Transgender Women and HIV Prevention and Care
Transgender Women and HIV Prevention and Care
‘Transgender women’ is an umbrella term to refer to persons who identify as women or trans women, or who have a feminine gender identity that differs from the male sex they were assigned at birth. Transgender women may identify with certain terms and not others and may express gender in a variety of ways. Gender identity terms vary by geographic region, race, ethnicity, age, and other factors, so it is best to ask people what they prefer. Best practices for obtaining information on gender identity in the context of research and health services continue to evolve.1
Transgender Women and HIV Risk
Transgender women are at disproportionate risk for HIV; an estimated 19.1% of transgender (‘trans’) women are living with HIV, according to a meta-analysis of studies from around the world.2 Internationally, trans women have 49 times higher odds of living with HIV compared to the general adult population;3 in the US they have the highest rates of new diagnoses by gender.4 Black and Latina trans women experience an extremely high HIV burden; more than half of trans people diagnosed with HIV are Black (44%) or Hispanic/Latinx (26%).5 Intersectional stigma—oppression rooted in racism, transphobia, and misogyny6—fuels structural vulnerabilities among trans women of color7-9 and has been linked with trauma symptoms, inconsistent condom use, suboptimal PrEP and ART adherence, and detectable viral load.10-12 Like many populations, those at greatest risk are more likely to be poor, homeless, young, people of color, and engage in sex work.13,14
Not all trans women are at risk for HIV; however, stigma and discrimination faced by trans women often results in social marginalization, increasing risk of poor health outcomes.15 Social isolation and rejection by family members is common, which can lead to anxiety, depression, experiencing homelessness at a young age, and heightened risk of suicidal ideation and attempts.16,17 School-based stigma and bullying make young trans women vulnerable to dropping out and poor mental health, disrupting education and employment pathways.18-20 Sex work, recent homelessness, and school dropout are associated with incarceration, which trans women experience at higher rates than the general population.21
HIV Prevention and Care for Transgender Women
The provision of gender-affirming HIV prevention and care services is of utmost importance to serving trans women effectively.22 Trans people often report avoiding health care settings due to stigma and past negative experiences; when seeking care, they tend to prioritize gender-affirming medical care, such as hormone therapy, over HIV prevention services such as PrEP.23-25 Barriers to PrEP use among trans women include low PrEP awareness, concerns about drug interactions with hormone therapy, and low access to gender-affirming care.26-28 A 2020 national probability sample of trans people found only 3% of sexually active respondents were currently taking PrEP.29
Efficacious prevention programming prioritizing the needs of trans women has increased in the last decade, although much work remains. The first National Transgender HIV Testing Day was held on April 18, 2016. In 2018, the Health Resources and Services Administration Special Projects of National Significance Division published the Transgender Women of Color Initiative: Project Interventions Manual and then in 2019, the Centers for Disease Control and Prevention published their Toolkit for Providing HIV Prevention Services to Transgender Women of Color. Trans women experience unique barriers to prevention and care, and therefore, trans women should not be subsumed into MSM programming.30 Research consistently demonstrates that programs based in gender affirmation have the greatest impact in optimizing health outcomes for trans women.31-38
Training for healthcare providers in creating inclusive, gender-affirming clinical environments. Quality, affirming healthcare is important for trans women. Despite their sincere concern to serve patients effectively, providers may have very little knowledge, experience, skills and therefore comfort with trans patients though the availability of transgender-specific training for medical students is increasing39. UCSF Transgender Care provides free online resources for healthcare providers and other professionals for guidance on staff training, creating welcoming spaces, and data collection.
HIV Testing and Prevention. Three interventions designed for trans women have demonstrated efficacy with reducing risk and increasing HIV testing. Couples HIV Intervention Program (CHIP) is designed for trans women and their cisgender male partners as an intervention to support the couple and promote HIV testing and safe sex practices. Project Life Skills is a group-based intervention for young trans women focused on communication skills and condom negotiation. Sheroes is an intervention for adult trans women of color comprised of five weekly group sessions emphasizing healthcare empowerment and gender affirmation.40 Facilitating PrEP use among HIV prevention strategies is a developing area in services that prioritize trans women. Recent research provides emerging evidence for a trans-specific advertising campaign promoting PrEP use (PrEP4Love)41 and there is also emerging evidence for a program to increase PrEP adherence using peer navigators (A.S.K.-PrEP).42
Linkage and retention in HIV care. Transgender Women Entry and Engagement to Care Project (TWEET) is a group-based intervention to link transgender women living with HIV to care and support their engagement in care. Transgender Women Involved in Strategies for Transformation (TWIST) is a peer-led, small-group, skills-building, and educational high-impact prevention (HIP) intervention for adult trans women living with HIV. Healthy Divas combines individual sessions with a peer counselor and a group workshop with a medical provider to promote engagement in gender-affirming and HIV medical care.43-45
Unaddressed Needs of Transgender Women
To address the devastating effects of stigma and discrimination on trans people, large-scale anti-stigma campaigns, as well as anti-discrimination laws, should be implemented across the country. Structural interventions such as job training, housing, and educational programs should be widely implemented and evaluated. Ongoing capacity building and sensitivity training should be provided for healthcare workers, school officials, service providers, and researchers working with trans women. More research is needed with sexual partners of trans women, as well as programs that work with trans women and partners together as a couple.46 Finally, more research should be done with trans youth to identify and develop strategies for HIV prevention for young adults identifying as trans and gender diverse.47 Interventions and programs that leverage the inherent resilience and support networks within trans communities are also promising approaches to optimizing health outcomes among trans women.48
- Center of Excellence for Transgender Health
- Transgender Law Center
- National Center for Transgender Equality
- Transgender HIV/AIDS Services Best Practices Guidelines
- World Professional Association for Transgender Health
|Fact Sheet Date||Authors|
|September 2008 / Revised 2015||
JoAnne Keatley MSW / CAPS and Pacific AETCWalter Bockting Ph.D. / University of Minnesota
|Revised June 2021||
Beth Bourdeau, Ph.D. / Division of Prevention Science
Jae Sevelius, Ph.D. / Division of Prevention Science
Greg Rebchook, Ph.D. / Division of Prevention Science
Jenna Rapues, MPH / San Francisco Department of Public HealthNasheedah Bynes-Muhammad/ The Journey Partners LLC
Orientation and Gender Identity Questions: A Qualitative Study. Archives of sexual behavior. 2020;49(7):2301-2318.
2. Baral S, Poteat T, Stromdahl S, Wirtz A, Guadamuz T, Beyrer C. Worldwide burden of HIV in transgender women: A systematic review and meta-analysis. The Lancet Infectious Diseases. 2013;13(3):214-222.
3. Baral SD, Poteat T, Stromdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. The Lancet infectious diseases. 2013;13(3):214-222.
4. Herbst J, Jacobs E, Finlayson T, McKleroy V, Neumann M, Crepaz N. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS and Behavior. 2008;12(1):1-17.
5. Clark H, Babu AS, Wiewel EW, Opoku J, Crepaz N. Diagnosed HIV infection in transgender adults and adolescents: results from the National HIV Surveillance System, 2009–2014. AIDS and Behavior. 2017;21(9):2774-2783.
6. Bailey M, Trudy. On misogynoir: citation, erasure, and plagiarism. Feminist Media Studies. 2018:1-7.
7. Palazzolo SL, Yamanis TJ, et al. Documentation status a contexual determinent of HIV risk among young transgender Latinas. LGBT Health. 2016;3(2):132-138.
8. Fletcher JB, Kisler KA, Reback CJ. Housing status and HIVrisk behaviors among transgender women in Los Angeles. Arch Sex Behav 2014;43:1651-1661.
9. Operario D, Nemoto T. HIV in transgender communities: Syndemic dynamics and a need for multicomponent interventions. J Acquir Immune Defic Syndr. 2010;55:S91-S93.
10. Richmond KA, Burnes T, Carroll K. Lost in trans-lation: Interpreting systems of trauma for transgender clients. Traumatology. 2012;18(1):45-57.
11. Smith LR, Yore J, Triplett DP, Urada L, Nemoto T, Raj A. Impact of Sexual Violence Across the Lifespan on HIV Risk Behaviors Among Transgender Women and Cisgender People Living With HIV. J Acquir Immune Defic Syndr. 2017;75(4):408-416.
12. Wirtz AL, Poteat TC, Malik M, Glass N. Gender-Based Violence Against Transgender People in the United States: A Call for Research and Programming. Trauma Violence Abuse. 2018:1524838018757749.
13. Becasen JS, Denard CL, Mullins MM, Higa DH, Sipe TA. Estimating the Prevalence of HIV and Sexual Behaviors Among the US Transgender Population: A Systematic Review and Meta-Analysis, 2006–2017. American Journal of Public Health. 2019;109(1):e1-e8.
14. Reback CJ, Clark K, Holloway IW, Fletcher JB. Health Disparities, Risk Behaviors and Healthcare Utilization Among Transgender Women in Los Angeles County: A Comparison from 1998–1999 to 2015–2016. AIDS and behavior. 2018;22(8):2524-2533.
15. Wesp LM, Malcoe LH, Elliott A, Poteat T. Intersectionality Research for Transgender Health Justice: A Theory-Driven Conceptual Framework for Structural Analysis of Transgender Health Inequities. Transgend Health. 2019;4(1):287-296.
16. Kota KK, Salazar LF, Culbreth RE, Crosby RA, Jones J. Psychosocial mediators of perceived stigma and suicidal ideation among transgender women. BMC public health. 2020;20(1):125-125.
17. Testa RJ, Michaels MS, Bliss W, Rogers ML, Balsam KF, Joiner T. Suicidal Ideation in Transgender People: Gender Minority Stress and Interpersonal Theory Factors. Journal of abnormal psychology (1965). 2017;126(1):125-136.
18. Hereth J, Garthe RC, Garofalo R, Reisner SL, Mimiaga MJ, Kuhns LM. Examining Patterns of Interpersonal Violence, Structural and Social Exclusion, Resilience, and Arrest among Young Transgender Women. Criminal justice and behavior. 2021;48(1):54-75.
19. Leppel K. Transgender Men and Women in 2015: Employed, Unemployed, or Not in the Labor Force. Journal of homosexuality. 2021;68(2):203-229.
20. Vance SR, Jr., Boyer CB, Glidden DV, Sevelius J. Mental Health and Psychosocial Risk and Protective Factors Among Black and Latinx Transgender Youth Compared With Peers. JAMA Network Open. 2021;4(3):e213256-e213256.
21. Hughto JMW, Reisner SL, Kershaw TS, et al. A multisite, longitudinal study of risk factors for incarceration and impact on mental health and substance use among young transgender women in the USA. J Public Health (Oxf). 2019;41(1):100-109.
22. Sevelius JM, Deutsch MB, Grant R. The future of PrEP among transgender women: the critical role of gender affirmation in research and clinical practices. Journal of the International AIDS Society. 2016;19(7Suppl 6):21105.
23. Braun HM, Candelario J, Hanlon CL, et al. Transgender Women Living with HIV Frequently Take Antiretroviral Therapy and/or Feminizing Hormone Therapy Differently Than Prescribed Due to Drug–Drug Interaction Concerns. LGBT health. 2017;4(5):371-375.
24. Reisner SL, Perez-Brumer AG, McLean SA, et al. Perceived Barriers and Facilitators to Integrating HIV Prevention and Treatment with Cross-Sex Hormone Therapy for Transgender Women in Lima, Peru. AIDS and behavior. 2017;21(12):3299-3311.
25. Sevelius JM, Keatley J, Calma N, Arnold E. 'I am not a man': Trans-specific barriers and facilitators to PrEP acceptability among transgender women. Global public health. 2016;11(7-8):1060-1075.
26. Cahill SR, Keatley J, Wade Taylor S, et al. “Some of us, we don’t know where we’re going to be tomorrow.” Contextual factors affecting PrEP use and adherence among a diverse sample of transgender women in San Francisco. AIDS Care. 2020;32(5):585-593.
27. Sevelius JM, Keatley J, Calma N, Arnold E. “I am not a man”: Trans-specific barriers and facilitators to PrEP acceptability among transgender women. Global Public Health. 2016(Special issue, The Trouble with ‘Categories’: Rethinking MSM, Trans and their Equivalents in HIV Prevention and Health Promotion).
28. Poteat T, Wirtz A, Malik M, et al. A Gap Between Willingness and Uptake: Findings From Mixed Methods Research on HIV Prevention Among Black and Latina Transgender Women. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2019;82(2).
29. Sevelius JM, Poteat T, Luhur WE, Reisner SL, Meyer IH. HIV Testing and PrEP Use in a National Probability Sample of Sexually Active Transgender People in the United States. Journal of acquired immune deficiency syndromes. 2020.
30. Sevelius JM, Keatley J, Calma N, Arnold E. 'I am not a man': Trans-specific barriers and facilitators to PrEP acceptability among transgender women. 2016.
31. Lacombe-Duncan A, Newman P, Bauer G, et al. Gender-affirming healthcare experiences and medical transition among transgender women living with HIV: A mixed-methods study. Sexual health. 2019;16(4):367-376.
32. Lama J, Mayer K, Perez-Brumer A, et al. Integration of gender-affirming primary care and peer navigation with HIV prevention and treatment services to improve the health of transgender women: Protocol for a prospective longitudinal cohort study. JMIR Research Protocols. 2019;8(6):e14091.
33. Mayo-Wilson L, Benotsch E, Grigsby S, et al. Combined effects of gender affirmation and economic hardship on vulnerability to HIV: A qualitative analysis among US adult transgender women. BMC PUBLIC HEALTH. 2020;20(1):782-717.
34. Reisner S, Bradford J, Hopwood R, et al. Comprehensive transgender healthcare: The gender affirming clinical and public health model of Fenway Health. Journal of Urban Health. 2015;92(3):584-592.
35. Reisner SL, White Hughto JM, Pardee D, Sevelius J. Syndemics and gender affirmation: HIV sexual risk in female-to-male trans masculine adults reporting sexual contact with cisgender males. International journal of STD & AIDS. 2016;27(11):955-966.
36. Sevelius J. Gender affirmation: A framework for conceptualizing risk behavior among transgender women of color. Sex Roles. 2013;68(11-12):675-689.
37. Sevelius JM, Chakravarty D, Dilworth SE, Rebchook G, Neilands TB. Gender Affirmation through Correct Pronoun Usage: Development and Validation of the Transgender Women's Importance of Pronouns (TW-IP) Scale. International journal of environmental research and public health. 2020;17(24):9525.
38. Sevelius JM, Deutsch MB, Grant R. The future of PrEP among transgender women: the critical role of gender affirmation in research and clinical practices. 2016.
39. Dubin SN, Nolan IT, Streed CG Jr, Greene RE, Radix AE, SD M. Transgender health care: improving medical students' and residents' training and awareness. Adv Med Educ Pract. 2018;9:377-391.
40. Sevelius J, Neilands T, Dilworth S, Castro D, Johnson M. Sheroes: Feasibility and acceptability of a community-driven, group-level HIV intervention program for transgender women. AIDS and behavior. 2019;24(5):1551-1559.
41. Phillips II G, Raman A, Felt D, et al. PrEP4Love: The Role of Messaging and Prevention Advocacy in PrEP Attitudes, Perceptions, and Uptake Among YMSM and Transgender Women. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2020;83(5):450-456.
42. Reback CJ, Clark KA, Rünger D, AE F. A Promising PrEP Navigation Intervention for Transgender Women and Men Who Have Sex with Men Experiencing Multiple Syndemic Health Disparities. J Community Health. 2019;44(6):1193-1203.
43. Cahill SR, Keatley J, Wade Taylor S, et al. "Some of us, we don't know where we're going to be tomorrow." Contextual factors affecting PrEP use and adherence among a diverse sample of transgender women in San Francisco. AIDS care. 2020;32(5):585-593.
44. Maiorana A, Sevelius J, Keatley J, Rebchook G. “She is like a sister to me”: Gender-affirming services and relationships are key to the implementation of HIV care engagement interventions with transgender women of color. AIDS and behavior. 2020.
45. Poteat T, Malik M, Scheim A, Elliott A. HIV Prevention Among Transgender Populations: Knowledge Gaps and Evidence for Action. Current HIV/AIDS Reports. 2017;14(4):141-152.
46. Gamarel KE, Sevelius JM, Neilands TB, et al. Couples-based approach to HIV prevention for transgender women and their partners: study protocol for a randomised controlled trial testing the efficacy of the ‘It Takes Two’intervention. BMJ Open. 2020;10(10):e038723.
47. Reisner SL, Jadwin-Cakmak L, Sava L, Liu S, Harper GW. Situated Vulnerabilities, Sexual Risk, and Sexually Transmitted Infections' Diagnoses in a Sample of Transgender Youth in the United States. AIDS Patient Care STDS. 2019;33(3):120-130.
48. Lacombe-Duncan A, Logie CH, Newman PA, Bauer GR, Kazemi M. A qualitative study of resilience among transgender women living with HIV in response to stigma in healthcare. AIDS Care. 2020;32(8):1008-1013.