As state legislatures continue to debate banning gender-affirming care for transgender people, new evidence suggests that providing such care is associated with better health for people living with HIV.

Transgender New Yorkers living with HIV who received gender-affirming surgeries through Medicaid saw their viral load drop in the years following surgery, according to data presented last week at the Conference on Retroviruses and Opportunistic Infections (CROI).

Though Medicaid doesn’t report transgender identity, researchers described an algorithm at last year’s CROI that they developed to cross reference transgender-related diagnosis codes, restrictions and exceptions, prescription medications and sex to collect data on transgender people on Medicaid in New York. Then they cross-referenced that data with the New York City HIV Registry to identify trans people with HIV receiving medical transition care through the public insurance program.

At this year’s meeting, epidemiologist Cristina Rodriguez-Hart, PhD, of the New York City Department of Health and Mental Hygiene said it’s very likely that the algorithm undercounts transgender people.

In this new analysis, the researchers used the algorithm to identify 1,730 adults of transgender experience living with HIV in New York City who had access to Medicaid between 2013 and 2017. Within that group, they searched for people whose medical data showed codes for gender-affirming surgeries. They excluded facial feminization surgeries because there were too few to perform an analysis (just 10 in four years.)

For comparison, they also gathered data on transgender people with HIV for whom there was no evidence of access to Medicaid and cisgender people with HIV, both with and without Medicaid.

Then they looked at viral load data for all groups. For people who accessed gender-affirming surgery between 2013 and 2017, they also tracked viral load for two years before surgery and two years after it.

“Anecdotally, we heard that surgeons usually require [transgender people living with HIV] to be virally suppressed prior to surgery,” Rodriguez-Hart said in her presentation. “So we felt it was important to look at viral suppression before and after surgery for those found to be suppressed at their last labs. Without this, we wouldn’t know if these individuals had achieved viral suppression just for surgery.”

What they found was that 185 of the 1,730 trans people with HIV on Medicaid had gender-affirming surgery. More than half of these study participants (57%) were Black, 22% were between ages 20 and 29 and nearly half (44%) lived in high-poverty areas—all groups that are less likely to have viral suppression in New York City, Rodriguez-Hart said. The 1,730 HIV-positive trans people on Medicaid accounted for 1.7% of the people living with HIV in the city during that time.

When the researchers looked at viral load, they found that transgender people with HIV on Medicaid saw the greatest improvement between 2013 and 2017: The proportion with undetectable viral load rose to 75%. Still, this put the group on the low end of viral suppression rates among the people with HIV in the analysis. For comparison, 83% of transgender people not on Medicaid, 82% of cisgender women and 86% of cisgender men with HIV had an undetectable viral load in 2017.

However, when the team looked at transgender people with HIV on Medicaid who received gender-affirming surgery, the numbers looked different. Within this subgroup, 85% had an undetectable viral load—nearly even with cisgender men. The proportion rose from 66% with an undetectable viral load two years before surgery to 77% maintaining undetectable status one year before surgery to 86% doing so one year after surgery. By two years after surgery, 88% of those people still had an undetectable viral load.

Those were the overall findings. When they broke the data down according to top surgery, bottom surgery or both, the researchers found that the proportion of trans people with viral suppression ticked up. People who received top surgery were on track with the overall trends before surgery. But by one year after, 92% had an undetectable viral load. People who had bottom surgery had marginally higher rates of viral suppression before surgery but saw their rate dip to 84% one year after surgery. However, they were expected to reach 90% viral suppression by two years out. (This was a combination of projections for people who were not yet two years out from surgery and based on data from people who’d already reached that mark.)

For people who had both top and bottom surgery, 84% had an undetectable viral load both one and two years prior to surgery, but 100% of them had viral suppression one year out from surgery.

But we can’t say that the surgery led to undetectable viral loads, Rodriguez-Hart said. This was an association, not causation. Any number of things could contribute to viral suppression among people receiving surgery. One, she said, was that receiving the care they needed from professionals trained to work with transgender people could have built trust in a health care system that has often misgendered and otherwise mistreated people of trans experience.

“Obtaining affirming surgery, a process that involves multiple interactions with the health system, may provide greater opportunities for affirmation, positive experiences with providers and better management of HIV and non-HIV outcomes,” she said. “The higher viral suppression for those with top and bottom surgery suggests a possible positive synergistic impact that we should look into further. This is all the more reason why [transgender people living with HIV] need more support—so that they can obtain better overall health and obtain affirming surgeries that they may wish to obtain.”

Click here to read the study abstract.

Click here to read more about HIV care and prevention for people of trans experience.