Transgender is an umbrella term for persons whose gender identity or expression (masculine, feminine, other) is different from their sex (male, female) at birth. Gender identity refers to one’s internal understanding of one’s own gender, or the gender with which a person identifies. Gender expression is a term used to describe people’s outward presentation of their gender.
Because data for transgender people are not uniformly collected, information is lacking on how many transgender people in the United States are infected with HIV. However, data collected by local health departments and scientists studying these communities show high levels of HIV and racial/ethnic disparities.
- In 2013, a meta-analysis (Baral et al.) reported that the estimated HIV prevalence among transgender women was 22% in five high-income countries, including the United States.
- Findings from a systematic review (Herbst et al.) of 29 published studies showed that 28% of transgender women had HIV infection (4 studies), while 12% of transgender women self-reported having HIV (18 studies). This discrepancy suggests many transgender women living with HIV don’t know their HIV status.
- In the systematic review, black/African American transgender women were most likely to test HIV positive, compared to those of other races/ethnicities: 56% of black/African American transgender women had positive HIV test results compared to 17% of white or 16% of Hispanic/Latina transgender women.
- Among the 3.3 million HIV testing eventsa reported to CDC in 2013, the highest percentages of newly identified HIV-positive persons were among transgender persons.
- Although HIV prevalence among transgender men is relatively low (0-3%), a 2011 study (Rowniak et al.) suggests that transgender men who have sex with men are at substantial risk for acquiring HIV.
Individual behaviors alone do not account for the disparate HIV diagnoses among transgender people. Many cultural, socioeconomic, and health-related factors contribute to these diagnoses and prevention challenges in transgender communities.
Sexual behaviors and factors that may contribute to the high risk of HIV infection among transgender people include receptive anal sex without a condom or medicines to prevent HIV, a high prevalence of HIV in sexual networks, sex with multiple partners, and exchanging sex for drugs or money.
Other factors that contribute to high rates of HIV among transgender people include drug and alcohol abuse, mental health disorders, incarceration, homelessness, unemployment, lack of familial support, violence, stigma, discrimination, limited health care access, and negative health care encounters.
Many transgender people face social rejection and marginalization that excludes them from participating and functioning in society. Lack of legal recognition of gender identity can result in the denial of educational, employment, and housing opportunities. Some transgender people who experience poverty rely on sex work to meet their basic survival needs.
Insensitivity to transgender identity can be a barrier for those who are diagnosed with HIV and seek quality treatment and care services. Research shows transgender women with diagnosed HIV infection are less likely to be on antiretroviral therapy (ART) or achieve viral suppression. Furthermore, few health care providers receive adequate training or are knowledgeable about transgender health issues and their unique needs.
Transgender-specific data are limited. Currently, many federal, state, and local agencies inaccurately collect data about individuals’ sex and gender. Using the two-step data collection method of asking for sex assigned at birth and current gender identity can help to increase the likelihood that transgender people will be accurately identified in HIV surveillance programs.
Behavioral HIV prevention interventions developed for other at-risk groups with similar behaviors have been adapted for use with transgender people; however, their effectiveness is still unknown. There is a need for effective interventions that address the multiple co-occurring public health problems in transgender persons.
Transgender men’s sexual health has been understudied. Additional research is needed to understand HIV risk behavior among transgender men, especially those who have sex with men.
What CDC Is Doing
CDC and its partners are pursuing a high-impact prevention approach to achieve the goals of the National HIV/AIDS Strategy: Updated to 2020 and maximize the effectiveness of current HIV prevention methods among transgender people. Activities include:
- Funding community-based organizations (CBOs) to enhance their capacities to increase HIV testing, link transgender persons with diagnosed HIV infection to medical care, increase referrals to partner services, and provide prevention and support services for transgender persons at risk for or diagnosed with HIV.
- Supporting health department demonstration projects that provide pre-exposure prophylaxis (PrEP) support services and data-to-care activities prioritizing gay and bisexual men and transgender persons at substantial risk for acquiring HIV, particularly persons of color.
- Providing support and technical assistance to providers that help CBOs enhance structural interventions for transgender people (e.g., condom distribution, community mobilization, HIV testing, and coordinated referral networks and service integration).
- Developing Act Against AIDS communication materials to reach transgender people, including campaigns such as:
- Doing It, which encourages all adults to get tested for HIV and know their status, and includes images and testimonial videos featuring transgender leaders.
- Let’s Stop HIV Together, which raises awareness about HIV and fights stigma, and includes the stories of transgender women.
- HIV Treatment Works, which encourages people living with HIV to stay in care, and features a transgender woman’s story of staying healthy while living with HIV.
- Through its Capacity Building Assistance initiative, CDC is working with the Center of Excellence for Transgender Health to support National Transgender HIV Testing Day. This day recognizes the importance of routine HIV testing, status awareness, and continued focus on HIV prevention and treatment efforts among transgender people.
a An HIV testing event is one or more HIV tests performed with a person to determine that person’s HIV status. During one testing event, a person may be tested once or multiple times.
For more information, visit CDC’s Lesbian, Gay, Bisexual, and Transgender Health website.