HIV levels are disproportionately higher among transgender people, especially those from underrepresented racial and ethnic groups. However, no uniform monitoring system has so far gathered information that may shed light on the factors that increase a person’s risk of contracting the virus.
The Centers for Disease Control and Prevention conducted a study of transgender people with the goal of gathering and analyzing comprehensive information for the first time regarding HIV risk and prevention. The high levels of social and economic exclusion that trans women experience as possible contributors to the group’s higher risk for HIV are highlighted in an examination of the survey results, which was released on Tuesday in the CDC-published Morbidity and Mortality Weekly Report.
Between 2019 and 2020, the survey was conducted at locations in seven U.S. cities by more than 1,600 transgender women. Additionally, they were given HIV tests. 42% of the test-takers tested HIV-positive. That percentage increased to 62% of Black trans women, up from 35% of Hispanic and Latina trans women and 17% of white transgender women.
The report’s additional analyses focused on issues relating to HIV exposure and other health-related issues for trans women, such as access to and use of the prophylactic HIV treatment pre-exposure prophylaxis (PrEP), as well as factors like homelessness and sexual assault that are associated with having more condomless anal sex and suicidal ideation.
The bias that trans women experience increases their exposure to conditions like assault, homelessness, incarceration, and more, which in turn raises their risk of contracting HIV, according to the report’s key findings.
To improve the living conditions and quality of life for trans women, it is crucial to integrate housing, behavioral health services, employment, gender-affirming health care, and medical care.
Utilization of PrEP
More than 900 of the respondents were HIV-negative, making them eligible to use PrEP. Although the majority of adults in the United States who could benefit from it are not taking it, it is frequently taken as a daily pill that can be 99% effective in lowering the risk of contracting HIV through sex.
Only about a third (32%) of the sample had recently used PrEP, but 92% of them were aware of it and over half (57%) had recently discussed it with their healthcare provider. PrEP was more likely to be used by people who had previously received transgender-specific medical care or who already had such health insurance coverage, as well as those who knew their previous sex partner had HIV and had multiple partners or engaged in condomless sexual activity in the previous year. Compared to their white counterparts, trans women of color, Hispanic, and Latina were all more likely to use PrEP.
The authors note that despite relatively low uptake, the study’s findings were encouraging because there was a higher level of awareness than in earlier studies.
Prevalence of condomless anal sex
Another area of study examined how structural psychosocial conditions (homelessness, exchanging sex for money, and sexual violence), as well as psychological distress, relate to the likelihood of having condomless anal sex.
HIV is primarily spread through anal sex without the use of a condom, and in the sample group of 1,350 Black, Hispanic, or Latino respondents, almost half of them had positive HIV status. 55% of respondents said they engaged in condomless anal sex. According to a similar study on cisgender men who have sex with men, people were more likely to do so the more emotional and structural stressors they experienced.
Transgender women of all races were affected by the compounding factors, but white women were more likely to experience substance use, sexual assault, emotional distress, and homelessness. The highest rates of exchanging sex for cash or drugs and imprisonment were among Black and Hispanic respondents.
Employment bias
In the United States, access to health insurance and, consequently, affordable health care is frequently directly correlated with employment. About 10% of survey respondents reported being fired for being transgender in the previous year, and 32% reported having trouble finding jobs for the same reason. In the previous year, at least one of these types of job discrimination was experienced by seven out of ten transgender people surveyed.
62% of those who had trouble finding work had Medicaid coverage. The majority of survey respondents resided in states where the Medicaid program does include gender-affirming care, but those who did not were twice as likely to struggle to find employment. Nearly 22% of respondents who had trouble finding work were wholly uninsured.
The findings imply that trans women may even engage in behaviors like survival sex work that raise their risk of contracting HIV, such as employment bias, which was directly linked to poorer access to healthcare in general.
Hormones that are non-prescription female affirming
Hormone therapy is essential for many transgender women to treat gender dysphoria and other mental health issues, but access to it can be challenging because of costs, issues with insurance coverage, and a lack of accessible, equitable health professionals. Nearly 1,200 respondents’
use of gender-affirming hormone therapies without a prescription—possibly without the right dosage, administration, or health monitoring—was evaluated in one book analysis. People who take estrogen without medical supervision might not be aware of any potential side effects.
According to the study, trans women were less likely to use nonprescription medication if they reported using gender-affirming hormones in the past or having insurance coverage. However, those who were homeless or had to trade sex for cash or medicines were more likely. Younger people, between the ages of 18 and 29, were also more likely to use hormones without a prescription.
Future studies may examine why people use non-prescription hormones, according to the experts. It’s unclear how many trans women may be impacted by a lack of prescriptions as anti-trans legislation that targets both children and adults becomes more prevalent across the nation.
Homelessness
Nearly a third of 1,600 respondents said they had been homeless for at least one night out of the previous year, on average for about six months. 55% of respondents who claimed to have been evicted or denied housing due to their gender identity and 58% of those who had been imprisoned also reported experiencing periods of homelessness.
According to the authors, addressing housing instability and combining housing services with behavioral health services may also be effective at preventing HIV. Living in poverty, experiencing violence and abuse, and a lack of social support are some of the same factors that increase psychosocial risk factors for HIV.
Suicidal thoughts and social support
Over the past year, 60% of survey respondents reported gender-based violence, including verbal abuse (53%), physical abuse (26%), or sexual violence (15%), and nearly 18% reported having suicidal thoughts. Although this level of suicidal ideation is actually lower than what other studies on transgender people have discovered, it is still significantly higher than the general population of the United States.
Young people (18 to 24) had higher rates of suicidal ideation than older groups, including those who had an unmet need for gender-affirming surgery, were HIV-negative, disabled, poor, and reported substance use.
Only 47% of all participants reported receiving similar social support from family, while 75% reported having high levels from significant others. The risk of suicidal ideation among trans women increased when they experienced these types of assault and abuse with little social support.
The authors emphasize the need for more inclusive and alternative approaches to abuse and harassment for when social support is insufficient, even though it was generally protective against experiencing suicidal ideation for transgender women who experience crime.
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