Chapter 16: Screening and Prevention of HIV and Sexually Transmitted Infections

INTRODUCTION

Transgender and gender diverse (TGD) people have disparate rates of HIV infection and sexually transmitted infections (STIs) compared with cisgender populations, and they are often reluctant or unable to access health services that can provide treatment and preventive care. Although there are many reasons why TGD patients may not readily engage in health care, including sexual and reproductive health services, pervasive structural, interpersonal, and individual-level stigma is prominent.¹ TGD people often face discrimination in health care settings, including denial of medical care and health care professionals who lack relevant clinical knowledge and cultural responsiveness. In addition, they may also experience financial barriers that limit access to sexual health screenings and evidence-based prevention interventions.^2,3 This chapter discusses how clinicians can provide individualized screening recommendations, risk-reduction counseling, and biomedical interventions that enable the provision of gender-affirming and welcoming health care for TGD patients.

BACKGROUND

Approximately 1 million, or 0.4% of adults in the United States, identify as transgender, i.e., with a gender identity that differs from the sex they were assigned at birth.^4–6 A higher proportion of youth (about 2% of high-school-aged individuals) identify as transgender.⁷ Although there are no population-based estimates for the prevalence of gender nonbinary people (those who identify outside the gender binary of boy/man or girl/woman), 35% of the respondents of the 2015 U.S. Transgender Survey (USTS) identified as gender nonbinary.² Some TGD individuals may seek gender-affirming interventions, such as medical (hormonal, surgical, or both), social (changing pronouns, gender presentation), or legal interventions.^6,8 Over the past decade, the incidence of gender-affirming surgeries, especially genital surgeries, has increased in the United States.⁹

EPIDEMIOLOGY OF HIV INFECTION AND STIS IN THE TRANSGENDER POPULATION

The risk of HIV transmission is influenced by the type of sexual exposure (e.g., whether anal, vaginal, or oral) and the presence of coexisting STIs, genital inflammation, or mucous membrane tears. Condomless anal receptive sex carries the highest risk of HIV transmission.¹⁰ Health care professionals must understand the demographics of their patients’ sexual partners and potential sexual exposures to assess their risk of becoming infected with HIV. TGD people may have diverse sexual partners who may be cisgender, transgender, or gender diverse. Sexual orientation identity is similarly diverse; in the USTS, transgender respondents identified as queer (21%), pansexual (18%), gay/lesbian/same gender loving (16%), bisexual (14%), and asexual (10%).² Several studies have also indicated that the sexual orientation identity of some TGD people may shift over time, potentially altering their risk for HIV and STIs.¹¹

A recent systematic review of HIV infection among transgender women in the United States estimated the prevalence of HIV to be 14% among transgender women, with the highest rates among Black (44%) and Hispanic/Latinx (26%) transgender women.¹² Similar elevated rates of HIV infection are seen in international settings, with approximately one in five transgender ...