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Homelessness, violence, incarceration, and socioeconomic discrimination are linked to a high risk of HIV in transgender women, according to the CDC's National HIV Behavioral Surveillance Among Transgender Women (NHBS-Trans) survey.

Despite engaging in high-risk behaviors, only one-third of transgender women in the survey used pre-exposure prophylaxis (PrEP) for HIV. Employment discrimination also negatively impacted transgender women's access to health insurance and gender-affirming care.

Results of the NHBS-Trans survey appeared in a .

"These results underscore the importance of prioritizing HIV prevention interventions that address social determinants of health (e.g., housing and poverty), providing supportive interventions that encourage positive attitudes toward transgender women, improving access to gender-affirming healthcare, and working with clinicians serving transgender women to incorporate HIV prevention, including PrEP, into their service," the CDC wrote in a summary.

Transgender women are , especially those belonging to racial and ethnic minority groups. To better understand behavioral risk factors, PrEP usage, and HIV prevalence in this understudied population, the CDC implemented the NHBS-Trans program, said Dafna Kanny, PhD, of the CDC's National Center for HIV, Viral Hepatitis, STD, and TB Prevention, and colleagues in an .

From 2019 to 2020, approximately 1,600 transgender women in seven urban areas in the U.S. participated in the NHBS-Trans survey, which consisted of standardized, anonymous questionnaires about HIV-related behavioral risk factors.

HIV Risk Behaviors and PrEP

Awareness of PrEP among transgender women was high (92%), noted Elana Morris, MPH, and colleagues from the CDC in their report on the among transgender women without HIV. However, only 32% said they used HIV PrEP in the prior 12 months, and 56.6% said they discussed PrEP with a healthcare provider.

Of the 902 HIV-negative transgender women interviewed in the survey:

• 42.5% reported having five or more sex partners in the past year
• Nearly 65% reported having condomless sex
• Approximately 34% received money or drugs in exchange for sex
• 41.1% reported that they did not know the HIV status of their last sex partner
• 14.5% had condomless sex with the last partner whose HIV status was positive or unknown
• 5% reported injecting drugs

Transgender women ages 40 and up were the least likely to discuss PrEP with their healthcare provider. Those who received gender-affirming healthcare were more likely to discuss PrEP and use it. Hispanic and Black transgender women were more likely than white transgender women to use PrEP. This was an encouraging finding, the authors commented, given that HIV disproportionately affects these groups.

Condomless Anal Intercourse and Co-Occurring Conditions

Among, , 55% reported condomless anal intercourse (CAI) in the past year, CDC researcher Rebecca Hershow, PhD, and colleagues said.

Approximately one in four of these transgender women reported three or more co-occurring harmful social conditions that included incarceration, homelessness, exchange sex, poly-drug use, sexual violence, or psychological distress. Looking at the survey population overall, the researchers found statistically significant positive associations between engagement in CAI within the past year and all co-occurring conditions.

The authors noted that some factors in combination were associated with engaging in CAI, and these factors differed by racial and ethnic groups. Black transgender women who were homeless and engaged in exchange sex were more likely to engage in CAI. Among Hispanic transgender women, there were associations between CAI, exchange sex, and poly-drug use. For white transgender women, multiple interconnected associations existed between CAI and co-occurring conditions. These associations should be taken into consideration when designing interventions to prevent HIV acquisition, the authors wrote.

Nonprescription Hormone Use

In the NHBS-Trans survey, 1,165 transgender women during the past 12 months, and 91.7% of these individuals reported current hormone use, wrote Evelyn Olansky, MPH, of Social & Scientific Systems in Silver Spring, Maryland, and colleagues.

Transgender women ages 18 to 29 were significantly more likely to use hormones compared with those ages 40 to 49 and those over 50 (22.8% vs 9.7% and 16.1%). Nonprescription hormone use was more common among those who weren't seeing a healthcare provider, those who lacked transgender-specific health insurance or access to transgender-specific care, those who reported recent or current homelessness, or those who engaged recently in exchange sex.

Notably, transgender women without transgender-specific health insurance coverage were more than twice as likely to use nonprescription hormones than those who had transgender-specific health insurance coverage.

"Hormone treatment can cost hundreds of dollars to initiate even when insured and might come from a culturally insensitive provider," Olansky and team wrote. "As a result, many transgender persons choose to independently obtain and administer their own hormone treatment."

"Even if the dangers of using nonprescription hormones are known, the dangers of stigmatizing and unsupportive experiences in healthcare and high medical costs might be more salient for those who desire hormonal treatment," they added.

Homelessness

People who experience homelessness are at increased risk for HIV acquisition and poor HIV outcomes. Among responding to the NHBS-Trans survey, 40% experienced homelessness during the past 12 months, reported CDC researcher Ruthanne Marcus, PhD, and colleagues.

Of this group:

• 31% were homeless for 30 to 365 nights, and 9% were homeless for 1 to 29 nights
• 50% of participants who reported intimate partner violence and 47% who reported forced sex experienced 30 to 365 nights of homelessness
• 58% of those who were incarcerated during the past year were homeless for 30 to 365 nights
• Transgender women who were younger, had a disability, or higher psychological distress scores had higher odds of longer durations of homelessness
• Those who were less educated, had less social support, and lived below the federal poverty level had longer homelessness durations

"Efforts to prevent HIV transmission and to address housing instability for transgender women are urgently needed," the authors wrote. "These efforts should focus on systemic problems of economic instability, housing discrimination, and antitransgender discrimination that affect transgender women's ability to access safe and affordable housing."

Employment Discrimination

Seven in 10 of reported experiencing transphobic discrimination in the past year, and approximately one in three reported some form of employment discrimination, said Amy Baugher, MPH, of the CDC, and colleagues.

Because healthcare access is linked to employment in the U.S., employment discrimination may adversely affect the health of transgender women, including access to HIV prevention and treatment, the authors wrote.

Approximately 32% of transgender women reported difficulties getting a job because of being transgender, and 10% were terminated from their jobs. Transgender women who were younger and of lower socioeconomic status were more likely to experience employment discrimination.

Notably, difficulties obtaining employment or staying employed were associated with problems accessing healthcare, unmet medical needs due to cost, and lack of access to transgender-specific care and gender-affirming procedures, Baugher and team added.

Violence and Harassment

Among , nearly 6 out of 10 experienced some type of violence or harassment in the past 12 months, and approximately 18% reported suicidal ideation, said Patrick Eustaquio, MD, of Oak Ridge Institute for Science and Education in Tennessee, and colleagues.

Despite these statistics, a majority reported high levels of social support from significant others (75.2%) and friends (69.4%), and nearly half (46.8%) reported support from family members. However, social support did not completely moderate the effects of violence and harassment on suicidal ideation.

The findings of the NHBS-Trans survey had several limitations, Kanny and authors wrote. The self-reported survey results are not generalizable to all transgender women. Additionally, NHBS-Trans was a one-time cross-sectional survey, so causality or directionality was not determined.