Although transgender people -- especially trans women of color -- have among the higher rates of HIV infection, this population has not been adequately studied. Many HIV prevention studies have miscategorized transgender women as men who have sex with men, and there has been little specific research on HIV among trans men.
One meta-analysis of 29 studies published in 2008 found that 28% of transgender women in the U.S. were living with HIV, with a large proportion not knowing their status. A more recent worldwide meta-analysis showed that transgender women were nearly 50 times more likely to be HIV-positive than non-transgender (cisgender) people.
However, HIV prevention and services for transgender women and men were the focus of several presentations at the 2015 National HIV Prevention Conference (NHPC), which took place from Dec. 6 to Dec. 9 in Atlanta, Georgia. In addition, the upcoming Conference on Retroviruses and Opportunistic Infections (CROI) will feature a plenary session on transgender people -- a first for this research conference focused on HIV/AIDS and related infectious diseases.
HIV Prevention Programs for Transgender People
One NHPC session looked at studies of transgender people who receive services funded by the Centers for Disease Control and Prevention (CDC).
Mesfin Mulatu from the CDC's Program Evaluation Branch presented findings from a study of HIV testing, seropositivity rates and linkage to care among transgender people at CDC-funded testing sites in the U.S. between 2012 and 2013.
Despite their high HIV risk, barriers including stigma, discrimination, violence, poverty, unstable housing, substance use and mental health issues may prevent transgender people from accessing HIV prevention services, and there is a shortage of trans-specific or gender-affirming programs, Mulatu noted.
In this study, as well as several others presented in the same session, using a "two-step" method of asking about gender -- gender assigned at birth plus current gender -- identified far more transgender people than asking only one of these questions.
Traditional "one-step" data collection approaches can make it difficult to accurately identify trans people. Many researchers categorize study participants according to either their current gender identity (often requiring participants to choose from limited options) or their assigned sex at birth -- both of which can result in misclassification.
For example, the international iPrEx trial of tenofovir/emtricitabine (Truvada) pre-exposure prophylaxis -- better known as PrEP -- included male-to-female transgender people in its population of 2,499 "men who have sex with men."
The initial published iPrEx report said the study included just 29 trans women. But a later analysis led by Madeline Deutsch from the UCSF Center of Excellence for Transgender Health used a broader definition -- including male-assigned people who identified as women, trans or "travesti" and those who identified as men but used feminizing hormones -- that brought the number up to 339.
Mulatu's team analyzed HIV testing data reported by 61 local and state health departments in 2012 and 2013, covering 5.2 million test events that included valid information on sex at birth and current gender.
Two-Step Approach Reveals High Seropositivity in Trans Women
Most of the tested population were cisgender men and women. Using the one-step approach, 10,201 participants (0.2%) identified as transgender women or male-to-female, 1,769 (0.03%) identified as transgender men or female-to-male and 515 (0.01%) identified as unspecified transgender or other.
Using the two-step approach, the researchers found that 5,363 people (0.1%) who identified as women had been assigned male at birth, while 3,244 people (0.06%) who identified as men had been assigned female. This brought the total number of transgender participants up from 12,485 to 21,092 -- a 69% increase.
The study found that 443 self-identified trans women, 11 self-identified trans men and 5 unspecified/other transgender participants tested HIV-positive, as did 76 women assigned male and 16 men assigned female at birth. Using the two-step approach increased the total number of trans people testing positive from 459 to 551 -- a gain of 20%.
Among the transgender participants who tested HIV-positive, most (80.4%) were self-identified trans women. This group also had the highest likelihood of testing positive, at 4.3%, followed by male-assigned people who identified as unspecified/other (1.6%) and women assigned male (1.4%). Self-identified trans men and men assigned female had lower rates (0.6% and 0.5%, respectively).
Looking at HIV risk factors, just over 75% of self-identified trans women and people assigned male who identified as women or unspecified/other reported having sex without condoms -- similar to the rates for cisgender men and women. Self-identified trans men were less likely to have condomless sex (64.5%) but more likely to report injection drug use (10.1%). Drug injection varied across the other subgroups, from 3.0% among women assigned male to 7.3% among self-identified trans women.
Just over 70% of transgender participants who tested HIV positive were linked to care, with no significant differences across subgroups, which was close to the linkage rates for cisgender men (73.9%) and women (72.8%).
"The two-step approach improves data collection on transgender persons receiving HIV testing services" and "improves accuracy and avoids potential misclassification," the researchers concluded.
The study also revealed significant differences in HIV testing, prevalence and behavioral risk factors across gender groups, including unexpected differences between self-identified trans women and women assigned male at birth.
Risk Reduction Interventions and Partner Services
Hui Zhang, also from the Program Evaluation Branch, presented findings from a study of transgender people enrolled in CDC-funded behavioral risk-reduction evidence-based interventions (EBIs) implemented by 48 state and local health departments during 2012-2013.
Out of a total of 179,045 clients, the one-step approach found 3,537 people who self-identified as trans women, trans men or unspecified/other. But using the two-step approach identified an additional 297 women assigned male at birth and 185 men assigned female at birth -- a 14% gain.
Overall, transgender people represented 2.2% of all EBI clients, most of whom were self-identified trans women (81.9%) followed by women assigned male (7.4%). Interestingly, there were about equal proportions of self-identified trans men and men assigned female at birth (4.2% and 4.6%, respectively).
Self-identified trans women were the most likely to report being HIV-positive (40%) while self-identified trans men were the least likely (6%), with women assigned male and men assigned female falling in between at about 33%.
Trans women were older, on average, than trans men, who were mostly in their twenties. Self-identified trans women were more likely than the other transgender subgroups to be African-American or Latino. Trans women were more likely to live in the West or Northeast, while there were a larger proportion of trans men in the South. As in Mulatu's study, trans men were more likely than trans women to have history of injection drug use (25% versus 15%).
Transgender people were most likely to be enrolled in "locally developed or homegrown interventions," but the researchers acknowledged that they did not know what these programs entailed or whether they targeted trans communities. The well-established SISTA intervention encouraging condom use among African-American women and the VOICES/VOCES intervention for African-American and Latino men enrolled 6.8% and 3.2% of the trans participants, respectively.
Wei Song's team described transgender people who used partner services programs implemented by 55 state and local health departments during 2012-2013.
Out of 31,305 total index clients and 14,914 partners, the two-step approach identified 515 participants (1.1%) as transgender -- 30% more than the one-step method. Again, most (71.4%) were self-identified trans women, followed by women assigned male at birth (14.9%), men assigned female (8.0%) and self-identified trans men (2.1%).
Self-identified trans women were more likely to be black or Latino and live in the Northeast, while the women assigned male and men assigned female were more likely to live in the South or West. Overall, 56.2% of transgender people reported sex without condoms and 6.8% reported injection drug use, but unlike the previous studies there were no notable differences across subgroups.
"These transgender subgroup variations imply the need to tailor partner service programs and for further studies to examine the underlying social and structural factors responsible for the disparities," the researchers concluded.
HIV Testing for Young Trans People of Color
Finally, Ekaterine Shapatava presented findings from as assessment of six CDC-funded community-based organizations (CBOs) offering HIV prevention services for young transgender people of color and their partners in Baltimore, Detroit, Oakland, New York City and Washington, D.C. The program aimed to increase the number of young trans people with HIV who are aware of their status and linked to medical care, treatment and prevention services.
Over the first three years of the five-year program, the number of young trans people getting tested increased from 530 during the first year to 748 during the third year. However, even as the number of tests rose, the number of people diagnosed with HIV declined -- from 5.1% and 7.6% during the first two years to just 0.9% during year three. Results varied across CBOs, however, and one agency conducted nearly 400 tests but did not find anyone HIV-positive. The researchers said this underlines the need to better target HIV testing to reach young trans people who are most likely to be positive.
All CBOs were able to meet the goal of linking at least 70% of HIV-positive participants to HIV medical care during all three years, and 100% of newly diagnosed participants were linked to care during year three.
The research team identified factors that characterize successful programs, including well-trained and culturally sensitive staff, non-traditional hours, ability to serve low-income and uninsured clients, and providing a "one-stop shop" offering HIV testing along with a broad range of other services, potentially including hormone prescription.
PrEP Resources for Trans Women and Men
Other NHPC sessions focused on related research, including a panel looking at studies of social determinants that drive poor HIV health outcomes among transgender and gender variant people, an overview of HIV prevention and care "best practices" for trans women of color, and a discussion of trans women and PrEP.
Although no randomized studies have looked specifically at PrEP for transgender women or men, Deutsch's iPrEx analysis found that trans women who had blood drug levels indicating consistent tenofovir/emtricitabine use appeared to be protected. Trans women, however, had lower drug levels on average, showing they were less likely to take tenofovir/emtricitabine on a daily basis than gay men, possibly in part due to uncertainty about how it might interact with gender-affirming hormones.
Project Inform and Outshine NW recently released a new information booklet about PrEP for transgender women entitled "Transcending Barriers for Safer Pleasure" -- the first major PrEP resource by and for the transgender community. The agencies also worked together to update Project Inform's existing booklet for gay and bisexual men -- "Is Taking PrEP the Right Choice for You?" -- to be more inclusive of transgender men who have sex with men. These and all of Project Inform's PrEP education materials are available online and hard copies can be ordered at www.projectinform.org/prep.
National HIV Prevention Conference Abstracts
The following NHPC abstracts are referenced in the above article:
Ekaterine Shapatava, Adanze Eke, Renata Ellington, Gary Uhl. Assessment of Six Community-Based Organizations' Efforts in Preventing HIV among Young Transgender Communities of Color. Abstract 1422.
Mesfin Mulatu, Guoshen Wang, Hui Zhang, Wei Song, Choi Wan, John Gilford. HIV Testing, Seropositivity, and Linkage to Care among Transgender Persons in CDC-Funded Testing Sites in the United States, 2012-2013. Abstract 1559.
Wei Song, Mesfin Mulatu, Hui Zhang, Michele Rorie, Guoshen Wang, Choi Wan, John Gilford. Transgender Persons Served in Partner Services Programs Implemented by State and Local Health Departments in the United States, 2012-2013. Abstract 1627.
Hui Zhang, Mesfin Mulatu, Wei Song, Goshen Wang, Choi Wan, John Gilford, Benny Ferro. Transgender Persons Enrolled in CDC- Funded Risk-Reduction Behavioral Intervention Implemented by State and Local Health Departments in the United States, 2012-2013. Abstract ID 1754.
Liz Highleyman is a San Francisco-based health journalist who has covered HIV and viral hepatitis for more than 20 years. She is editor of HIVandHepatitis.com and has written for publications including POZ, BETA, Aidsmap, Positively Aware and the Bay Area Reporter_. She attended Harvard School of Public Health and has worked with ACT UP/Boston and other HIV advocacy groups._