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HIV Care for Transgender People
Integrating Care: Is This the Way to Reach Transgender People Living With HIV?

Released: July 10, 2024

Expiration: July 09, 2025

Marta Boffito
Marta Boffito, MD, PhD, FRCP, MBA
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Key Takeaways
  • Transgender people are more likely to have HIV and to be diagnosed late, which increases the risk for complications and poor outcomes.
  • Many of the barriers to care faced by transgender people with HIV can be addressed by integrating HIV services and gender-affirming care. 

Transgender women are a key, underserved population in HIV care. A 2013 meta-analysis of several small-scale studies from the USA and Asia-Pacific, Latin American, and European countries suggests a 49-fold higher likelihood of HIV transmission in transgender women, in comparison with all other populations of reproductive age. This equates to an estimated 19% global prevalence of HIV in transgender women. These numbers are staggering.

Furthermore, transgender people living with HIV are more likely to be diagnosed late and with a CD4 count below 200 cells/mm3, resulting in increased risk of complications and poorer outcomes. This represents a major gap in HIV care and demonstrates the vital need for better strategies to optimize linkage of these populations to HIV care.

Integrating Care
Transgender people living with HIV have been shown to present with different comorbidities and to report high levels of experienced stigma, violence, unsafe sex, guilt and shame, suicidal ideation, and fear of rejection.

Transgender people also often feel greater concern about side effects of antiretrovirals and potential drug–drug interactions with their hormones, which are frequently purchased over the internet because of the challenges associated with accessing gender healthcare.

But when transgender people living with HIV have access to HIV clinics that have been integrated with gender and sexual health services, these challenges seem to be overcome. Integrated care is associated with high rates of both patient satisfaction and viral suppression. 

These findings demonstrate that, to promote HIV care linkage, HIV services should provide joint gender-affirming healthcare and sexual healthcare. Since feminizing or masculinizing hormonal therapy is so important to patients, such services should be complemented with drug reconciliation and drug–drug interaction expertise. Ideally, such integration should also be supported by gender health–trained psychologists to support acute and long-term mental health conditions.

In addition, providing integrated care can improve quality of life and reduce burden of healthcare on transgender people by reducing the frequency of medical appointments and blood tests. Trans-inclusive healthcare should be implemented by providing our staff with specific training on trans people's health needs and how to overcome barriers rooted in societal stigma and discrimination against transgender people.

Most important, the design and implementation of such restructure and interventions should be the result of a comprehensive collaboration between the community and healthcare professionals (HCPs). The primary goals of integrated care should be to improve the health and the quality of life of transgender people with HIV and to reduce disparities in the HIV care continuum, to further the UNAIDS vision of zero new HIV diagnoses, zero discrimination, and zero AIDS-related deaths. 

Building a Welcoming Environment for Trans People
In practice, this entails understanding that gender-affirming care is the process of helping patients recognize, accept, and express their gender identity. As HCPs, our responsibility is to support patients medically, as well as socially and psychologically. At the most basic level, HCPs should understand the correct use of gender identity terms and appreciate that gender identity is multifaceted.

Before or at the very beginning of the appointment, it is important to assess whether the person you are seeing understands and speaks your language. The presence of an interpreter, especially one who is trained in transgender healthcare, can be remarkably helpful in making patients feel safe and understood. With new patients, HCPs should make it a point to ask for an individual’s chosen name and pronouns, and to use them throughout. HCPs should also be culturally competent with respect to the populations we serve, and knowledgeable of available mental health resources.

Ideally, the clinic should be a safe and affirming space for people who often experience increased discrimination, societally and institutionally. Transgender representation is key, and can take on many forms, including displaying images of transgender people and providing gender-neutral resources, such as gender-neutral restrooms. Peer navigation services and hiring transgender staff can also go a long way towards building trust.

In summary, gender-diverse populations may present with distinctive physical and mental health needs. Therefore, service structures and HCPs must address such needs by delivering gender-affirming, inclusive care with an informed approach across all features of healthcare. Advances in providing trans-inclusive HIV care and prevention are fundamental to overcome the remarkable HIV burden experienced by transgender people and to ending the HIV epidemic. 

Your Thoughts?
What are some ways that you provide a welcoming environment for transgender patients? Leave a comment to join the discussion!