Transgender, gender--nonconforming and nonbinary people are at greater risk for HIV and are more likely to be living with the virus than the population at large. Targeted studies and tailored services have helped close this gap, but recent political shifts put this progress in jeopardy.

 

About 1.6 million adults in the United States identify as transgender, but accurate data about how many are living with HIV have been hard to come by. Trans women used to be classified as “men who have sex with men,” while trans men were generally excluded from research. Recent studies have done a better job, but the Trump administration has changed how trans people are counted, removed data from federal health agencies and reduced funding for targeted research and services.

 

According to the latest available data from the Centers for Disease Control and Prevention (CDC), transgender people accounted for 2% of new HIV diagnoses in 2019. Of these, 625 were trans women and 46 were trans men. Based on data from seven U.S. cities, 42% of transgender women were living with HIV (62%, 35% and 17% of Black, Latina and white trans women, respectively).

 

Increased focus on transgender people has led to more tailored services. According to the 2019 CDC estimates, 96% of trans women have been tested for HIV, 92% are aware of pre-exposure prophylaxis (PrEP) and 32% have used it—figures that compare favorably with those for gay and bisexual men.

 

The daily PrEP pill tenofovir disoproxil fumarate/emtricitabine (Truvada) is highly effective for trans women, but it has not been studied in trans men. Tenofovir alafenamide/emtricitabine (Descovy) is also effective for trans women, but due to inadequate research, it is not approved for people exposed to HIV through vaginal sex .

 

Long-acting injectable cabotegravir PrEP (Apretude), which is administered every other month, is even more effective than daily pills for transgender women, but again, studies have not included trans men. Long-acting lenacapavir PrEP, administered every six months, was highly effective in a trial that included trans women, trans men and nonbinary people.

 

Some older research found that trans people are less likely to receive ongoing HIV care and treatment, but things have improved thanks to targeted education and services. According to the 2019 CDC data, 84% of trans women received some HIV care, and 67% achieved viral suppression on antiretroviral therapy; for trans men, the rates were 85% and 68%.

 

Studies have shown that transgender women respond as well as cisgender (non-trans) men and women to antiretroviral medications, and those who remain in care are as likely to maintain viral suppression. There has been little research on trans men with HIV, but there’s no reason to think they would not also respond well to treatment.

 

Many trans people are concerned that the medications used for PrEP or HIV treatment could interfere with gender--affirming hormones. But research to date has found that commonly used antiretrovirals do not have clinically significant interactions with feminizing hormones, nor does hormone therapy alter the effectiveness of antiretrovirals.

 

Trans and gender-nonconforming people often face stigma and discrimination, which contributes to higher levels of poverty, unemployment, homelessness, sex work, mental health problems and substance use—all of which are linked to higher rates of HIV acquisition and worse treatment adherence. What’s more, many trans people have had negative experiences with the health care system, which can discourage them from seeking care.

 

Yet gender-affirming care can improve outcomes: One recent study found that trans people who received hormone therapy were 37% less likely to acquire HIV and 44% more likely to achieve viral suppression.

 

Recent improvements in HIV prevention, care and treatment for transgender and gender-diverse people are welcome, but new restrictions on research and services threaten to reverse this progress. Finding providers who are knowledgeable about and sensitive to trans people can be a challenge, but LGBTQ advocacy groups or local AIDS service organizations may be able to point you in the right direction.