A session at the recent Conference on Retroviruses and Opportunistic Infections (CROI)—conducted virtually due to the ongoing coronavirus crisis—included several presentations on HIV among transgender men and women.

Studies to date have found that transgender, gender-nonconforming and nonbinary people have higher rates of HIV than the population as a whole, but to date such research has been limited.

According to the Centers for Disease Control and Prevention, 2,351 transgender people in the United States were diagnosed with HIV between 2009 and 2014. Of these, 84% were trans women, 15% were trans men and 1% had another gender identity. Black trans women and young trans women had the highest rates. Trans people may not have access to HIV prevention information that uses appropriate language to describe their body parts and how they have sex, and few HIV services are tailored to this population.

Trans Men

Asa Radix, MD, MPH, of Callen–Lorde Community Health Center in New York, presented some of the first data on HIV prevalence among transgender men, a group that has been less studied than trans women.

This analysis was based on electronic health records from 577 trans and gender diverse individuals receiving care at the clinic who were assigned female at birth. Of these, 74% identified as trans men, 15% identified as male, about 4% said they were genderqueer and the rest identified as female-to-male, transsexual, gender-nonconforming or other.

The average age was 33. Just over half (55%) were white, 14% were African American, 12% were Latino, 6% were Asian or Pacific Islanders and 14% identified as “other.”

Overall, the group had a higher socioeconomic status than trans women in previous studies. They had a fairly high level of education (12% with a high school diploma, 32% with some college, 33% with a bachelor’s degree and 12% with a graduate degree), more than two thirds were employed, almost all had stable housing and nearly 90% had private or public health insurance. Just 3% reported a substance use disorder, and none reported doing sex work.

Two hundred and fifty participants (43%) had ever been tested for HIV, and seven of them (2.8%) were HIV positive. African-American transmasculine individuals had a higher HIV prevalence than the study population as a whole: 6.8% versus 2.8%, respectively.

Two of the 18 participants (11%) who reported having sex only with cisgender (non-trans) men and three of the 86 people (3.5%) who had sex with both cisgender men and others were HIV positive. Two of the 94 people (2.1%) who reported sex only with cisgender women and three of the 163 people who had sex with cisgender women and others tested positive. People who had at least a high school diploma were less likely to have HIV.

Based on these findings, the researchers concluded that studies looking at HIV among transgender people should investigate behavioral risk as well as gender identity and that transgender men need to be included in HIV prevention efforts. Finally, they added, this study “underscores the need for collection of gender identity and sexual orientation [data] in electronic medical records and national health studies.”

Trans Women

Morgan Keruly of the National Institutes of Allergy and Infectious Diseases presented findings from the Leading Innovation for Transgender Women’s Health and Empowerment (LITE) study, which recruited participants from six eastern and southern cities in the United States.

The researchers looked at factors associated with having HIV, hepatitis C, herpes simplex type 2 (HSV-2), syphilis, gonorrhea or chlamydia. Blood samples were collected from 561 trans women living in Atlanta, Baltimore, Boston, Miami, New York and Washington, DC, between March 2018 and March 2019. Demographic, behavioral and socioeconomic data were available for all but 10 of them.

Nearly a third (29%) were HIV positive, 5% had hepatitis C and 48% had HSV-2. Rates of other sexually transmitted infections were lower: 14% for syphilis, 5% for chlamydia and 2% for gonorrhea. However, 20% had two concurrent infections and 12% had three or more.

Trans women in Boston had a lower burden of disease than those in the other cities. Black women had higher rates of HIV, HSV-2 and syphilis, followed by Latina and mixed-race women. Among Black women, the HIV prevalence exceeded 50%, and the HSV-2 rate was over 70%.

Overall disease burden increased with age, from 30% among trans women under 26 to 77% for those over 45. In the latter group, half had HIV, just over 70% had HSV-2, 20% had syphilis and more than 15% had hepatitis C.

Consistent with prior research, women who were homeless or had unstable housing and those who were not employed full-time had higher disease rates. But surprisingly, those who said they had family support and those with more knowledge about HIV also had higher rates. What’s more, condom use, illegal drug use, feeling like they were part of a community and pride in their gender identity did not appear to affect disease status one way or the other.

Finally, Catherine Lesko, PhD, of Johns Hopkins Bloomberg School of Public Health, presented findings from a study of progression through the HIV care continuum among transgender women in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD).

Prior cross-sectional (one-time) estimates of HIV care have suggested that trans women are less likely to receive antiretroviral treatment, be retained in care and achieve viral suppression than cisgender women or men, the researchers noted as background. However, cross-sectional estimates do not account for population dynamics or differences over time.

This analysis included 144,054 HIV-positive people engaged in care between 2000 and 2016 in the 15 cohorts that participated in the North American Transgender Cohort Collaboration (NA-TRACC), nested within NA-ACCORD.

Of these, 420 were trans women. The trans women were younger on average (median age 35) and had enrolled more recently than cisgender men or women. Among the trans women, 47% were Black, 32% were white and 22% were Latina. Three quarters had sexual contact, 4% had injection drug use and 10% had both as an HIV risk factor.

Estimating the average time spent at each step of the care continuum, the researchers found that trans women spent more time on antiretroviral treatment and more time with undetectable viral load during their 10 years of follow-up, compared with cisgender women or men.

Trans women spent 17 more months in care than cisgender women and 14 more months in care than cisgender men. What’s more, they spent 15 more months on treatment with viral suppression than either cisgender women or men.

“In our sample, transgender women who successfully engage in HIV care have similar or better HIV care continuum outcomes than cisgender men and women,” the researchers concluded. “Future studies should consider what gender-affirming practices promote engagement of transgender individuals in continuity HIV care.”

Click here to learn more about HIV among transgender, gender-nonconforming and nonbinary people.