Why Transgender Women Are at Higher Risk for HIV

Factors that increase the risk of contracting HIV in transgender women

Why is the risk so high for transgender women?

“When we think about risk factors, we often think about risk at the individual level,” he said. Asa Radix, MD, MPHSenior Director of Research and Education at Callen-Lorde Community Health Center In New York City, clinical professor at NYU Langone and CDC clinical ambassador. “I think it’s really important to reframe that a little bit when we talk about HIV because it’s often related to structural issues, not just at the individual level.”

Structural inequalities These are policies that prevent certain groups of people from having equal access to resources. The statistics are overwhelming when it comes to the results of these inequalities for the transgender community in the U.S.:

• Almost 3 in 10 trans women living in povertyearning less than $14,000 a year
• 3 in 10 trans people say they have experienced homelessness In their life
• Almost half According to the National Sexual Violence Resource Center, a total of 1,000 transgender people have been sexually assaulted.
• More than 1 in 4 trans people have lost a job due to prejudice, according to the National Center for Transgender Equalityand 3 in 4 say they have experienced discrimination in the workplace.

The impact of these structural problems is even greater on Black and Hispanic people. CDC Study A study of seven U.S. cities found that 62% of Black trans women and 35% of Hispanic/Latina trans women surveyed were HIV-positive, compared with 17% of white trans women.

“If you think about all these social determinants of health, it’s very clear that if someone is homeless, uneducated, unemployed, unhoused, their risk of contracting HIV is going to increase,” Radix said.

Read: Social determinants of health, health disparities and health equity >>

With fewer job options, Radix explained, trans women may turn to sex work to make ends meet, which increases their risk of exposure to HIV. study A study published in 2023 found that 41.8% of trans women reported engaging in sex work and said they were motivated to do so by “better pay” and not being able to “get a job due to gender discrimination.”

In addition to structural inequalities, transgender women often experience high levels of family rejection, stigma, and discrimination, which can lead to high levels of anxiety and depression. Radix explained that people may try to alleviate their anxiety and depression by engaging in risky behaviors, such as injecting drug use or needle sharing. All of these challenges can lead to worse health outcomes on their own, and when inequalities at the individual and structural levels are combined, the negative effects are compounded.

Access to healthcare is key to preventing HIV

With these higher risk factors, access to healthcare is extremely important. But 24 states They currently restrict gender-affirming attention in some ways, legislators In at least 10 states, there are proposals to restrict transgender people’s access to public services, and in several states it is legal for health care providers to They refuse to treat LGBTQ patientsAll of this makes it difficult for trans people to find health care providers with whom they can have an open and honest dialogue, or even disclose that they are trans in the first place.

The 2022 U.S. Trans Survey found that nearly 1 in 4 trans respondents did not go to a doctor when needed in the year before the survey because they feared being mistreated. And of those who did go to a doctor, nearly half reported having a bad experience because of being transgender, such as being denied medical care, being assigned the wrong gender, or being verbally or physically mistreated by a provider.

Read: What does sexual orientation have to do with it? LGBTQ people face discrimination in health care >>

Pre-exposure prophylaxis, also called PrEP, is a medication that reduces the risk of contracting HIV through sex by 99% and reduces the risk of contracting HIV through needle exposure by 74%. But for it to be effective, it must be taken consistently. PrEP is only available by prescription. In an as-yet-unpublished study that Radix is ​​working on, preliminary findings show that less than 15% of trans women are currently taking PrEP. For trans men, that number drops to less than 6%.

“Lack of access to health care — which can be due to lack of insurance from not having a job or inconvenience of going to a provider’s office — means there’s no access to PrEP,” Radix said. “We know that PrEP is probably the most important intervention to reduce HIV, but we’re not at a point where you can just walk into a store and get PrEP off the shelf.”

Even when transgender people do go to their health care provider, the burden of asking about PrEP may fall on them rather than their provider initiating the conversation, which can be another hurdle.

Watch: No HIV for me: protect yourself from HIV with PrEP and PEP >>

“Some providers are very uncomfortable asking trans people about their sexual health because they often don’t know what words to use or they make a lot of assumptions about who people’s sexual partners are,” Radix said. “We see that a lot with transmasculine people. People just assume their partners are going to be cisgender women.” [people whose gender identity matches their sex assigned at birth]They don’t think to ask them if they are having sex with someone who has a penis, which would put them at greater risk. [of HIV].”

While there have been a large number of studies looking at the LGBTQ community and HIV in general, they often present an incomplete picture due to lack of data or misconceptions about gender, sex, and identity.

At his clinic, for example, Radix claims to have found a 2.8% HIV prevalence among transgender people. But when they looked specifically at transgender men who have sex with cisgender men, the HIV infection rate rose to 11%.