A new systematic review conducted by researchers at the Centers for Disease Control and Prevention (CDC) estimates that 14% of trans women and 3% of trans men are living with HIV. The estimate in trans women is lower than previous calculations, but the new estimates still show that transgender people are a vulnerable population with a substantial risk of contracting HIV.
There are approximately one million individuals in the United States who identify as transgender. Previous estimates had suggested that between 25% and 28% of transgender women in the U.S. were living with HIV. CDC researchers wanted to update these estimates, examine differences in HIV prevalence between trans women and trans men, and understand the behavioral factors that impact risk of contracting HIV. To do this, they reviewed 88 studies published between 2006 and 2017. Most of these studies included a majority of non-white participants.
According to the review, the laboratory-confirmed HIV prevalence rate among transgender people is 9.2% overall, and it is significantly higher among trans women (14.2%) than trans men (3.2%). Black trans women had the highest prevalence estimate (44.2%) compared with Hispanic trans women (25.8%), white trans women (6.7%), and trans women of other races or ethnicities (9.8%). Interestingly, the self-reported rates of HIV were different from the laboratory-confirmed rates, with 21% of trans women and just 1.2% of trans men reporting being HIV-positive.
The authors explain that while their estimates are lower than those in past research, this does not necessarily mean that HIV prevalence is actually decreasing among transgender women. Instead, it is likely that newer studies include participants from more diverse locations and backgrounds rather than over-representing populations such as sex workers or people in prison, who are at higher risk for HIV than the overall transgender population.
The review also looked at risk factors known to contribute to higher HIV rates. It found that 31% of transgender people reported participating in sex work (defined as trading sex for money or goods). Again, trans women were much more likely to report this (38%) than trans men (13%). There were no major differences, however, between trans women and men when it came to other risk factors, including having condomless vaginal or anal sexual intercourse (38% compared with 25%), having sex while drunk or high (37% compared with 32%), having multiple sex partners (42% compared with 43%), or having sex with an HIV-positive partner or a partner with unknown HIV status (20% for both).
Understanding behavioral risk factors is key to helping prevent HIV among the transgender population, and this study is the first to look separately at both trans women and men. While trans women were more likely to report sex work and condomless sex, other behavioral factors were mostly equal. The researchers note that trans men have been considered at lower risk -- likely because their sexual partners are often cisgender women -- and are, therefore, understudied. These results, however, suggest that trans men remain at risk for HIV and that more research is needed.
In looking at other factors, the review found that 44% of trans women and 54% of trans men reported depression, and that 25% of all transgender individuals in the reviewed studies reported suicide attempts. Approximately half of the participants (48%) also reported a history of mental or physical abuse, and 40% reported sexual abuse. In addition, almost half (48%) reported experiencing gender-based discrimination, and 30% of participants said they had experienced homelessness or unstable housing. Trans women have additional burdens, with 43% reporting a history of incarceration and only 39% reporting being employed full- or part-time (compared with 57% of trans men).
Understanding HIV risk within the context of the lived experiences of transgender people is an important step toward creating successful interventions. These results show that stigma is still a big problem for transgender people, and the authors suggest that anti-discrimination laws in housing and employment as well as more generalized anti-stigma campaigns could help reduce overall HIV rates among transgender people.
Despite calculating lower HIV rates than previously thought, this study shows that the transgender community remains at disproportionate risk for HIV and highlights the need for public health programs that are tailored specifically for transgender women and men.
Martha Kempner is a freelance writer, consultant, and sexual health expert.