms of HIV incidence and mortality [8], and according to the incomplete statistics of existing surveys, sexual minorities account for a relatively large proportion of HIV infections, and TGWs are relatively active in the region, with an extremely high risk of TGWs contracting HIV. As a disease with strong transmission, great harm and no effective treatment methods or drugs, AIDS has seriously threatened the health of the population in cities. Therefore, how TGWs can reduce or avoid high-risk behaviors related to AIDS and adhere to preventive behaviors has become a crucial means for preventing HIV infection and controlling the epidemic. Thus, special groups of people, such as TGWs, must be studied, and targeted research must be conducted from the perspective of public health. Currently, research on TGWs focuses more on high-risk behaviours and influencing factors and less on AIDS based on °ì²Ô´Ç·É±ô±ð»å²µ±ð–a³Ù³Ù¾±³Ù³Ü»å±ðâ€Ëð°ù²¹³¦³Ù¾±³¦±ð (KAP) theory. The KAP survey is a scientific and widely used tool with significant feasibility in assessing health behaviours and identifying priority areas for health education [11]. Studies have also shown that although a significant proportion of TGWs are aware of HIV prevention measures, the actual use rate is low [12]. On this basis, a cross-sectional HIV KAP survey was conducted with TGWs in Chongqing to, first, investigate the current status of KAPs; second, discover the knowledge blindness and misconceptions of this population; and third, analyse the influencing factors to formulate HIV health education intervention strategies for TGWs.

Methods

Study subjects

The inclusion criteria were as follows: (1) 18 years of age or older; (2) assigned ‘male’ at birth (if gender reset surgery was performed, then the biological sex was based on the presurgery period); (3) self-identification as female; (4) residing in Chongqing Municipality and residing for more than 6 months; (5) physical condition that allowed him/her to complete the questionnaire survey; and (6) voluntary participation with informed consent. This study was approved by the Medical Research Ethics Committee of Chongqing Medical University.

Recruitment

The snowball sampling method was used in the recruitment process, and given the specificity of the study subjects, the study subjects were recruited as follows: First, the Chongqing Jiangbei District Center for Disease Control (CDC) and Prevention and the Chongqing Municipal Center for Disease Control and Prevention were commissioned to recruit study participants who met the inclusion criteria. Second, study participants who met the inclusion criteria were recruited with the help of social welfare organisations and LGBT associations contacted by the CDC. Third, mobilize participants of the questionnaire and introduce the TGWs who meet the inclusion criteria. Finally,

recruit subjects who meet the inclusion criteria through the ‘CD’ TGW social software and QQ groups and WeChat groups of TGW community groups and other network platforms, so that the ‘snowball’ will keep rolling until it reaches saturation.

Survey instruments and scoring methods

The survey was conducted from October 2022 to March 2023. Using the snowball sampling method, an online questionnaire in the form of collected questionnaires was employed. The quality of the collected questionnaires was reviewed, and the data were normalised. Responses with complete information that did not contain logical errors were regarded as valid. A total of 131 questionnaires were collected, amongst which 128 questionnaires were valid.

The collection of literature related to TGW at home and abroad [3, 4, 13, 14] was based on the internationally recognised guidelines for constructing the core indicators of the Common Declaration on HIV/AIDS (CDA) on issues in the indicators of the United Nations Special Session [15], combined with the KAP theory to prepare the questionnaire. On the basis of the results of the presurvey, the questionnaire entries and contents were discussed again with experts in the field of AIDS prevention and treatment, and experts who had long been engaged in the causes related to sexual minorities and the unreasonable content and entries in the questionnaire were further modified to improve the questionnaire. The questionnaire included five parts: demographic characteristics; AIDS-related knowledge, AIDS-related attitudes and AIDS-related practices; and AIDS knowledge acquisition and needs.

The knowledge section adopts the eight questions of ‘Basic Knowledge of AIDS’ in the Supervision and Evaluation Framework for AIDS Prevention and Control in China, and those who answered six or more questions correctly are labelled knowledgeable, with correct answers assigned a score of 1 and incorrect answers assigned a score of 0. The attitude section refers to the study conducted by Zhuo Xiaokang [13], which includes personal attitudes and subjective norms, with personal attitudes comprising four questions and a score of 12. The higher the scores are, the greater the tolerance toward AIDS and people living with AIDS. Attitudes include personal attitudes and subjective norms. The personal attitudes scale has four questions with a total score of 12 points. The higher the score is, the greater the tolerance of AIDS and AIDS patients is. Subjective norms have two questions with a total score of 6 points. The higher the score is, the stronger the awareness of people around them toward AIDS prevention. The practices scale has three questions with a total score of 9 points. ‘Unwillingness/rare use’ was assigned 1 point, ‘general/sometimes’ was assigned 2 points and ‘willingness/frequent use’ was assigned 3 points. The average value of missing values was assigned 2 points. The reliability of the questionnaire was good, with Cronbach’s α = 0.701. The CR values were all greater than 0.7, and the KMO value was 0.66.

Data collection

A total of 131 eligible TGWs participated in the study. The survey was conducted in the form of an electronic questionnaire, and the content of the informed consent form was set on the first page of the questionnaire. A gift pack, which included a pair of Bluetooth headphones, a box of condoms, a box of lubricant and a box of HIV antibody oral mucosal exudate test reagents, was provided to all study participants at the end of the survey. The Ethics Committee of the School of Public Health of Chongqing Medical University approved the recruitment procedure and the study protocol.

Quality control

The questionnaire in this study was logically verified several times, and some TGWs who met the inclusion criteria were invited to participate in the presurvey to adjust and improve the questionnaire again. Uniform training was provided to all the investigators before the survey, and timely feedback and adjustments for improvement were provided when problems were identified during the survey. For the authenticity of the questionnaire information to be ensured, each IP address could only fill out the questionnaire once to avoid duplication. The questionnaire data were entered via a two-person, two-machine entry method to ensure the accuracy of information entry.

The studies were screened strictly on the basis of the inclusion and exclusion criteria. Sample sources were obtained from four sources to ensure that the samples were sufficiently diverse. The survey was conducted over a period of six months to increase the sample size to be representative.

Statistical analysis

All the data were entered into Excel software to create a database and statistically analysed via SPSS 27.0 software. Count data are expressed as frequencies and rates, and continuous data are described as the means and standard deviations. The chi-square test was used to analyse the differences in whether the different demographic groups were aware of HIV knowledge, and analysis of variance (ANOVA) was used to explore the differences in HIV attitudes and practice scores amongst the different demographic groups. Statistical significance was taken as p &±ô³Ù; 0.05.

Results

Demographic characteristics of the subjects

The 128 subjects were concentrated in the 18–24 years age group (50.00%), followed by the 25–34 years age group (36.72%). The household registration of the participants was mainly urban (75.78%), and their ethnicity was mainly Han Chinese (92.97%). The education level of the participants was concentrated in colleges or undergraduate degrees (64.06%), and their marital status was mainly unmarried (84.38%). The participants had mainly had full-time regular jobs (38.28%), followed by students (28.91%). An average monthly income of 3001–5000 yuan and ‘no income’ both accounted for 30.00%. The details are shown in TableÌý1.

Table 1 Demographic information of the subjects

TGW AIDS-related knowledge

Eight questions were asked about AIDS. The answers to these questions are shown in TableÌý2. The question with the lowest percentage of correct answers was ‘Can a person infected with HIV be seen from his or her appearance?’, with a 68.75% rate of correct answers. The question with the highest percentage of correct answers was ‘Is it possible to get AIDS by sharing syringes with HIV-infected people?’, with a 97.66% rate of correct answers.

Table 2 Knowledge of AIDS-related knowledge amongst TGW

Comparison of TGW HIV knowledge by demographic characteristics

The total HIV knowledge score of the subjects was 6.77 ± 1.47 (95% CI: 3.89–9.65) (range: 0–8) (TableÌý3). A comparison of TGW HIV-related knowledge by different demographic characteristics is shown in TableÌý4. The awareness rate of TGW AIDS-related knowledge was 82.03%, and the differences in age, education level, marital status, occupation and mean monthly income were statistically significant (p < 0.05). The knowledge rate of the subjects aged 18–24 years was higher than that of the other age groups. The older the individual is, the lower the knowledge rate. In terms of education, the knowledge rate of the participants with a college degree or undergraduate degree was higher than that of the other education levels. The knowledge rate of the participants with junior high school education or below was obviously lower. In terms of marital status, the knowledge rate of the cohabiting and widowed participants was 100%, which was higher than that of the other marital statuses. In terms of occupation, the awareness rate of the students was 100%, which was higher than that of the other occupations. In terms of average monthly income, the knowledge rate of the participants with an average monthly income of 5,001–8,000 yuan was higher than that of the other income groups, and the knowledge rate of the participants with an average monthly income of 3,001–5,000 yuan was significantly lower.

Table 3 TGW AIDS-related KAP scores

Table 4 Comparison of TGW HIV-related knowledge by demographic characteristics

TGW AIDS-related attitudes

The survey shows that amongst the four questions on personal attitudes, ‘Would you like to sympathise with and help people living with or affected by HIV?’ has the highest approval rate of 50%. Amongst the two questions on subjective norms, ‘If your regular sexual partner is infected with the AIDS virus, do most people around you object to your continuing sexual relationship with the other party?’ has the highest approval rate of 88.29%. The details are shown in TableÌý5.

Table 5 TGW AIDS-related attitudes

Comparison of TGW AIDS-related attitudes by demographic characteristics

Differences in personal attitudes were statistically significant (p < 0.05) in terms of place of domicile and level of education. In the domicile location subgroup, participants in urban areas scored significantly higher than did those in rural areas. In the educational level subgroup, college or university undergraduate and postgraduate participants scored significantly higher. The details are shown in TableÌý6.

Table 6 TGW AIDS-related attitudes scores for different demographic characteristics (mean ± SD)

The difference in subjective norms was statistically significant (p < 0.05) in terms of educational level. In the subgroup of educational level, college or university undergraduate and graduate participants scored significantly higher, and participants with junior high school and lower levels scored the lowest. The details are shown in TableÌý6.

Amongst all the participants, the total AIDS-related attitude score was 14.22 ± 2.37 (95% CI: 9.57–18.87) (range: 0–18), the total personal attitude score was 8.91 ± 2.42 (95% CI: 4.18–13.65) (range: 0–12), and the total subjective norm score was 5.31 ± 0.85 (95% CI: 3.65–6.97) (range: 0–6). The details are shown in TableÌý3.

TGW AIDS-related practices

HIV-related practices involved three questions. More than half (53.90%) of the subjects were willing to use condoms when having sex, 46.16% always used condoms when having regular sex and 72.37% always used condoms when having casual sex. The details are shown in TableÌý7.

Table 7 TGW AIDS-related practices

Comparison of TGW AIDS-related practice scores by demographic characteristics

The total HIV-related practice score of the subjects was 6.66 ± 1.79 (95% CI: 3.16–10.17) (range: 0–9) (TableÌý3), which was not statistically significant at p > 0.05 between the groups. The details are shown in TableÌý8.

Table 8 TGW AIDS-related practice scores by demographic characteristics (mean ± SD)

TGW AIDS knowledge acquisition and demand

This part includes three questions: ‘What are your ways to obtain AIDS-related knowledge?’, ‘What publicity activities do you prefer to accept?’ and ‘What AIDS knowledge points do you think need to be strengthened?’. The survey revealed that ‘Internet/smartphone’ (81.68%), ‘television/radio’ (49.62%), ‘education on AIDS prevention topics in schools’ (48.09%), ‘roadside bulletin boards’ (44.27%) and ‘newspapers/books’ (44.27%) were the main approaches for subjects to acquire knowledge about AIDS (Fig.Ìý1). The subjects were more inclined to receive/participate in the following publicity/intervention activities: ‘WeChat push’ (58.02%), ‘peer education’ (44.27%) and ‘mobile phone app management’ (37.40%) (Fig.Ìý2). The knowledge points about AIDS that the subjects thought needed to be disseminated were ‘means of transmission’ (71.76%), ‘knowledge about voluntary counselling and testing’ (67.94%), ‘knowledge about the virus’ (64.89%) and ‘the dangers of AIDS’ (64.12%) (Fig.Ìý3).

Fig. 1

Pareto chart of TGW’s access to HIV knowledge

Fig. 2

Pareto chart of TGW’s preferred awareness campaigns

Fig. 3

Pareto chart of TGW’s HIV knowledge points that they feel need to be better communicated

Discussion

The results revealed that the awareness rate of AIDS knowledge of TGW in Chongqing, China, was 82.03%. Compared with other studies, the awareness rate is higher than that of Wang Xiaodan’s study on TGW in Kunming [7] but lower than the requirement that the awareness rate of prevention and control knowledge of the floating population, young students, supervised persons in regulatory places and other key groups and those who are vulnerable to AIDS risk behaviours should exceed 90% (the requirement that the awareness rate of AIDS prevention and control knowledge of residents should exceed 85%) in the 13th Five Year Action Plan for China’s Containment and Prevention of AIDS issued by the State Council. These findings indicate that the awareness rate of TGW AIDS knowledge in Chongqing should be improved.

Amongst the eight questions concerning AIDS-related knowledge, ‘Can a person infected with HIV be seen from the outside?’ and ‘Can mosquito bites spread AIDS?’ The correct response rate for these two questions was less than 70%, which is a blind spot and a misconception for this population. The low level of knowledge on whether HIV is transmitted through mosquito bites is more in line with the findings of the study by Paula Tiittala et al. [11]. Many studies have shown that the older a person is, the less knowledge about HIV, and they are unaware of HIV prevention [16]. The higher education level group has a greater advantage in terms of knowledge of HIV [17]. In this study, a higher education level and occupation of the subjects as students had higher awareness rates of AIDS konwledge. These findings demonstrate that schools significantly affect the education and publicity of related knowledge about HIV. The better economic conditions of a group are more likely to lead to people with better economic conditions being more likely to acquire knowledge about AIDS [18, 19], and those with lower income are likely to engage in sex work, which leads to a higher rate of AIDS infection [20]. Therefore, the health sector and social organisations should focus on TGWs aged 35 years and older, with lower literacy and income, provide social support and services and promote education and awareness through social media to increase their knowledge of HIV and AIDS.

In terms of AIDS-related attitudes, the Chongqing TGW in China had a greater degree of tolerance toward AIDS patients and AIDS patients as a whole, and the people around them were more aware of AIDS prevention. In terms of personal attitudes, subjects with household registrations in urban areas were more tolerant than those in rural areas were, and those with higher literacy levels were more tolerant. Moreover, in terms of subjective norms, people around the subjects with a college or university undergraduate or postgraduate education were more aware of HIV prevention, and those with a junior high school education or below were the lowest. Previous studies have shown that in rural and low-income people, knowledge of AIDS is low [21], and AIDS-related publicity in rural areas is less common. The mean score of the attitude component in this study was 14.22 ± 2.37, of which the personal attitude score was 8.91 ± 2.42 and the subjective norm was 5.31 ± 0.85, both of which were in the middle to high level, indicating that the subjects had a more tolerant attitude toward AIDS and people living with AIDS and were able to perceive the expectations and norms of people around them for the prevention of AIDS. TGWs are a group of people who face multiple social pressures and discrimination. These pressures and types of discrimination include but are not limited to conflict over gender identity, social exclusion and economic marginalisation [22], and TGWs themselves are at high risk of HIV infection [23]. Life experiences and personal-level risks in this context may lead them to hold more sympathetic and supportive attitudes toward HIV and its sufferers. In addition, several studies have shown that TGW participation in HIV care can be effectively increased by providing gender-affirming health services and enhancing community support [24, 25].

In terms of HIV-related practices, the knowledge rate of Chongqing TGW in China was 93.75% for ‘correct use of condoms can reduce the transmission of HIV’, which is a strong awareness of HIV prevention, but the frequency of condom use during regular/temporary sex was 46.16% and 72.37%, respectively. This situation indicates a ‘separation of knowledge and action’ phenomenon in this population. Transgender MSM have a knowledge–do gap [7], and they face higher levels of substance abuse and multiple partner relationships, which are important pathways for HIV transmission [6]. Moreover, TGWs face barriers to accessing HIV-related healthcare services with lower accessibility, which further exacerbates the knowledge–activity gap [26]. In addition to the increasing knowledge of HIV amongst TWGs revealed in this study, further research is needed to explore the causes of knowledge and behavioural segregation and to develop effective behavioural interventions for TGWs.

On the basis of the aforementioned findings, the main approaches for TGWs to gain knowledge about HIV are internet/smartphone, TV/radio and school education on HIV prevention topics, and they are more inclined to receive WeChat pushes, peer education and mobile phone apps to manage intervention activities. Some studies have shown that internet and social media interventions are being conducted and have begun to prevent high-risk sexual behaviour in China [27, 28]. Foreign studies have also confirmed that online social networking apps can be used as interactive platforms for disease prevention interventions and health promotion for people at high risk of HIV because of their convenience, affordability and timeliness [29]. The use of online methods to disseminate HIV knowledge and prevention services is accessible to the youth population [30]. Moreover, the peer education model has proven to be effective in promoting the acceptance of HIV health education and behavioural interventions amongst sexual minorities [31]. In addition, the TGW considers that the knowledge of AIDS that needs to be strengthened includes the means of transmission, knowledge of voluntary counselling and testing, knowledge of the virus and the harms of AIDS. In response to the abovementioned needs for AIDS knowledge, publicity should increase, and a direction for the popularisation and promotion of AIDS knowledge must be provided in the future.

The findings indicate that the health and wellness sector should strengthen health education and HIV prevention campaigns for TGWs through various channels, such as social media and peer education. More targeted interventions for TGWs, including HIV testing services, information and access to preexposure prophylaxis (PrEP) drugs, should be conducted [32]. Furthermore, improving public understanding and acceptance of TGWs and eliminating stigma and discrimination against them are essential to improving their health [26].

At present, most of the existing domestic and international studies on HIV high-risk behaviours with the help of KAP have focused mainly on MSM, AIDS patients, healthcare workers, college students and other populations and are relatively mature in their use, whereas KAP is less commonly used in TGW HIV infection. Therefore, experience in KAP in populations similar to the transgender population of women, which is of certain reference significance, is applied. The needs and barriers of TGWs in accessing health information and taking preventive measures to cope with HIV are revealed in this study. The results can provide a basis for developing more effective interventions.

This study has several limitations. First, cross-sectional studies limit researchers’ ability to make causal inferences. Longitudinal studies are needed to further explore the causes and influences of knowledge‒action separation. Second, owing to the small and hidden population of TGW, a nonprobability sampling method, namely, ‘snowball’ sampling, was adopted. This approach might have resulted in sampling bias in the study. Moreover, the sample size collected in this survey was limited, and in the ANOVA of HIV-related practices, missing values may cause partial bias in the results. In addition, the results may not be generalisable to TGWs in other regions of China, as the study participants were all from Chongqing Municipality. Finally, owing to the small number of HIV KAP studies for TGWs, the results of this study are difficult to compare with those of studies in other regions, and less content is covered in the discussion section. Future studies should be conducted to further expand the sample size, explore in depth the causes of TGW knowledge‒behaviour separation and develop targeted interventions.

Conclusion

The awareness rate of AIDS knowledge among TGWs in Chongqing, China, still has room for improvement. They are more tolerant of AIDS and AIDS patients, and have a strong awareness of AIDS prevention. However, studies have shown that there is a separation between knowledge and behavior among TGWs, and the incidence of high-risk sexual behaviors related to AIDS is relatively high. In addition, the high knowledge rate amongst students in the TGW group indicates that the AIDS-related health education and publicity conducted in schools are effective. Health and health departments and the CDC should focus on TGWs aged 35 years and older who have low income and low literacy. Long-term plans and policies for AIDS prevention and treatment must be formulated, and the goals and strategies of publicity and education for high-risk groups must be clarified. Furthermore, social organisations and online platforms must be promoted to further strengthen AIDS health education and publicity from the perspective of knowledge access and demand.