This study described HIV prevalence, risk behaviors, health care use, and mental health status of male-to-female and female-to-male transgender persons and determined factors associated with HIV. The researchers recruited transgender persons through targeted sampling, respondent-driven sampling, and agency referrals; 392 male-to-female and 123 female-to-male transgender persons were interviewed and tested for HIV. Researchers hired three male-to-female transgender persons (African-American, Filipina, and Latina) and three female-to-male transgender persons (one Vietnamese and two white) to conduct the interviews, and each received 35 training sessions that included HIV counseling, interviewing, confidentiality, harm reduction, street outreach, suicide prevention, and referrals.

Eligible subjects (18 years or older who lived, worked or socialized in San Francisco; spoke English, Spanish, Vietnamese, or Tagalog; and stated that their primary gender was transgender, transsexual, bigender, transvestite, cross-dresser, intersexed, or the opposite sex of that at birth) were interviewed at one of eight community-based organizations. Interviewers obtained information regarding subjects' sexual history (type, frequency, number of partners, gender of partners, and number of exchange partners), drug use (lifetime and recent, or in the last six months, and including hormone use or injection) and mental health (including emergency and outpatient visits, hospitalization, and suicide attempts). Subjects were also tested for HIV and in two weeks received HIV test results and further counseling and referrals from the same interviewer.

According to the researchers, 35 percent "of the male-to- female participants (n=137) had positive HIV test results, of whom 65% (n=89) knew they were infected, 20% (n=27) learned their status through study participation, and 15% (n=21) did not know their status and failed to return for test results." Of these, only 50 percent of all the male-to-female persons who were HIV- positive were receiving HIV-related medical care. After control for other covariates, the researchers reported that "African American race was found to be the strongest risk factor for HIV infection (63% of the African American male-to-female participants were HIV positive)." Other factors associated with HIV prevalence included "having less than a high school degree, having had more than 200 lifetime sexual partners, and using nonhormonal injection drugs," they wrote.

Among the female-to-male participants, only two (2 percent) had positive HIV test results, both of whom "knew their status and were receiving HIV-related health care," the authors reported. And recent risk behaviors "were uncommon among female- to-male participants overall."

The researchers' "estimate of HIV prevalence among male-to- female transgender persons is higher than estimates from studies with gay men and injection drug users of the same age in San Francisco," they wrote. "These findings highlight the importance of counseling male-to-female transgender persons about HIV and the benefits of early intervention." But the researchers pointed to "a particular need to intervene with African-American male-to-female transgender persons, two thirds of whom had positive HIV test results" in the study, which was consistent with other studies. "As with previous studies," they reported, "socioeconomic and behavioral differences did not account for the disproportionate level of HIV infection among African- Americans" in the study.

Among the male-to-female participants, the researchers noted high levels of current risk behaviors among those who were HIV- positive and HIV-negative, noting that these participants were more likely to engage in receptive rather than insertive anal sex and more likely to report inconsistent condom use.

The researchers' data described "an important population in San Francisco with many needs," they wrote. "Similar studies in other US cities are needed to assess the role of transgender individuals in local HIV epidemics. . . . Similar peer-based approaches could be used to provide culturally appropriate HIV, substance use, mental health, education, employment, and other social services for transgender persons," they concluded.

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