What puts young trans* women at risk for HIV? A Q&A with two San Francisco researchers
Transgender women have one of the highest HIV prevalences in the U.S. It’s estimated that over a quarter—28%—of adult trans* women in the U.S., and nearly 40% in San Francisco, are living with HIV. Why are rates of HIV so high among trans* women in our communities?
That’s something Erin Wilson, DrPh, MPH, from the Center for Public Health Research at San Francisco Department of Public Health, has been studying for many years. In a recent study published in JAIDS, Wilson and lead author Caitlin Turner, MPH, examined the personal, social and environmental factors that may lead young trans* women to engage in HIV risk behaviors. In the Q&A below, Wilson and Turner talk to BETA about their research, and what their research says about how we can improve the health of young trans* women everywhere.
(In this article, we use the term “trans* woman” as an overarching term to refer to people who were assigned a male sex at birth and who identify as female, transgender, non-binary, and/or non-conforming now.)
BETA: Why is it important to have a better understanding of how and why young trans* women are at risk of HIV?
Erin Wilson, DrPH, MPH: I started doing research 15 years ago at an adolescent health clinic in Los Angeles. We provided a number of programs for youth and young adults, and served young trans* women in our clinic, up to age 24. It was striking how many young trans* women were coming in and testing positive for HIV. We did a small study and found that 19% of our 151 youth were living with HIV. That’s extraordinarily higher than any other youth population.
Fifteen years later, unfortunately, not a lot has changed. We do a lot of surveillance of HIV among adult trans* women in San Francisco—San Francisco Department of Public Health was actually the first organization to respond to a community need to understand how the HIV epidemic was affecting the trans* population. In 1997 they conducted the first study [with adult trans* women], and found that 35% of the population was living with HIV. In 2010, another study found that the prevalence was around 35%. In 2013, we saw similar rates—closer to 40%.
So we see this extraordinarily high prevalence of HIV among adult trans* women, but among young trans* women the prevalence is much lower. We see this climb—from about 6% to about 40%—which is a huge leap, and a major problem.
That’s why we’re focusing on youth. We want to know, what’s happening between the ages of 24 and 35 to increase this HIV risk? Why are they at risk? And how can we gather data to create prevention that’s relevant for them?
Your year-long study involved surveys with over 250 trans* women in San Francisco between the ages of 16 and 24. What did you learn?
Turner: In general, we were interested in looking at HIV-related risk behavior, infection and transmission through a social epidemiology lens. This posits that social, structural and individual factors interact to produce HIV risk behavior over time. We looked at things like racial and gender-based discrimination. And parent or caregiver factors like acceptance of gender identity. We asked whether participants had ever run away from home. We looked at individual-level factors like substance use and depression. And we wanted to see which experiences or factors were associated with behaviors that put people at risk for HIV—namely condomless receptive anal sex.
Here’s what we found.
Higher income in the last month and higher exposure to gender-based discrimination were significantly associated with increased sexual risk behavior over a 12-month follow-up period. So were crack or cocaine use and reporting being in a serious relationship since identifying as trans*.
Trans* female youth who identified as Black or African American, Hispanic or Latina/o, or another racial minority had higher engagement in condomless anal intercourse compared to white trans* female youth.
It seems surprising that having a higher income and being in a serious relationship were both associated with more risk behavior. Do you know why this was?
Turner: We thought higher income would have a protective effect, so we did an analysis afterwards to explore why this was. We looked at relationship between higher income reported in the past month and sex work—and it looks like the two are related. Sex work may explain why some people in the study had a higher income, and why they were also engaging in more condomless anal intercourse.
We were curious about why being in a relationship since identifying as trans* predicted higher risk. I think these findings affirmed that there’s a lack of understanding about sexual risk in the context of primary partnerships for trans* women. It could be that trans* women are serosorting—having partners with the same HIV status but still engaging in condomless receptive anal intercourse.
What does your research say about how to improve the health of young trans* women in our community?
Turner: I think one of the major takeaways was that there are a lot of structural things going on here that may require more policy work or community engagement. That might include higher-level anti-discrimination interventions that happen in schools or work settings. Or that include access to gender-affirming medical care.
Wilson: It’s not as simple as a health education intervention—that’s not going to move the needle. We need to address all of the structural factors, too—housing, unemployment, discrimination, and ways to cope with these stressors, all the way down to health education. The approach has to be comprehensive.
Trans* identified individuals and their allies are welcome to join the San Francisco AIDS Foundation TransLife counseling and harm reduction group meetings at 1035 Market Street in San Francisco. Look here for more information about TransLife. Read more about transgender health issues on BETA.