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 Transgender communities in the United States
(US) are among the groups at highest risk for HIV
infection. The term gender identity refers to a
person’s basic sense of self, of identifying as male,
female, or some other gender (e.g., transgender, bigender, intersex). Transgender refers to people
whose gender identity does not conform to norms
and expectations traditionally associated with a
binary classification of gender based on external
genitalia, or, more simply, their sex assigned at
birth. It includes people who self-identify as gender
variant; male-to-female (MtF) or transgender
women; female-to-male (FtM) or transgender men;
many other gender nonconforming people with
identities beyond the gender binary; and people
who self-identify simply as female or male. Gender
identity, gender expression, and sexual orientation
are separate, distinct concepts, none of which is
necessarily linked to one’s genital anatomy.
The Numbers
Because surveillance data for this population are
not uniformly collected, information is lacking
on how many transgender people in the US are
infected with HIV. However, data collected by
local health departments and scientists studying
transgender people show high HIV positivity.
- Data from CDC-funded HIV testing programs
show high percentages of newly identified HIV
infections among transgender people. In 2009,
about 4,100 of 2.6 million HIV testing events
were conducted with someone who identified as
transgender. Newly identified HIV infection was
2.6% among transgender persons compared with
0.9% for males and 0.3% for females. Among
transgender persons, the highest percentage of
newly identified HIV infection was among blacks
(4.4%) and Hispanics (2.5%). More than half
(52%) of testing events with transgender persons
occurred in non-clinical settings.
- In New York City, from 2005–2009, there were 206
new diagnoses of HIV infection among transgender
people, 95% of which were among transgender
women. Approximately 90% of MtF and FtM
people newly diagnosed with HIV infection were
black or Hispanic. Newly diagnosed transgender
people were more likely to have been in their teens
or twenties than their non-transgender counterparts.
Also, among newly diagnosed people, 50% of
transgender women had documentation in their
medical records of substance use, commercial sex
work, homelessness, incarceration, and/or sexual
abuse as compared with 31% of other people who
were not transgender.
- Findings from a meta-analysis of 29 published
studies showed that 27.7% of transgender women
tested positive for HIV infection (4 studies),
but when testing was not part of the study, only
11.8% of transgender women self-reported
having HIV (18 studies). In one study, 73% of
the transgender women who tested HIV-positive
were unaware of their status. Studies also
indicate that black transgender women are more
likely to become newly infected with HIV.
Prevention Challenges
Many cultural, socioeconomic, and healthrelated
factors contribute to the HIV epidemic
and prevention challenges in US
transgender communities.
- Identifying transgender people can be
challenging. Using gender alone is not enough
because some people in this community do not
self-identify as transgender. Using the 2-step data
collection method of asking for sex assigned at
birth and current gender identity increases the
likelihood that all transgender people will be
accurately identified. It is important to avoid
making assumptions about sexual orientation and
sexual behavior based on gender identity as there
is great diversity in orientation and behavior
among this population, and some identify as
both transgender and gay, bisexual, or lesbian.
The Institute of Medicine has recommended that
behavioral and surveillance data for transgender
men and women should be collected and
analyzed separately and not grouped with data
for men who have sex with men (MSM).
- High levels of HIV risk behaviors have been
reported among transgender people. HIV infection among transgender women
is associated with having multiple sex
partners and unprotected receptive or insertive anal intercourse.
- Additionally, many transgender women
reported high levels of alcohol and substance
use. These substances can affect judgment
and lead to unsafe sexual practices, which can
increase HIV risk.
- The few studies examining HIV risk behaviors
among transgender men suggest some have
multiple male sex partners and engage
in unprotected receptive anal or vaginal
intercourse with men; however, no studies have
reported links between these behaviors and HIV
infection among transgender men. Nonetheless,
these are established HIV risk behaviors in
other populations.
- Discrimination and social stigma can hinder
access to education, employment, and housing
opportunities. In a study conducted in San
Francisco, transgender people were more
likely than MSM or heterosexual women to
live in transient housing and have completed
fewer years of education. Discrimination may
help explain why transgender people who
experience significant economic difficulties
often pursue high-risk activities, including
commercial sex work, to meet their basic
survival needs. Social stigma also may explain
why some transgender people engage in
unprotected receptive intercourse with their
sex partners. Qualitative data suggest that
some transgender people who fear sex partner
rejection or need their gender affirmed through
sex may engage in unprotected receptive
intercourse. High rates of depression, emotional
distress, loneliness, and social isolation have
been linked to suicidal thoughts and suicide
attempts by transgender people. Therefore,
interventions that address multiple cooccurring,
syndemic public health problems—
including substance use, poor mental health,
violence and victimization, discrimination, and
economic hardship—should be developed and
evaluated for transgender people.
- Health care provider insensitivity to
transgender identity or sexuality can be a barrier
for HIV-infected transgender people seeking
health care. Although research shows a similar
proportion of HIV-positive transgender women
have health insurance coverage as compared
with other infected people who are not
transgender, HIV-positive transgender women
were less likely to be on antiretroviral therapy.
- Additional research is needed to
identify factors that prevent HIV in
this population. Several behavioral HIV
prevention interventions developed for
transgender people have been reported,
generally involving relatively small
samples comprised entirely or primarily
of transgender women. Most have shown
at least modest reductions in HIV risk
behaviors, such as fewer sex partners and/or
reducing unprotected anal sex acts, although
none have involved a control group.
What CDC Is Doing
 CDC recognizes that accurate information is
key to understanding the HIV epidemic, public
health needs, and gaps in services among all
people at risk for HIV infection.
- In response to recommendations for collecting
data from transgender people, CDC is currently
revising the national system for reporting
HIV cases to capture sex assigned at birth and
current gender identity. This will improve the
likelihood of accurately identifying diagnoses
of HIV infection among transgender people.
- CDC is developing an HIV-related behavioral
survey to monitor current HIV-related risk
behaviors and prevention experiences among
transgender women.
- CDC is currently collecting information on
gender identity in its HIV testing programs.
- To respond to a shortage of proven
behavioral HIV prevention interventions for
the transgender community, CDC funded
researchers to develop ground-breaking
interventions for transgender people. Data from
this research will be available later in 2011.
- CDC has funded organizations to adapt
proven behavioral HIV prevention
interventions for use with transgender people.
Adapted curricula and supporting materials
and technical assistance for implementing
agencies are available.
- CDC-funded capacity building assistance
(CBA) providers help community-based
organizations (CBOs) serving transgender people to enhance structural
interventions such as condom distribution, community mobilization, HIV
testing, and coordinated referral networks and service integration.
- YMSM and YTransgender CBO Project —
CDC currently funds prevention programs
for transgender youth of color through the
Prevention Program Branch.
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