HIV Among Transgender People in the United States
April 18, 2018
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.
- A 2017 paper used meta-analysis and synthesized national surveys to estimate that 1 million adults in the United States are transgender.1
- From 2009 to 2014, 2,351 transgender people were diagnosed with HIV in the United States.2
- 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 from 2009 to 2014 lived in the South.
- According to current estimates, around a quarter (22-28%) of transgender women are living with HIV, and more than half (an estimated 56%) of black/African American transgender women are living with HIV.
- Among the 3 million HIV testing events3 reported to CDC in 2015, the percentage of transgender people who received a new HIV diagnosis was more than 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.
Multiple factors have put transgender people at risk for HIV infection and transmission, including multiple sexual partners, anal or vaginal sex without condoms or medicines to prevent HIV, injecting hormones or drugs with shared syringes and other drug paraphernalia, commercial sex work, mental health issues, incarceration, homelessness, unemployment, and high levels of substance misuse compared to the general population, as well as violence and lack of family support.
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. 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.
Insensitivity to transgender issues by health care providers can be a barrier for transgender people diagnosed with HIV and 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 the United States, transgender and other gender minority youth are an at-risk group understudied in HIV prevention (e.g., PrEP) and HIV treatment. In one study, medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. In a study of transgender men living 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. Sustaining an undetectable viral load through effective treatment is the best thing people living with HIV can do to stay healthy and protect their sexual partners. People living with HIV who sustain an undetectable viral load have effectively no risk of sexually transmitting HIV to an HIV-negative partner.
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.
- Partnering with Fenway Health to offer a free web-based CME/CEU program to address ways health care providers can help high-risk transgender people prevent HIV, improve care for transgender people living with HIV, and incorporate strategies to make clinical environments more welcoming to transgender patients.
- Supporting 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.
- Conducting 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 10 NHBS sites.
- Providing 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 is working 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.
- Developed Act Against AIDS communication materials to reach transgender people, including campaigns such as:
Doing It, which encourages all adults to get tested for HIV and know their status, and includes images and testimonial videos featuring transgender leaders.
Let's Stop HIV Together, which raises awareness about HIV and fights stigma, and includes the stories of transgender women.
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.
For more information, visit CDC's Lesbian, Gay, Bisexual, and Transgender Health website.
- These data may underreport HIV diagnoses among transgender people because of challenges in accurately identifying and reporting gender identity in HIV surveillance.
- Includes Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia.
- 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.
- Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis 2013;13(3):214-22.
- Brennan J, Kuhns LM, Johnson AK, Belzer M, Wilson EC, Garofalo R, and the Adolescent Medicine Trials Network for HIV/AIDS Interventions. Syndemic theory and HIV-related risk among young transgender women: the role of multiple, co-occurring health problems and social marginalization. Am J Public Health 2012;102(9):1751-7.
- CDC. CDC-funded HIV testing: United States, Puerto Rico, and U.S. Virgin Islands, 2015. July 2017. Accessed March 30, 2018.
- CDC. Funding opportunity announcement: PS15-1502: Comprehensive high-impact HIV prevention projects for community-based organizations. Accessed February 27, 2017.
- CDC. Funding opportunity announcement: PS15-1506: Health department demonstration projects to reduce HIV infections and improve engagement in HIV medical care among men who have sex with men (MSM) and transgender persons. Accessed February 27, 2017.
- Chen S, McFarland W, Thompson HM, Raymond HF. Transmen in San Francisco: what do we know from HIV test site data? AIDS Behav 2011;15:659-62.
- 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. December 2016. Accessed February 27, 2017.
- De Santis JP. HIV infection risk factors among male-to-female transgender persons: a review of the literature. J Assoc Nurses AIDS Care 2009;20(5):362-72.
- Flores AR, Herman JL, Gates GJ, Brown TNT. How many adults identify as transgender in the United States? Los Angeles, CA: The Williams Institute. June 2016. Accessed February 27, 2017.
- Garofalo R, Johnson AK, Kuhns LM, Cotton C, Joseph H, Margolis A. Life Skills: evaluation of a theory-driven behavioral HIV prevention intervention for young transgender women. J Urban Health 2012;89(3):419-31.
- Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality; 2011.
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- Meerwijk EL, Sevelius JM. Transgender population size in the United States: a meta-regression of population-based probability samples. Am J Public Health 2017; 107(2):e1-e8.
- Mizuno Y, Frazier EL, Huang P, Skarbinski J. Characteristics of transgender women living with HIV receiving medical care in the United States. LGBT Health 2015;2(00):1-7.
- New York City Department of Health and Mental Hygiene. Surveillance slide sets: HIV among people identified as transgender in New York City, 2011-2015. December 2016. Accessed April 18, 2017.
- Nuttbrock L, Hwahng S, Bockting W, et al. Lifetime risk factors for HIV/sexually transmitted infections among male-to-female transgender persons. J Acquir Immun Def Syndr 2009;52(3):417-21.
- Reisner SL, Perkovich B, and Mimiaga MJ. A mixed methods study of the sexual health needs of New England transmen who have sex with nontransgender men. AIDS Patient Care STDS 2010;24(8):501-13.
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- Sanchez T, Finlayson T, Murrill C, Guilin V, Dean L. Risk behaviors and psychosocial stressors in the New York City House Ball community: a comparison of men and transgender women who have sex with men. AIDS Behav 2010;14:351-8.
HIV Testing Among Transgender Women and Men -- 27 States and Guam, 2014-2015. MMWR 2017;66:883-887.
Lemons A, Beer L, Finlayson T, Hubbard McCree D, Lentine D, Shouse RL. Characteristics of HIV-Positive Transgender Men Receiving Medical Care: United States, 2009-2014. Am J Public Health 2018;108(1):128-30.
- Reisner SL, Jadwin-Cakmak L, White Hughto JM, Martinez M, Salomon L, Harper GW. Characterizing the HIV Prevention and Care Continua in a Sample of Transgender Youth in the U.S. AIDS Behav. 2017; 21(12):3312-3327.
- Poteat T, Malik M, Scheim A, Elliott A. HIV Prevention Among Transgender Populations: Knowledge Gaps and Evidence for Action. Curr HIV/AIDS Rep. 2017;14(4):141-152.
- Mizuno Y, Frazier EL, Huang P, Skarbinski J.Characteristics of Transgender Women Living with HIV Receiving Medical Care in the United States. LGBT Health. 2015;2(3):228-34.
- National Center for Transgender Equality; Annual Report 2016. The T's Not Silent.
[Note from TheBody: This article was created by the Centers for Disease Control and Prevention, who last updated it on Apr. 18, 2018. We have cross-posted it with their permission.]
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