March 31 was International Transgender Day of Visibility. The day is a celebration of the lives of transgender, non-binary, and gender diverse (trans) people worldwide and their huge contribution to society. It recognises the successes, achievements, and resilience of trans populations despite discrimination and criminalisation, and provides an opportunity for increased awareness of the challenges and barriers to inclusion faced by the community worldwide. In the current shifting political climate, showing allyship with trans communities is more important than ever, not least in the fight against HIV.
Trans people are a key population affected disproportionately by HIV, but they are also one of the most underserved in the HIV response and remain unrecognised in the health data from many countries. Among 34 countries reporting estimates for trans populations, median HIV prevalence is estimated at 9·2%, with the upper range being 58% in South Africa. In 2022, according to UNAIDS estimates, the relative risk of acquiring HIV was 20 times higher for trans women than for the general population. Among trans people living with HIV, the rate of those receiving antiretroviral therapy is shockingly low, a median of 55%, and adherence and viral suppression can be poor when on treatment. Pre-exposure prophylaxis awareness, willingness, and uptake are also suboptimal.
A complex set of social and structural drivers and inequities affect trans populations and their take-up and access to appropriate health care, which in turn can lead to poor outcomes for HIV. For example, stigma and discrimination experienced by trans people can lead to reduced employment opportunities, higher levels of homelessness, drug misuse, physical and sexual violence, legal problems, and poor mental health.
In this issue, a Personal View by Sari Reisner, sets out a conceptual framework, the Situated Vulnerabilities and Resiliencies Framework, to better understand the drivers of the HIV epidemic among trans populations. The framework highlights the need to establish integrated strategies and interventions to reduce stigma and achieve HIV equity. Trans people are made vulnerable to HIV through causes and conditions that put them at risk for risk, and these vulnerabilities relate to the biopsychosocial contexts in which trans people live. Leveraging resiliencies can help reduce stigma and advance HIV equity. Reisner emphasises the need for integrated strategies that include HIV status-neutral interventions based on health and human rights, that engage with the trans community, and that include gender affirmation and gender-affirming care.
Access to gender-affirming hormone therapy is associated with improved mental health outcomes for trans people, but few studies have investigated if it is associated with HIV outcomes. In a research Article in this issue, Reisner and colleagues report a longitudinal cohort study in the USA that shows trans people receiving gender-affirming hormone therapy had reduced rates of HIV seropositivity and viral non-suppression. Although the authors did not investigate the mechanism by which gender-affirming therapy affects HIV outcomes, in this month’s podcast, Reisner posits that improved mental health and quality of life might lead to improved health behaviours, such as condom use or adherence, or gender-affirming hormone therapy-related care might also increase trust, and reduce barriers to discussing sexual health or adherence challenges. The podcast also discusses the Personal View and the future of trans research.
Trans populations affected by HIV do have positive outcomes when given the right support and health care. However, the recent actions of the US administration of President Donald Trump around gender identity, diversity and inclusion, health care, and research aim to erase trans people’s existence and threaten to undo years of progress for transgender rights in the USA. And the withdrawal of the President’s Emergency Plan for AIDS Relief and USAID foreign aid has put the lives of thousands of trans people and other marginalised populations in peril globally.
In light of dictats from the US Government to federally funded researchers, The Lancet Group has reaffirmed its commitment to diversity and inclusion, and we continue to recognise the importance of trans health. We continue to recommend the use of inclusive language, accepting authors’ ultimate choice of terminology when it is scientifically accurate and respectful. Trans people should be able to live open and safe lives free of stigma and discrimination. On Transgender Day of Visibility, and 365 days of the year, we stand steadfast in support of and as allies to trans people.
For The Lancet HIV in conversation with Sari Reisner, listen: https://www.thelancet.com/multimedia/podcasts/in-conversation-with/lanhiv
The Lancet HIV April 2025 issue
Source : The Lancet HIV
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