Beyond Prevention: How Gender-Affirming Care Can Transform HIV Outcomes for Transgender and Gender-Diverse Populations

Transgender and gender-diverse (TGD) people, or those whose gender identities do not align with the gender typically attributed with their assigned sex at birth, are disproportionately affected by HIV, a reality that stems from complex social, legal, and structural inequities. For decades, public health efforts to address HIV have focused on prevention, treatment, and testing strategies, but many of these approaches have not considered the unique needs of TGD people.¹ A growing body of research shows that gender-affirming care for TGD individuals, including a comprehensive and personalized set of health care services that help people align their physical and mental health with their gender identity, is an essential component of achieving better health outcomes, particularly in the realm of HIV prevention and treatment.²

Access to gender-affirming care is crucial for improving HIV outcomes in TGD populations. Specifically, integration of gender-affirming care into HIV services can empower individuals, address long-standing health care inequities, and ultimately contribute to ending the HIV epidemic. Data overwhelmingly demonstrate that where gender-affirming care is available, HIV prevention and care outcomes improve, including stronger engagement with preexposure prophylaxis (PrEP), retention in HIV care, adherence to antiretroviral therapy (ART), and viral suppression.² However, major barriers such as lack of access to affirming care, discriminatory policies and practices, and insufficient health care infrastructure continue to prevent widespread adoption of this critical intervention.³

HIV DISPARITIES IN TRANSGENDER POPULATIONS

The global burden of HIV is acutely felt in TGD communities, particularly among transgender women.² For instance, one meta-analysis that examined worldwide HIV rates revealed a prevalence of 19.9% among transgender feminine individuals (i.e., people who were assigned male at birth but now identify with a feminine gender identity) and 2.56% among transgender masculine individuals (i.e., people who were assigned female at birth but now identify with a masculine gender identity).⁴ Studies estimate that transgender women have 66 times the odds of reporting an HIV infection than the general population, with a global HIV prevalence rate of 19% in this group.⁴ These staggering statistics reflect a constellation of risk factors that disproportionately affect TGD people, particularly transgender women, including higher rates of poverty, unemployment, homelessness, substance use, and involvement in sex work, all of which increase vulnerability to HIV exposure.⁴

Moreover, health care systems often fail to meet the needs of TGD individuals, exacerbating these vulnerabilities. Transgender people frequently face stigma and discrimination when seeking care, including being misgendered, denied services, or subjected to invasive questioning about their gender identity.^5,6 For instance, one 2022 survey of more than 92 000 TGD people in the United States showed that nearly half of all survey respondents who saw a health care provider in the preceding year experienced at least one negative interaction because of their gender identity, such as being refused care.⁷ These burdens create barriers to accessing HIV prevention and treatment services such as PrEP, HIV testing, and ART.

HIV disparities are even more pronounced for TGD people of color. As an illustration, data collected by the Centers for Disease Control and Prevention from seven US cities revealed that the HIV prevalence was 62% among Black transgender women and 35% among Hispanic/Latina transgender women, as compared with 17% among White transgender women.⁸ These statistics indicate that TGD women, particularly TGD women of color, are among the most at-risk groups for HIV infection globally.⁴ This intersection of racial, gender, and health care inequities requires targeted interventions that address structural determinants of health, such as public policy and the organization of health care systems, and the individual needs of those most affected by HIV.

GENDER-AFFIRMING CARE IS MORE THAN MEDICAL INTERVENTION

At its core, gender-affirming care refers to a range of medical, social, psychological, and legal interventions that support TGD individuals in living authentically according to their gender identity.² These services can include hormone therapy, gender-affirming surgeries, mental health counseling, voice therapy, and legal support for name and gender marker changes on official documents. However, gender-affirming care often goes beyond medical procedures; it includes the development of health care environments where providers, practitioners, and staff treat TGD individuals with respect; where TGD people’s gender identities are affirmed; and where their specific health needs are understood and addressed.

Gender-affirming care is highly relevant in the context of HIV prevention and treatment. For TGD individuals, access to gender-affirming care can be a vital entry point to the health care system, building trust and encouraging sustained engagement with HIV-related services.⁹ Research consistently shows that when TGD people feel supported and affirmed in their gender identity by health care providers, they are more likely to access HIV testing, engage with PrEP, adhere to ART, and achieve viral suppression.^10–12

Gender affirmation is not just a matter of identity; it is closely linked to health outcomes. Studies have shown that TGD individuals who receive gender-affirming care report better mental health and quality of life.¹³ These psychosocial benefits, in turn, increase individuals’ capacity to engage in health-promoting behaviors, including safer sex practices, consistent PrEP use, and ART adherence.¹⁴ For many TGD patients, gender-affirming care offers a pathway to empowerment and health autonomy, helping to break the cycle of stigma and marginalization that often undermines HIV care.²

GENDER-AFFIRMING CARE IS INTEGRAL TO THE HIV CARE CONTINUUM

The HIV care continuum, which comprises the stages of HIV prevention, diagnosis, treatment, and viral suppression, is a useful framework for understanding how gender-affirming care can improve outcomes at each step. Across the continuum, TGD people experience disparities that are both driven by and exacerbated by inadequate access to affirming care.^1,3,7 Research indicates that access to gender-affirming care can optimize the effectiveness of the HIV care continuum by increasing PrEP uptake and adherence, encouraging regular screening, enhancing retention in care and ART adherence, and mitigating barriers to long-term health.^10–12

Gender-affirming care plays a major role in HIV prevention, the first stage of the HIV care continuum. PrEP is a cornerstone of HIV prevention, yet many TGD individuals remain unaware of or unable to access this life-saving intervention. A 2019 study revealed that although 92% of transgender women in the United States without HIV were aware of PrEP, only 32% had used it.⁸ Barriers to PrEP access include lack of knowledge, stigma, and concerns about drug interactions with gender-affirming hormone therapy.^15,16 Research has shown that when PrEP is integrated with gender-affirming care, uptake and adherence improve significantly.² In fact, in a focus group and interview study of transgender women living in the San Francisco Bay Area, researchers found that having a culturally competent medical provider was the most often cited facilitator of PrEP acceptability.¹² These findings suggest that by offering PrEP in a gender-affirming context, health care systems can improve both prevention and engagement in care.

Improvement of HIV testing and diagnosis, the second stage of the HIV care continuum, also goes hand in hand with greater access to gender-affirming care. Routine HIV testing is essential for early diagnosis and treatment, yet TGD individuals are less likely to be regularly tested than their cisgender counterparts.¹⁷ Fear of discrimination and negative experiences with health care providers discourage many TGD people from seeking out testing services.^6,7 Gender-affirming care can play a pivotal role in reducing these barriers by creating environments where TGD people feel safe and respected. In fact, researchers often find that TGD patients who receive gender-affirming care are also significantly more likely to undergo regular HIV testing than those who lack access to such care.^10,18,19 This outcome demonstrates the potential of gender-affirming care to normalize HIV testing as part of routine health care for TGD populations.

Access to gender-affirming care can optimize HIV treatment, the third stage of the HIV care continuum, by enhancing retention in care and ART adherence. Retention in HIV care is important for achieving viral suppression, but many TGD individuals struggle to remain engaged in care as a result of discrimination, stigma, and competing priorities such as accessing gender-affirming hormone therapy.^1,2 Studies show that transgender women are less likely to be retained in HIV care than cisgender people with HIV.¹ However, when gender-affirming care is integrated with HIV treatment, retention rates improve.² By addressing the needs of the whole person, in terms of both gender identity and HIV care, integrated care models can reduce the drop off in engagement that often occurs in the HIV treatment cascade.

Achieving and maintaining viral suppression is the ultimate goal of HIV treatment, as it can improve individual health outcomes and reduce the likelihood of HIV transmission. For TGD individuals, however, achieving viral suppression can be particularly challenging, especially when access to gender-affirming care is limited.

One study of 858 transgender women of color with HIV showed that access to gender affirmation in health care mediated the relationship between experiencing transgender-related discrimination and viral suppression.¹¹ In other words, having access to gender-affirming care improved respondents’ ability to achieve viral suppression despite other experiences of discrimination. The reasons for this outcome are multifaceted. For many TGD people, gender-affirming care is a prerequisite for overall well-being. When individuals are forced to prioritize either their gender-related health care or their HIV care, it can create a cycle of disengagement from both. Addressing this barrier requires health care models that integrate gender-affirming care with HIV services, ensuring that patients do not have to choose between the two.

EXPANDING GENDER-AFFIRMING CARE ACCESS

Despite the clear benefits of gender-affirming care for HIV prevention and treatment, many TGD individuals face significant barriers to accessing these services.²⁰ In the United States, discriminatory policies in many states have attempted to limit access to gender-affirming care, particularly for youths. These policies undermine the rights of TGD individuals but also represent a public health failure. To address these challenges, policymakers could take action to expand access to gender-affirming care and integrate it with HIV services. As described subsequently, specific policy developments that could expand access to gender-affirming care and, consequently, improve HIV outcomes include mandating insurance coverage, funding community-based health clinics, expanding provider training in TGD health, integrating gender-affirming care and HIV health services, and protecting TGD people against discrimination, particularly within the health care system.

Policies could require public and private insurers to cover gender-affirming care, including hormone therapy, surgeries, and mental health services, as medically necessary treatment. Many insurers currently classify gender-affirming treatments as elective, making these interventions inaccessible to many because of high out-of-pocket costs. Mandating coverage for these services as medically necessary ensures that TGD individuals can access the care they need without financial barriers. This policy also normalizes gender-affirming care within health care systems, reinforcing its legitimacy and necessity and fostering increased engagement with related health services such as HIV prevention and treatment.

Governments could also increase investments in community health centers that specialize in TGD health care. Community-based health clinics that specialize in TGD health care are uniquely positioned to address the complex needs of transgender individuals, particularly in underserved areas. These clinics often provide not only gender-affirming care but also culturally competent HIV prevention, testing, and treatment services in a welcoming environment. Expanding funding for these centers enables them to increase their reach, hire specialized staff, and offer integrated care tailored to TGD populations. In addition, investments in these clinics ensure that care is available to marginalized groups that may face barriers to accessing traditional health care systems, ultimately improving health equity and HIV outcomes.

Health care and medical organizations could implement stronger training requirements in TGD health for all providers, focusing on the principles of gender-affirming care and cultural competency. Such principles include respectful communication, use of correct names and pronouns, and an understanding of the distinct health needs of TGD populations. Equipping providers with cultural competency skills could enhance patient trust and increase the likelihood of TGD individuals seeking and remaining engaged in care. This approach is particularly crucial in HIV prevention and treatment, wherein relationships between providers and patients are foundational to long-term engagement and adherence.

Developing integrated care models that combine gender-affirming care with HIV prevention and treatment services addresses two critical health care needs of TGD populations in a single coordinated system.² Clinics offering integrated care create a streamlined experience for patients, reducing logistical and emotional barriers that can arise from navigating multiple providers. For example, pairing hormone therapy consultations with routine HIV testing or PrEP counseling can improve access and adherence to both gender-affirming and HIV-related care. This approach improves health outcomes and fosters a sense of community and support, making health care systems more inclusive and efficient.

Strengthening antidiscrimination laws is foundational to ensuring equitable access to health care for TGD individuals. Discrimination in medical settings not only deters TGD people from seeking care but also contributes to poorer health outcomes, including those related to HIV prevention and treatment.^2,6,7 Robust legal protections, including at the state level,²¹ should prohibit health care providers from denying or delaying care on the basis of gender identity and ensure that all patients are treated with dignity and respect. These protections should be paired with mechanisms for enforcement and accountability, such as training requirements and penalties for violations, to create a health care environment where TGD individuals feel safe and valued.

CONCLUSION

HIV disparities among TGD populations are not inevitable; they are the consequence of systemic failures that can be mitigated and resolved through evidence-based interventions. Gender-affirming care is one such intervention, with the potential to transform HIV prevention and treatment among TGD individuals. By affirming identities, empowering individuals, and addressing structural barriers, gender-affirming care creates pathways to health and equity. Public health professionals, policymakers, and advocates have a responsibility to ensure that TGD people enjoy access to the care they need to thrive. Expanding access to gender-affirming care is not only a matter of justice; it is a public health imperative.