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HIV and Transgender People

Terminology

The first bullet is an icon of a transgender symbol. The text reads transgender: People whose gender identity or expression is different from their sex assigned at birth.The second bullet is an icon of a person with a thought bubble. The text reads gender identity: person’s internal understanding of their own gender.The third bullet is an icon of a shirt with a question mark. The text reads gender expression: person’s outward presentation of their gender (example, how they dress).The fourth bullet is an icon of a female person. The text reads transgender women: people who were assigned the male sex at birth but identify as women.The fifth bullet is an icon of a male person. The text reads transgender men: people who were assigned the female sex at birth but identify as men.

The Numbers

  • A 2017 paper used meta-analysis and synthesized national surveys to estimate that nearly 1 million adults in the United Statesa are transgender.b
  • From 2009 to 2014, 2,351 transgender people received an HIV diagnosis in the United States.c
    • 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% [844] of transgender women; 54% [193] of transgender men) who received an HIV diagnosis lived in the South.d
  • A 2019 systematic review and meta-analysis found that an estimated 14% of transgender women have HIV. By race/ethnicity, an estimated 44% of black/African Americane transgender women, 26% of Hispanic/Latinaf transgender women, and 7% of white transgender women have HIV.g
  • Among the 3 million HIV testing eventsh 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.

HIV Diagnoses Among Transgender People in the United Statesc
by Race/Ethnicity, 2009-2014

Pie charts show the number of HIV diagnoses between 2009 and 2014 among transgender people in the United States by race and ethnicity. Transgender Men=361. Black/African American=211. Hispanic/Latino=578. White=212. Other=182. Transgender Women=1,974. Black/African American=1,002. Hispanic/Latina=578. White=212. Other=182.
Source: Clark H, Babu AS, Wiewel EW, Opoku J, Crepaz N. Diagnosed HIV Infection in Transgender Adults and Adolescents: Results from the National HIV Surveillance System, 2009-2014. AIDS Behav 2017;21(9):2774-2783. Hispanics/Latinos can be of any race.

Prevention Challenges

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 sexi without protectionj (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 a 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.

What CDC Is Doing

CDC and its partners are pursuing a high-impact prevention approach to maximize the effectiveness of current HIV prevention methods among transgender people. Activities include:

  • In 2017, CDC awarded nearly $11 million per year for 5 years to 30 CBOs to provide HIV testing to young gay and bisexual men of color and transgender youth of color, with the goals of identifying undiagnosed HIV infections and linking those who have HIV to care and prevention services.
  • As part of its Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention, CDC recently identified the Couples HIV Intervention Program as an evidence-based intervention that focuses on transgender women and their primary cisgender male partners. The goals of the intervention are to reduce HIV risk behaviors, improve relationship communication, and improve partner interpersonal dynamics.
  • CDC supports health department demonstration projects that provide pre-exposure prophylaxis (PrEP) support services and data-to-care activities prioritizing gay and bisexual men and transgender people at substantial risk for acquiring HIV, particularly people of color.
  • CDC is funding a National HIV Behavioral Surveillance (NHBS) activity among transgender women that will use NHBS methods to conduct a behavioral interview and HIV testing among transgender women in 7 NHBS sites.
  • CDC provides support and technical assistance to health departments, CBOs, and providers to support interventions for transgender people (e.g., condom distribution, community mobilization, HIV testing, and coordinated referral networks and service integration).
  • Through its Capacity Building Assistance initiative, CDC works with the Center of Excellence for Transgender Health to support National Transgender HIV Testing Day. This day promotes HIV testing, prevention, and treatment efforts among transgender people.
  • CDC developed communication materials to reach transgender people through its Let’s Stop HIV Together (formerly Act Against AIDS) suite of campaigns.  Let’s Stop HIV Together campaigns are aimed at stopping HIV stigma and promoting HIV testing, prevention, and treatment.  The stigma materials include stories and issues relevant to transgender people, as do the following:
    • Transforming Health, which addresses ways to reduce new HIV infections among transgender people, particularly transgender women of color, and improve the health of transgender people who are living with HIV.
    • Doing It, which encourages all adults to get tested for HIV and know their status, and includes images and testimonial videos featuring transgender leaders.
    • HIV Treatment Works, which encourages people living with HIV to stay in care, and features transgender women’s stories of staying healthy while living with HIV.
    • Start Talking. Stop HIV., which helps gay and bisexual cisgender and transgender men communicate about safer sex, testing, and other HIV prevention issues.

a Includes 50 states and the District of Columbia.

b These data may under report HIV diagnoses among transgender people because of challenges in accurately identifying and reporting gender identity in HIV surveillance.

c Includes 45 states plus the District of Columbia.

d Includes Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia.

e Black refers to people having origins in any of the black racial groups of Africa, including immigrants from the Caribbean, and South and Latin America. African American is a term often used for Americans of African descent with ancestry in North America. Individuals may self-identify as either, both, or choose another identity altogether.

f Hispanics/Latinas can be of any race.

g Estimate for transgender women overall includes laboratory-confirmed infections only. Estimates by race/ethnicity include laboratory-confirmed and self-reported infections.

h An HIV testing event is one or more HIV tests performed with a person to determine that person’s HIV status. During one testing event, a person may be tested once or multiple times.

i Information is lacking with regards to how sex reassignment surgery such as vaginoplasty, metoidioplasty or phalloplasty, for example, may increase or decrease HIV transmission risk.

j It is important to avoid assumptions regarding the types of sexual activity that transgender people engage in or how they may refer to their body parts.

For more information, visit CDC’s Lesbian, Gay, Bisexual, and Transgender Health website.

Bibliography

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