Trans people are diverse, and HIV affects different sectors differently.
People who were assigned as male at birth but have a female gender identity and/or expression are at high risk of having or contracting HIV.
HIV prevalence among trans women in high-income countries such as the U.S. is around 22 percent. Trans women regardless of country wealth were some 49 times more likely to be living with HIV compared to all adults of reproductive age.
Even given this backdrop, trans women of color, especially African-Americans and Latinas, experience disproportionately high rates of HIV in the U.S. The literature suggests that racism, not just race, influences these high risks. Transphobia, homophobia, and racism appear to collectively increase risk among transgender women of color.
The Centers for Disease Control and Prevention (CDC) reports that 73 percent of trans women living with HIV are unaware of their status – leading to a higher incidence of HIV and negative health outcomes.
The higher HIV prevalence and lower HIV testing rates among trans women compared to other high-risk groups may be due to greater disparities, stigma, and discrimination across many environmental and social contexts. For example, due to lack of job opportunities for trans women, many often engage in sex work for survival. Sex work involves multiple sex partners, a factor that’s a driver for HIV. Trans women sex workers have a higher HIV prevalence than non-trans female or male sex workers.
Prevalence of unprotected receptive anal sex, the highest sexual risk behavior for transmitting HIV, can be as high as 55 percent. Differences in rates of receptive anal sex occur across ethnic groups – Asian and Pacific Islander trans people, for instance, are 3.6 times more likely to be anally penetrated than Latina trans women.
Additional high-risk behaviors include injection drug and alcohol use, inadequate negotiation skills for safer sex, and low self-efficacy in communicating sexual history with a partner. Trans women who report injection of non-prescribed hormone and “silicone” or soft tissue fillers that have compounded health risk factors.
But it’s not just behavior. Cultural, socioeconomic, and health-related cofactors compound the HIV epidemic and pose prevention challenges.
Unemployment rates, for example, are upwards of 23 percent among trans women; without the opportunity for equal pay and safe, non-discriminatory working conditions, trans women often turn to sex work as one of the only options for sustainable incomes.
The situation with HIV and trans men – people who were assigned female at birth and have a male gender identity or expression – is less clear. To date, research on HIV among trans people has almost exclusively focused on trans women. However, there is growing evidence that there is a significant group of trans men who have sex with men (TMSM) and trans men who engage in sex work.
Several areas – including Philadelphia, Washington, San Francisco, and Ontario – have conducted needs assessments that focus on trans men and HIV risk.
The few published studies that report HIV rates among samples of trans men have reported zero to three percent prevalence. These rates are self-reported, however, and are based on small, non-representative samples, so the data remains insufficient, and resources for finding out more are scanty.
For more information on the NTHTD, visit Transhealth.ucsf.edu/trans.