Women of transgender experience in the United States were 12% more likely to receive HIV care and 79% more likely to take HIV prevention pills in 2019 and 2020 if they had a gender-affirming healthcare provider, according to data published in Morbidity and Mortality Weekly Report.

Kathryn Lee, MPH, and colleagues at the National Center for HIV, Viral Hepatitis, STD and TB Prevention at the Centers for Disease Control and Prevention (CDC) used 2019 to 2020 data provided by 1,608 transgender women through the National HIV Behavioral Surveillance system. The women lived in seven cities across the U.S.: Atlanta, Los Angeles, New Orleans, New York City, Philadelphia, San Francisco and Seattle.

About half the women were younger than 30 years, 35% were Black and 40% were Latina. Overall, the women were struggling financially: 40% reported going hungry (severe food insecurity), 39% had been homeless and 44% earned less than $10,000 a year. However, there was no difference in the rate of homelessness between women with and without HIV.

While 83% reported that they currently had health insurance, one in five said they’d gone without medical care in the last year. This was despite the fact that 74% of those who had gone without care did have a usual source of care. Lack of access to health care was also associated with higher rates of severe hunger and more nights of homelessness over the last year.

Nearly two out of five women (37%) had received a positive HIV test, with the rest either knowing they were negative or not knowing their status. Nearly nine out of 10 women living with HIV reported that they had a regular health care provider and 87% reported having a provider they were comfortable talking with about their gender. This was higher than women without diagnosed HIV, 72% of whom had a provider they felt comfortable with.

Most trans women living with HIV (90%) were currently taking antiretroviral medications, and around 75% reported having an undetectable viral load. But viral suppression varied widely depending on life circumstances. For instance, women who’d experienced homelessness were 12% less likely than their stably housed sisters to have an undetectable viral load. And that proportion increased with the number of days without housing: 55% of women who’d been homeless for a full year were undetectable, compared with 70% of those who’d been homeless for more than a month but less than a year, 78% who’d been homeless less than a month and 82% among women with stable housing.

The same trends were evident when the researchers looked at income. If women earned at least $20,000 a year, they were 18% more likely to have an undetectable viral load than those earning less than $10,000. Women with health insurance were 14% more likely to have viral suppression than those without, and severe hunger was associated with a 16% reduction in viral suppression.

Lack of access to a regular health care provider was associated with a 7% reduced likelihood of having an undetectable viral load. But there was good news too. Women who were comfortable with their provider were 16% more likely to currently be taking HIV medications and 17% more likely to have viral suppression.

The data also showed that similar trends held true for HIV-negative trans women who could potentially benefit from pre-exposure prophylaxis (PrEP). While just 29% of women had used PrEP in the last year, that rate went up dramatically if they were comfortable with their provider—a 79% increase. Socioeconomics also correlated with PrEP use. Women who had stable access to food used PrEP more often (a 23% increase) as did those with consistent access to a safe place to sleep (a 33% increase compared with women who’d been homeless for a year).

These findings led Lee and colleagues to conclude that structural changes, as well as access to gender-affirming care, could move the needle on HIV acquisition and viral suppression for women of trans experience, citing the need for programs such as Housing Opportunities for Persons with AIDS.

“Early detection of HIV, appropriate treatment and proven prevention interventions are effective tools in the fight against HIV and are key strategies in ending the HIV epidemic,” they wrote. “Although access to health insurance and gender-affirming health care is critical to connecting transgender women to HIV prevention and care services, access to food, housing and income are also essential.” 

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