WHAT DOES ASSIGNED FEMALE AT BIRTH MEAN?
Assigned female at birth (AFAB) is a term that is used for people who have external sex traits that are identified at birth as female. It is used as a way to refer to the sex on one’s birth certificate or to discuss medical issues that primarily face AFAB people without making assumptions about current sex, body, or gender identity. AFAB people are typically raised with the assumption that they will identify as women, however AFAB people can be any gender and can have any gender presentation. The term AFAB is an umbrella term to describe the following people:
- Cisgender women (AFAB and identify as women)
- Transgender men (AFAB and identify as men)
- Non-binary and genderqueer people (AFAB and identify as something other than women)
Growing research on transgender men (transmen) and non-binary/genderqueer AFAB people shows increased HIV risk and burden, although not much is known about these transgender populations. Read more about HIV among cisgender women and girls.
WHAT DOES ASSIGNED MALE AT BIRTH MEAN?
Assigned male at birth (AMAB) is a term that is used for people who have external sex traits that are identified at birth as male. It is used as a way to refer to the sex on one’s birth certificate or to discuss medical issues that primarily face AMAB people without making assumptions about current sex, body, or gender identity. AMAB people are typically raised with the assumption that they will identify as men, however AMAB people can be any gender and can have any gender presentation. The term AMAB is an umbrella term to describe the following people:
- Cisgender men (AMAB and identify as men)
- Transgender women (AMAB and identify as women)
- Non-binary and genderqueer people (AMAB and identify as something other than men)
Most of the information below refers to transgender women because there is a glaring lack of research and knowledge about vulnerability to HIV among all other transgender people. Read more about HIV among cisgender men who have sex with men (MSM).
Transgender: A person whose gender identity is different from their sex assigned at birth.
Cisgender: A person whose sex assigned at birth is the same as their gender identity.
Gender expression: A person’s outward presentation of their gender (for example, how they act or dress).
Gender identity: A person’s internal understanding of their own gender.
HOW SERIOUS IS HIV FOR TRANSGENDER PEOPLE?
There are an estimated 25 million transgender people living around the world. The existing data specific to transgender people demonstrate a heavy burden of HIV among transgender women, specifically transgender women who have sex with cisgender men. Transgender women are one of the groups most affected by HIV and are 49 times more likely to have HIV than the general population. Globally, it is estimated that around 19% of transgender women have HIV. HIV among transgender women sex workers is estimated to be 27%, compared with 15% among transgender women who did not engage in sex work.
In the U.S., nearly 1 million people identify as transgender. According to the Centers for Disease Control and Prevention (CDC), transgender people made up 2% of new HIV diagnoses in 2018 and 2,351 transgender people were diagnosed with HIV from 2009-2014. Of these, 84% were transgender women, 15% were transgender men, and 1% had another gender identity. Black/African American transgender women and young transgender women had the highest rates. About 42% of transgender women in the U.S. have HIV. Racial and ethnic disparities are quite stark among transgender women in the U.S.:
- 62% of Black/African American transgender women have HIV
- 35% of Latina/Hispanic transgender women have HIV
- 17% of White transgender women have HIV
WHY ARE TRANSGENDER PEOPLE PARTICULARLY AT RISK FOR HIV?
There are many factors that put transgender people at heightened risk of HIV. The following factors contribute to the global burden of HIV among transgender people:
Social, economic, and legal exclusion: Across the world transgender and gender-nonconforming people face stigma and discrimination, which contributes to higher levels of unemployment, poverty, homelessness, sex work, depression and other mental health issues, substance use, incarceration, and violence, all of which are linked to higher rates of HIV. Most transgender people have experienced some form of abuse or harassment because of their gender identity or presentation. This may negatively impact accessing HIV testing, care, and/or getting treatment for HIV.
Overlapping social, cultural, legal, and economic factors contribute to pushing transgender people to society’s margins. Transgender people are more likely to drop out of school, be rejected from family and friends, and face workplace discrimination, limiting educational and economic opportunities. They can encounter problems accessing basic goods and services and even public spaces. These challenges are exacerbated by a lack of legal recognition of their gender and the absence of anti-discrimination laws that explicitly include them.
Data from the recently released Trans Legal Mapping Report showed the following about transgender people around the world:
- 13 countries have explicit laws specifically criminalizing transgender people, mostly using cross-dressing laws, punishing them with prison, corporal punishment and, where anti-gay laws are also used against trans people, even death
- 37 countries have de facto laws laws criminalizing transgender people (de facto refers to something that exists in practice but is not necessarily ordered by law or officially established)
- 47 countries prohibit transgender people from changing their gender legally
Racism and discrimination increase HIV risk-related behaviors and lead to health disparities in HIV, particularly among transgender women of color. Intersections of race, gender, and age contribute to disparities in HIV testing, prevention, treatment, and viral suppression. Issues associated with racism and discrimination—including limited access to health care, employment, and housing—can increase the risk for HIV and affect the health and well-being of transgender people.
In addition, many transgender people have had negative experiences with healthcare providers, which discourages them from seeking care. Finding providers who are knowledgeable about and sensitive toward transgender and gender-nonconforming people can be challenging. Transgender 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.
Sex work: Social exclusion, economic vulnerability, and lack of employment opportunities means that sex work is often the only form of income available to transgender people. The proportion of transgender people who engage in survival sex work is estimated to be up to 90% in India, 84% in Malaysia, 81% in Indonesia, 47% in El Salvador, and 36% in Cambodia.
Data suggests that HIV prevalence is up to 9 times higher for transgender sex workers compared to cisgender sex workers. Knowledge and reported use of condoms is generally low among transgender sex workers. In Asia and the Pacific, only 50% of transgender sex workers are aware of HIV and HIV testing, and only 50% report using condoms consistently with clients and casual partners. Sex workers may get paid more for unprotected sex and often feel pressured to not use condoms, which makes them highly vulnerable to HIV. Read more about HIV among sex workers.
High-risk sex: There are high rates of unprotected anal sex among transgender women. Receptive anal intercourse carries the highest risk because the lining of the rectum is very thin and can be damaged very easily during sexual activity. This makes it easier for HIV to enter the body. Stigma and discrimination, leading to low self-esteem and disempowerment, can make it harder for transgender women to insist on condom use. In many settings, condom use is often controlled by the insertive sexual partner, so many transgender women who have sex with cisgender men may feel unable to negotiate condom use. Gender affirming hormonal therapy (GAHT), which many transgender women use, can lead to erectile dysfunction, increasing the likelihood of taking the receptive role during sex.
There are other factors that make transgender people more likely to engage in high-risk sex. Some transgender people who want to affirm their gender identity through sex, or who fear rejection from sexual partners, can be more likely to agree to unprotected sex. The stress of social isolation may also lead to a much higher rate of drug and alcohol use among transgender people that can affect their judgement and make them less likely to use condoms.
For the above reasons, many transgender people do not use condoms or take medicines to prevent or treat HIV consistently. These medicines include pre-exposure prophylaxis (PrEP) to prevent HIV transmission and antiretroviral therapy (ART) to treat HIV infection.
Injecting hormones. Many transgender people self-administer injectable hormones as part of GAHT. Without counseling on safe injecting practices, people going through this process may be very vulnerable to HIV transmission because of the risk of sharing needles with others.
WHAT DO WE KNOW ABOUT HIV AMONG TRANSGENDER MEN?
The transgender community is diverse and not enough research has been conducted with transgender people in general. In particular, very little is known about transgender men and their vulnerability to HIV. This is partly because transgender men are assumed to have sex primarily with other AFAB people and therefore be at low risk for HIV.
To date, research related to HIV among transgender people has almost exclusively focused on transgender women. However, there is evidence that there is a significant subgroup of transgender men that engage in unprotected sex with AMAB people, including some transgender men who engage in sex work. If cisgender men and transgender women are a priority for HIV prevention and sexual health care, transgender men should be as well.
Generally, HIV prevalence among transgender women is higher than transgender men. Few studies have been done on HIV prevalence among transgender men and gender non-conforming AFAB people, but there is reason to believe that these communities are more vulnerable to HIV than the general population.
Several studies show that a majority of transgender men report not using condoms consistently during receptive anal and/or frontal (vaginal) sex with AMAB partners, low rates of HIV testing, and low perception of risk.
HIV testing is the gateway to care for people who have HIV and to prevention services for people who don’t have HIV. In the U.S., 96% of transgender women have ever been tested for HIV compared with 82% of transgender men.
Few HIV prevention interventions have been developed that address the unique needs of transgender men and specific eligibility criteria for PrEP have not been devised. Nonetheless, a review of U.S. data by the CDC showed that 15% of the 2,351 transgender people diagnosed with HIV in a five-year period were transgender men. A 2017 survey of more than 800 transgender men who have sex with AMAB people found that a majority engaged in behavior that could put them at risk for HIV, and most had heard of PrEP but only 22% were using it.
Many researchers have 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.
PREVENTING HIV INFECTION AMONG TRANSGENDER PEOPLE
It is evident that prevention strategies are failing to reach this group due to high HIV prevalence in communities around the world. When transgender people are targeted by HIV prevention campaigns they can be extremely effective. It is important that a combination of prevention programs are available.
Encourage less risky sexual behaviors
Unprotected receptive anal/vaginal sex (bottoming) is the riskiest type of sex for getting HIV. Unprotected insertive anal sex (topping) is less risky for getting HIV but very risk for passing HIV to others. In general, there is little to no risk of getting or transmitting HIV from oral sex. Read more about safer sex guidelines.
Limit the number of sex partners. The more partners you have, the more likely you are to have a partner with poorly controlled HIV or to have a partner with an STI. Both factors can increase the risk of HIV transmission.
Use condoms correctly every time you have sex. Read more about how to use condoms correctly and consistently.
HIV counseling and testing
Effective ways to encourage HIV testing among transgender people are to provide home-based testing and community-based testing. Community-based testing is carried out at local pop-up clinics or mobile vans in areas where transgender people feel comfortable. This removes the need to test in clinics where they may experience discrimination and mistreatment. Home-based testing has the benefit of the person being able to avoid identification by healthcare workers. The privacy of conducting an HIV test alone at home makes this an appealing option for many transgender people.
HIV self-testing should be made more widely available to help increase testing and earlier diagnosis. Transgender people should be educated about the use of self-testing kits to heighten their confidence in using them as an alternative to testing at regular healthcare settings.
Whether you test HIV positive or HIV negative, you can take action to protect your health and prevent HIV transmission. The CDC recommends that everyone between the ages of 13-64 get tested for HIV at least once as part of routine health care. People with certain risk factors should get tested at least once a year or more frequently. Find an HIV testing site near you.
Pre-exposure prophylaxis (PrEP)
PrEP is the daily use of antiretroviral medications (ARVs) to reduce the risk of HIV infection among HIV-negative people. PrEP can be combined with other prevention methods, such as condoms, to reduce the risk of HIV even further.
The first approved medication for PrEP, Truvada, has been tested in a few hundred transgender women and shown to be highly effective at preventing HIV when used consistently. Some studies have found that the drugs in Truvada do not reach as high a level in the vagina as they do in the rectum, so transgender men and other AFAB people who have vaginal/frontal sex should be especially careful to take PrEP consistently.
A large study of Descovy, the second PrEP option approved for some people, did not include AFAB people, and the Food and Drug Administration (FDA) declined to approve it for people who have vaginal/frontal sex until more research is done.
Many transgender people are concerned that the medications used for PrEP may interact with GAHT. But in studies so far, the drugs in Truvada have not been found to interfere with hormones.
Post-exposure prophylaxis (PEP)
PEP is the use of ARVs to prevent HIV infection as soon as possible after potential exposure to HIV. It must be taken within 72 hours of possible exposure. It must also be coupled with counseling about the importance of finishing the treatment course. PEP is not the right choice for people who may be exposed to HIV frequently. If a person is at ongoing risk for HIV, such as through repeated exposures to HIV, they should talk to a healthcare provider about taking PrEP.
ANTIRETROVIRAL THERAPY (ART) AMONG TRANSGENDER PEOPLE
Generally, data on transgender people’s access to HIV treatment is scarce. One study of people with HIV in the U.S. found that only 59% of transgender participants, compared to 82% of cisgender people, were accessing ART.
As with access to HIV prevention information, transgender people may delay seeking treatment due to transphobia and insensitivity among healthcare professionals. Depression and isolation are often associated with poor adherence to HIV treatment. A lack of supportive relationships can affect important aspects of living healthily with HIV, such as remembering to take medication. One study found that transgender people with HIV were less likely to report adherence to treatment of above 90% compared to cisgender people. The study found that many transgender people found it difficult to take regular medication alongside other treatments such as hormone therapy.
In the U.S., transgender women have about the same viral suppression rates and transgender men have higher viral suppression rates compared to all people with HIV.
|Received some care||Retained in care||Achieved viral suppression|
|Transgender Women with HIV||84%||66%||65%|
|Transgender Men with HIV||87%||61%||72%|
|All people with HIV||76%||58%||65%|
Taking HIV medicine every day can make the viral load undetectable. People who get and keep an undetectable viral load (or remain virally suppressed) can stay healthy for many years and have effectively no risk of transmitting HIV to their sex partners.
WHO has produced comprehensive guidance on HIV services for transgender people and recommends that adherence can be increased significantly by addressing HIV stigma and discrimination.
THE BOTTOM LINE
In the U.S. and around the world, transgender people are disproportionately affected by HIV. With early testing and treatment, transgender people with HIV can live longer, healthier lives.
There is a critical lack of data and limited funding for, and research about, transgender people and what drives their vulnerability to HIV. This is particularly true for transgender men and non-binary/genderqueer transgender people.
Transgender people at high risk for HIV should get tested for HIV at least once a year, and in some cases more frequently. This is especially true for transgender people who have multiple sex partners, who are engaged in sex work, who inject drugs, or who share needles for gender affirming hormonal injections. If they test positive for HIV, they can take steps to reduce the risk of infecting their partners and ensure their own health.
The best way to prevent infection is by using condoms, taking PrEP if HIV-negative, and taking strong ART if HIV-positive. Transgender people who use intravenous drugs or inject hormones should not share injection equipment and supplies.
The most commonly used HIV medications do not interfere with hormones and vice versa. However, it is important to tell your healthcare provider about all the medications you are taking, including hormone therapy.
WHO: Transgender People
WHO Policy Brief: Transgender People and HIV
Reviewed May 2021