Surprising Facts About HIV Risk in Transgender People

Unique Vulnerabilties and Medical Needs Still Being Unmet by Health Authorities

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International Transgender Day of Remembrance, Washington, DC, 2014. Photo © Ted Eytan

There has been increasing public interest in the lives of transgender people following the much-publicized coming out of Caitlyn Jenner in Vanity Fair magazine, as well as the efforts of such activists as Orange Is The New Black actress Laverne Cox and advocate/writer Chaz Bono. 

Despite being a part of the larger LGBT (lesbian, gay, bisexual and transgender) community, not a lot of focus has been placed on transgender people, particularly in regards to the health risks and needs of both male-to-female (MTF) and female-to-male (FTM) transgender persons.

Recent research has looked into the impact of HIV on the transgender population, including the clinical outcomes of those with living with the virus. What most have determined is that HIV risk is not only different among this population group but that there is still is great misunderstanding as to the health needs of transgender women and men, many of which are still being unmet.

HIV Prevalence in Transgendered People

In a nationally representative sample of HIV-infected people receiving medical care, an estimated 1.3% identified as transgender women. A systematic review further concluded that, in 16 countries with a male-predominant epidemic (including the U.S.), HIV prevalence among transgender women was estimated to be 19.1%—an inordinately high rate considered to be hyper-prevalent (i.e., occurring in 15% of the population or more).

HIV rates, surprisingly, were higher in the high-income countries (21.6%) than in low- and medium-income countries (17.7%), with an overall three-fold  risk of acquiring HIV when compared to the general population.

The highest rate of all, however, was in the U.S., with a staggering 27.7% HIV prevalence.

While there is not as much data regarding HIV in transgender men, prevalence rates and risk behaviors are considered to be low, according to a 2008 study by the Centers for Disease Control and Prevention (CDC).

HIV Risk in Transgender Persons

Transgender women in the U.S. are generally more marginalized and socioeconomically challenged than non-transgender people, oftentimes homeless with low incomes and little-to-no health coverage.  The majority (60-70%) do not regularly access medical care, due not only to cost but to the lack of transgender-friendly services. As a result, a large proportion—both MTF and FTM—are forced to obtain hormonal therapy through illicit sources, a practice known to increase the likelihood of HIV Infection.

These issues are only further exacerbated in MTF transgender youth, wherein high rates of forced sex (52%), incarceration (37%), sex in exchange for resources (59%), and difficulty in finding employment (63%) place them at inherently high risk of HIV.

Moreover, high rates of sex under the influence of drugs or alcohol (53%) were also linked with higher levels of unprotected receptive anal sex (49%). And while injecting drug use and needle-sharing were considered rare, 29% reported to have illicitly injected liquid silicon—a practice not directly linked to HIV but one which is associated with poorer health outcomes (including scleroderma, respiratory embolism and autoimmune disorders).

Medical Needs Unmet in Transgender Women

All of these factors only add to the vulnerability of transgender women in general, with isolation and stigmatization further impacting HIV rates, as well as the long-term care of those infected.

This is evidenced by the lack of disclosure seen in many transgender women with HIV. A 2008 analysis by the CDC concluded that, while 27.7% of the transgendered women tested positive for HIV, only 11.8% identified themselves as being HIV-positive.  

This may explain, in part, why a lower of percentage of transgender women are able to maintain adherence to therapy and why only 50% on therapy are able to sustain complete viral control.

Even among transgender women with health insurance who regularly see a general practitioner, 25% consider cost, access to specialists, and the paucity of transgender-friendly and transgender-knowledgeable practitioner as barriers to care.

A transformation of current clinical practices—as well as a better understanding of the needs for transgender men and woman—could effectively improve the quality of HIV care and prevention for this at-risk population. According to sociologist Dr. Emilia Lombardi of Baldwin Wallace University, this would need to include:

  • Greater sensitivity and relevant services to better interact with the  transgender community
  • Recognizing the identity of a transgender person as authentic, including the use of appropriate pronouns and titles
  • Better access to healthcare resources
  • Education and prevention materials appropriate to the transgender experience


Mizuno, Y.; Frazier, E.; Huang, P.; et al. "Characteristics of Transgender Women Living With HIV Receiving Medical Care in the United States." LGBT Health. April 28, 2015; published online ahead of print; doi:10.1089/lgbt.2014.0099.

Baral, S.; Poteat, T.; Strömdahl, S.; et al. "Worldwide burden of HIV in transgender women: a systematic review and meta-analysis." The Lancet Infectious Diseases. March 2013; 13(3):214-222.

Herbst, J.; Jacobs, E.; Finlayson, T.; et al. "Estimating HIV Prevalence and Risk Behaviors of Transgender Persons in the United States: A Systematic Review." AIDS Behavior. January 2008; 12(1):1-17.

Sanchez, N.; Sanchez, J.; and Danoff, A. "Health Care Utilization, Barriers to Care, and Hormone Usage Among Male-to-Female Transgender Persons in New York City." American Journal of Public Health. April 2009; 99(4):713-719.

Lombardi, E. "Enhancing transgender health care." American Journal of Public Health. June 2001; 91(6):869-872.

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