HIV among Transgender People
Transgender communities in the United States
(US) are among the groups at highest risk for HIV infection. The term gender identity
refers to a person’s basic sense of self, of identifying as male, female, or some
other gender (e.g., transgender, bigender, intersex). Transgender refers to people
whose gender identity does not conform to norms and expectations traditionally associated
with a binary classification of gender based on external genitalia, or, more simply,
their sex assigned at birth. It includes people who self-identify as gender variant;
male-to-female (MtF) or transgender women; female-to-male (FtM) or transgender men;
many other gender nonconforming people with identities beyond the gender binary;
and people who self-identify simply as female or male. Gender identity, gender expression,
and sexual orientation are separate, distinct concepts, none of which is necessarily
linked to one’s genital anatomy.
Because surveillance data for this population are not uniformly collected, information
is lacking on how many transgender people in the US are infected with HIV. However,
data collected by local health departments and scientists studying transgender people
show high HIV positivity.
- Data from CDC-funded HIV testing programs show high percentages of newly identified
HIV infections among transgender people. In 2009, about 4,100 of 2.6 million HIV
testing events were conducted with someone who identified as transgender. Newly
identified HIV infection was 2.6% among transgender persons compared with 0.9% for
males and 0.3% for females. Among transgender persons, the highest percentage of
newly identified HIV infection was among blacks (4.4%) and Hispanics (2.5%). More
than half (52%) of testing events with transgender persons occurred in non-clinical
- In New York City, from 2005–2009, there were 206 new diagnoses of HIV infection
among transgender people, 95% of which were among transgender women. Approximately
90% of MtF and FtM people newly diagnosed with HIV infection were black or Hispanic.
Newly diagnosed transgender people were more likely to have been in their teens
or twenties than their non-transgender counterparts. Also, among newly diagnosed
people, 50% 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. Studies also indicate that black transgender women are more likely
to become newly infected with HIV.
Many cultural, socioeconomic, and healthrelated factors contribute to the HIV epidemic
and prevention challenges in US transgender communities.
- Identifying transgender people can be challenging. Using gender alone is
not enough because some people in this community do not self-identify as transgender.
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 as there is great diversity
in orientation and behavior among this population, and some identify as both transgender
and gay, bisexual, or lesbian. 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
- High levels of HIV risk behaviors have been reported among transgender people.
HIV infection among transgender women is associated with having multiple sex partners
and unprotected receptive or insertive anal intercourse.
- Additionally, many transgender women reported high levels of alcohol and substance
use. These substances can affect judgment and lead to unsafe sexual practices, which
can increase HIV risk.
- The few studies examining HIV risk behaviors among transgender men suggest some
have multiple male sex partners and engage in unprotected receptive anal or vaginal
intercourse with men; however, no studies have reported links between these behaviors
and HIV infection among transgender men. Nonetheless, these are established HIV
risk behaviors in other populations.
- 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 MSM or heterosexual women to live in transient housing and
have completed fewer years of education. Discrimination may help explain why transgender
people who experience significant economic difficulties often pursue high-risk activities,
including commercial sex work, to meet their basic survival needs. Social stigma
also may explain why some transgender people engage in unprotected receptive intercourse
with their sex partners. Qualitative data suggest that some transgender people who
fear sex partner rejection or need their gender affirmed through sex may engage
in unprotected receptive intercourse. High rates of depression, emotional distress,
loneliness, and social isolation have been linked to suicidal thoughts and suicide
attempts by transgender people. Therefore, interventions that address multiple cooccurring,
syndemic 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-positive
transgender women were 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, generally involving relatively small samples comprised entirely
or primarily of transgender women. Most have shown at least modest reductions in
HIV risk behaviors, such as fewer sex partners and/or reducing unprotected anal
sex acts, although none have involved a control group.
Information published courtesy of CDC.GOV.
This article was last modified in: 06/18/2012