CDC: Many factors contribute to high HIV risk for trans women

  • by Liz Highleyman, BAR Contributor
  • Wednesday February 14, 2024
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Epidemiologists Evelyn Olansky, MPH, left, and Dafna Kanny, Ph.D., were part of a team that did research on HIV risk and trans women. Photos: Olansky, courtesy AIDSVu; Kanny, CDC
Epidemiologists Evelyn Olansky, MPH, left, and Dafna Kanny, Ph.D., were part of a team that did research on HIV risk and trans women. Photos: Olansky, courtesy AIDSVu; Kanny, CDC

Several factors, including discrimination, homelessness, and violence, help explain why transgender women have a higher risk for HIV, according to a report from the federal Centers for Disease Control and Prevention.

"To accelerate health equity, leaders of health care institutions should better recognize transgender patients' health disparities and work to remediate barriers to primary and preventive care," B. Kaye Hayes and colleagues wrote in a summary for Public Health Reports. "Transgender people's health can thrive both when they are free to express who they are and when they are able to access affirming health care services."

The findings, described in seven articles in the CDC's Morbidity and Mortality Weekly Report, come from the National HIV Behavioral Surveillance Among Transgender Women project (NHBS-Trans). More than 1,600 participants in Atlanta, Los Angeles, New Orleans, New York City, Philadelphia, San Francisco, and Seattle were interviewed about their HIV risk and underwent HIV testing during 2019-2020. Nearly 90% were women of color.

The new findings confirm that transgender women — especially Black and Latina trans women — have a disproportionately high HIV rate. Among those surveyed, 42% had been diagnosed with HIV, far above the rate for gay and bisexual men. But this varied greatly by race/ethnicity: 62% of Black trans women and 35% of Latina trans women tested positive for HIV, compared with 17% of white trans women. HIV prevalence also varied by city, ranging from 21% in Seattle to 58% in Atlanta; San Francisco was in the middle, at 41%.

HIV care indicators were promising, but respondents had more trouble accessing gender-related care. A majority of trans women living with HIV (63%) received HIV care within a month after diagnosis and most (90%) were currently on antiretroviral treatment. More than 70% were taking gender-affirming hormones, while another 20% said they wanted to do so, and over half said they wanted, but had not received, gender-affirming surgery. One in five reported using non-prescription hormones, which could become increasingly common as some states restrict or ban gender-affirming care.

"Hormone treatment can cost hundreds of dollars to initiate even when insured and might come from a culturally insensitive provider. As a result, many transgender persons choose to independently obtain and administer their own hormone treatment," wrote study author Evelyn Olansky, MPH, who is trans, and her colleagues. "Even if the dangers of using nonprescription hormones are known, the dangers of stigmatizing and unsupportive experiences in health care and high medical costs might be more salient for those who desire hormonal treatment."

Among the 902 HIV-negative survey respondents, over 90% said they knew about PrEP and nearly 60% had discussed it with a health care provider, but only 32% had recently used it. PrEP use ranged from 17% in Seattle to 46% in San Francisco. Of note, Black and Latina trans women were more likely to use PrEP than white trans women — the opposite of PrEP uptake among gay and bi men. Trans women who received gender-affirming health care were more likely to discuss and use PrEP. Concern about interactions with hormones is a potential barrier to PrEP use, the research authors suggested, though studies have not found this to be a problem.

"Improving access to gender-affirming care for transgender women and training health care providers that serve transgender women to incorporate HIV prevention, including PrEP, into their services are strategies that might help increase PrEP use among transgender women," Elana Morris and co-authors wrote.

In San Francisco, the Department of Public Health's latest HIV epidemiology annual report shows that trans women accounted for 6% of people living with HIV and 3% of those newly diagnosed with HIV in 2022. More than 90% of those diagnosed in 2021 were linked to care within a month, but just 73% had achieved viral suppression within a year (compared with 89% for gay men). Among those screened for PrEP at the San Francisco AIDS Foundation, trans women were most likely to schedule an appointment and receive a prescription (76% and 55%, respectively) but least likely to still be taking PrEP three months later (9%).

Social determinants of health

Trans women who participated in the nationwide survey reported several socioeconomic factors, or social determinants of health, linked to HIV risk. Poverty, unstable housing, employment discrimination, and violence can both increase the likelihood of acquiring HIV and make it more difficult to access medical care.

Around two-thirds of respondents were living in poverty, 17% incarcerated in the last 12 months or 58% at some point in their lives, 40% said they experienced severe food insecurity, 31% had been homeless for a month or more during the past year, and 17% had no health insurance.

A large majority (70%) reported that they had experienced some type of trans-related discrimination during the past year. More than 30% said they had difficulty finding a job, 10% said they were fired because they were transgender, and 14% said they had been evicted or denied housing due to their gender identity. More than half (54%) reported gender-based verbal abuse or harassment, 27% reported physical abuse, and 15% reported sexual violence or forced sex.

These challenges had a negative effect on trans women's mental health, the survey found. More than a quarter reported recent psychological distress and 18% said they had considered suicide during the past year. Three-quarters said they had a high level of support from significant others or friends, but less than half had support from their family. More than 20% said they did not have a health care provider with whom they could discuss issues related to their gender identity.

Looking at sexual risk factors, 77% reported anal sex during the past year — and 55% reported condomless anal sex — but only 14% reported vaginal sex. Just over a third reported exchanging sex for money or drugs. Trans women who reported social disadvantages, substance use, or psychological distress were more likely to say they had condomless sex. On the other hand, injection drug use and use of non-sterile syringes to administer hormones were uncommon.

A limitation of this analysis is that the survey did not include a representative sample of transgender women in the United States. In particular, those who are employed, stably housed, and do not have other social disadvantages were likely underrepresented. A subset of participants were asked to recruit others from their community, so their social determinants of health may have been similar. A majority of trans women in the U.S. are white () (versus 11% in this survey) and the 40% HIV prevalence rate is about twice that reported in previous studies.

Nonetheless, the report underscores that trans women are at greater risk for HIV due to multiple intersecting factors.

"Data from NHBS-Trans have reaffirmed that transgender women need to be a priority population in preventing HIV infection," Dafna Kanny, Ph.D., and colleagues wrote. "The disproportionate effect of HIV infection among transgender women is the result of a complex layering of syndemics, and more remains to be understood. NHBS-Trans highlights the social and economic factors that are contributing to this disparity."

The full CDC report is available here.

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