Intersecting Structural and Psychosocial Conditions: Investigating Injection Drug Use and HIV Among Transgender Women

Abstract

Background:

Transgender women continue to face a significant burden of health disparities with HIV infection as a critical public health concern. Substance use is higher among transgender women than among cisgender women. However, little is known about transgender women who inject drugs and risk for HIV in the United States. The objectives were to explore HIV prevalence, injection-related behaviors, and HIV prevention and care outcomes among transgender women who inject drugs and to compare transgender women with a general sample of persons who inject drugs.

Methods:

Participants from the National HIV Behavioral Surveillance were recruited through respondent-driven sampling, interviewed, and tested for HIV infection in 2019–2020. Log-linked Poisson regression models were used to test for associations between injection drug use and selected characteristics.

Results:

Among 1561 transgender women, 7% injected drugs in the past 12 months. HIV prevalence was higher among transgender women who inject (adjusted prevalence ratio = 1.5, 95% confidence interval: 1.2 to 1.8) than among those who do not. Multiple psychosocial conditions were associated with injection drug use. Among transgender women with HIV, those who inject were less likely to take antiretroviral therapy (adjusted prevalence ratio = 0.8, 95% confidence interval: 0.7 to 1.0) than those who do not. Methamphetamine was the most commonly injected drug (67%); most accessed a syringe services program (66%).

Conclusions:

Transgender women who inject have substantial challenges related to health outcomes including high HIV prevalence and exposure to psychosocial conditions, such as homelessness, incarceration, and exchange sex, that may exacerbate risks associated with injection drug use. This population may benefit from increased access to nonjudgmental and culturally competent harm reduction services.

INTRODUCTION

In the United States, transgender women continue to face a significant burden of health disparities with HIV infection as a critical public health concern within this population. In a systematic review within the United States, transgender women had an estimated HIV prevalence of 14.1%.¹ In comparison, the estimated HIV prevalence in the general US population is <0.5%.^2,3 Transgender women in the United States navigate a complex landscape of social, economic, and health care disparities, often magnified by the persistent stigmatization of transgender identity and diverse gender expression.⁴ High HIV prevalence among transgender women is a reflection of the systemic challenges they face in accessing inclusive and culturally competent health care services.⁵

Among the myriad of challenges faced by transgender women, substance use is a pressing concern. Transgender women report high prevalence of drug use^6,7; several studies have shown elevated use of methamphetamine.^8–11 There are limited studies comparing drug use among transgender women with that among cisgender persons. However, 1 analysis in the United States showed that transgender adults reported higher levels of substance use disorders for the use of cocaine (0.5% vs. 0.1%) and opioids (1.3% vs. 0.4%).^12–14 There is even more limited data on transgender women who inject drugs in the United States. Substance use, particularly injection drug use, is a well-established risk factor for HIV transmission among persons who inject drugs (PWID). A systematic review from the United States estimated that 12% of transgender women had a history of injection drug use¹⁵ and another literature review estimated approximately 0.4% of people who inject identify as transgender.¹⁶ Although syringe sharing has been observed to be rare among transgender women,¹⁵ sharing of syringes during injection drug use and/or hormone use could potentially represent substance-related HIV risk factors in this population.^17,18 There are limited data on sharing of needles used for hormone use, but hormone injection syringes are longer than those used for injection drug use, and potentially increases the likelihood that syringes could be shared.¹⁹ A systematic review reported approximately 2% of transgender women sharing syringes for injecting hormones, and 6% sharing syringes for injecting silicone.¹⁵

The minority stress model suggests that sexual minorities are chronically exposed to unique stress related to stigma-induced experiences.²⁰ Conceptual frameworks developed from minority stress theories posit that engaging in substance use and experiencing negative mental health outcomes result from stigmatizing attitudes and behaviors expressed toward transgender individuals.^13,20 Findings show that substance use may be used as a coping mechanism for the stressors related to stigma and discrimination, gender dysphoria, and social rejection and marginalization.^21–24 Transgender women report rates of depression and suicidality at levels much higher than the general population.^25–27 Mental health challenges are further exacerbated by gender-based abuse and violence.^13,28 In a systematic review, approximately half of participants reported prior mental or physical abuse.¹ Both mental health challenges and experiences of violence correlate with substance use—particularly with the use of illicit drugs among transgender women.^29–31 Transgender women often experience social rejection, marginalization, and familial estrangement because of their gender identity and expression,³² often resulting in high rates of homelessness, incarceration, and survival sex in this population.^9,33,34 To date, very little has been researched on how these negative health and social marginalization outcomes are associated with injection drug use among transgender women.

Widespread stigma and discrimination contribute to a reluctance among transgender women to seek health care services—including HIV care and treatment.^35–39 Transgender women who use and inject drugs may face additional challenges in accessing services. They may be reluctant to disclose their drug use and be hesitant to access health services, including substance use treatment, for fear of further stigmatization and discrimination.^40,41 Although the extent to which transgender women are hindered from accessing substance use treatment or harm reduction services is largely unknown, a study found that transgender people are more likely than cisgender people to want help reducing their substance use.⁴² Existing research supports a need for tailored services and interventions to address substance use, such as cultural sensitivity training for providers and staff to be prepared to address the unique experiences and needs of transgender people.^{40,41,43–45}

Transgender women who inject drugs grapple not only with the challenges posed by pervasive stigma and discrimination of their gender identity but also with navigating the complex intersections of substance use and HIV transmission. This analysis seeks to explore the multifaceted relationship between injection drug use and HIV-associated risks among transgender women, shedding light on the factors that contribute to increased vulnerability and the potential impact on overall health outcomes. Because there is so little research on transgender women who inject drugs, our second objective is to compare injection-related characteristics of transgender women who inject drugs with persons of any gender who inject drugs to understand unique needs among transgender women who inject drugs. By examining the intersecting issues of injection drug use, social determinants, stigma/discrimination, and mental health, this study aims to provide a more nuanced understanding of the challenges faced by transgender women who inject drugs.

METHODS

The Centers for Disease Control and Prevention’s National HIV Behavioral Surveillance among Transgender Women (NHBS-Trans) monitors sexual and drug behaviors, access to prevention services, and HIV prevalence in the United States in metropolitan statistical areas (MSAs) with high HIV prevalence. Cross-sectional data reported in this analysis were collected among transgender women from NHBS-Trans from June 2019 to February 2020. Participating MSAs included Atlanta, GA; Los Angeles, CA; New Orleans, LA; New York City, NY; Philadelphia, PA; San Francisco, CA; and Seattle, WA.

Survey participants were recruited using respondent-driven sampling,⁴⁶ a peer-referral recruitment strategy. Eligible persons were aged ≥18 years, lived in a participating MSA, were able to complete the interview in English or Spanish, and provided informed consent. In addition, participation was limited to persons who reported a gender identity of woman or transgender woman and were assigned male or intersex at birth. Participants completed a standardized questionnaire administered face-to-face by trained interviewers and were offered anonymous HIV testing. Incentives were offered for completing the interview, HIV testing, and peer recruitment (up to 5 coupons). Because HIV prevalence is a primary outcome in this analysis, the analysis sample is limited to those who had a valid HIV test result. Detailed sampling and data collection procedures has been published elsewhere.^47,48

To meet the second objective comparing injection-related characteristics of transgender women who inject drugs with persons of any gender who inject, estimates were used from the NHBS-PWID 2018 cycle. Participants from NHBS-PWID 2018 were also recruited using respondent-driven sampling. Eligible participants were aged ≥18 years, lived in a participating MSA, were able to complete the interview in English and Spanish, provided informed consent, and had injected unprescribed drugs in the past 12 months. Only NHBS-PWID 2018 participants who lived in the same 7 participating MSAs as NHBS-Trans participants were included. Injection-related behavioral questions were the same in NHBS-PWID 2018 and NHBS-Trans. More detailed information on NHBS-PWID 2018 is published elsewhere.⁴⁹

NHBS activities were deemed nonresearch by CDC and approved by local institutional review boards in each of the participating MSAs.

Measures

Injection drug use was defined as having injected any drugs other than those prescribed in the past 12 months (eg, drugs such as heroin or methamphetamine). Injection drug use did not include drugs used for gender transition or affirmation, such as hormones or silicone. This population will be referred to hereafter as “transgender women who inject drugs.”

Eligible participants could select >1 response for current gender identity: woman, man, transgender woman, transgender man, and a gender not listed, as long as either the response woman or transgender woman was selected.

The recall period for all outcomes is in the 12 months before the interview unless otherwise noted.

Social Determinants of Health

Poverty was defined as income at or below the 2019 Department of Health and Human Services poverty guidelines.⁵⁰ Food insecurity was defined as cutting the size of meals or skipping meals or not eating for a whole day because of not having enough money for food. Physical violence included being physically abused or harassed because of gender identity or presentation or being physically abused or harassed by a sexual partner. Forced sex was defined as being physically forced or verbally threatened to have sex.

Discrimination Measures

Discrimination because of being transgender or gender nonconforming included having trouble getting a job, being denied access to bathrooms that were appropriate to the participant’s gender identity, being denied housing or evicted, being denied or given lower quality health care, and receiving poorer services than other people in restaurants, stores, or other businesses.

Psychosocial Functioning Measures

Disability was defined as having serious difficulty hearing, seeing, doing cognitive tasks, walking, or climbing stairs, dressing or bathing, or doing errands alone. Social support was measured using the Multidimensional Scale of Perceived Social Support, dichotomized as low–moderate (mean < 3.57) and high social support (mean ≥ 3.57).⁵¹ The Kessler-6 scale was used to determine psychological distress in the past 30 days that was dichotomized and defined as a score of 13 or higher.⁵²

Drug Use Measures

For the measures comparing NHBS-Trans and NHBS-PWID, frequency of injection was asked for any drug and the responses “once a day” and “more than once a day” were combined to “at least once a day.” Receptive sharing of syringes was defined as responding at least “rarely” when asked about using needles that someone else had already injected with. Accessing drug treatment was defined as participating in a program to treat drug use.

Analysis

Descriptive, unweighted data of the sample are presented to describe sociodemographic characteristics, behaviors, access to care and prevention services, and HIV prevalence. Bivariate analyses, using log-linked Poisson regression models with generalized estimating equations clustering on recruitment chain, were conducted to assess associations with injection drug use in the past 12 months. Owing to complexities associated with respondent-driven sampling, all models controlled for the participant’s personal network size and MSA. Injection drug use was conceptualized as an outcome with demographics, social determinants, mental health and safety outcomes, and stigma and discrimination as predictors. For HIV prevalence, care, and prevention outcomes, injection drug use was conceptualized as a predictor. For the latter models, selected variables were included to control for potential confounding: age, race/ethnicity, current health insurance, MSA, and network size. Referent groups were selected a priori or by lowest prevalence.

To compare drug use and drug use-related behaviors between NHBS-PWID participants and NHBS-Trans PWID participants, we presented descriptive, unweighted data from the NHBS-PWID 2018 cycle alongside NHBS-Trans 2019–2020. NHBS-Trans data were limited to those who reported injecting drugs in the past 12 months. Statistical comparisons were not possible because of differences in the sample populations. However, a priori, we determined a difference in 10 or more percentage points as a meaningful comparison of estimates between NHBS-Trans and NHBS-PWID.

All analyses were conducted in SAS 9.4.

RESULTS

Overall Sample of Transgender Women

This analysis included 1561 transgender women. Approximately 40% of the participants reported being Hispanic/Latina, 35% Black or African American, and 11% White (Table 1). More than half identified as a transgender woman (64%) and 60% were younger than 40 years. Most participants reported currently having health insurance (83%) and seeing a health care provider in the past 12 months (94%). Approximately half reported having at least 1 disability (53%). An estimated 63% reported an income below the poverty level and 59% reported food insecurity. Overall, 16% had ever injected drugs and 7% had injected drugs in the past 12 months.

TABLE 1.

Select Demographic Characteristics and Social Determinants of Health Among Transgender Women (N = 1561)—NHBS-Trans, 7 US Cities, 2019–2020

Characteristic	n*	Col %*
Race/ethnicity
American Indian/Alaska native	17	1.1
Asian	30	1.9
Black/African American	548	35.2
Hispanic/Latina†	626	40.2
Native Hawaiian/other Pacific Islander	42	2.7
White	176	11.3
Multiple races/other race	119	7.6
Gender identity
Transgender woman	1003	64.3
Woman	174	11.2
Multiple genders listed	384	24.6
Age group (yr)
18–29	483	30.9
30–39	447	28.6
40–49	294	18.8
≥50	337	21.6
Education
Less than high school	336	21.6
High school or equivalent	574	36.8
Some college or more	649	41.6
Currently insured
No	263	16.9
Yes	1297	83.1
Saw a health care provider, past 12 mo
No	100	6.4
Yes	1461	93.6
Has any disability
No	725	46.7
Yes	828	53.3
Poverty level
Above poverty level	569	36.8
Below poverty level	978	63.2
Food insecurity
No	646	41.5
Yes	912	58.5
Ever injected drugs
No	1308	83.9
Yes	251	16.1
Injected drugs, past 12 mo
No	1454	93.3
Yes	104	6.7
Total	1561	100.0

^*N’s do not include missing values. Percentages may not add up to 100% because of rounding.

^†Hispanic/Latina can be of any race.

Transgender Women Who Inject Drugs

Approximately 12% of White transgender women and 8% of transgender women aged 30–39 year reported injecting drugs in the past 12 months (Table 2). An estimated 9% of participants who reported food insecurity, 9% of participants who had a disability, 16% of participants who reported being currently homeless, and 15% of participants who had recently been incarcerated reported injecting drugs. In the adjusted models, no differences were found in injection drug use by demographic characteristics such as gender identity, age, or education. Reporting White race, food insecurity, disability, current homelessness, recent incarceration, noninjection drug use, psychological distress, verbal abuse or physical violence, forced sex, receiving money or drugs for sex, being denied access to an appropriate bathroom, being denied housing or being evicted, and receiving poorer services than other people were associated with injection drug use (Table 2).

TABLE 2.

Association Between Injection Drug Use and Select Demographic, Mental Health, Safety, and Discrimination Outcomes Among Transgender Women—NHBS-Trans, 7 US Cities, 2019–2020

	Total	Injected Drugs, Past 12 mo		Adjusted Models*
	N†	n†	Row%	aPR (95% CI)	P
Overall	1558	104	6.7
Race/ethnicity‡
Hispanic/Latina§	624	37	5.9	Ref
Black/African American	547	35	6.4	1.40 (0.94 to 2.08)	0.098
White	176	21	11.9	1.97 (1.34 to 1.40)	<0.001
Gender identity
Transgender woman	1001	60	6.0	Ref
Woman	174	12	6.9	1.19 (0.77 to 1.85)	0.431
Multiple genders listed	383	32	8.4	1.29 (0.92 to 1.82)	0.145
Age group (yr)
18–29	483	27	5.6	Ref
30–39	446	37	8.3	1.43 (0.74 to 2.74)	0.288
40–49	293	18	6.1	0.95 (0.51 to 1.74)	0.859
≥50	336	22	6.6	0.95 (0.53 to 1.69)	0.851
Education
Less than high school	335	25	7.5	Ref
High school or equivalent	573	48	8.4	1.19 (0.67 to 2.12)	0.560
Some college or more	648	31	4.8	0.63 (0.35 to 1.15)	0.134
Currently insured
No	262	12	4.6	Ref
Yes	1295	92	7.1	1.56 (0.76 to 3.17)	0.223
Saw a health care provider, past 12 mo
No	100	5	5.0	Ref
Yes	1458	99	6.8	1.37 (0.66 to 2.82)	0.397
Poverty level, past 12 mo
Above poverty level	567	33	5.8	Ref
Below poverty level	977	71	7.3	1.25 (0.84 to 1.87)	0.270
Food insecurity, past 12 mo
No	646	22	3.4	Ref
Yes	909	82	9.0	2.45 (1.50 to 4.01)	<0.001
Has a disability
No	725	30	4.1	Ref
Yes	825	73	8.9	1.85 (1.18 to 2.89)	0.007
Currently homeless
No	1201	49	4.1	Ref
Yes	356	55	15.5	3.59 (2.54 to 5.07)	<0.001
Incarcerated, past 12 mo
No	1285	62	4.8	Ref
Yes	270	41	15.2	3.21 (2.32 to 4.44)	<0.001
Social support
Low/moderate	848	45	5.3	Ref
High	706	58	8.2	1.35 (0.84 to 2.15)	0.214
Noninjection drug use
No	628	19	3.0	Ref
Yes	929	85	9.2	3.07 (1.97 to 4.79)	<0.001
Mental health and safety outcomes
Psychological distress, past 30 d
No	1151	66	5.7	Ref
Yes	403	38	9.4	1.57 (1.06 to 2.32)	0.024
Verbally abused or harassed, past 12 mo
No	710	30	4.2	Ref
Yes	846	74	8.8	1.96 (1.36 to 2.81)	<0.001
Physical violence (including intimate partner violence), past 12 mo
No	1045	51	4.9	Ref
Yes	512	53	10.4	2.04 (1.51 to 2.76)	<0.001
Forced sex, past 12 mo
No	1321	73	5.5	Ref
Yes	233	31	13.3	2.30 (1.62 to 3.29)	<0.001
Received money or drugs for sex, past	12 mo
No	1024	39	3.8	Ref
Yes	534	65	12.2	3.23 (2.47 to 4.23)	<0.001
Discrimination because of gender identity or presentation
Trouble getting a job, past 12 mo
No	1032	61	5.9	Ref
Yes	504	42	8.3	1.37 (0.96 to 1.98)	0.085
Denied access to appropriate bathroom, past 12 mo
No	1203	70	5.8	Ref
Yes	348	34	9.8	1.68 (1.22 to 2.30)	0.001
Denied housing or evicted, past 12 mo
No	1333	75	5.6	Ref
Yes	217	28	12.9	2.16 (1.65 to 2.82)	<0.001
Denied health care, past 12 mo
No	1377	86	6.3	Ref
Yes	169	17	10.1	1.49 (0.95 to 2.31)	0.079
Received poorer services, past 12 mo
No	942	44	4.7	Ref
Yes	608	59	9.7	2.06 (1.46 to 2.90)	<0.001

^*Models adjusted for network size and MSA.

^†N’s do not include missing values.

^‡The other race/ethnicity categories were too small to report.

^§Hispanic/Latina can be of any race.

Among transgender women who injected drugs, 84% had received an HIV test in the past 12 months (Table 3), >90% were aware of preexposure prophylaxis (PrEP), and a little >30% reported using PrEP. In the adjusted models, there were no significant differences in HIV testing, PrEP awareness or use, or having had a recent HIV care visit within the past 6 months by injection drug use. However, among transgender women who had self-reported being HIV positive, those who injected were less likely to be currently on antiretroviral therapy (ART) (aPR = 0.8; 95% CI:| 0.7 to 1.0). In addition, when adjusted for age, race, MSA, and network size, transgender women who injected had a significantly higher HIV prevalence than those who did not inject (aPR = 1.5; 95% CI: 1.2 to 1.8).

TABLE 3.

Associations Between HIV Prevention and Care Outcomes, HIV Prevalence, and Injection Drug Use Among Transgender Women—NHBS-Trans, 7 US Cities, 2019–2020

	Injected Drugs, p12m
	No	Yes
	n (col%)*	n (col %)*	Adjusted Models aPR (95% CI)	P
Self-reported HIV negative (N = 954)†
Had an HIV test, past 12 mo
No	156 (17.4)	8 (16.0)	NA	NA
Yes	743 (82.7)	42 (84.0)	0.99 (0.86 to 1.17)	0.993
Aware of PrEP
No	71 (8.3)	3 (6.7)	NA	NA
Yes	784 (91.7)	42 (93.3)	1.00 (0.91 to 1.11)	0.931
Used PrEP, past 12 mo
No	582 (68.1)	30 (66.7)	NA	NA
Yes	273 (31.9)	15 (33.3)	1.06 (0.72 to 1.55)	0.777
Self-reported HIV positive (N = 606)†
Recent HIV care visit within past 6 mo
No	47 (8.6)	6 (11.3)	NA	NA
Yes	497 (91.4)	47 (88.7)	0.99 (0.90 to 1.09)	0.867
Currently on ART
No	37 (6.8)	13 (24.5)	NA	NA
Yes	507 (93.2)	40 (75.5)	0.82 (0.72 to 0.95)	0.007
NHBS test result (HIV prevalence, N = 1561)‡
HIV negative	856 (58.9)	45 (43.3)	NA	NA
HIV positive	587 (41.1)	59 (56.7)	1.46 (1.22 to 1.75)	<0.001

^*N’s do not include missing values. Percentages may not add up to 100% because of rounding.

^†Models adjusted for age, race, current health insurance, MSA, and network size. aPRs compare the row outcome by column. The referent group in this table is “no injection drug use, p12m.”

^‡Models adjusted for age, race, MSA, and network size. aPRs compare the row outcome by column. The referent group in this table is “no injection drug use, p12m.”

p12m, past 12 months; NA, not analyzed.

Comparison of Transgender Women Who Inject Drugs with PWID From NHBS-PWID

For the second objective, injection behaviors among transgender women were different from a general PWID population. Injection of methamphetamine was more common among NHBS-Trans PWID participants who injected drugs compared with NHBS-PWID participants (78% vs. 48%) as was noninjection use of methamphetamine (68% vs. 48%) (Table 4). Methamphetamine was reported as the drug most injected by NHBS-Trans PWID participants (67%), while heroin was reported as the drug most injected by NHBS-PWID participants (51%). More than half of NHBS-Trans PWID participants reported always using sterile syringes (62%), while approximately a third of NHBS-PWID participants (37%) reported the same. An estimated 47% of NHBS-Trans PWID participants compared with 88% of NHBS-PWID participants reported injecting at least daily. Accessing drug treatment for both populations was approximately 43%. Approximately 66% of NHBS-Trans PWID and 78% of NHBS-PWID participants reported accessing syringe services programs (SSPs). HIV prevalence was 57% among NHBS-Trans PWID participants compared with 7% among NHBS-PWID participants.

TABLE 4.

Descriptive Injection-Related Characteristics Among Persons Who Inject Drugs From NHBS-Trans 2019–2020 and NHBS-PWID 2018–7 US Cities

	NHBS-Trans 2019–2020		NHBS-PWID 2018
Characteristic	n*	Col %*	n*	Col %*
Injected Methamphetamine, past 12 mo
No	23	22.1	1871	51.6
Yes	81	77.9	1756	48.4
Injected heroin, past 12 mo
No	67	64.4	365	10.1
Yes	37	35.6	3262	89.9
Drug most injected, past 12 mo
Speedball	3	2.9	219	6.1
Heroin	29	27.9	1832	50.7
Methamphetamine	70	67.3	332	9.2
Oxycontin or painkillers	2	1.9	12	0.3
Other drug(s)†	NA	NA	1220	33.7
Frequency of injection, past 12 mo
At least once a day	48	47.4	3184	87.9
More than once a week	19	18.8	258	7.1
Once a week or less	34	33.7	179	4.9
Noninjection drug use, past 12 mo
No	19	18.3	608	16.8
Yes	85	81.7	3019	83.2
Noninjection methamphetamine use, past 12 mo
No	33	31.7	1901	52.5
Yes	71	68.3	1721	47.5
Shared syringes (receptive), past 12 mo
No	64	72.7	2551	70.4
Yes	24	27.3	1074	29.6
Always sterile syringe use, past 12 mo
No	40	38.5	2288	63.1
Yes	64	61.5	1339	36.9
Accessed syringe services programs, past 12 mo
No	34	34.0	782	22.6
Yes	66	66.0	2686	77.5
Accessed drug treatment, past 12 mo
No	58	57.0	2045	56.4
Yes	46	43.0	1580	43.6
NHBS HIV test result
Negative	45	43.3	235	93.5
Positive	59	56.7	3372	6.5
Total	104	100.0	3627	100.0

^*N’s do not include missing values. Percentages may not add up to 100% because of rounding.

^†NHBS-Trans transgender women who inject did not report any other most injected drugs. Other drugs reported by NHBS-PWID persons who inject included cocaine, crack, multiple drugs, or other drugs not specified.

NA, not applicable.

DISCUSSION

There are very limited data on prevalence of injection drug use and factors associated with injection drug use among transgender women. However, a pooled analysis approximated 7% of transgender persons in the United States currently inject drugs.¹⁶ We found similarly that approximately 7% of transgender women reported injecting drugs in the past 12 months, while 16% had ever injected. Stigma, rejection, and discrimination contribute to a range of negative health outcomes including substance use.^4,53–56

In this analysis, increased injection drug use was associated with food insecurity, psychological distress, experiences of stigma and discrimination, verbal, physical, and sexual violence, current homelessness, incarceration, and engaging in exchange sex. The intersection of these conditions among transgender women is a complex and multifaceted issue that often involves significant societal, economic, and structural challenges. Individually, these factors have been associated with HIV infection among transgender women and access to HIV care and treatment.^{11,32,37,57–59} However, a syndemic framework⁶⁰ can be used to better understand HIV among transgender women by examining how these structural (eg, experiencing homelessness and incarceration) and psychosocial issues (eg, sexual violence and drug use) cooccur, often mutually reinforcing interaction and sometimes acting multiplicatively to predict risk of HIV.^6,28,59 For example, Brennan et al³² found that among young transgender women, the syndemic factors of low self-esteem, lifetime polysubstance use, intimate partner violence, and victimization were additively associated with HIV prevalence. It is crucial to consider the context in how these factors, including injection drug use, syndemically contribute to HIV—especially when designing interventions that may otherwise focus on only 1 of many interrelated factors. Syndemic analyses reveal that more complex HIV prevention approaches are needed among transgender women. Research has suggested combining HIV prevention services with other health and social services for meaningful improvements in public health.^59,61,62

HIV prevalence was high among transgender women who inject drugs (>50%). In addition, HIV prevalence was significantly higher among transgender women who injected than among transgender women who did not inject. There are very limited data examining HIV among transgender women who inject drugs. However, in a targeted sample of transgender persons, transgender women who injected drugs were 2.6 times more likely to have HIV than those who did not inject.⁶³ Furthermore, among transgender women who self-reported having HIV, those who injected drugs were less likely to currently be on ART. This finding suggests that injection drug use may amplify challenges faced by transgender women, necessitating a focused examination of the factors that impede or facilitate their access to critical services such as HIV prevention, care, and treatment. It is encouraging that awareness of PrEP is high and there were no differences in PrEP use by injection drug use. However, given that transgender women who inject could potentially be exposed to multiple factors that increase their HIV risk, purposeful efforts are needed to link transgender women who inject to PrEP.

Systemic barriers, such as health care discrimination, lack of cultural competency, and economic disparities, can deter transgender women from seeking regular health care, including HIV care.^37,62 Transgender women who inject drugs may experience intersectional discrimination that may lead to unique structural barriers when trying to access basic needs, such as housing, employment, public bathrooms, and public places of business.^{24,33,64–66} In this analysis, discrimination was not always higher among transgender women who inject; however, this is likely, in part, because of transphobic discrimination already being so high. With stigma and discrimination potentially compounded because of injection drug use,^67–69 transgender women who inject drugs need to seek services where they feel safe, comfortable, and accepted.

SSPs have historically been safe places with nonjudgmental staff and increasingly provide comprehensive services to people who use drugs. SSPs are a critical tool in the plan to reduce new HIV infections for the Ending the HIV Epidemic initiative⁷⁰ through the provision of sterile syringes and services related to HIV care and treatment.^71–74 In this analysis, most transgender women who injected accessed an SSP for sterile syringes. However, the needs of transgender women who inject differ from other persons who inject drugs. Transgender women who injected had a higher preference for injection or use of methamphetamine (rather than heroin), injected less frequently, and reported always using sterile syringes compared with nontransgender persons who inject drugs. The starkest difference between NHBS-Trans transgender women who injected and NHBS-PWID participants was in HIV prevalence—transgender women had a substantially higher HIV prevalence. Although the comparisons are limited because of differences in sampling, there are clearly different needs from this population. Given that transgender women are indeed accessing SSPs, it is vital to support SSPs in tailoring services needed by this population: for example, supplies for specific substances (eg, methamphetamine), supplies for persons who may be exchanging sex, safer hormone injection supplies, knowledge of local underground economy and supply of hormones, silicone, and other transition supplies, and trans-specific resources and referrals/linkage to gender-affirming care. Transgender women who inject were more likely to experience homelessness and engage in exchange sex; resources should be available that would be considered safe for this population.

Furthermore, culturally sensitive principles should be prioritized when providing substance use treatment for transgender women. There is limited information on transgender women who have sought substance use treatment.^24,40 Despite higher rates of substance use among transgender women, there is an alarming scarcity of studies focusing on developing interventions related to care for substance use designed specifically for transgender women.⁴⁴ Transgender women are more likely to need additional help for substance use when compared with cisgender persons who use drugs,⁴² and researchers have requested more transgender-specific support systems, including treatment for substance use.^44,75 Despite these calls for transgender-specific services, only 5% of substance use service providers report formal education surrounding the needs of transgender clients.⁷⁶ To date, there are no studies on transgender women who inject and their access and use of substance use treatment. In the comparison with NHBS-PWID, we found that transgender women who injected in NHBS-Trans had similar percentages in treatment for substance use.

Although efforts, overall, should be made to promote equitable health care access and improve health outcomes for this population, culturally competent substance use interventions, such as SSPs and treatment for substance use, could fill a gap that traditional health care services are not currently addressing.⁴⁴ At the least, staff should receive formal training on cultural humility and ongoing education to support a safe environment for transgender women. Stigma, harassment, poor treatment, and cultural incompetence from staff because of gender identity have led to deterring some from seeking treatment.⁷⁷ In contrast, in the same study, transgender patients report feeling more positive about their substance use treatment when staff respected their gender identity, including room and group placement. Other examples to provide a supportive environment for transgender women could include access to gender-affirming bathrooms within SSPs or treatment facilities; having staff or counselors use preferred names and pronouns; or providing housing and employment support tailored to the needs of transgender women. Further investigation is needed to explore factors that facilitate transgender women’s engagement with harm reduction or substance use interventions and to enhance or tailor culturally competent services, peer support, and outreach initiatives geared toward transgender women who inject drugs.

This analysis is subjected to several limitations. First, the data are self-reported and may be subject to social desirability and recall biases. Second, because NHBS-Trans is a cross-sectional study, it is not possible to infer causality. Associations with injection drug use may be related to other structural or behavioral characteristics not covered in this analysis. Third, NHBS-Trans data are not nationally representative and may not be generalizable to the United States or all transgender women. Lastly, owing to the limited sample size of transgender women who inject drugs, further statistical comparisons could not be performed to investigate, for example, factors associated with HIV prevalence among transgender women who inject drugs.

CONCLUSIONS

Transgender women who inject drugs face unique challenges that call for a comprehensive understanding and targeted interventions by the harm reduction community. In addition, addressing injection drug use in this population requires culturally competent approaches that address the root causes of structural and psychosocial conditions. The disproportionate burden of HIV among transgender women who inject drugs requires multifaceted interventions, including destigmatizing health care, improving access to mental health and harm reduction services, and addressing the social determinants that contribute to vulnerability. Culturally competent and inclusive approaches are crucial to reducing HIV prevalence and promoting the overall well-being of transgender women who inject. Efforts must be collaborative, involving the transgender community, health care providers, policymakers, and community organizations to create inclusive and supportive environments for transgender women.

APPENDIX

The NHBS-Trans Study Group: Atlanta, GA: Pascale Wortley, Genetha Mustaafaa, Brittany Taylor; Los Angeles, CA: Ekow Kwa Sey, Gia Olaes, Yingbo Ma; New Orleans, LA: William T. Robinson, Narquis Barak, Jasmine Davis; New York City, NY: Sarah Braunstein, Alexis Rivera, Jasmine Lopez; Philadelphia, PA: Kathleen A. Brady, Tanner Nassau, Andrea Harrington; San Francisco, CA: Erin Wilson, Dillon Trujillo, Sofia Sicro; Seattle, WA: Sara Glick, Aleks Martin, Jennifer Reuer; CDC: Christine Agnew Brune, Dita Broz, Susan Cha, Johanna Chapin-Bardales, Dafna Kanny, Teresa Finlayson, Senad Handanagic, Rashunda Lewis, Elana Morris, Taylor Robbins, Amanda Smith, Lindsay Trujillo, and Mingjing Xia.