Why transgender women are at higher risk for HIV

Factors that increase HIV risk for transgender women

Why is the risk so high for trans women?

“When we think about risk factors, we often think about risk at the individual level,” he said Asa Radix, MD, Ph.D., MPHsenior director of research and education at Callen-Lorde Community Health Center in New York, a clinical professor at NYU Langone and a clinical ambassador for the CDC. “I think it’s really important to redefine it a little bit when we talk about HIV because it’s often related to structural issues, not just individual-level issues.”

Structural disparities is when policies prevent certain groups of people from having equal access to resources. The statistics are overwhelming when it comes to the effects of these disparities on the transgender community in the US:

• Almost 3 in 10 trans women they live in povertymaking less than $14,000 a year
• 3 in 10 transgender people say they have experienced homelessness during their lifetime
• Almost half transgender people have been sexually assaulted, according to the National Sexual Violence Resource Center.
• More than 1 in 4 transgender people have lost their job due to bias, according to the National Center for Transgender Equalityand 3 in 4 say they have experienced discrimination in the workplace.

The impact of these structural issues is even greater among blacks and Hispanics. A CDC study from seven US cities found that 62% of black trans women and 35% of Hispanic/Latina trans women surveyed had HIV—compared to 17% of white trans women.

“If you think about all these social determinants of health, it’s very clear that if you’re homeless with no education, no job opportunities, or a home to live in, your risk for HIV is going to increase,” Radix said.

Read: Social Determinants of Health, Health Inequalities and Health Equity >>

With fewer options for work, Radix explained, trans women may turn to sex work to make ends meet, skyrocketing their risk of HIV exposure. A study published in 2023 found that 41.8% of transgender women reported engaging in sex work, saying they were motivated to do it for “better pay” and that they could not “find work due to gender discrimination.”

In addition to structural inequalities, trans 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 relieve their anxiety and depression by engaging in risky behaviors, such as injecting drugs or sharing needles. All of these challenges alone can lead to worse health outcomes, and when individual-level and structural inequalities combine, the negative effects are compounded.

Access to health care is key to HIV prevention

With these higher risk factors, access to healthcare is extremely important. But 24 states currently limit gender-affirming care in some way, legislators at least 10 states propose restricting transgender access to public services, and it is legal in many states for health care providers to refuse to treat LGBTQ patients. All of this makes it difficult for transgender people to find health care providers (HCPs) with whom they can have an open and honest dialogue—or even to disclose that they are transgender in the first place.

The 2022 US Trans Survey found that nearly 1 in 4 respondents from the transgender community did not see a doctor when needed in the year before the survey because they feared they would be mistreated. And of those who did see doctors, nearly half reported having a bad experience because they were transgender, including being denied health care, misgendered, or verbally or physically abused 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 medication that reduces the risk of contracting HIV from sex by 99%. And it reduces HIV from needlestick exposure by 74%. But to be effective, it must be taken consistently. PrEP is only available with a prescription from an HCP. In a yet-to-be-published study by Radix, preliminary findings show that less than 15% of transgender women are currently on PrEP. For trans men, the number drops to less than 6%.

“Lack of access to health care — which might be lack of insurance because they didn’t have a job or they’re uncomfortable walking into a provider’s office — means you don’t have that access to PrEP,” Radix said. “We know that PrEP is probably the most important intervention to reduce HIV, but we’re not at a place right now where you can just walk into a store and take PrEP off the shelf.”

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

Watch: No HIV for Me: Protect Yourself from HIV with PrEP and PEP >>

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

While there has been an abundance of studies looking at the LGBTQ community and HIV as a whole, they often present an incomplete picture due to missing data or misconceptions about sex, gender, and identity.

In their clinic, for example, Radix says it found an HIV prevalence of 2.8% among male subjects. But when they looked specifically at trans men who have sex with cisgender men, the HIV infection rate jumped to 11 percent.