Transgender People and HIV/AIDS

back to top Introduction

In every society there are expectations that people will look and act a certain way depending on whether they are male or female. However, for many people this is just not the case. What gender you identify with (gender identity), may not necessarily be the same as the biological gender you were born with.

‘Transgender’ is a broad term that refers to people whose gender identity and expression are different to the social expectations of gender. It is estimated that there are 15 million transgender people globally.¹ They may see themselves as male, female, gender non-conformist, or one of many other gender-variant categories.² They may identify with a culturally specific term such as ‘gender queer’, a phrase that developed in the USA during the 1990s, or ‘hijra’ a far older term describing people in parts of South Asia who reject their masculine identity.

Transgender people are often very affected by HIV, with HIV prevalences among this group ranging from 8 percent to 68 percent,³ and yet they remain severely overlooked in the HIV and AIDS response worldwide.

Whilst the HIV needs of transgender people are often discussed alongside those of men who have sex with men, many transgender people do not identify as men, so it is appropriate to look at the HIV-related needs of the two groups separately. Many of the issues discussed on this page relate predominantly to ‘transgender women’ (people who are born as men but identify as being women). Generally, there is a higher HIV prevalence among transgender women then transgender men (people who are born as women but identify as being men).⁴ However, less is known about the HIV risk factors faced by transgender men, as in many regions this is a new emerging identity, and it is important to emphasise that transgender men and women who have sex with women in many instances do face HIV risks.^{5 6}

back to top What makes transgender people vulnerable to HIV/AIDS?

“I am not a 'high-risk' person; I am a member of a community that is put at high risk.” Marcela Romero, Coordinator of REDLACTRANS, a Latin American and Caribbean transgender network⁷

Transgender people are one of the groups most vulnerable to HIV:

• HIV prevalence among 11,066 transgender women, living around the world, was found to be 19 percent.⁸
• Only 43 percent of countries address the needs of transgender people in their national AIDS strategies.⁹
• Stigma, discriminatory laws, social exclusion and a general lack of understanding about transgender issues all make it extremely difficult for transgender people to protect themselves from HIV infection.

Stigma and discrimination

Transgender people often face high levels of stigma and discrimination, both at a community and a national level. The way that stigma exacerbates their vulnerability to HIV has been described as the ‘stigma-sickness slope’:¹⁰ Transgender people face stigma and discrimination, preventing them from accessing opportunities that others can. This can push them into sex work to make money, putting them at risk of sexually transmitted infections, and can lower self-esteem, leading to less inclination to protect their own health. All of these factors make transgender people vulnerable to HIV infection, which in itself can create more stigma – and so people are caught in a cycle of ‘stigma and sickness’.

There is often a strong association between transgender people and HIV and AIDS which can be very damaging. As a group, they are sometimes viewed as ‘vectors’ of HIV, passing the infection to sexual partners and therefore their partners’ partners, who are often birth-assigned women.¹¹

Many countries do not legally recognise the gender of transgender people, meaning that they often lack official identification, passports and travel rights, welfare entitlements and the right to marry.¹² This can encourage discrimination within healthcare services, making it hard to access sexual health services.

“Nine out of ten trans people do not consult doctors even in case of serious illness, because of the mistreatment they know they will face in health services. ” Campaigner in Venezuela¹³

In some cases, police shut down organisations that provide HIV prevention services on the basis that these services aid illicit activity such as sex work.¹⁴

78 countries still have laws that prohibit same-sex sexual activity, which can also affect transgender people, hindering their ability to access information about HIV risk and prevention.¹⁵ For example, if a transgender woman were legally recognised as a man because that was the gender she was born with, sex with a birth-assigned men would be illegal, so she may risk prosecution if she discussed her own sexual history with a healthcare professional.¹⁶

Laws such as these can legitimise acts of stigma, discrimination and violence against individuals.¹⁷ This can put transgender people at more risk of sexual abuse and attack, and at risk of HIV infection.¹⁸ Worryingly, violence towards transgender people is being increasingly reported worldwide.^{19 20} In Latin America, where 35 percent of transgender women are living with HIV, much of this violence is from authorities:

“Altogether I have been shot nine times. There are witnesses but they are also afraid to make a statement. I myself have witnessed many other police attacks but I’m also afraid to report them. This is what the police call “social cleansing”. According to them, it’s because there are lots of complaints against transgender women doing sex work.” Specialist in Public Health and transgender human rights defender in San Pedro Sula, Honduras, July 2012²¹

Additionally, for transgender women facing criminal prosecution, incarceration with male inmates can also put them at risk of sexual assault.²²

High-risk sex

Though anal sex with condoms and lubricants does not in itself put somebody at high-risk of HIV, there are high rates of unprotected anal sex among transgender women, which carries a high risk of HIV transmission.²³ Several factors affect this situation. Stigma and discrimination, leading to low-self esteem and disempowerment, can make it harder for transgender people to insist on condom use.²⁴ In many settings, condom use is often controlled by the insertive sexual partner, so transgender women who have sex with men can feel unable to instigate condom use.²⁵ Gender-changing hormones, which some transgender women use, can lead to erectile dysfunction, increasing the likelihood of taking the receptive role during sex.²⁶

Globally, a high proportion of transgender people are engaged in sex work, up to 44 percent according to UNAIDS.²⁷ This can be for various, complex reasons. Often, due to social marginalisation and a lack of employment opportunities, sex work is the only income available to transgender people. The high costs associated with transition healthcare can put extra pressure on transgender people to make money.²⁸ Sex workers sometimes get paid more for unprotected sex, and often feel under pressure not to use a condom, which makes them highly vulnerable to HIV. 

There are other social factors that make transgender people more likely to engage in high-risk sex. Studies have shown that some transgender people who want to affirm their gender through sex or who fear rejection from sexual partners can be more likely to agree to unprotected sex.²⁹ The stress of social isolation also leads to a much higher rate of drug and alcohol use among transgender people, which can affect people's judgement of risk and make people less careful to use condoms effectively.³⁰

Currently, there is not enough research on HIV infection and unprotected neo-vaginal sex (sex between a man and a woman who has a surgically constructed vagina) for the transmission risk to be fully understood.³¹ It is possible that this carries a higher risk than unprotected vaginal sex. Many transgender women who have a neo-vagina find that sexual health services often cater only towards birth-assigned men and women, and healthcare professionals don't have adequate knowledge about transitional healthcare.³²

HIV and hormone injections

Another way that this group can be at risk of HIV is through injecting substances for gender enhancement.³³ It is common in some settings for transgender people to obtain injectable hormones, the most common form of gender enhancement, and carry out the injecting themselves. Without counselling on safe injecting practices, people going through this process may be very vulnerable to HIV transmission.

back to top HIV prevention

Prevention initiatives that empower transgender people, by enabling them to lead the way in delivering HIV prevention that meets the needs of their community, are the most effective.³⁴ It is imperative that people of varied gender identity inform national prevention strategies.

“The best part is we know exactly what we are.”

Transgender people, like many other high-risk groups, need access to support beyond HIV and STI services to effectively reduce their risk of HIV infection. Providing welfare, employment initiatives and housing can address the factors that make transgender people more likely to have risky sex.³⁵ Services for other needs should also be provided, such as mental health counselling and support for a sex change operation.

“The best intervention you can provide for transgenders regarding HIV is to employ them. ” Joanne Keatley, Director of the Center for Excellence for Transgender Health, San Francisco.³⁶

Transgender people can have very diverse HIV prevention needs. Targeted prevention approaches that respond to the specific needs of individuals are essential to reducing HIV infections. In an Australian sexual health clinic, transgender clients were found to have very different needs – half of the transgender women reported having had no sexual activities with anyone for at least a year, whilst the other half had high numbers of sexual partners, high rates of injecting drug use and were largely involved in sex work.³⁷ Unfortunately, generalisations about the sexual behaviour of transgender people exist, which can impact upon the effectiveness of HIV prevention interventions.³⁸ In many regions, knowledge about the HIV prevention needs of the young, the elderly and the rural transgender people has been found to be seriously lacking.³⁹

Being part of another 'high-risk group' can put a transgender person at an even higher risk of HIV. In 2009 in the USA, the highest proportion of transgender people newly diagnosed with HIV were Black or Hispanic.⁴⁰ Transgender people need to be able to access prevention advice that is culturally appropriate for their background and community.^{41 42}

Case study: TLBz Sexperts

TBLz Sexperts is a project that uses social media for HIV prevention in Thailand. The website provides a space where transgender people can talk about issues or topics that are relevant to them, such as fashion, sex or socialising. The project then uses this space to advise users on safer sex.^{43 44}

The project was created in response to transgender people being a ‘hard to reach’ group in Thailand. Although there is a large population of transgender women in Thailand, they are often a closed community.  As the project leader Nada Chaiyajit states, ‘transgender people only wanted to engage with inner circles’.⁴⁵ It was therefore imperative that HIV prevention messages came from within the community. Many transgender people were already sharing video clips and using the internet to socialise, so it made sense to create an internet forum to discuss topics such as how the Thai constitution effects transgender people’s human rights in a way that was accessible to the audience.

“The best part is we know exactly what we are. ” Nada Chaiyajit transgender activist from Chiang Mai, who leads the TLBz Sexpert programme.⁴⁶

Online peer counselling has the potential to be adapted by transgender people to meet the different sexual health needs of different community settings.

Case study: The Tamil Nadu Transgender Welfare Board

In Tamil Nadu, a southern state of India, transgender women, or ‘Aravanis’ as they are known, have a history that goes back centuries.⁴⁷ However, in the present day they face many of the structural factors that make transgender people at risk of HIV. One study in India found that 46 percent of transgender women questioned reported being subjected to forced sex. Many Aravanis consume alcohol excessively, to ‘manage rough clients’ or ‘forget worries’.⁴⁸

In 2008 the state government established a ‘Transgender Welfare Board’ to address many of the problems faced by the community that make them vulnerable to HIV. The scheme helps by ensuring access to education, providing different forms of income generation such as land, and putting housing and health measures in place. Many transgender people in the state have now been issued with official identity cards stating their gender as ‘Aravani’, addressing the barrier to healthcare faced by transgender people who don’t have official identification. They also run an official ‘Transgender Day’, promoting the culture, tradition and healthcare of transgender people, and therefore self-esteem.⁴⁹ Tamil Nadu is also the only state to provide free sex reassignment surgery.⁵⁰  

States in India, such as Tamil Nadu, that have a history of transgender people organising groups to advocate for their own rights, tend to also have the highest standards of care and the most community-based organisations meeting transgender people’s needs.⁵¹ This demonstrates that, whilst the welfare board provides a good example of state-level practice that could be replicated across South Asia, there is also a real need to support the formation and organising of groups of transgender people, who can lead the way in addressing their own HIV-related needs.

back to top HIV treatment

Barriers to accessing antiretroviral treatment among HIV-positive transgender people are well-documented.^{52 53} Discrimination from healthcare providers, a lack of knowledge about transgender needs and the refusal of many national health systems or health insurance providers to cover their care all contribute to situations where it is difficult for transgender people to receive adequate treatment. One study of HIV-positive people in the USA found that only 59 percent of transgender participants, compared to 82 percent of those with birth-assigned gender, were accessing HAART.⁵⁴  

HIV-related stigma also creates a barrier to getting tested for many transgender people. In a study in the USA, 73 percent of transgender women who tested HIV-positive were unaware of their status.⁵⁵ As with access to HIV prevention advice, transgender people may delay seeking testing and treatment due to transphobia and insensitivity among healthcare professionals.⁵⁶

“Yes I tested and was not of the best as the person who pricked me urged me to change my life, as I being like I am is immoral, she said. ” Transgender person, South Africa⁵⁷

General isolation and social exclusion also affect access to treatment. Transgender people can be afraid to get tested if they don’t have a strong support network to help them cope with a long-term condition like HIV:

“No, I won’t test. Who will take care of me when I test positive? I have no-one” Transgender person, South Africa⁵⁸  

In some instances, transgender people fear hostility from within transgender communities if they test positive to HIV.⁵⁹ People who are socially isolated may see the loss of a support network as more detrimental to health than not taking antiretroviral treatment.

Depression and isolation are often associated with a 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 HIV-positive transgender people were significantly less likely to report 90 percent or above adherence to treatment than patients who weren’t transgender.⁶⁰ The study found that many transgender people found it difficult to integrate taking regular medication into their lives, and recommended combining antiretroviral treatment regimens with other treatment such as hormone therapy.

For HIV treatment to be effective, it is vital that discrimination against transgender people is tackled, support networks for transgender people living with HIV are created and HIV-related stigma, both within and outside of transgender communities, is tackled.

back to top The way forward

“It would be good to have a transgender health worker who can treat me well and with respect ”⁶¹

For HIV prevention services to be effective, they need to be well-informed. However, research into the factors that make transgender people vulnerable to HIV is still seriously lacking.⁶² There is a real need for researchers, governments and NGOs to research ways to hinder the spread of HIV among this group, particularly in places where their legal rights are not respected. Research is needed not only into what makes transgender people vulnerable to HIV, but also the resilience, support and strength among transgender communities and individuals that can help to hinder the spread of HIV infection.⁶³

Although it is vital that transgender people around the world are informed about safer sex and how to protect themselves from HIV, until their rights are protected by law and respected by society they will continue to be vulnerable to HIV-infection. 

As well as protection by law, transgender people need better access to housing, employment and education if they are not to be driven towards high-risk behaviour.⁶⁴ They must be able to access appropriate transgender specific healthcare services and sexual health information, free from the fear of criminalisation and discrimination.