Overall, 42 percent of transgender women surveyed in seven major metro areas have HIV. The results of the study are even more startling when it comes to Black transgender women. Some 62 percent have HIV compared to 35 percent of Hispanic trans women and 17 percent of white trans women.
In addition to transgender women being disproportionately impacted by HIV – especially in Atlanta – 63 percent of the women surveyed lived at or below the poverty level, 42 percent experienced homelessness in the last 12 months and nearly 54 percent experienced verbal abuse or harassment in the last year.
Healthcare providers in Atlanta who work with transgender women said they aren’t surprised by the report. They said it shows the impact of the marginalization transgender women face and the need for culturally competent care.
“We don’t have gender-affirming facilities and processes for folks trying to receive services,” said Justine Ingram, a capacity-building assistance specialist at the Southern AIDS Coalition and program manager for Trans Housing Atlanta Program.
“That negatively affects them and pushes people to go into survival mode and continue to be marginalized and makes it difficult for them to get jobs and continue their education, to find stable and affordable housing. That makes the risk even greater for transgender women,” Ingram added.
Transgender women will avoid seeking healthcare for fear of facing transphobic providers, an issue that must be addressed by starting “at the front desk,” according to Queen Hatcher-Johnson, the gender-inclusive program manager at Positive Impact Health Centers.
“From the front door to the backdoor, people should be trained on people of trans experience and what this encounter will look like,” Hatcher-Johnson said. “There is transphobia in the healthcare system, there is misgendering – a whole lot of things that keep people out of care.”
The report from the Centers for Disease Control & Prevention was based on interviews with 1,608 transgender women conducted in 2019 and early 2020 across seven metro areas – Atlanta, Los Angeles, New Orleans, New York City, Philadelphia, San Francisco and Seattle. The CDC asked the women about HIV, risk factors, PrEP, sexual behaviors, drug and alcohol use, abuse and suicide.
Across the seven metro regions, 42 percent of transgender women have HIV. But HIV prevalence varied dramatically from a high of 58 percent in Atlanta to a low of 21 percent in Seattle. The other cities were New York (52 percent), Philadelphia (51 percent), New Orleans (45 percent), San Francisco (41 percent) and Los Angeles (33 percent).
“These data provide a clear and compelling picture of the severe toll of HIV among transgender women and the social and economic factors – including systemic racism and transphobia – that are contributing to this unacceptable burden,” Demeter Daskalakis, director of CDC’s Division of HIV/AIDS Prevention, said in a prepared statement.
“Reducing HIV in these communities will require that public health and other providers of social and prevention services design innovative and comprehensive status-neutral solutions to overcome barriers to whole person prevention and care,” Daskalakis added.
PrEP use low among Atlanta trans women
Georgia already faces one of the highest rates of HIV infection in the U.S. The new CDC report showed that the issue is even more acute among transgender women in metro Atlanta:
• Atlanta had the second-lowest rate of HIV testing for transgender women among the seven cities – 78 percent, compared to 82 percent overall. Only Seattle had a testing rate lower than Atlanta at 61 percent.
• Transgender women without HIV are aware of PrEP at a higher rate than most other major cities. Some 92 percent of trans women are aware of the once-a-day pill to help prevent HIV, which matches the overall rate in the report. Only Philadelphia (96 percent) and San Francisco (95 percent) had higher PrEP awareness than Atlanta.
• In Atlanta, PrEP usage among trans women without HIV was among the lowest seen in the report. Overall, 32 percent said they use PrEP. In Atlanta, it’s 23 percent, which is second-lowest only to Seattle (17 percent). The highest PrEP usage is in San Francisco (46 percent).
Some 67 percent of trans women without HIV in the study are taking hormones for gender affirmation. Concern about drug interactions between the hormones and PrEP could impact its usage, according to the CDC.
The low use of PrEP among transgender women in Atlanta is also driven by a variety of factors that also impact the higher rates of HIV seen across the South, according to Joel Rosenstock, medical director of AbsoluteCare Atlanta.
“A lack of access to care, lack of Medicaid expansion and social determinants of health all contribute to the low uptake of PrEP. The lack of low cost PrEP clinics in the Atlanta area contributes to these numbers,” Rosenstock said.
The high rates of poverty and homelessness among transgender women reflected in the CDC report also contribute to the HIV rates seen in Atlanta, he added.
Transgender people are drawn to metro Atlanta from across the South, but the region struggles to provide healthcare services to prevent HIV among trans women, Ingram said.
“We have a lot of transgender people relocating to Atlanta for a better life. They may move from rural towns or families that don’t provide that support and acceptance. They will come to Atlanta to get that acceptance and be around like people,” Ingram said.
But a lack of gender-affirming healthcare, stable housing and accepting jobs makes it difficult for trans women, she added.
“If we don’t have housing and we don’t have a safe place to sleep at night or store our things or food, then how we can we worry about our health? If this community is fearing for their safety all the time, you don’t want to go out to doctor’s appointments and be proactive and stay on top of your health,” Ingram said.
Many healthcare options for transgender women focus on those with HIV, Hatcher-Johnson said, but offering robust and holistic care that addresses mental health would impact HIV rates.
“The way the prevention system is currently set up is for them to be HIV-positive. People who are not living with HIV see the benefits of having HIV. They are not getting what they need to stay HIV-negative,” Hatcher-Johnson said.