- Studies reveal high HIV prevalence rates among transgender women in the United States.
- Black/African American transgender women are more likely to have HIV than transgender women of other races/ethnicities.
- Many social and structural factors pose challenges to preventing HIV among transgender people.
Transgender is an umbrella term for persons whose gender identity or expression (masculine, feminine, other) is different from their sex (male, female) at birth. Gender identity refers to one's internal understanding of one's own gender, or the gender with which a person identifies. Gender expression is a term used to describe people's outward presentation of their gender.
Because data for transgender people are not uniformly collected, information is lacking on how many transgender people in the United States are infected with HIV. However, data collected by local health departments and scientists studying these communities show high levels of HIV and racial/ethnic disparities.
- In 2013, a meta-analysis (Baral et al.) reported that the estimated HIV prevalence among transgender women was 22% in five high-income countries, including the United States.
- Findings from a systematic review (Herbst et al.) of 29 published studies showed that 28% of transgender women had HIV infection (4 studies), while 12% of transgender women self-reported having HIV (18 studies). This discrepancy suggests many transgender women living with HIV don't know their HIV status.
- In the systematic review, black/African American transgender women were most likely to test HIV positive, compared to those of other races/ethnicities: 56% of black/African American transgender women had positive HIV test results compared to 17% of white or 16% of Hispanic/Latina transgender women.
- Among the 3.3 million HIV testing events* reported to CDC in 2013, the highest percentages of newly identified HIV-positive persons were among transgender persons.
- Although HIV prevalence among transgender men is relatively low (0-3%), a 2011 study (Rowniak et al.) suggests that transgender men who have sex with men are at substantial risk for acquiring HIV.
Individual behaviors alone do not account for the disparate HIV diagnoses among transgender people. Many cultural, socioeconomic, and health-related factors contribute to these diagnoses and prevention challenges in transgender communities.
Sexual behaviors and factors that may contribute to the high risk of HIV infection among transgender people include receptive anal sex without a condom or medicines to prevent HIV, a high prevalence of HIV in sexual networks, sex with multiple partners, and exchanging sex for drugs or money.
Other factors that contribute to high rates of HIV among transgender people include drug and alcohol abuse, mental health disorders, incarceration, homelessness, unemployment, lack of familial support, violence, stigma, discrimination, limited health care access, and negative health care encounters.
Many transgender people face social rejection and marginalization that excludes them from participating and functioning in society. Lack of legal recognition of gender identity can result in the denial of educational, employment, and housing opportunities. Some transgender people who experience poverty rely on sex work to meet their basic survival needs.
Insensitivity to transgender identity can be a barrier for those who are diagnosed with HIV and seek quality treatment and care services. Research shows transgender women with diagnosed HIV infection are less likely to be on antiretroviral therapy (ART) or achieve viral suppression. Furthermore, few health care providers receive adequate training or are knowledgeable about transgender health issues and their unique needs.
Transgender-specific data are limited. Currently, many federal, state, and local agencies inaccurately collect data about individuals' sex and gender. Using the two-step data collection method of asking for sex assigned at birth and current gender identity can help to increase the likelihood that transgender people will be accurately identified in HIV surveillance programs.
Behavioral HIV prevention interventions developed for other at-risk groups with similar behaviors have been adapted for use with transgender people; however, their effectiveness is still unknown. There is a need for effective interventions that address the multiple co-occurring public health problems in transgender persons.
Transgender men's sexual health has been understudied. Additional research is needed to understand HIV risk behavior among transgender men, especially those who have sex with men.
What CDC Is Doing
CDC and its partners are pursuing a high-impact prevention approach to achieve the goals of the National HIV/AIDS Strategy: Updated to 2020 and maximize the effectiveness of current HIV prevention methods among transgender people. Activities include:
- Funding community-based organizations (CBOs) to enhance their capacities to increase HIV testing, link transgender persons with diagnosed HIV infection to medical care, increase referrals to partner services, and provide prevention and support services for transgender persons at risk for or diagnosed with HIV.
- 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 persons at substantial risk for acquiring HIV, particularly persons of color.
- Providing support and technical assistance to providers that help CBOs enhance structural interventions for transgender people (e.g., condom distribution, community mobilization, HIV testing, and coordinated referral networks and service integration).
- Developing 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 a transgender woman's story of staying healthy while living with HIV.
- 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 recognizes the importance of routine HIV testing, status awareness, and continued focus on HIV prevention and treatment efforts among transgender people.
* 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.
For more information, visit CDC's Lesbian, Gay, Bisexual, and Transgender Health website.
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- Bockting WO, Rosser BRS, Scheltema K. Transgender HIV prevention: implementation and evaluation of a workshop. Health Educ Res 1999;14:177-83.
- Bockting WO, Robinson BE, Forberg J, Scheltema K. Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community. AIDS Care 2005;17:289-303.
- Bockting WO, Robinson BE, Rosser BRS. Transgender HIV prevention: a qualitative needs assessment. AIDS Care 1998;10(4):505-25.
- 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, 2013. June 2015. Accessed April 14, 2016.
- CDC. Funding opportunity announcement: PS11-1113: Human immunodeficiency virus (HIV) prevention projects for young men of color who have sex with men and young transgender persons of color. Accessed April 14, 2016.
- CDC. Funding opportunity announcement: PS15-1502: Comprehensive high-impact HIV prevention projects for community-based organizations. Accessed April 14, 2016.
- 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 July 28, 2015.
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- New York City Department of Health and Mental Hygiene. Surveillance slide sets: HIV among transgender persons in New York City, 2009-2013. February 2015. Accessed April 14, 2016.
- Nemoto T, Luke D, Mamo L, Ching A, Patria J. HIV risk behaviors among male-to-female transgenders in comparison with homosexual or bisexual males and heterosexual females. AIDS Care 1999;11(3):297-312.
- Nemoto T, Operario D, Keatley J, Villegas D. Social context of HIV risk behaviors among male-to-female transgenders of color. AIDS Care 2004;16(6):724-35.
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- 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.
- Rowniak S, Chesla C, Rose CD, Holzemer WL. Transmen: the HIV risk of gay identity. AIDS Educ Prev 2011;23(6):508-20.
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- Sausa LA, Sevelius J, Keatley J, Iñiguez JR, Reyes M. Recommendations for inclusive data collection of trans people in HIV prevention, care & services. San Francisco, CA: University of California, San Francisco, Center of Excellence for Transgender HIV Prevention; 2009. Accessed July 28, 2015.
- University of California, San Francisco, Center for AIDS Prevention Studies and AIDS Research Institute. What are male-to-female transgender persons' (MTF) HIV prevention needs? September 2008.
- Xavier J, Bobbin M, Singer B, Budd E. A needs assessment of transgendered people of color living in Washington, DC. Int J Transgend 2005;8(2/3):31-47.
- Xavier J, Honnold J, Bradford J. The health, health-related needs, and lifecourse experiences of transgender Virginians. Richmond, VA: Virginia HIV Community Planning Committee and Virginia Department of Health; 2007. Accessed April 14, 2016.
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