Transgender men and transmasculine people in the United States have a higher rate of HIV than the general population, but this appears to be largely driven by those who have sex with cisgender men, according to a study published in the Journal of the International AIDS Society.

“These findings have important implications for clinicians, researchers and policymakers, since transgender men are often not included in HIV prevention research and are not prioritized for HIV prevention intervention efforts, which may contribute to their suboptimal utilization of HIV pre-exposure prophylaxis (PrEP),” the study authors wrote.

Research on HIV among transgender people has historically been scarce. Studies of transgender women have increased in recent years, showing that this group has a high rate of HIV. Data on trans men remain limited, but the epidemiology of the recent mpox (formerly monkeypox) outbreak shows that many transmasculine people are part of gay and bi men’s sexual networks, suggesting they have an elevated risk for exposure to HIV.

Asa Radix, MD, PhD, of Columbia University’s Mailman School of Public Health, and colleagues assessed HIV prevalence among transgender men and transmasculine people who received care at Callen-Lorde Community Health Center in New York City, a clinic that specializes in care for the LGBT community.

Estimates of the prevalence of HIV among trans men range up to 4%, but previous U.S. studies have not stratified participants based on the sex and gender of their sex partners, the researchers noted as background. This study aimed to take into account this and other relevant factors, including socio-demographics and receiving gender-affirming care, such as hormone therapy or surgery.

The Transgender Data Project was a retrospective chart review of all adult transgender and gender-diverse clients at the clinic between January 2009 and December 2010. Data included birth sex, current gender, race/ethnicity, education, employment, housing, insurance status, sex and gender of sex partners, HIV screening and status, and receipt of gender-affirming care.

The analysis included 577 transmasculine people, defined as those who were assigned female at birth and currently identified as transgender men, transsexual men, FTM (female-to-male), gender-nonconforming or genderqueer. The average age was 32 years. Just over half (55%) were white, followed by 14% Black and 12% Latino. Most (79%) had received testosterone, and 42% had undergone at least one gender-affirming surgery, most often mastectomy. A majority (64%) reported having at least one cisgender (not transgender) female sex partner, while 32% reported at least one cisgender male partner; 9% had cisgender male partners only.

HIV screening was “suboptimal,” with less than half of the participants (43%) having ever been tested. Those who had been screened were less likely to be white and more likely to be Black. This low rate was unexpected, the authors noted, at a health center with a robust HIV program where all clients presumably had good access to HIV and sexually transmitted infection screening services.

Of the 250 people screened, seven were HIV positive, for an overall HIV prevalence of about 2.8%, “notably higher than the U.S. population prevalence,” the researchers reported.

The prevalence was about twice as high for trans men who had sex with cisgender men compared with those who had sex with cisgender women (3.5% versus 1.8%, respectively). The prevalence was highest among transmasculine people who reported having sex only with cisgender men, at 11%, but the numbers were likely too small (two positive cases out of 18 people tested) to consider this a meaningful difference compared with participants who reported any sex with cisgender men. People with at least a high school education were less likely to have HIV, but again, the numbers were small.

“Although HIV prevalence has been estimated to be low among transgender men, the analysis found heterogeneous results when stratified by gender of sexual partners,” the study authors concluded. “The results underscore the need to understand sexual risk among transmasculine individuals and to disaggregate HIV data for those having sex with cisgender men, thus also allowing for better inclusion in HIV prevention efforts.”

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