The Impact of Discrimination on Elevated HIV Risk in Transgender Women

Transgender women, especially those from marginalized racial and ethnic backgrounds, face disproportionately high rates of HIV. Despite this, there has been a lack of a standardized surveillance system collecting data to understand the factors contributing to the elevated risk of contracting the virus. The Centers for Disease Control and Prevention conducted a survey aimed at gathering and evaluating behavioral data related to HIV prevention and risk among transgender women. The results, outlined in the CDC’s Morbidity and Mortality Weekly Report, highlight the significant social and economic marginalization experienced by trans women as potential factors contributing to their heightened risk of HIV.  

 

Over 1,600 transgender women participated in the survey across seven U.S. cities between 2019-2020, receiving HIV testing as part of the study. Shockingly, 42% of participants tested positive for HIV. Breaking down the numbers, Black trans women faced an even higher rate of 62%, compared to 35% for Hispanic and Latina trans women and 17% for white trans women. These findings underscore the urgent need for targeted interventions and support systems to address the specific challenges faced by transgender women, particularly those at the intersection of racial and ethnic marginalization.

 

A key takeaway from the report emphasizes that the discrimination faced by trans women amplifies their vulnerability to various conditions—such as violence, homelessness, and incarceration—ultimately elevating their risk of contracting HIV. The authors underscore the need for a comprehensive approach, integrating housing services, behavioral health support, employment opportunities, gender-affirming medical care, and clinical services to enhance the living circumstances and overall quality of life for transgender women.

 

Awareness and Utilization of PrEP 

Exploring the utilization of PrEP, over 900 respondents, identified as HIV-negative, were eligible for its use. PrEP, a daily pill, boasts a 99% effectiveness in reducing the risk of HIV transmission through sex, yet its adoption among eligible adults in the U.S. remains limited.  

 

Within the surveyed group, an encouraging 92% were aware of PrEP, with 57% having recently discussed it with a healthcare provider. However, only a third (32%) had recently used it. Notably, those who had transgender-specific healthcare or coverage, multiple sex partners, engaged in condomless sex in the last year, or were aware of their last partner having HIV were more likely to use PrEP. Furthermore, Black, Hispanic, and Latina trans women exhibited a higher likelihood of PrEP usage compared to their white counterparts. While the uptake remains relatively low, the report finds optimism in the heightened awareness compared to previous studies.

 

The Impact of Employment Discrimination

In the U.S., access to health insurance often hinges on employment, creating a direct link between job security and affordable healthcare. Shockingly, 10% of surveyed respondents disclosed being fired within the past year solely because of their transgender identity, while 32% faced difficulties securing employment for the same reason. A staggering seven out of 10 transgender women experienced at least one form of employment discrimination in the last year.  

 

For those grappling with job challenges, 62% had Medicaid coverage. Interestingly, respondents in states where Medicaid covers gender-affirming care faced fewer hurdles, while those without such coverage were twice as likely to encounter job difficulties. Alarmingly, almost 22% of those struggling to find employment were entirely uninsured.  

 

The findings suggest a troubling cycle where employment discrimination not only restricts access to healthcare but may also lead transgender women to engage in risky behavior, such as survival sex work, increasing their vulnerability to HIV.

 

Nonprescription Gender-affirming Hormones Among Trans Women

Another critical aspect explored in the study is the use of nonprescription gender-affirming hormones. For many transgender women, accessing hormone treatments can be hindered by cost, insurance limitations, and a lack of inclusive medical providers. Analyzing responses from nearly 1,200 participants, the study found that those with recent healthcare use or insurance coverage for gender-affirming hormones were less likely to resort to nonprescription treatments. However, individuals facing homelessness or engaging in sex work for survival were more likely to opt for nonprescription hormones. Additionally, younger individuals (18-29) were more prone to using nonprescription hormones.  

 

The researchers emphasize the need for further exploration into the motivations behind opting for nonprescription hormones. In a landscape where anti-trans legislation is on the rise, particularly affecting both youth and adults, the study underscores the potential impact of restricted access to prescriptions for transgender women.

 

Homelessness and HIV Prevention

Homelessness emerged as a pressing concern among the surveyed respondents, with almost a third reporting bouts of homelessness lasting a median of approximately six months in the last year. This instability was notably prevalent among those who faced eviction or housing denial due to gender identity (55%) and those with a history of incarceration (58%).  

 

The authors underscored the potential efficacy of addressing housing instability as an HIV prevention strategy. The factors contributing to prolonged housing instability mirror those that heighten behavioral risk factors for HIV, such as living in poverty, experiencing violence and abuse, and lacking social support.

 

Social Support and Suicidal Ideation

Among the respondents, a significant 60% experienced gender-based violence in the form of verbal abuse (53%), physical abuse (26%), or sexual violence (15%) over the past year. While the rate of suicidal ideation (18%) was comparatively lower than in other transgender-focused studies, it remains markedly higher than that of the general U.S. population. Suicidal ideation was more prevalent among young people (ages 18-24), those with unmet needs for gender-affirming surgery, HIV-negative individuals, disabled individuals, the homeless, and those reporting drug use. Despite 75% of participants reporting high social support from significant others, only 47% received comparable support from family. Experiencing violence and harassment, coupled with low social support, amplified the risk of suicidal ideation among trans women.  

 

The report advocates for holistic approaches to combat abuse and harassment, emphasizing the need for interventions that go beyond social support in addressing the complex challenges faced by transgender women. Joseph Osmundson, a researcher at NYU, emphasizes the actionable insights this research provides for shaping policies to enhance the health of trans women. He asserts the importance of policies addressing poverty, improving healthcare access, and combatting homelessness, with a crucial emphasis on involving trans individuals as leaders in these efforts for maximum effectiveness.