• A new study finds that HIV infections disproportionately affect transgender individuals.
• “Marginalization, discrimination, and stigma” are blamed for the high rate of infections.
• While effective HIV prevention is generally available, healthcare systems inhospitable to trans people inhibit access.

According to the Centers for Disease Control and Prevention (CDC), pre-exposure prophylaxis, or PrEP, medications are highly effective at preventing new HIV infections. When taken as prescribed, PrEP reduces the chances of acquiring HIV from sex by roughly 99% and injection drug use by at least 74%.

A new global meta-study by researchers from Maastricht University in the Netherlands finds that, despite the availability of PrEP, trans individuals are still acquiring HIV infections at a high rate.

The study finds that transfeminine people are 66 times more likely than other people over the age of 15 to be HIV-positive, with transmasculine people 6.8 times as likely.

The meta-study analyzed data from 98 existing studies conducted in 34 nations from January 2000 to January 2019. It concluded that 19.9% of trans feminine individuals were HIV positive, as were 2.56% of transmasculine people.

First author of the study, Dr. Sarah E. Stutterheim of Maastricht University, explained to Medical News Today,

“Trans individuals have a higher likelihood of acquiring HIV because they hold a particularly vulnerable position in society as a result of marginalization, discrimination, and stigma.”

Such factors, said Dr. Stutterheim, stand in the way of delivering the benefits of PrEP to this community:

“We need to better tailor HIV prevention to the needs of trans individuals and make PrEP available for trans people. Also, we need to address structural factors that make trans folks more vulnerable, such as discrimination, judgment in healthcare settings, and a lack of legal recognition.”

The researchers also found that the burden of HIV infections among trans people varies worldwide.

For example, the highest odds of HIV infections among transfeminine individuals were seen in sub-Saharan Africa and Latin America. The authors write this finding “may point to greater disapproval of gender fluidity and the accompanying marginalization that puts transgender individuals more at risk for HIV in these regions.”

The study appears in PLOS ONE.

What may explain HIV’s high prevalence among trans people

“Pervasive structural violence and social exclusion drive high HIV prevalence among trans people,” Dr. Tonia Poteat of UNC-Chapel Hill, North Carolina — who was not involved in the study — told Medical News Today:

“For example, employment discrimination and limited access to gender congruent identity documents limit income-generating opportunities for trans people, resulting in a greater reliance on sex work to make a living than in the general population. The use of alcohol and/or drugs to cope with pervasive stigma and discrimination may increase sexual risk behaviors.”

Dr. Poteat commented, “Trans women, in particular, are often targeted by law enforcement due to a presumption that they are sex workers,” adding that, “Engagement with the criminal legal system is well-documented to increase vulnerability to HIV.”

“Surviving in a transphobic society,” continued Dr. Poteat, “and accessing gender affirmation in order to live authentically frequently take precedence over HIV.”

Doing better for trans individuals

“We must address,” said Dr. Poteat, “the structural drivers — employment discrimination; widespread stigma, discrimination, and violence; housing discrimination and instability — that both increase HIV vulnerability and reduce access to HIV prevention and care services.”

Dr. Poteat stated that taking concrete steps can achieve this, such as:

• “passing and enforcing legislation banning discrimination not only in employment but also housing and public accommodations
• reducing barriers to updating identity documents to be congruent with one’s gender
• reducing police profiling of trans women
• leveraging the strength of supportive social networks among trans people to increase awareness of and access to HIV prevention and care services
• ensuring that all healthcare services and providers are competent in the care of trans people.”

Seeking a more accurate understanding

“In sum,” write the study authors, “this systematic review and meta-analyses have served to update our understanding of HIV prevalence over the course of the epidemic as well as HIV burden in both transfeminine and transmasculine individuals using a larger sample than ever before, and has shown that, worldwide, both carry a substantially higher burden of HIV than other individuals over 15 years of age.”

The authors pointed out several limitations to this meta-analysis. The studies where transfeminine individuals were less than 40 years old were excluded from the analysis. The same criteria did not apply to studies of transmasculine individuals. The studies of African regions and Latin America had smaller sample sizes than the other regions, which might have impacted the prevalence rates.

Overall, the authors note the difficulty of integrating and analyzing a large body of studies from different places and years and based on differing data-sampling methodologies. They recommend further research to guarantee a timely, accurate assessment of the HIV burden for trans people.

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