HIV Testing Among Transgender Women and Men — 27 States and Guam, 2014–2015

Transgender persons are at high risk for human immunodeficiency virus (HIV) infection; in a recent analysis of the results of over nine million CDC funded HIV tests, transgender women* had the highest percentage of confirmed positive results (2.7%) of any gender category (1). Transgender men,^† particularly those who have sex with cisgender^§ men, are also at high risk for infection (2). HIV testing is critical for detecting and treating persons who are infected and delivering preventive services to those who are uninfected. CDC recommends that persons at high risk for HIV infection be screened for HIV at least annually, although transgender persons are not specified in the current recommendations. CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) to describe HIV testing among transgender women and men and two cisgender comparison groups in 27 states and Guam. After adjusting for demographic characteristics, transgender women and men had a lower prevalence of ever testing and past year testing for HIV (35.6% and 31.6% ever, and 10.0% and 10.2% past year, respectively) compared with cisgender gay and bisexual men (61.8% ever and 21.6% past year) and instead reported testing at levels comparable to cisgender heterosexual men and women (35.2% ever, and 8.6% past year). This finding suggests that transgender women and men might not be sufficiently reached by current HIV testing measures. Tailoring HIV testing activities to overcome the unique barriers faced by transgender women and men might increase rates of testing among these populations.

BRFSS is an annual, state-based, random-digit–dialed cellular and landline telephone survey of the noninstitutionalized U.S. adult population.^¶ Gender identity was uniformly assessed in an optional module used by 20 jurisdictions** in 2014 and 22 jurisdictions^†† in 2015. Fourteen jurisdictions participated in the module during both years, six participated only in 2014, and eight participated only in 2015, for a total of 28. Jurisdiction-specific response rates ranged from 33.0% to 59.2%^§§ and 34.4% to 57.6%^¶¶ in 2014 and 2015, respectively. Transgender respondents were defined as those who answered affirmative to the question if they considered themselves to be transgender. Those who answered affirmative were asked to identify as male-to-female (defined as transgender women in this report), female-to-male (defined as transgender men in this report), or gender nonconforming. Because of small sample size, responses from gender nonconforming persons (n = 272) were not included in this analysis.

Pooled data collected in 2014 and 2015 were used to compare demographic characteristics and HIV testing among transgender and cisgender respondents. Cisgender men who reported sexual orientations of gay or bisexual represent a group at high risk for HIV infection (3). Cisgender men and women who reported an orientation of straight (hereafter referred to as cisgender heterosexual men and women) represent a group at lower risk for infection (4). The proportion of respondents who reported ever and past year HIV testing was calculated, and unadjusted prevalence ratios and 95% confidence intervals were estimated to identify characteristics associated with ever testing among transgender women and men. Multivariable logistic regression models compared self-reported prevalence of ever and past year testing among transgender women and men with cisgender gay and bisexual men while adjusting for characteristics associated with testing in univariate models (p<0.10). All estimates were weighted to account for the complex multistage sampling design; because only 14 of 28 jurisdictions participated in the optional module during both years of data collection, weights for these 14 jurisdictions were averaged across the 2-year period to account for varying levels of participation over time. Estimates with relative standard error ≥30% were not reported.

During 2014–2015, 28 jurisdictions collected data on gender identity, resulting in a total sample of 732 transgender women, 451 transgender men, 3,798 cisgender gay and bisexual men, and 301,524 cisgender heterosexual men and women (Table 1). The unadjusted prevalence of ever testing for HIV was 37.5% among transgender women, 36.6% among transgender men, 66.2% among cisgender gay and bisexual men, and 35.2% among cisgender heterosexual men and women. The unadjusted prevalence of past year testing was 11.7% among transgender women, 12.4% among transgender men, 27.5% among cisgender gay and bisexual men, and 8.6% among cisgender heterosexual men and women.

Black transgender women (62.6%) and men (66.9%) had a higher prevalence of ever testing than their white counterparts (33.2% and 30.7%, respectively). Among transgender women, the highest prevalence of ever testing (68.5%) was reported by those who had ever received a diagnosis of a depressive disorder (Table 2). After adjusting for demographic characteristics, transgender women and men had a lower prevalence of ever testing and past year testing for HIV (35.6% and 31.6% ever, and 10.0% and 10.2% past year, respectively) compared with cisgender gay and bisexual men (61.8% ever, and 21.6% past year) and reported testing at levels comparable with those of cisgender heterosexual men and women (35.2% ever, and 8.6% past year) (Table 3).

Acknowledgments

Rashida Dorsey, Rachel Hornstein, and colleagues at the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.

Corresponding Author: Marc Pitasi, mpitasi@cdc.gov, 404-639-6361.

¹Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, CDC; ²Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

References

1. Habarta N, Wang G, Mulatu MS, Larish N. HIV testing by transgender status at CDC-funded sites in the United States, Puerto Rico, and US Virgin Islands, 2009–2011. Am J Public Health 2015;105:1917–25. CrossRef PubMed
2. Reisner SL, Murchison GR. A global research synthesis of HIV and STI biobehavioural risks in female-to-male transgender adults. Glob Public Health 2016;11:866–87. CrossRef PubMed
3. CDC. HIV infection risk, prevention, and testing behaviors among men who have sex with men—National HIV Behavioral Surveillance, 20 U.S. cities, 2014. HIV surveillance special report, no 15; Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-hssr-nhbs-msm-2014.pdf
4. Lansky A, Johnson C, Oraka E, et al. Estimating the number of heterosexual persons in the United States to calculate national rates of HIV infection. PLoS One 2015;10:e0133543. CrossRef PubMed
5. Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N; HIV/AIDS Prevention Research Synthesis Team. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav 2008;12:1–17. CrossRef PubMed
6. Cooley LA, Wejnert C, Rose CE, et al. ; National HIV Behavioral Surveillance Study Group. Increases in recent HIV testing among men who have sex with men coincide with the CDC’s expanded testing initiative. Clin Infect Dis 2015;60:483–5. CrossRef PubMed
7. Yehia BR, Cui W, Thompson WW, et al. HIV testing among adults with mental illness in the United States. AIDS Patient Care STDS 2014;28:628–34. CrossRef PubMed
8. Lippman SA, Moran L, Sevelius J, et al. Acceptability and feasibility of HIV self-testing among transgender women in San Francisco: a mixed methods pilot study. AIDS Behav 2016;20:928–38. CrossRef PubMed
9. Scheim AI, Santos G-M, Arreola S, et al. Inequities in access to HIV prevention services for transgender men: results of a global survey of men who have sex with men. J Int AIDS Soc 2016;19(Suppl 2):20779. CrossRef PubMed
10. Reback CJ, Ferlito D, Kisler KA, Fletcher JB. Recruiting, linking, and retaining high risk transgender women into HIV prevention and care services: an overview of barriers, strategies, and lessons learned. Int J Transgenderism 2015;16:209–21. CrossRef PubMed

TABLE 1. Selected demographic characteristics and HIV testing behaviors among transgender and cisgender respondents* — Behavioral Risk Factor Surveillance System, 27 states and Guam,^† 2014–2015

Abbreviations: CI = confidence interval; ED = emergency department; HIV = human immunodeficiency virus; HMO = health maintenance organization.
* Chi-square tests were conducted to assess differences in demographic characteristics and HIV testing behaviors between gender identity categories; all p ≤0.01 (data not shown).
^† Data were collected in the following jurisdictions: Colorado (2015), Connecticut (2015), Delaware, Georgia (2015), Guam (2014). Hawaii, Idaho, Illinois (2015), Indiana, Iowa, Kansas, Kentucky (2014), Louisiana (2014), Maryland, Massachusetts (2015), Minnesota, Missouri (2015), Montana (2014), Nevada, New York, Ohio, Pennsylvania, Texas (2015), Vermont (2014), Virginia, West Virginia (2015), Wisconsin, and Wyoming (2014).
^¶ Includes cisgender men and women who reported a sexual orientation of straight.
** Weighted column percent excludes missing values and responses of don’t know, not sure, or not asked unless otherwise noted.
^†† Estimate suppressed because relative standard error of the estimate was ≥30%.
^§§ Includes counseling and testing sites, correctional facilities, drug treatment facilities, at home, or somewhere else.

TABLE 2. Prevalence of ever testing for HIV by demographic characteristics among transgender women and men — Behavioral Risk Factor Surveillance System, 27 states and Guam,* 2014–2015

Abbreviations: CI = confidence interval; HIV = human immunodeficiency virus; PR = prevalence ratio; Ref = reference category.
* Data were collected in the following jurisdictions: Colorado (2015), Connecticut (2015), Delaware, Georgia (2015), Guam (2014), Hawaii, Idaho, Illinois (2015), Indiana, Iowa, Kansas, Kentucky (2014), Louisiana (2014), Maryland, Massachusetts (2015), Minnesota, Missouri (2015), Montana (2014), Nevada, New York, Ohio, Pennsylvania, Texas (2015), Vermont (2014), Virginia, West Virginia (2015), Wisconsin, and Wyoming (2014).
^† Percentage is weighted and excludes missing values and responses of don’t know, not sure, not asked.
^§ Estimate suppressed because relative standard error of the estimate was ≥30%.

TABLE 3. Prevalence of ever testing and testing in past 12 months for HIV, by gender identity category — Behavioral Risk Factor Surveillance System, 27 states and Guam,* 2014–2015

Abbreviations: aPR = adjusted prevalence ratio; CI = confidence interval; HIV = human immunodeficiency virus; Ref = reference category.
* Data were collected in the following jurisdictions: Colorado (2015), Connecticut (2015), Delaware, Georgia (2015), Guam (2014), Hawaii, Idaho, Illinois (2015), Indiana, Iowa, Kansas, Kentucky (2014), Louisiana (2014), Maryland, Massachusetts (2015), Minnesota, Missouri (2015), Montana (2014), Nevada, New York, Ohio, Pennsylvania, Texas (2015), Vermont (2014), Virginia, West Virginia (2015), Wisconsin, and Wyoming (2014).
^† Includes cisgender men who reported a sexual orientation of gay or bisexual.
^§ Includes cisgender men and women who reported a sexual orientation of straight.
^¶ Adjusted for: race/ethnicity, age, education, annual household income, health insurance, marital status, geographic region, metropolitan county of residence, ever diagnosed with depressive disorder.