Abstract and Introduction
Transgender women* are disproportionately affected by HIV. Among 1,608 transgender women who participated in CDC's National HIV Behavioral Surveillance (NHBS) during 2019–2020, 42% received a positive HIV test result. This report provides results from seven U.S. urban areas where the 2019–2020 NHBS questionnaire was administered. Thirty-eight percent of participants reported having previously received a positive test result for HIV. Detrimental socioeconomic factors, including low income (44%), homelessness (39%), and severe food insecurity in the past 12 months (40%), were common and associated with lower receipt of HIV prevention and treatment services. Having a usual health care source or a provider with whom the participant was comfortable discussing gender-related health issues was associated with improved HIV prevention and treatment outcomes, including HIV testing, preexposure prophylaxis (PrEP) use, and viral suppression. These findings illustrate the benefit of gender-affirming approaches used by health care providers, and highlight the challenging socioeconomic conditions faced by many transgender women. Ensuring access to gender-affirming health care approaches and addressing the socioeconomic challenges of many transgender women could improve access to and use of HIV prevention and care in this population and will help achieve the goals of the Ending the HIV Epidemic in the United States initiative.
Initiated in 2003, NHBS conducts biobehavioral surveillance among persons at high risk for HIV infection. During June 2019–February 2020, NHBS surveyed 1,608 transgender women in seven U.S. urban areas using respondent-driven sampling.† Eligible participants§ completed an interviewer-administered questionnaire and were offered an HIV test. The questionnaire included measures of gender identity,¶ income, health insurance, housing,** food insecurity,†† HIV status, viral suppression (if HIV-positive), comfort with their health care provider in discussing gender-related health issues (hereafter referred to as comfort with a provider), unmet need for health care,§§ and usual source of health care. Because of racial and ethnic disparities in HIV prevalence, recruitment was focused on Black or African American and Hispanic or Latina transgender women as initial sampling recruits. Incentives were provided for completion of the interview and HIV test. Adjusted prevalence ratios (aPRs) and 95% CIs for prevention and treatment outcomes, by self-reported HIV status, were estimated using log-linked Poisson regression models with generalized estimating equations clustered on recruitment chain and urban area; models were adjusted for age, race and ethnicity, and urban area. Analyses were conducted using SAS software (version 9.4; SAS Institute). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.¶¶
Data from 1,608 transgender women were included in this analysis (Table 1). Thirty-eight percent reported having previously received a positive HIV test result.*** Forty-four percent earned <$10,000 annually. During the past 12 months 39% experienced homelessness, and 40% experienced severe food insecurity. Nearly one third (31%) of participants were interviewed in Los Angeles. By urban area, reports of homelessness ranged from 22% to 59%, and reports of recent severe food insecurity ranged from 28% to 47%. Comfort with a provider varied by urban area from 66% to 91%.
Socioeconomic status and health care accessibility were associated with health outcomes (Table 2). Among participants who reported a previous positive test result for HIV, self-reported viral suppression was less common among participants who reported experiencing homelessness during the past 12 months (aPR = 0.88; p = 0.003), and the likelihood of viral suppression decreased as the number of nights of homelessness increased. Severe food insecurity (aPR = 0.84; p<0.001) and unmet need for health care (aPR = 0.89; p = 0.027) were also less common among participants who reported viral suppression. Comfort with a provider (aPR = 1.17; p = 0.007) was more common among participants who reported viral suppression. Similar associations were found for current use of antiretroviral medication. Having a usual source of health care was also associated with current use of antiretroviral medication (aPR = 1.16; p = 0.015).
Among participants who did not report a previous positive test result for HIV, testing for HIV during the past 12 months was more likely among those who reported having a usual source of health care (aPR = 1.16; p<0.001) and comfort with a provider (aPR = 1.12; p = 0.004) (Table 3). PrEP use was more common among participants who reported having health insurance (aPR = 1.54; p<0.001), a usual source of health care (aPR = 2.54; p<0.001), and comfort with a provider (aPR = 1.79; p<0.001), and less likely among participants who reported an unmet need for health care (aPR = 0.82; p = 0.050). PrEP use was also more common among participants who had experienced severe food insecurity than those who had not (aPR = 1.23; p = 0.024).
Morbidity and Mortality Weekly Report. 2022;71(20):673-679. © 2022 Centers for Disease Control and Prevention (CDC)