What You Need to Know About HIV in Gay, Lesbian, Bisexual, and Transgender People in the U.S.

For as long as HIV has existed in the public consciousness, it has been associated with queerness.

The first story written about AIDS in any newspaper appeared in the New York Native, a gay biweekly publication, which in May 1981 tried to push back against rumors of a “gay cancer” spreading in the U.S. Later that year, The New York Times published a now-infamous story entitled, “Rare Cancer Seen in 41 Homosexuals,” which raised alarm bells within the LGBTQ+ community—and also set the stage for decades of stigma against the LGBTQ+ community from those outside it.

To this day, HIV continues to be associated primarily with gay men in America’s imagination. Films depicting HIV, save a Dallas Buyers Club here or there, focus mainly on a similar archetype: the white gay man. From earlier films like And the Band Played On to Philadelphia up through How to Survive a Plague and The Normal Heart, media continue to connect HIV with gay men, one of the “four Hs” thought to be the groups that contracted the virus: homosexuals, Haitians, heroin users, and hemophiliacs.

The truth is, even in the LGBTQ+ community, more than just gay men get HIV. HIV affects many people of various sexual orientations and gender identities living under the LGBTQ+ umbrella—and the reasons behind the statistics explain a lot about why these groups are still so heavily affected by HIV in the U.S. today.

HIV Among Gay and Bisexual Men in the U.S.

Over half of people living with HIV in the United States are gay and bisexual men. According to the Centers for Disease Control and Prevention (CDC):

• Out of the 1.1 million people living with HIV in the U.S., roughly 700,000 of them attained the virus through male-male sexual intercourse.
• Roughly three out of every four people in the U.S. who became HIV positive in 2017 were men who have had sex with men.
• Among all U.S. gay and bisexual men, the lifetime risk of acquiring HIV is currently one in six.
• Lifetime HIV risk is even higher among Black gay and bisexual men (one in two) and Latinx gay and bisexual men (one in four).
• An estimated 17% of gay and bisexual men living with HIV haven’t been diagnosed.

But when you dive into these numbers, what they really mean gets a little murkier.

Defining “Gay” in the CDC’s HIV Statistics

The CDC doesn’t cull HIV data by sexual identity, but rather by behavior. Out of the 1.1 million people living with HIV in the United States as of 2016, about 648,500 of them reported male-male sexual intercourse as their main activity that put them at risk for HIV.

Of course, that doesn’t mean that everyone in that category is the “G” in LGBTQ. For instance, men reporting sex with another man could include gay men, bisexual men and—unfortunately, due to antiquated and transphobic reporting policies—transgender women.

Similarly, tens of thousands of men living with HIV in the U.S. reported “heterosexual contact” as their main risk activity, which is the CDC’s way of saying opposite-sex sexual intercourse. But that doesn’t tell us whether the person who had opposite-sex sexual intercourse was gay, bisexual, pansexual, or any other term for a person who has sex with people of multiple genders. The person could also have been transgender and had sex with an opposite-sex cisgender or transgender person.

Meanwhile, a large number of men living with HIV in the U.S. reported drug use as their main risk activity (about 78,000) or reported a combination of drug use and male-to-male sex (58,600). (There is no category for a combination of drug use and opposite-sex intercourse.) The injection drug-use category could include people who are LGBTQ+ but did not obtain the virus through sex. And the “drug use and male-to-male sexual intercourse” category probably includes gay men, bisexual men, pansexual men, and transgender men.

HIV Rates Are Higher Among Gay and Bisexual Men of Color

Gay and bisexual men of color, specifically Black and Latinx gay and bisexual men, are disproportionately affected by HIV. These numbers reflect the reality of having an intersectional identity in America. While queerness often means that people will have inadequate access to proper sexual education and medical care, being a queer Black man or a queer Latinx man will often lead to worse health outcomes due to worse access to care and sexual education, as well as higher rates of poverty.

Among all gay and bisexual men, the lifetime risk of acquiring HIV is currently one in six. However, that aggregate number becomes even worse when broken down by race. For Black gay and bisexual men, the lifetime risk is one in two, while the lifetime risk for Latinx gay and bisexual men is one in four.

Black gay and bisexual men, along with Black transgender women, are more affected by HIV than any other group in the United States. Black gay and bisexual men accounted for 26% of all the new infections in the United States in 2018, despite Black Americans comprising only 13% of the U.S. population—and despite Black gay and bisexual men making up only a fraction of that 13%.

Overall, new diagnoses among Black gay and bisexual men are stable, according to the CDC. But that stability doesn’t hold true when you look at specific age groups. Among Black gay and bisexual men, from 2010 to 2017:

• The rate of HIV diagnoses among 13 to 24 year olds went down by 11%.
• The rate among 25 to 34 year olds went up 42%.
• The rate among 35 to 44 year olds went down 21%.
• The rate among 45 to 54 year olds went down 36%.
• The rate among those 55 and older was stable.

Latinx gay and bisexual men account for 20% of all new infections in the United States, despite Latinx people as a whole accounting for 17% of the U.S. population. HIV diagnosis rates are on the rise among Latinx gay and bisexual men. From 2010 to 2016:

• Among 13 to 24 year olds, the rate went up 17%.
• Among 25 to 34 year olds, the rate went up 34%.
• The rate was stable among 35 to 44 year olds.
• The rate among 45 to 54 year olds went up 14%.
• The rate among those 55 years old and older went up 10%.

Increased rates of HIV among gay and bisexual men of color have nothing to do with an inherent risk based on their identities, but rather on the many sociocultural and socioeconomic factors that hurt Black and Latinx queer people every day. For instance, many gay men of color have lower incomes, higher rates of homelessness, and less health insurance overage overall than the general population.

On top of that, because HIV rates in the community are already high and dating pools for many people of color often include people within their own racial or ethnic group, it means that a person who does not use a condom or experiences condom failure may have a much higher risk of being exposed to HIV than a white person in the same situation.

Rather than conceiving of risk as based on an individual's actions, it's much more realistic to think of risk as what could happen based on a person's actions in their given environment—especially since, in America, people of color are forced to live with the realities of systemic racism.

HIV Risk Depends on Whether You’re the Insertive vs. Receptive Partner During Sex

Gay and bisexual men can be both insertive and receptive partners—often referred to colloquially as “tops” or “bottoms”—during sex. So, while statistics may refer to the overall risk of transmitting HIV during gay sex, each position poses different risks.

Receptive anal sex has a much higher risk of acquiring HIV than insertive anal sex. In fact:

• A “bottom” is 13 times more likely to acquire HIV than a partner who is a top.
• Being a receptive partner (or bottom) during anal sex is the highest-risk sexual activity for getting HIV. That’s because the lining of the rectum is thin and can allow HIV to enter the body during anal sex.
• The insertive partner is still at risk, albeit a lower one. HIV can enter a top’s body through the opening at the tip of their penis or through any cuts, scratches, or sores on the penis.

Statistics on HIV Treatment and Viral Suppression Among Gay and Bisexual Men

Of the gay and bisexual men living with HIV in the U.S., about 62% are receiving HIV care and 52% are virally suppressed, meaning that the amount of virus in their blood is so small that it cannot be passed on to partners. This is known as treatment as prevention, or undetectable equals untransmittable (U=U): It’s the idea that treating the virus is actually a public health good, as well as being good for the person receiving treatment.

There is a small amount of research that shows that there are differences in HIV viral suppression rates when broken down by race. One 2018 study of over 1,300 gay and bisexual men found that 72% of Black participants were virally suppressed, compared to 91% of white participants and 81% of Latinx participants. (As you can see, all of these rates are much higher than the 52% nationwide rate—this is because the study was done in an HIV outpatient clinic where everyone was receiving care.)

Researchers determined that HIV care must address social determinants of health, which are aspects of health like poverty rate, geographic location, and race that determine a person’s health beyond just the presence and treatment of HIV itself.

Statistics on HIV Pre-Exposure Prophylaxis (PrEP) Use Among Gay and Bisexual Men

As of 2017, around 35% of gay and bisexual men in the U.S. were on PrEP. That’s a much higher percentage than only three years prior, when just 6% of gay and bisexual men were on PrEP.

Broken down by race, we again see major differences:

• 26% of Black gay and bisexual men are on PrEP.
• 30% of Latinx gay and bisexual men are on PrEP.
• 42% of white gay and bisexual men are on PrEP.

HIV Among Lesbians and Bisexual Women in the U.S.

Of the 1.1 million people living with HIV in the United States, about 23%—that’s about 250,000 people—are women. In addition, about 19% of new diagnoses in 2018 occurred in women, which amounts to roughly 7,000 U.S. women newly diagnosed with HIV that year.

While male-to-female sexual contact accounts for a large portion (85%) of new HIV diagnoses in women, that does not mean those women identify as heterosexual. As we noted in the section on gay and bisexual men, the CDC doesn’t report HIV numbers by identity, only by behavior. And for women, only sex with men and injection drug use are behaviors that are reported in official HIV CDC statistics.

Especially when we take into account women who reported drug use as their main HIV risk activity, there may be a considerable yet underreported section of the population of women living with HIV who identify as queer in some way.

HIV does not care about a person’s gender identity or sexual orientation. The reason that women who engage in sex with other women are at lower risk of HIV infection is not because of any inherent protection from being a lesbian, but because sex between women usually involves less direct exchange of infectious fluids than sex between gay and bisexual men. In order for an HIV infection to occur, there needs to be a port of entry (a mucous membrane, like the anus or vagina) and a fluid that contains HIV.

Still, there is HIV risk between women. Some activities that can put women at risk include fingering, fisting, oral sex, and sharing sex toys. And, of course, not all women have vaginas. For women who have penises, risk of transmission can include unprotected contact with semen or precum.

There have been no confirmed cases of female-to-female sexual HIV transmission among cisgender women. Still, there is some theoretical HIV risk in sex between women. Some activities that could potentially put women at risk include fingering/fisting, oral sex, and sharing sex toys.

And, of course, not all women are cisgender or have vaginas. For trans women who have penises, risk of transmission can include unprotected contact with semen or presemen.

However, there are many lesbians who are living with HIV. A host of studies have showed that, while lesbians may not transmit HIV to a female sex partner, many lesbians may have a higher risk for HIV due to:

• Injection drug use.
• Sex with men, including bisexual men.
• Discomfort discussing their sexuality with their physicians.
• Poor mental and physical health.
• Barriers to health care.

How Gender Discrimination and Violence Affect HIV Risk for Lesbians and Bisexual Women

Many bisexual and lesbian women are put at risk for HIV because of their gender. Gender-based discrimination and abuse extend to many fields of life, including in the medical field and in sexual relationships, two areas that can potentially impact a person’s health status.

The 2010 National Intimate Partner Violence and Sexual Violence survey found that 44% of lesbian women and 61% of bisexual women experience intimate partner violence—which is more common among people living with HIV—at some point in their lives. This is compared to 26% of gay men and 37% of bisexual men experiencing intimate partner violence. LGBTQ youth are also much more likely to experience this than their heterosexual and cisgender counterparts.

Bisexual women are between 1.8 and 2.6 times more likely than heterosexual women to experience intimate partner violence.

Both men and women contribute to rates of intimate partner physical and sexual violence among lesbians and bisexual women. The CDC found that 89.5% of bisexual women reported only male perpetrators for instances of intimate partner physical violence, rape, and stalking, while a third of lesbian women who have experienced these forms of violence from intimate partners have had one or more male perpetrators.

Poverty is also a factor in a person’s HIV risk and overall health—and couples consisting of two women are more likely to face poverty than mixed-gender couples. A 2013 report found that 7.6% of lesbian couples live in poverty, compared to 5.7% of married opposite-sex couples. Rates of poverty go up if both partners are Black.

HIV and Health Risks Among Lesbian and Bisexual Women Are Worsened by Invisibility

One reason that some lesbian and bisexual women may be at risk for HIV is their relative invisibility in male-dominated HIV messaging. For instance, as discussed above, a queer woman who has sex with (or is raped by) a man and contracts HIV is statistically counted as a heterosexual woman by the CDC.

In addition, many doctors who speak to women about their sex life may not even ask about sex with women if the person indicates that she has had sex with a man, making queer female sexuality even more invisible.

A 2018 report even found that the U.S. Office of Women’s Health removed from its website a link to a factsheet about bisexual and lesbian women’s health. A page on the website titled “Lesbian and Bisexual Health” that had previously been listed as a health topic was no longer there as of June 2020.

HIV Among Transgender People in the U.S.

There are nearly 1 million transgender adults in the United States, though that number continues to grow as more people come to understand transgender identity.

Here are several key statistics regarding HIV among transgender people in the U.S.:

• Approximately 2,351 transgender people were diagnosed with HIV in the United States between 2009 and 2014.
  • Of those, 84% were transgender women, and 15% were transgender men. One percent had a nonbinary identity.
  • About half of transgender people—43% of transgender women and 54% of transgender men—who received an HIV diagnosis during that period lived in the U.S. South.
• Transgender women around the world are 49 times more at risk for HIV acquisition than the general public. The HIV prevalence rate among U.S. adults is less than 0.5%. A 2019 analysis estimated that about 14% of transgender women in the U.S. are living with HIV. However, that number changes when taking race into account.
  • An estimated 44% of Black transgender women are living with HIV.
  • An estimated 26% of Latinx transgender women are living with HIV.
  • An estimated 7% of white transgender women are living with HIV.
• Around 3.2% of transgender men are living with HIV, while 9.2% of transgender people overall live with HIV.
• At testing events around the country in 2017, transgender people had a new HIV diagnosis rate of three times the national average.

Stigma and Discrimination Are at the Core of Heightened HIV Risk for Trans People

Transgender people are put at increased risk of HIV not because of any inherent quality about being trans, but because of how our society marginalizes transgender people.

• Transgender people face intense stigma, discrimination, social rejection, and exclusion from many areas of life, including health care, education, employment, and housing.
• Transgender people also face high rates of incarceration, mental health issues, and violence.
• Of the 2% of students who identify as transgender, 35% have been bullied at school, and 35% have attempted suicide.
• Transgender people have higher rates of activities that might put them at risk for HIV, though many of these are ways of coping with societal rejection, including sex without condoms, commercial sex work, and drug use.

Another huge problem transgender people face is insensitivity and ignorance to transgender issues in the health field. Doctors who misgender, mistreat, and cast blame on transgender people can traumatize their trans patients. In one survey, 19% of transgender people said they were refused medical care because of their gender identity, while 28% had been harassed in a doctor’s office. This can lead to poorer health outcomes and limited health care access for transgender people—and can deter them from seeking health care altogether.

There is also a lack of sufficient research about HIV among transgender people, meaning that many prevention and treatment options created specifically for cisgender people have often not been tested in transgender people or designed with them in mind. Within the little research there is, much of it focuses on transgender women, with few studies focusing on HIV prevalence and risk among trans men and gender-nonconforming transgender people.

Often, the problems facing transgender people compound and end up heightening risk for HIV acquisition. Transgender people are much more likely to acquire HIV if they:

• Have been sexually assaulted because of their gender identity.
• Do not have a high school diploma.
• Have incomes below $10,000 a year.
• Are unemployed due to gender bias.

The reality is that nothing is more harmful to transgender people’s health than cisgender people’s opinions and treatment of them. The world is built for cisgender people to navigate; if institutions and governments changed their business-as-usual to be more helpful toward trans people, then we might see some progress in these high HIV numbers.

That would include programs to decrease violence against transgender people; law enforcement sensitivity training; training for school officials; enacting gender-affirming policies in correctional, education, and medical facilities; laws prohibiting discrimination against transgender people; and making HIV testing a norm for all people.

Improving medical and mental health care for transgender people similarly includes training providers to improve their attitudes toward trans patients; making gender-affirming, knowledgeable, and sensitive care the norm; making transgender-sensitive substance and alcohol abuse programs more widely available; and making sure HIV care providers are also knowledgeable on hormone replacement therapy.

HIV Among Bisexual People in the U.S.

Despite making up the largest part of the LGBTQ community, bisexual people continue to be erased in many ways. And, as we’ve discussed above, invisibility and erasure often lead to worse health outcomes.

The CDC does not include data specific to bisexuals in its HIV data. Although men, women, and people of all genders can identify as bisexual, data about sexual HIV transmission is often recorded as either “heterosexual” or ”male to male,” even if one or both people involved in the transmission are bisexual. Because data is aggregated by mode of transmission and not a person’s identity, bisexual people are often unseen within HIV data.

Bisexual people are much less likely than gay men or lesbians to disclose their sexual orientation to their sexual health care providers—not because they don’t want to, but because they often feel like their sexuality is misunderstood or because providers may assume that they are either exclusively straight or exclusively gay. One 2013 study found that 39% of bisexual men and 33% of bisexual women did not disclose their bisexuality to their health care provider, compared to only 13% of lesbians and 10% of gay men.

Along with creating barriers to health care, biphobia among the general population can often lead to compromised sexual health for bisexual people, as well.

• Biphobia has led to bisexual men being less likely to come out and get tested for HIV.
• Bisexual women have lower rates of human papillomavirus (HPV) screening, while bisexual men have higher rates of HPV, which can lead to anal cancer.
• Bisexual women combine substance and alcohol abuse with sexual activity more frequently than gay or straight women.

How Mental Health Issues Can Worsen HIV Among Bisexual People

Bisexual people often also have worse mental health outcomes, often as a result of biphobia and bisexual erasure. For instance, many bisexual people deal with being told that their sexuality is either nonexistent or invalid. This includes being told that bisexuals are greedy, confused, or sexually promiscuous.

Bisexual people have a number of measurably worse mental health outcomes than their straight and gay counterparts—each of which can lead to increased HIV risk and poorer health while living with HIV.

• Bisexual adults have double the rates of depression than straight adults.
• Bisexual adults are more likely to engage in self-harm than straight people, lesbians, or gay men.
• Bisexual women have worse mental health outcomes than both lesbians and straight women, including higher rates of emotional stress, double the rate of eating disorders as lesbian women, higher rates of drug use than straight women, and higher rates of alcohol use and abuse than other women.
• Bisexual women who are not out about their sexuality reported higher rates of suicidal ideation than straight women.
• Bisexual women have less social support and a lower quality of life than straight and gay women.
• Bisexual adults are three times more likely to report suicidal thoughts than straight adults.
• Bisexual youth are less likely than lesbian and gay youth to report having a supportive adult they can turn to if they’re sad.
• Only 5% of bisexual youth report being very happy, compared to 8% of lesbian and gay youth and 21% of non-LGBT youth.
• Bisexual youth are twice as likely as non-LGBTQ youth to experiment with drugs and alcohol.

HIV Risk and Health Factors Shared by All LGBTQ People

LGBTQ people experience intimate partner violence, just as people in straight relationships do. And, as in any relationship, violence is tied to a heightened risk of contracting HIV and other sexually transmitted infections (STIs), specifically because partners who are living in a violent relationship are often unable to negotiate terms of sexual encounters, including if and how protection is used.

In a 2006 survey of LGBTQ people in abusive relationships, 41% of respondents said they had been forced by their partners to have sex, while 28% said they were scared to ask their abusive partners to use protection during intercourse. Several participants reported sexual (19%), physical (21%), and vocal (32%) abuse after asking a partner to use protection.

Our cultural understanding of domestic violence is often exclusively in male-female relationships, with men abusing women. However, LGBTQ people can experience unhealthy power dynamics in their relationships as well. Researchers have found that gay and bisexual men who are survivors of domestic violence often exhibit similar outcomes to women who experience domestic violence, including having lower incomes, being unemployed, experiencing depression, and using substances.

How Homelessness Among LGBTQ People Ties in to HIV

Homelessness is a major risk factor for acquiring HIV. People who experience homelessness are not only at a much higher risk for acquiring HIV, they are also much less likely to receive HIV medical treatment, and they have worse health outcomes than people with HIV who have housing.

Unfortunately, LGBTQ people—especially LGBTQ youth—are much more likely to experience homelessness than the general population. LGBTQ youth are 120% more likely to experience homelessness than their cisgender, straight counterparts. And though LGBTQ people do not comprise 40% of the population, LGBTQ youth comprise 40% of all homeless youth.

LGBTQ homeless youth experience many other hardships that are considered risk factors for acquiring HIV, including poor mental health, minority stress, substance use, unprotected sex, and survival sex.

Within the LGBTQ youth population, a person’s identity can affect how they experience homelessness and the factors that lead to homelessness. For instance:

• Gay and lesbian homeless youth between 16 and 20 years old are more likely to report a history of sexual abuse than bisexual youth.
• Lesbian homeless youth are more likely to report being physically abused by caretakers than straight female youth.
• Lesbian, gay, and bisexual runaways are all more likely to have been sexually abused by caretakers than straight homeless youth.
• Among homeless LGBTQ youth, 35% of girls and 65% of boys report a history of violence.
• Among queer young men, family violence and stranger violence are more common than partner violence, while partner violence and stranger violence are more common among young queer women.

Homelessness among young gay and bisexual men (aged 17 to 28) has been connected with a greater lifetime risk for HIV—meaning the risk extends much longer than their period of homelessness. Young gay and bisexual men who run away from home engage in oral and anal sex on average one year younger than non-runaway young gay and bisexual men. They are also more likely to experience forced sexual contact, get diagnosed with an STI, and use drugs, including injection drugs.

Within this very vulnerable group, homeless transgender youth may be the most vulnerable. Transgender youth face higher victimization rates in school than cisgender gay, lesbian, or bisexual youth. Trans youth often also face humiliation at homeless shelters, as well as physical and sexual victimization. Often, transgender youth are forced to stay in quarters that reflect their gender assigned at birth rather than their gender identity, if they are welcome in shelters at all.

Mental Health: A Major Issue Affecting HIV in LGBTQ Communities

LGBTQ people are disproportionately at risk for a variety of mental health issues, including major depression, bipolar disorder, and generalized anxiety disorder. These issues can lead to detrimental outcomes, like drug use, suicide—and, of course, HIV.

Poor LGBTQ mental health comes from a myriad of factors. Some are societal, including the stigma and shame associated in some communities with having a queer or transgender identity. Others are interpersonal, like the need to stay in the closet or the fear of being outed. Often, queer and transgender children are told that they are not “good” at performing their assigned gender, which can lead them to internalize a sense of failure early in their lives.

Most of the research studying LGBTQ people and mental health centers around gay and bisexual men. Researchers tend to consider mental illness and HIV to be a syndemic in gay and bisexual men, meaning they intertwine with one another—each epidemic perpetuates the other. Depression, trauma, and substance use are all linked to HIV acquisition risk in different ways.

In addition, as with so many other health disparities in the U.S., racism worsens the impact of mental health issues on people living with (or at risk for) HIV.

While people of any race in the queer community can experience poor mental health outcomes, structural racism often accounts for poorer mental health outcomes among gay and bisexual men of color. Even though there is no difference in HIV risk behaviors between gay and bisexual men who are white and gay and bisexual men of color, the HIV rate among gay and bisexual men of color is much higher.

One reason behind the discrepancy is the double-minority status of being both a person of color and queer. This stress has been associated with risk factors for contracting HIV, including sex without condoms and a history of STIs. Research has shown that, among a group of gay and bisexual men of color, racism they’ve experienced within their LGBTQ community—as well as homophobia from their heterosexual friend networks—can lead to depression and anxiety.

There are further differences in experience among different racial groups. For instance, one study found that that gay and bisexual Latinx men are more likely than other racial groups to report condomless receptive anal sex with a casual partner as a response to both homophobia and racism. Meanwhile, “gender role strain,” or the pressure of conforming to culturally appropriate ideas of masculinity, has put Black gay and bisexual men at greater risk for psychological distress and sexual risk when compared to white gay and bisexual men.

Racial and ethnic disparities don’t only account for differences in HIV risk among groups of gay and bisexual men; they also account for worse health outcomes among men of color who are diagnosed with HIV. Of course, these gaps are also due to different levels of access to medical and mental health care, among many other ways in which America’s systems consciously and unconsciously discriminate against people of color.