Risk Perception, Chemsex Engagement, and Transactional Sex Among Transgender Women: A National Survey Across South Africa
1
Aurum Institute, Johannesburg, South Africa
2
University of Utrecht, Utrecht, Netherlands
Popul. Med. 2026;8(Supplement Supplement 1):A2568
ABSTRACT
BACKGROUND:
Transgender women (TGW) face elevated risks for HIV and sexually transmitted infections (STIs), with chemsex, representing an emerging concern. Chemsex has been associated with increased sexual risk behaviors, including condomless sex and multiple partners. This study investigated associations between HIV/STI risk perception and chemsex engagement: overall chemsex frequency among South African TGW.
METHODS:
Cross-sectional data were collected from April to September 2025 from 232 TGW participants. HIV/STI risk perception was measured using a scale assessing concern about contracting HIV/STIs on a 4-point scale. Chemsex engagement was assessed through frequency of chemsex in the past six months and frequency of drug use during transactional sex encounters. Chi-square tests and binary logistic regression analyses examined associations between risk perception levels and both chemsex measures.
RESULTS:
Over half of participants (54.6%, n=119) reported being "very concerned" about HIV/STI transmission, while 19.3% (n=42) were slightly concerned and 10.6% (n=23) not concerned. Regarding behaviors, 24.3% reported chemsex engagement in the past six months, while 27.0% reported drug use during transactional sex. Logistic regression treating risk perception as ordinal revealed that each one level increase in HIV/STI concern was associated with 44.0% higher odds of chemsex engagement (OR = 1.44, 95% CI: 1.03-2.01, p = 0.032). Similar trends appeared for drug use during transactional sex, with each level increase corresponding to 34.1% higher odds, approaching significance (OR = 1.34, 95% CI:0.98-1.83, p = 0.065). Chemsex rates increased from 13.0% among those not concerned to 30.1% among those very concerned.
CONCLUSIONS:
Paradoxically, higher HIV/STI risk concern was associated with greater chemsex engagement among South African TGW, suggesting risk compensation patterns or that risky behaviors heighten risk awareness. Risk perception alone is insufficient for behavior change. Findings highlight needs for comprehensive harm reduction interventions addressing structural factors, substance use, and HIV prevention within TGW's unique life contexts.
Transgender women (TGW) face elevated risks for HIV and sexually transmitted infections (STIs), with chemsex, representing an emerging concern. Chemsex has been associated with increased sexual risk behaviors, including condomless sex and multiple partners. This study investigated associations between HIV/STI risk perception and chemsex engagement: overall chemsex frequency among South African TGW.
METHODS:
Cross-sectional data were collected from April to September 2025 from 232 TGW participants. HIV/STI risk perception was measured using a scale assessing concern about contracting HIV/STIs on a 4-point scale. Chemsex engagement was assessed through frequency of chemsex in the past six months and frequency of drug use during transactional sex encounters. Chi-square tests and binary logistic regression analyses examined associations between risk perception levels and both chemsex measures.
RESULTS:
Over half of participants (54.6%, n=119) reported being "very concerned" about HIV/STI transmission, while 19.3% (n=42) were slightly concerned and 10.6% (n=23) not concerned. Regarding behaviors, 24.3% reported chemsex engagement in the past six months, while 27.0% reported drug use during transactional sex. Logistic regression treating risk perception as ordinal revealed that each one level increase in HIV/STI concern was associated with 44.0% higher odds of chemsex engagement (OR = 1.44, 95% CI: 1.03-2.01, p = 0.032). Similar trends appeared for drug use during transactional sex, with each level increase corresponding to 34.1% higher odds, approaching significance (OR = 1.34, 95% CI:0.98-1.83, p = 0.065). Chemsex rates increased from 13.0% among those not concerned to 30.1% among those very concerned.
CONCLUSIONS:
Paradoxically, higher HIV/STI risk concern was associated with greater chemsex engagement among South African TGW, suggesting risk compensation patterns or that risky behaviors heighten risk awareness. Risk perception alone is insufficient for behavior change. Findings highlight needs for comprehensive harm reduction interventions addressing structural factors, substance use, and HIV prevention within TGW's unique life contexts.
| eISSN: | 2654-1459 |
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