- Transgender women are at high risk for HIV infection.
- By race/ethnicity, black/African American transgender women have the highest percentage of new HIV-positive test results.
- Efforts are under way to improve the quality of HIV data collected on transgender communities.
Transgender communities in the United States are among the groups at highest risk for HIV infection. The term gender identity
refers to a person's basic sense of self, and transgender refers to people whose gender identity does not conform to a binary classification of gender based on biological sex, external genitalia, or their sex assigned at birth. It includes gender-nonconforming people with identities beyond the gender binary who self-identify as: male-to-female or transgender women; female-to-male or transgender men; two-spirit; and people who self-identify simply as women or men.
Because data for this population 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 infection and racial/ethnic disparities.
- In 2010, more than half of the HIV testing events among transgender people occurred at non-healthcare facilities (55.1%). The Centers for Disease Control and Prevention (CDC) reported that the highest percentage of newly identified HIV-positive test results was among transgender people (2.1%). For comparison, the lowest percentages of newly identified HIV-positive test results were among females (0.4%), followed by males (1.2%). Among transgender people in 2010, the highest percentages of newly identified HIV-positive test results were among racial and ethnic minorities: blacks/African Americans comprised 4.1% of newly identified HIV-positive test results, followed by Latinos (3.0%), American Indians/Alaska Natives and Native Hawaiians/Other Pacific Islanders (both 2.0%), and whites (1.0%).
- In New York City, from 2007-2011, there were 191 new diagnoses of HIV infection among transgender people, 99% of which were among transgender women. The racial/ethnic disparities were large: approximately 90% of transgender women newly diagnosed with HIV infection were blacks/African Americans or Latinos. Over half (52%) of newly diagnosed transgender women were in their twenties. Also, among newly diagnosed people, 51% of transgender women had documentation in their medical records of substance use, commercial sex work, homelessness, incarceration, and/or sexual abuse as compared with 31% of other people who were not transgender.
- Findings from a meta-analysis of 29 published studies showed that 27.7% of transgender women tested positive for HIV infection (4 studies), but when testing was not part of the study, only 11.8% of transgender women self-reported having HIV (18 studies). In one study, 73% of the transgender women who tested HIV-positive were unaware of their status. Higher percentages of newly identified HIV-positive test results were found among black/African American transgender women (56.3%) than among white (16.7%) or Latino (16.1%) transgender women; and self-reported HIV infection in studies made up of predominantly of black/African American transgender women (30.8%) was higher than positivity reported in studies comprising mainly white transgender women (6.1%). Studies also indicate that black transgender women are more likely to become infected with HIV than non-black transgender women.
- A review of studies of HIV infection in countries with data available for transgender people estimated that HIV prevalence for transgender women was nearly 50 times as high as for other adults of reproductive age.
Individual behaviors alone do not account for the high burden of HIV infection among transgender people. Many cultural, socioeconomic, and health-related factors contribute to the HIV epidemic and prevention challenges in U.S. transgender communities.
- Identifying transgender people within current data systems can be challenging. Some transgender people may not identify as transgender due to fear of discrimination or previous negative experiences. Since some people in this community do not self-identify as transgender, relying solely upon gender to identify transgender people is not enough. Gender expression may fluctuate for some transgender people due to issues such as perceived safety or reluctance to identify as transgender in certain situations. The Institute of Medicine has recommended that behavioral and surveillance data for transgender men and women should be collected and analyzed separately and not grouped with data for men who have sex with men. Using the 2-step data collection method of asking for sex assigned at birth and current gender identity increases the likelihood that all transgender people will be accurately identified.
- It is important to avoid making assumptions about sexual orientation and sexual behavior based on gender identity because there is great diversity in orientation and behavior in this population, and some identify as both transgender and gay, heterosexual, bisexual, or lesbian. For example, transgender men claim a variety of sexual orientations and have sexual partners that include gay men and transgender women.
- Transgender men's sexual health has been understudied. Compared to transgender women, little is known about HIV risk and sexual health needs among transgender men. One meta-analysis of 29 studies involving transgender people showed that only 5 of them had separate data concerning transgender men.
- Behaviors and factors that contribute to high risk of HIV infection among transgender people include higher rates of drug and alcohol abuse, sex work, incarceration, homelessness, attempted suicide, unemployment, lack of familial support, violence, stigma and discrimination, limited health care access, and negative health care encounters.
- Police policies can conflict with public health initiatives. For example, some law enforcement officers and agencies view the presence of condoms as evidence of sex work, even though public health initiatives identify condoms as a way to prevent HIV infection.
- Discrimination and social stigma can hinder access to education, employment, and housing opportunities. In a study conducted in San Francisco, transgender people were more likely than men who have sex with men or heterosexual women to live in transient housing and be less educated. Discrimination and social stigma may help explain why transgender people who experience significant economic difficulties often pursue high-risk activities, including sex work, to meet their basic survival needs.
- Interventions that address multiple co-occurring public health problems -- including substance use, poor mental health, violence and victimization, discrimination, and economic hardship -- should be developed and evaluated for transgender people.
- Health care provider insensitivity to transgender identity or sexuality can be a barrier for HIV-infected transgender people seeking health care. Although research shows a similar proportion of HIV-positive transgender women have health insurance coverage as compared with other infected people who are not transgender, HIV-infected transgender women are less likely to be on antiretroviral therapy.
- Additional research is needed to identify factors that prevent HIV in this population. Several behavioral HIV prevention interventions developed for transgender people have been reported in studies, generally involving relatively small samples of transgender women. Most have shown at least modest reductions in HIV risk behaviors among transgender women, such as fewer sex partners and/or unprotected anal sex acts, although none have involved a control group. 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.
What CDC Is Doing
CDC and its partners are pursuing a high-impact prevention approach to advance the goals of the National HIV/AIDS Strategy and maximize the effectiveness of current HIV prevention methods among transgender people. Activities include:
- Providing support and technical assistance to providers that help community-based organizations enhance structural interventions for transgender people (condom distribution, community mobilization, HIV testing, and coordinated referral networks and service integration).
- Funding researchers to develop groundbreaking HIV prevention interventions for transgender people. Examples include Life Skills (for young transgender women aged 16-24) and Girlfriends (for adult transgender women).
- Releasing campaigns under the Act Against AIDS umbrella, such as Let's Stop HIV Together to address HIV-related stigma and raise awareness, and HIV Treatment Works to encourage people living with HIV to overcome barriers to get in care and stay on treatment.
- Issuing awards of $55 million for HIV Prevention Projects for Young Men of Color Who Have Sex with Men and Young Transgender Persons of Color (FOA PS11-1113; September 2011), to provide effective HIV prevention services over 5 years to young transgender people of color and their partners regardless of age, gender, and race/ethnicity.
- Revising the fields used to identify transgender people in the National HIV Surveillance System, which is used for reporting diagnoses of HIV infection. In addition, CDC has developed guidance for state and local health departments that collect these data. Some city or state health departments include data on diagnosed HIV infection among transgender people in annual, quarterly, or special reports.
For more information, visit CDC's Lesbian, Gay, Bisexual, and Transgender Health website.
- Institute of Medicine. The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. Washington, DC: The National Academies Press; March 2011.
- 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.
- CDC. HIV testing at CDC-funded sites, United States, Puerto Rico, and the U.S. Virgin Islands, 2010. September 2012.
- New York City Department of Health and Mental Hygiene. Surveillance Slide Sets: HIV among transgender persons in New York City, 2005-2009. February 2011. Accessed October 2013.
- Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav 2008;12(1):1-17. PubMed abstract.
- Kellogg TA, Clements-Nolle K, Dilley J, Katz MH, McFarland W. Incidence of human immunodeficiency virus among male-to-female transgendered persons in San Francisco. J Acquir Immune Defic Syndr 2001;28(4):380-4. PubMed abstract.
- Simon PA, Reback CJ, Bemis CC. HIV prevalence and incidence among male-to-female transsexuals receiving HIV prevention services in Los Angeles County. AIDS 2000;14(18):2953-5.
- 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(2):351-8. PubMed abstract.
- CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data -- United States and 6 U.S. dependent areas -- 2010. HIV Surveillance Supplemental Report 2012;17(3).
- 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. PubMed abstract.
- Sausa LA, Sevelius J, Keatley J, Iñiguez JR, Reyes M. Policy 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 November 15, 2013.
- Rowniak S, Chesla C, Rose CD, Holzemer WL. Transmen: the HIV risk of gay identity. AIDS Educ Prev 2011;23(6):508-20. PubMed abstract.
- Reisner SL, Perkovich B, Mimiaga MJ. A mixed methods study of the sexual needs of New England transmen who have sex with nontransgender men. AIDS Patient Care STDS 2010;28(8):501-13.
- 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(3):659-62. PubMed abstract.
- Sevelius J. "There's no pamphlet for the kind of sex I have": HIV-related risk factors and protective behaviors among transgender men who have sex with non-transgender men. J Assoc Nurses AIDS Care 2009;20(5):398-410.
- 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, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011.
- Stevens S. Meeting the substance abuse treatment needs of lesbian, bisexual and transgender women: implications from research to practice. Subst Abuse Rehabil 2012:3(Suppl 1):27-36. Abstract.
- Human Rights Watch. Sex workers at risk: condoms as evidence of prostitution in four U.S. cities. July 19, 2012. Accessed October 22, 2013.
- Mermin J, Fenton KA. The future of HIV prevention in the United States. JAMA 2012;308(4):247-8.
- 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.
- Operario D, Nemoto T. HIV in transgender communities: syndemic dynamics and a need for multicomponent interventions. J Acquir Immune Defic Syndr 2010;55(Suppl 2):S91-3.
- Sevelius JM, Reznick OG, Hart SL, Schwarcz S. Informing interventions: the importance of contextual factors in the prediction of sexual risk behaviors among transgender women. AIDS Educ Prev 2009;21(2):113-27.
- Xavier J, Bobbin M, Singer B, Budd E. A needs assessment of transgendered people of color living in Washington, DC. International Journal of Transgenderism 2005;8(2/3):31-47. Abstract.
- Sperber J, Landers S, Lawrence S. Access to health care for transgendered persons: results of a needs assessment in Boston. International Journal of Transgenderism 2005:8(2/3):74-91. Abstract.
- 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.
- 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.
- Melendez RM, Exner TA, Ehrhardt AA, et al. Health and health care among male-to-female transgender persons who are HIV positive. Am J Public Health 2006;96(6):1034-7.
- Bockting WO, Rosser BRS, Scheltema K. Transgender HIV prevention: implementation and evaluation of a workshop. Health Educ Res 1999;14(2):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(3):289-303.
- Nemoto T, Operario D, Keatley J, Nguyen H, Sugano E. Promoting health for transgender women: Transgender Resources and Neighborhood Space (TRANS) program in San Francisco. Am J Public Health 2005;95(3):382-4.
- 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.
- Taylor RD, Bimbi DS, Joseph HA, Margolis AD, Parsons JT. Girlfriends: evaluation of an HIV-risk reduction intervention for adult transgender women. AIDS Educ Prev 2011;23(5):469-78. PubMed abstract.
- Gutierrez-Mock L, Thomas-Guess Y, Sevelius J, Keatley J, Cotten, P, Kegeles S. T-SISTA: a resource guide for adapting SISTA for transwomen of color. San Francisco, CA: University of California, San Francisco; 2009.
- CDC. Funding Opportunity Announcement (FOA) PS09-906: Capacity building assistance (CBA) to improve the delivery and effectiveness of human immunodeficiency virus (HIV) prevention services for high-risk and/or racial/ethnic minority populations. Accessed November 14, 2013.
- CDC. Funding Opportunity Announcement (FOA) 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 November 14, 2013.
- California Department of Public Health. HIV/AIDS surveillance in California. December 2012.
- Houston Department of Health and Human Services. HIV/AIDS in the Houston area. 2013.
- Los Angeles County Department of Public Health. 2012 annual HIV surveillance report. March 2013.
- Los Angeles County Department of Public Health. Los Angeles County transgender population estimates 2012.
- Michigan Department of Community Health. 2012 Profile of HIV in Michigan (statewide). Special populations: transgender persons.
- The New York City Department of Health and Mental Hygiene. HIV epidemiology and field services semiannual report. April 2011.
- San Francisco Department of Public Health. HIV/AIDS cases reported through March 2013. Quarterly HIV/AIDS Surveillance Report.
- San Francisco Department of Public Health. HIV/AIDS epidemiology annual report 2011. August 2012.
- Public Health - Seattle and King County. 2008 HIV/AIDS epidemiology profile for community planning public health -- Seattle & King County. July 2009. Accessed October 22, 2103.
CDC HIV Website
CDC Act Against AIDS Campaign