Each year, on April 18th, we recognize the importance of HIV testing and status awareness as well as prevention and treatment efforts among transgender individuals, a population particularly at risk for the virus.
With 1.2 million individuals living with HIV in the United States, healthcare providers everywhere are looking for ways to improve prevention strategies to protect more individuals from catching the virus, especially those at increased risk; one such population are those who identify as transgender. In fact, on a global scale, it’s estimated that transgender women are 50% more likely to be living with HIV compared with the general population.
Approximately 1.4 million individuals identify as transgender in the United States alone and those within this population face their own barriers when it comes to being tested and treated for the virus. Each year, on April 18th, we observe National Transgender HIV Testing Day, or NTHTD, a day dedicated to recognizing the importance of transgender individuals being tested for HIV so that they can know their status, in addition to ensuring that prevention and treatment efforts are inclusive to transgender individuals.
The Center of Excellence (CoE) for Transgender Health at the University of California, San Francisco, has developed a Transgender HIV Testing Toolkit that is comprised of five modules that include prevention research and best practice for “serving trans and gender non-binary” individuals. The toolkit includes guidelines meant to increase access to HIV testing as well as treatment options specifically for this population. According to the CoE, the toolkit aims “to encourage and support community-based organizations and prevention programs to host trans HIV testing community events, develop expanded trans HIV testing visibility campaigns, provide HIV testing services, and/or engage trans community members in promoting status awareness among all trans people.”
When it comes to the prevalence and burden of HIV among trans individuals, there is a large focus on HIV testing for trans women, or individuals who had been “assigned ‘male’ at birth but have a female gender identity and/or feminine gender expression.” Why? A global meta-analysis shows that the prevalence among trans women living in “high-income countries,” such as the United States, is around 22%. In fact, regardless of “country wealth,” trans women were found to be a staggering 49 times more likely to have HIV “compared to all adults of reproductive ages.”
Furthermore, it was also found that African-American and Latina trans women experience rates of HIV that are “disproportionately high.” In fact, a meta-analysis of 29 regional US studies conducted in 2008 found that “race was a significant mediating factor to HIV status among trans women.” According to the toolkit, race is not the only influencer when it comes to risk; racism is as well. The CoE writes, “Transphobia (specific discrimination experienced by trans people), homophobia, and racism appear to collectively increase risk among trans women of color.”
In addition, the Centers for Disease Control and Prevention reports that a staggering 73% of trans women remain unaware of their HIV-positive status; this results in an increased incidence of HIV as well as several health complications due to lack of needed treatment. An increase in HIV testing among trans women, and thus, status awareness is crucial to cutting back on these numbers.
So, why is there higher HIV prevalence and lower testing rates among trans women compared to other populations who are also at increased risk of HIV? The CoE postulates that it may be “due to greater disparities, stigma, and discrimination across many environmental and social contexts.” One example that provided is that many trans women turn to sex work due to a lack of job opportunities available to them; unemployment rates among trans women are “upwards of 23%.” Sex workers are prone to having several sexual partners and engage in particularly risky behaviors such as unprotected receptive anal sex (URAS) which is a major driver in HIV risk.
When it comes to trans men, currently, there is very limited data available, and the CoE notes that “due to the assumption of low rates of HIV among trans men relative to other high-risk groups, there is limited interest in conducting more research on risk behaviors among” this population.
The CoE provides what they call “pathways to health” when it comes to HIV testing. The big focus of the model is to drive home the fact that HIV testing and status awareness are imperative when it comes to HIV prevention. Those who test positive are encouraged to receive the needed medical treatment in order to “stay healthy and reduce the risk of transmission to others.” Those who test negative for the virus are encouraged to engage in a “HIV Prevention Continuum,” which consists of engaging in prevention services (such as receiving pre-exposure prophylaxis), attending counseling pertaining to reducing HIV risk, repeat testing, as well as engaging in other “medical, behavioral, and social services as indicated.”
Trans women experience particular barriers when it comes to getting tested for HIV and receiving appropriate care. One reason that they do not seek these services is simply because they are “miscategorized” as men who have sex with men (MSM) on several clinical forms. According to the toolkit, other barriers include:
By taking these barriers into account and by addressing transphobia, healthcare providers can make sure that trans individuals feel comfortable with getting tested or receiving medical treatment. The toolkit provides several steps that providers can take to ensure this; for example, having a gender-inclusive restroom policy, having trans individuals on staff, and ensuring that prevention brochures are inclusive of this population are just a few options.
Healthcare providers should remember the importance of being inclusive to trans individuals when it comes to HIV testing, prevention, and treatment efforts, not just on awareness days, but every day in order to make headway in the fight against the virus that continues to plague individuals worldwide.