The Transgender Community
The Center for Disease Control and Prevention defines Transgender as:
“Transgender is a term for people whose gender identity or expression is different from their sex assigned at birth. Gender identity refers to a person’s internal understanding of their own gender. Gender expression describes a person’s outward presentation of their gender (for example, how they dress). Transgender women describes people who were assigned the male sex at birth but identify as women. Transgender men describes people who were assigned the female sex at birth but identify as men.”
Fast Facts: Worldwide
An estimated 25 million people identify as transgender
Transgender women are 49 times more likely to be living with HIV than the general population
Around 14% of transgender women are living with HIV according to a review conducted in 2019
Transgender people living with HIV are less likely to report adherence to treatment of above 90% compared to patients who aren’t transgender
Fast Facts: United States
An estimated 1 million adults identify as transgender
From 2009 to 2014, 2,351 transgender people were diagnosed with HIV
Among the 3 million HIV tests reported in 2017, the percentage of transgender people who received a new HIV diagnosis was more than 3 times the national average
Around ½ of transgender people who received an HIV diagnosis during this time lived in the South (1,037)
Social, Economic, and Legal Exclusion
Across the world transgender people experience high levels of stigma, discrimination, gender-based violence and abuse, marginalization, and social exclusion. All of these factors make them less likely to be able to access medical services, which damages their health and wellbeing, putting them at a higher risk of HIV. Due to the pressures they face, they often drop out of school, move away from their loved ones, and are unable to find proper unemployment. They can even encounter difficulties accessing basic goods and public services. All of these challenges are exacerbated by a lack of legal recognition of their gender and the absence of anti-discrimination laws that are meant to specifically protect transgender people.
Due to social exclusion, economic vulnerability, and lack of employment opportunities, sex work is often the most viable form of income to transgender people. For example, the proportion of transgender people who sell sex is estimated to be up to 90% in India, 84% in Malaysia, 81% in Indonesia, 47% in El Salvador and 36% in Cambodia. HIV prevalence is up to nine times higher for transgender sex workers compared to non-transgender female sex workers. Furthermore, use of condoms is generally low among transgender sex workers. Knowledge and reported use of condoms is also generally low among transgender sex workers. In Asia and the Pacific, only 50% of transgender sex workers are aware of HIV and HIV testing, and only 50% reported using condoms consistently with clients and casual partners. The high costs associated with transition healthcare can also put extra pressure on transgender people to make money. Sex workers may also get paid more for unprotected sex, which makes them highly vulnerable to HIV and other diseases.
Transgender people may obtain injectable hormones, which is the most common form of gender enhancement. Without counselling on safe injecting practices, which they often do not have access to, people going through this process are very vulnerable to HIV transmission through sharing unsanitized needles with others.
Transgender Women of Color
Transgender women of color are at an even greater risk for HIV infection than their white peers. Studies have noted that African-American and Latina transgender women had the highest infection rates; among those transgender women of color surveyed, more than 56% of black trans women were HIV-positive, and Latina trans women had an HIV infection rate of 16%.
HIV Prevention for The Transgender Community
Transgender people can have very diverse HIV prevention needs. Targeted prevention approaches that respond to the specific need of individuals are essential to reducing the extremely high prevalence of HIV within their community. More importantly, the preventative measures should aim to empower transgender people and enable them to take the lead in fighting for their own needs. Many policymakers fail to address the needs of transgender women as a population distinct from men who have sex with men. Only 39% of countries in 2014 had specific programs for transgender people in their national HIV strategies. India is an example of a country where HIV services have been successfully targeted at transgender people, reaching an estimated 83% of the transgender population. The Indian government has officially recognized transgender people as a distinct gender, which means that local authorities need to ensure that they have health and social programs that meet their needs.
Criminal Justice System
JoAnne Keatley, director of the Center of Excellence for Transgender Health at the University of California, says “Once a trans person becomes part of the cycle of criminal injustice, it’s hard to break out of that.” The most direct correlation between criminalization and HIV is the existence of laws that criminalize non-disclosure of HIV status before sex. The laws are selectively enforced, meaning they place the burden of informing authorities and individuals on criminalized and stigmatized communities. 58% of the US transgender population believes it is justified to avoid testing and treatment for fear of criminalization. There is a similar situation in Europe, where similar laws target trans women, gay and bisexual men, sex workers, and black men. The cycle of mass incarceration worsens the spread of HIV, because trans women are labelled as MSM (men who have sex with men), making them more likely to experience abuse. They are placed in male prisons and are assaulted and abused by male prisoners and guards alike.
HIV and Transgender
A 2017 paper used meta-analysis and synthesized national surveys to estimate that nearly 1 million adults in the United States are transgender.
From 2009 to 2014, 2,351 transgender people received an HIV diagnosis in the United States.
Eighty-four percent (1,974) were transgender women, 15% (361) were transgender men, and less than 1% (16) had another gender identity.
Around half of transgender people (43%  of transgender women; 54%  of transgender men) who received an HIV diagnosis lived in the South.
A 2019 systematic review and meta-analysis found that an estimated 14% of transgender women are living with HIV. By race/ethnicity, an estimated 44% of black/African American transgender women, 26% of Hispanic/Latina transgender women, and 7% of white transgender women are HIV+.
Among the 3 million HIV testing events reported to CDC in 2017, the percentage of transgender people who received a new HIV diagnosis was 3 times the national average.
Nearly two thirds of transgender women and men surveyed by the Behavioral Risk Factor Surveillance System (BRFSS) in 2014 and 2015 from 28 jurisdictions reported never testing for HIV.
Problems Facing the Trans Community
There are numerous prevention challenges that may impact the HIV health outcomes for some transgender people. These include:
Certain behaviors and socioeconomic factors can affect outcomes, such as having multiple sex partners, anal or vaginal sex without protection (like a condom or medicine to prevent or treat HIV), and sharing needles or syringes to inject hormones or drugs. Additional factors include commercial sex work, mental health issues, incarceration, homelessness, unemployment, and high levels of substance misuse compared to the general population.
HIV behavioral interventions developed for other at-risk groups have been adapted for use with transgender people. However, the effectiveness of these interventions is understudied. According to a 2017 study, most existing interventions target behavior change among transgender women, with only one HIV prevention program evaluated for transgender men. Evidence-based multilevel interventions that address the structural, biomedical, and behavioral risks for HIV among transgender populations, including transgender men, are needed to address disparities in HIV prevalence.
Many transgender people face stigma, discrimination, social rejection, and exclusion that prevent them from fully participating in society, including accessing health care, education, employment, and housing, as well as violence and lack of family support. These factors affect the health and well-being of transgender people, placing them at increased risk for HIV.
Transgender women and men might not be sufficiently reached by current HIV testing measures. Tailoring HIV testing activities to overcome the unique barriers faced by transgender women and men might increase rates of testing among these populations.
Transgender men’s sexual health has not been well studied. Transgender men, particularly those who have sex with cisgender (persons whose sex assigned at birth is the same as their gender identity or expression) men, are at high risk for infection. Over half of transgender men with diagnosed HIV infection had no identified or reported risk. Additional research is needed to understand HIV risk behavior among transgender men, especially those who have sex with other men.
Lack of knowledge about transgender issues by health care providers can be a barrier for transgender people who receive an HIV diagnosis and are seeking quality treatment and care services. Few health care providers receive proper training or are knowledgeable about transgender health issues and their unique needs. This can lead to limited health care access and negative health care encounters.
Transgender women and men might not fully engage in medical care. In study of transgender men with HIV who were receiving medical care, 60% had maintained an undetectable viral load over the previous 12 months. A 2015 study found that 50.8% of transgender women who were receiving medical care had maintained an undetectable viral load over the previous 12 months. Taking HIV medicine as prescribed and keeping an undetectable viral load (or staying virally suppressed) is the best thing people with HIV can do to stay healthy and protect their sexual partners. People with HIV who keep an undetectable viral load have effectively no risk of sexually transmitting HIV to an HIV-negative partner.
Transgender and other gender minority youth are an at-risk group understudied in HIV prevention (e.g., PrEP) and HIV treatment. But one study of transgender youth found that medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments.
Transgender-specific data are limited. Some federal, state, and local agencies do not collect or have complete data on transgender individuals. Using the two-step data collection method of asking for sex assigned at birth and current gender identity can help increase the likelihood that transgender people are correctly identified in HIV surveillance programs. Accurate data on transgender status can lead to more effective public health actions.
All graphics by Jaclyn Saik