- Transgender people are 49 times more at risk of living with HIV compared to the general population.
- Transgender people often face social and legal exclusion, economic vulnerability, and are at an increased risk of experiencing violence. Disempowerment and low self-esteem make transgender women, in particular, less likely or less able, to negotiate condom use.
- HIV-related stigma and transphobia create barriers to the access of HIV testing and treatment services by transgender people.
- More targeted prevention approaches are needed in combination with increased welfare and employment opportunities to address the specific needs of transgender people.
Explore this page to find out more about why transgender people are at risk of HIV, HIV prevention for transgender people and successful prevention programmes, access to HIV testing and antiretroviral treatment, barriers to HIV treatment and the way forward.
Transgender people are one of the groups most affected by the HIV epidemic and are 49 times more likely to be living with HIV than the general population.1 Globally, it is estimated that around 19% of transgender women are living with HIV.2 Data from Latin America and the Caribbean show that HIV prevalence is much higher among transgender women sex workers than among non-transgender male and female sex workers.3
There are an estimated 25 million transgender people living around the world.4 The term transgender refers to people whose gender identity and expression are different to social expectations of their biological sex at birth. They may see themselves as male, female, gender non-conformist, or one of a spectrum other genders. Transgender people have diverse sexual orientation and behaviours.
Generally, HIV prevalence among transgender women (people who are assigned male at birth but identify as being women) is higher than transgender men (people who are assigned female at birth but identify as being men). However, very little is known about transgender men and their vulnerability to HIV.
Social, economic and legal exclusion
Across the world transgender people experience high levels of stigma, discrimination, gender-based violence and abuse, marginalisation and social exclusion. This makes them less likely or able to access services, damages their health and wellbeing, and puts them at higher risk of HIV.
Overlapping social, cultural, legal and economic factors contribute to pushing transgender people to society’s margins. Transgender people are more likely to have dropped out of education, had to move away from family and friends, and faced workplace discrimination, limiting their educational and economic opportunities. They can encounter problems accessing basic goods and services and even public spaces. These challenges are exacerbated by a lack of legal recognition of their gender and the absence of anti-discrimination laws that explicitly include transgender people.5 According to UNAIDS 17 out of 117 reporting countries had laws that criminalised transgender people.6
Social exclusion, economic vulnerability and a lack of employment opportunities means that sex work is often the most viable form of income available to transgender people, and a high proportion of transgender people engage in sex work. For example, the proportion of transgender people who sell sex is estimated to be up to 90% in India, 84% in Malaysia, 81% in Indonesia, 47% in El Salvador and 36% in Cambodia.7
HIV prevalence among transgender sex workers is as high as 32% in Ecuador and Panama compared to just 0.4% and 0.6% respectively among the general population.8 A 2008 systematic review showed that global HIV prevalence among transgender people who engaged in sex work was 27%, compared to 15% among transgender people who did not sell sex.9
Data suggests that HIV prevalence is up to nine times higher for transgender sex workers compared to non-transgender female sex workers.10
Knowledge and reported use of condoms is generally low among transgender sex workers. In Asia and the Pacific, only 50% of transgender sex workers are aware of HIV and HIV testing, and only 50% reported using condoms consistently with clients and casual partners.11
In addition, the high costs associated with transition healthcare can put extra pressure on transgender people to make money.12 Sex workers sometimes get paid more for unprotected sex, and often feel under pressure not to use a condom, which makes them highly vulnerable to HIV.
There are high rates of unprotected anal sex among transgender women, which carries a high risk of HIV transmission.13 Several factors contribute to this. Stigma and discrimination, leading to low self-esteem and disempowerment, can make it harder for transgender people to insist on condom use.14
In many settings, condom use is often controlled by the insertive sexual partner, so many transgender women who have sex with men can feel unable to instigate condom use.15 Gender-changing hormones, which some transgender women use, can lead to erectile dysfunction, increasing the likelihood of taking the receptive role during sex.16
There are other social factors that make transgender people more likely to engage in high-risk sex. Studies have shown that some transgender people who want to affirm their gender identity through sex, or who fear rejection from sexual partners can be more likely to agree to unprotected sex.17
The stress of social isolation may also lead to a much higher rate of drug and alcohol use among transgender people that can affect their judgement of risk and make them less likely to use condoms.
It is common for transgender people to obtain injectable hormones, the most common form of gender enhancement, and carry out the injecting themselves.
Without counselling on safe injecting practices, people going through this process may be very vulnerable to HIV transmission because of the risk of sharing needles with others.18
Transgender people can have very diverse HIV prevention needs. Targeted prevention approaches that respond to the specific needs of individuals are essential to reducing HIV infections. In addition, prevention initiatives that empower transgender people and enable them to take the lead in meeting the needs of their own community are the most effective.19
Sexual health care for transgender people is often inadequate, with many policy makers and service providers failing to address the needs of transgender women as a population distinct from men who have sex with men.20 Only 39% of countries in 2014 had specific programmes targeting transgender people in their national HIV strategies.21