MMWR Supplement on National HIV Behavioral Surveillance Among Transgender Women—Seven Urban Areas,United States,2019-2020

The analyses presented in the MMWR Supplement “National HIV Behavioral Surveillance Among Transgender Women—Seven Urban Areas, 2019-2020” highlight findings from the Centers for Disease Control and Prevention’s National HIV Behavioral Surveillance Among Transgender Women (NHBS-Trans) project conducted during 2019-2020. Each article in the supplement presents findings related to unique aspects of the lived experience and health of transgender women in the United States. However, taken together, the analyses elucidate a vivid picture of the challenging health care experiences of transgender women in the United States. To accelerate health equity, leaders of health care institutions should better recognize transgender patients’ health disparities and work to remediate barriers to primary and preventive care. Transgender people’s health can thrive both when they are free to express who they are and when they are able to access affirming health care services. The data presented in this supplement support scientific and journalistic evidence that not all transgender people experience health equity.

Transgender women disparately experience social marginalization and discrimination. ¹ Among the 1608 participants in the NHBS-Trans survey, 60% reported experiencing physical violence, verbal abuse, or rape during the past 12 months ² ; 70% reported experiencing some type of transgender-specific discrimination; >30% were either fired from employment or had trouble getting a job ¹ ; and 14% had been evicted or denied housing ³ during the past 12 months because of their gender identity. Nearly 18% had been incarcerated in the past 12 months. ⁴ Such experiences contribute to economic hardship: 63% of transgender women were living at or below the federal poverty level; 40% had experienced severe food insecurity during the past 12 months ¹ ; and 40% had experienced homelessness during the past 12 months. ³ Of those experiencing homelessness (n = 630), 24% were homeless on 365 of the previous 365 nights. ³ Economic deprivation and employment discrimination can increase the need for alternate means of survival that increase the risk for HIV, sexually transmitted infections, and violence. Transgender women are disparately affected by HIV: 42% of NHBS-Trans participants had confirmed HIV diagnoses, ⁴ yet only 32% of transgender women who were seronegative reported recently using any form of preexposure prophylaxis. ⁵

Repeated experiences of social marginalization and the constant struggle to meet basic needs exact a mental health toll that exacerbates the challenges experienced by transgender women in the United States. Among NHBS-Trans participants, 26% of transgender women had experienced psychological distress during the previous 30 days, ⁶ and 18% had seriously considered suicide during the previous 12 months. ² Of transgender women, 22% did not currently have any health care provider with whom they felt comfortable discussing gender identity, and 13% reported having never, at any point in their lives, had a health care provider with whom they had been comfortable discussing their gender identity. ¹ Communication and trust are cornerstones of patient-centered care, yet many transgender people in the United States do not have a trusted patient–provider relationship.

Addressing HIV through a syndemic lens is critical to our efforts to end the HIV epidemic in the United States. The syndemic approach means that for a disparately affected population such as transgender women, the following considerations are all relevant to one’s HIV risk: alcohol, tobacco, and other drug use; mental health challenges; and sexually transmitted infections. Similarly, the social determinants of health, particularly safe housing and communities, are central to transgender people’s basic needs. These syndemic factors and social determinants of health are at play in any HIV prevention conversation with transgender women.

The evidence is compelling. We must work at all levels of society to eliminate the causes of HIV disparities that affect transgender women.