Abstract
Recent studies have reported high rates of HIV infection among male-to-female transgender persons, but little research has examined how male-to-female transgender persons manage living with HIV. We compared demographic and health characteristics of 59 male-to-female transgender persons who were HIV positive with 300 nontransgender control subjects who were HIV positive. We found several demographic differences between the groups but no significant differences in HIV-related health status. Male-to-female transgender persons were less likely than the control group to take highly active antiretroviral therapy.
Research indicates high HIV prevalence and incidence among male-to-female trans-gender persons;1,2 however, little is known about how male-to-female transgender persons manage living with HIV. Factors such as low self-esteem, economic necessity, and substance abuse are cited as obstacles to health services for male-to-female transgender persons.3 Research has suggested that many male-to-female transgender persons prioritize obtaining medical care for gender reassignment procedures4 and that many experience health care discrimination.3–5 This study examined whether male-to-female transgender persons who are HIV positive face greater difficulties accessing health services than do non-transgender persons who are HIV positive.
METHODS
Participants were adults completing a baseline assessment for the Healthy Living Project, a clinical trial designed to reduce sexual risk behaviors among persons who are HIV positive. A total of 3819 individuals who were HIV positive from 4 cities (San Francisco, Calif; Los Angeles, Calif; New York, NY; and Milwaukee, Wis) participated. In each city, we used brochures, posters, advertisements, staff descriptions, and word of mouth to recruit a convenience sample of individuals who were HIV positive from medical clinics and community agencies serving patients who are HIV positive. Trained interviewers conducted all assessments and queried participants on several health-related topics.
To normalize having a transgender identity and to make it easier for some participants to identify as transgender, all participants were asked to identify as male, female, or transgender, and then all participants were asked to state their gender at birth; 64 participants identified as transgender. The term transgender is commonly used to identify a diverse group of individuals, including transsexual persons and cross-dressers.6 The extent of cross-gender identification in regard to dress, identity, or gender reassignment surgeries was not assessed. To ensure that the study was specific to male-to-female transgender persons, 1 intersex and 4 female-to-male participants were excluded from analyses.
The sample of 59 male-to-female transgender persons was compared with a control group of 300 nontransgender individuals who were HIV positive and who were selected to proportionally match the percentages of male-to-female transgender persons in each of the 4 recruitment cities (Table 1 ▶). Different recruitment strategies and geographic variations in health care7 necessitated matching on the basis of recruitment site. The control group was randomly selected via the random sample function from the Statistical Package for the Social Sciences (SPSS Inc, Chicago, Ill) from the remaining 3755 participants and was representative of the nontransgender sample consisting of men who have sex with men (49%), heterosexual women (23%), male injection drug users (13%), and heterosexual men (15%).
TABLE 1—
Demographic Information, Health Status, and Health Services Comparison of Male-to-Female Transgender Persons Who Were HIV Positive (n = 59) and Control Subjects Who Were HIV Positive (n = 300)
| Male-to-Female Transgender Persons | Control Group | P | |
| Demographics | |||
| Recruitment site,a % | |||
| Los Angeles, Calif | 29 | 29 | |
| San Francisco, Calif | 48 | 48 | |
| New York, NY | 17 | 17 | |
| Milwaukee, Wis | 7 | 7 | |
| Age, mean, y (SD; range = 17–68) | 38.8 (6.8) | 41.5 (7.2) | .009 |
| Education, mean, y (SD; range = 0–18) | 11.7 (1.9) | 12.5 (2.4) | .008 |
| Ethnicity, % | |||
| African American | 66 | 40 | <.001 |
| Latino | 15 | 18 | NS |
| White | 9 | 35 | <.001 |
| Other | 10 | 7 | NS |
| Living in welfare hotel or shelter, % | 32 | 12 | <.001 |
| History of incarceration, % | 81 | 51 | <.001 |
| Daily alcohol use, past 3 mo, % | 19 | 6 | .002 |
| Injection drug use, past year, % | 21 | 15 | NS |
| Health status | |||
| Most recent CD4 cell count, mean, mm3 (SD; range = 0–1906) | 436 (319) | 426 (292) | NS |
| Detectable viral load (self-report), % | 65 | 58 | NS |
| No. of AIDS-related symptoms, mean (SD; range = 0–25) | 12.1 (0.76) | 12.4 (0.34) | NS |
| Beck Depression Inventory, mean score (SD; range = 0–63) | 12.9 (8.9) | 13.0 (9) | NS |
| State-Trait Anxiety Inventory, mean score (SD; range = 20–80) | 34.1 (10.7) | 36.1 (10.5) | NS |
| Health services | |||
| No. of visits to primary care provider, past 3 mo, mean (SD; range=0–24) | 3.9 (2.7) | 3.4 (3.3) | NS |
| Health insurance coverage, % | 32 | 32 | NS |
| Currently taking highly active antiretroviral therapy, % | 59 | 82 | <.001 |
Note. NS = results that were not statistically significant.
a Site of recruitment was used to match the control group to male-to-female transgender persons.
These data provide a unique opportunity to examine how a group of male-to-female transgender persons who are HIV positive differ from nontransgender persons who are HIV positive with regard to (1) demographic characteristics, (2) health status, and (3) use of services. Furthermore, the data may help us to understand what factors, if any, explain any disparities.
RESULTS
We used cross-tabular analysis and t tests (see Table 1 ▶) to find several demographic differences between male-to-female transgender persons and the control group: male-to-female transgender persons were more likely to be younger, to be African American, to be currently living in a welfare home or shelter, to have less education, and to have a history of incarceration. Male-to-female transgender persons also were more likely to drink alcohol on a daily basis.
Despite differences in demographic characteristics, no discrepancies were seen between male-to-female transgender persons and the control group with regard to HIV-related health status. The 2 groups had similar CD4 cell counts, detectable viral loads (self-report), number of AIDS-related symptoms, and scores on the Beck Depression Inventory8,9 and the State-Trait Anxiety Inventory.10
Finally, fewer male-to-female transgender persons (59%) than control subjects (82%) reported currently taking highly active antiretroviral therapy (Table 1 ▶). To further investigate the decreased use of highly active antiretroviral therapy among male-to-female transgender persons, we examined whether differences in the proportion of highly active antiretroviral therapy use remained when comparing male-to-female transgender persons with men who have sex with men and heterosexual women in separate analyses: 86% of the men who have sex with men were currently taking highly active antiretroviral therapy (P < .001 when compared with male-to-female transgender persons; data not shown), and 73% of the heterosexual women were taking highly active antiretroviral therapy (P = .089 when compared with male-to-female transgender persons; data not shown).
To explore the possibility that the discrepancy in highly active antiretroviral therapy use could be explained by demographic differences, we controlled for age, education, ethnicity, living situation, history of incarceration, and daily alcohol use (Table 2 ▶). Demographic factors such as being African American and having less than 13 years of education had little effect on changing the magnitude of the difference between male-to-female transgender persons and the control group (Table 2 ▶). However, among participants who reported drinking alcohol every day for the past 3 months, 55% (both male-to-female transgender persons and control group) were currently taking highly active antiretroviral therapy.
TABLE 2—
Use of Highly Active Antiretroviral Therapy Among Subgroups of Male-to-Female Transgender Persons as Compared With Subgroups of Control Subjects Who Are HIV Positive
| Taking Highly Active Antiretroviral Therapy | Male-to-Female Transgender Persons, % | Control Group, % | P |
| Age < 41 ya | 61 | 76 | .063 |
| < 13 y educationb | 59 | 79 | .010 |
| African Americans | 56 | 84 | .001 |
| Whites | 60 | 82 | NS |
| Living in welfare hotel or shelter | 53 | 72 | NS |
| Ever incarcerated | 63 | 76 | .051 |
| Daily alcohol use, past 3 months | 55 | 55 | NS |
Note. Analyses were restricted to subgroups (i.e., African American male-to-female transgender persons and African American control subjects). NS = results that were not statistically significant.
aAge was dichotomized by dividing the sample into 2 groups according to the median (41 y).
bEducation was dichotomized by dividing the sample according to the median (13 y).
DISCUSSION
Little information is available about male-to-female transgender persons who are HIV positive, and these analyses help raise specific questions about their lives and needs. In this study, decreased highly active antiretroviral therapy use among male-to-female transgender persons emerged as an important and significant finding; however, the implications of this finding have yet to be determined. Decreased use of highly active antiretroviral therapy is troublesome because this therapy has been associated with prolonged life,11–13 and indirect evidence suggests that it may decrease the likelihood of sexually transmitting HIV.14,15
Although male-to-female transgender persons were less likely to take highly active antiretroviral therapy, we found that the health status of male-to-female transgender persons was similar to that of the control group. Decreasing alcohol dependence may be an important factor for male-to-female transgender persons and may assist in providing increased access to highly active antiretroviral therapy, although this too requires additional investigation. Counseling of transgender individuals by HIV educators may have had a positive effect on the lives of male-to-female transgender persons who are HIV positive.
It is impossible to know how representative this convenience sample was of all male-to-female transgender persons who are HIV positive. Inadequate funding and the difficulties associated with conducting research among a dispersed, hidden, and stigmatized population limited our knowledge of the needs of male-to-female transgender persons who are HIV positive. To bring the health needs and experiences of these individuals to the attention of the public health community requires both dedicated research projects and development of innovative and flexible approaches to recruitment, data collection, and data analysis.
Acknowledgments
This research was funded by the National Institute of Mental Health (NIMH) (grants R10-MH57636, R10-MH57631, R10-MH57616, and R10-MH57615).
The authors would like to thank Drs David Whittier, Susie Hoffman, and Bruce Levin for their assistance. We also thank the assessors in each city who conducted the interviews, our clinic and community-based organization collaborators, all other support staff involved in the project, and the men and women who participated in the interviews.
This project was conducted by the NIMH Healthy Living Trial Group: Research Steering Committee (site principal investigators and NIMH staff collaborator): Margaret A. Chesney, PhD, Anke A. Ehrhardt, PhD, Jeffrey A. Kelly, PhD, Mary-Jane Rotheram-Borus, PhD, and Willo Pequegnat, PhD.
Human Participant Protection The research was approved by the institutional review boards of the New York State Psychiatric Institute and Columbia University; University of California, Los Angeles; University of California, San Francisco; and Wisconsin University.
Peer Reviewed
Contributors R.M. Melendez codrafted the brief and initiated and completed analyses of the data. T.A. Exner codrafted the brief and analyzed the data. A.A. Ehrhardt contributed substantially to the initiation and design of the study as well as interpretation of the data. B. Dodge revised the brief. R.H. Remien revised the brief and contributed to interpretation of the data. M.-J. Rotheram-Borus and M. Lightfoot contributed to the initiation and design of the study and data management. D. Hong supervised data collection in Los Angeles. All authors provided final approval of the version to be published. The National Institute of Mental Health Healthy Living Project Team was responsible for acquiring funding, gathering and managing data, and making this large multisite study possible.
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