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Running head: HIVAmongst Transgender Population in the United States in 2017 Huynh, 1

HIV Amongst Transgender Population in the United States in 2017

Jenny Huynh

California State University, Long Beach

HSC 400 Section 1


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Define the Problem

Human Immunodeficiency Virus (HIV) is a problem that has continued to plague the

United States since its discovery in the late 1970s (Centers for Disease Control and Prevention

[CDC], 2017a). Once an individual acquires HIV, the virus never leaves the body and if left

untreated, it can develop into acquired immunodeficiency syndrome, or AIDS (CDC, 2017a).

HIV weakens the body’s immune system by attacking the T-cells (CDC, 2017a). This makes the

immune system unable to fight off infections, which as a result, makes the individual with HIV

more susceptible to infections or cancers related to infections (CDC, 2017a). The transgender

population in the United States is one of the more susceptible populations when it comes to

contracting the disease. According to the CDC (2017b), the number of new HIV diagnoses

amongst the transgender population is “three” times higher than the national average. The higher

than average diagnoses are due to many barriers that the transgender population faces, which will

be further discussed.

Extent of the Problem

Mortality. In the United States alone, there were “6,721” HIV related deaths in 2014

(CDC, 2017c). This means that “2.1” people out of “100,000” pass away due to HIV and HIV

related complications (CDC, 2017c). Unfortunately, no data was found regarding HIV related

mortalities amongst the transgender population. This may be due in part to the fact that male-to-

female (MTF) transgender individuals are sometimes classified as men who have sex with men

(MSM) (San Francisco Aids Foundation [SFAF], 2009). With that being said, according to the

CDC (2017d), the mortality rates for MSM HIV related deaths were reported at “6,110”.

However, this number is not entirely reflective of the transgender population because not every

MSM identify as transgender.


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Morbidity. As aforementioned, the CDC (2017b) states that the amount of transgender

individuals diagnosed with HIV is “triple” that of other populations in the United States. From

2009 to 2014, there were “2,351” newly diagnosed cases of HIV amongst the transgender

population (CDC, 2017b). Of those “2,351” cases, “84” percent were transgender women, “15”

percent were transgender men, and the remaining identified as another gender (CDC, 2017b).

Transgender individuals living in the American south have the highest morbidity rates for HIV

(CDC, 2017b). Approximately “50” percent of the transgender men and women newly diagnosed

with HIV from 2009 and 2014 were from the American South (CDC, 2017b).

Economic Impact. According the American Psychological Association ([APA], 2017),

transgender individuals have a lower socioeconomic status and are more “vulnerable to

conditions of poverty” than their cisgender counterparts. Medicine used to treat HIV is fairly

expensive, and can place even more financial burden on these individuals. On average, monthly

HIV treatment ranges from “$2000” to “$5,000” (Aguirre, 2012). In addition, it estimated that an

HIV infected individual may spend upwards of “$500,000” in their lifetime (Aguirre, 2012).

Also, the CDC (2017e) reports that it will cost the United States approximately “$16.6 billion” in

lifetime HIV treatment costs. In addition, it is reported that the government’s spending on HIV

research has increased by “$27 billion” per year (HIV, 2017a).

Agent of Disease

HIV is caused by a virus that attacks the CD4, or T-cells in the body (CDC, 2017a). T-

cells are white blood cells that the body uses to help fend off infections. Once a person becomes

infected with the virus, the number of CD4 cells in the body begin to diminish and the body is no

longer able to fight infections (CDC, 2017a). The structure of the HIV virus makes it extremely

easy for it to attack the CD4 cells in the body (Annenberg Learner, 2017). HIV is classified as a
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retrovirus, which means that once the viruses attaches itself to the host cell—in this case, the

CD4 cell—“the viral envelope fuses with the cell membrane, and the virus's RNA and enzymes

enter the cytoplasm,” (Annenberg Learner, 2017). Appendix A provides a visual representation

of the viral structure of HIV (Annenberg Learner, 2017). The enzyme reverse transcriptase

allows the RNA of HIV to be easily replicated, as well as makes it easier for its double-stranded

DNA structure to be generated (Annenberg Learner, 2017). From there, the enzyme integrase

allows the HIV virus to integrate itself into the T-cell’s cellular membrane (Annenberg Learner,

2017).

Clinical Symptoms

There are three stages of HIV: acute HIV infection, clinical latency, and AIDS (CDC,

2017a). In stage one, the individual usually exhibits flu like symptoms that may last “two to

four” weeks (CDC, 2017a). These symptoms include “chills, rash, night sweats, muscle aches,

sore throat, fatigue, swollen lymph nodes, and mouth ulcers,” (HIV, 2017b). During this stage,

individuals may not know that they have been infected with the virus, which is particularly

alarming due to the fact that during this time, the individual contains a large amount of the virus

in their blood and are considered to be highly infectious (CDC, 2017a). In stage two, also known

as the clinical latency stage, the virus is still active in the body, however it produces at much

lower levels (HIV, 2017b). The time an individual spends in stage two varies from person to

person, and depends on whether or not he or she is taking medication to help treat the disease

(HIV, 2017b). For instance, someone who is not actively taking antiviral therapy (ART) may be

in stage two for up to ten years (HIV, 2017b). On the other hand, those who are actively taking

ART to control the virus may spend many decades in this period before HIV progresses to AIDS

(HIV, 2017b). Finally, the last step is the progression into AIDS. Symptoms of AIDS may
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include “rapid weight loss, recurring fever or night sweats, extreme and unexplained tiredness,

and pneumonia,” (HIV, 2017b). In this stage, and individual’s immune system can no longer

fight off infections and are more susceptible to opportunistic illnesses (CDC, 2017a). If left

untreated, an individual may only live up to “three” years (CDC, 2017a). Appendix B provides a

visual representation of the different stages of HIV, based on the number of HIV versus CD4

cells in the body (AIDS Info, 2017).

Modes of Transmission

HIV is most commonly spread by having unprotected sex with an HIV positive person or

injected drug use (IDU) (HIV, 2017b). The virus is spread through bodily fluids such as blood,

semen, pre-seminal fluid, rectal fluid, vaginal fluid, and breast milk (HIV, 2017b). Contrary to

popular belief, HIV cannot be transmitted through tears, saliva, or sweat of an HIV positive

person (HIV, 2017b). Although uncommon, HIV can also be spread from mother to child during

childbirth (HIV, 2017b). Appendix C provides a visual of how an individual may contract AIDS

(Avert, 2017).

Mechanisms of Prevention

Primary. One of the most common ways that HIV is spread is through unprotected

sexual contact with an HIV positive person. Therefore, it is crucial for an individual to get tested

regularly for HIV and other STIs when engaging in sexual contact with a new partner. In

addition, it is important for the individual to know their partner’s sexual and testing history

(HIV, 2017b). As previously discussed, HIV is spread through bodily fluids such as seminal,

vaginal, and rectal fluids (2017b). Therefore, in order to protect oneself, an individual must wear

condoms when engaging in sexual intercourse. Another way to prevent the spread of HIV from

sexual intercourse is to take pre-exposure prophylaxis (PrEp) (HIV, 2017b). PrEp is a drug that
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is designed for individuals who do not have HIV, but are at risk for contracting HIV (HIV,

2017b). For instance, an individual who does not have HIV may take PrEp if their sexual partner

is infected (HIV, 2017b). Another primary prevention method is to not use injected drugs,

however if an individual does engage in IDU, it is imperative to sterilize equipment and to not

share used needles with anyone else (HIV, 2017b).

Secondary. According to the United States’ Department of Veterans Affairs (VA)

(2016), secondary HIV prevention is defined as “prevention activities directed toward people

who are HIV positive, with the intention of preventing transmission to those who are HIV

negative.” One secondary prevention method is to educate HIV positive patients on how they can

protect their sexual partners from the virus and how to limit the spread of disease to other people

(VA, 2016). Additionally, the VA (2016) aims to educate HIV positive patients on how to reduce

risky sexual behaviors and substance abuse. The VA (2016) also provides counseling to

encourage patients to take medication regularly.

Tertiary. The aim of tertiary prevention is to improve the quality of life of individuals

who have already been infected with HIV. One way to do this is to improve access to HIV

medications such as ART in order to prolong the transition from HIV to AIDS (Sahasrabuddhe

& Vermund, 2007). At times, many HIV positive patients feel ostracized from society, therefore

Sahasrabuddhe and Vermund (2007) suggest that they receive assistance for re-entering society

and the workforce as well as provide access to self-help groups. As for large-scale tertiary

prevention, Sahasrabuddhe and Vermund (2007) call for individuals to urge their legislators and

policymakers to make changes to health care so that it better serves the HIV positive and AIDS

population. Furthermore, transgender individuals face a lot of discrimination in the healthcare


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field. Thus, it is also necessary to push policy makers to make changes to the way that healthcare

professionals treat transgender individuals.

Host Factors

Gender. According to data collected by the CDC (2017b), transgender women have the

highest risk for contracting HIV. A large number of these transgender work in the sex industry,

which increases their risk of getting infected. According to Trans Equality (2016), “35.6” percent

of transgender individuals are involved in the sex work industry. Of those individuals, nearly half

of them are female (Trans Equality, 2016). Appendix D is a graph that shows the breakdown of

the number of transgender individuals in the sex industry, based on gender identity (Trans

Equality, 2016). Another factor that puts transgender women at a higher risk than transgender

males is that the majority of transgender women prefer anal sex (The Well Project, 2017). This

sexual position proves to be highly risky without protection because anal-penile intercourse tends

to leave tears in the anus, which allows the virus to enter the body (The Well Project, 2017). As

for women who have had sexual reconstructive surgery, their vaginas do not naturally lubricate

(The Well Project, 2017). With that being said, without proper lubrication the vaginal lining can

tear during intercourse, allowing HIV to enter the body (The Well Project, 2017).

Race. Data collected from the CDC (2017b) shows that African American transgender

individuals have a higher risk of contracting HIV than their white counterparts. “50” percent of

transgender individuals diagnosed with HIV are of African American descent (CDC, 2017b).

One reason for such a high prevalence of HIV amongst African American transgender

individuals is that they tend to have sexual relations within their race, which means “African

Americans face a greater risk of HIV infection with each new sexual encounter.” (CDC, 2017f).
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In general, African Americans also live in higher areas of poverty, which may limit their access

to quality health care and HIV preventative education (CDC, 2017f).

Geographic Location

As previously mentioned, the southern United States is home to nearly approximately

“half” of the newly diagnosed cases of HIV amongst transgender individuals (CDC, 2017b). This

is due to the fact that there are higher levels of transphobia in the southern United States when

compared to other regions of the country (CDC, 2017g). Appendix E is a visual representation of

the risk of getting HIV in the southern region of the United States versus the other regions of the

United States (CDC, 2017h). Transphobia produces a negative stigma, which results in

transgender individuals being afraid to seek out testing or treatment of HIV (CDC, 2017g).

Transphobia in the South also limits the access to quality information about HIV; therefore

transgenders living are not knowledgeable on how to protect themselves and others (CDC,

2017g). Furthermore, the South has yet to adopt new HIV prevention and testing methods, which

prevents people from finding out their HIV status (CDC, 2017g).

Socioeconomic Factors

Socioeconomic factors influence many aspects of one’s life, including the chances of

contracting HIV. Transgender individuals have a lower socioeconomic status than people who

identify as straight. A reason for this is because employers refuse to hire these individuals due to

their gender identity (Fletcher, Kisler, & Reback, 2014). Due to the lack of stable and legal jobs,

transgenders, especially trans women, turn to the sex industry in search of an income (Fletcher,

Kisler, & Reback, 2014). In order to afford housing and other necessities, these transgender sex

workers engage in riskier and more dangerous sex acts in exchange for more money (Fletcher,

Kisler, & Reback, 2014). Due to their lack of a stable income, they are usually not able to afford
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hormone replacement therapy, and as a result, turn to illegal and “do it yourself” methods in

order to receive these hormones (Fletcher, Kisler, & Reback, 2014). The needles used to inject

these hormone treatments are not properly sanitized and are shared amongst multiple individuals,

therefore raising the risk of contracting HIV (Fletcher, Kisler, & Reback, 2014).

Temporal Variation

As of 2017, HIV is considered an epidemic in the United States (CDC, 2016). Although

the new number of diagnoses have declined since the 1980s, there are still “50,000” new total

cases in the United States each year (CDC, 2016). As a result of medical advances, there are

more people living with HIV than dying of HIV related illnesses (Kaiser Family Foundation,

2017).

Additional Epidemiological Variables

Lack of Familial Support. Transgender individuals often face a lack of familial support

(CDC, 2017i). As a result, they are more likely to engage in risky behaviors, such as IDU in

order to cope with their situation (CDC, 2017i). Also, due to lack of familial support, many

young transgender individuals are not able to support themselves financially, which results in

them being involved in the sex industry, increasing their chances of getting HIV (Fletcher,

Kisler, & Reback, 2014).

Community Infrastructure. Due to strong feelings of transphobia found in the southern

states of the United States, many HIV positive transgender individuals lack the quality health

care that they need (CDC, 2017g). Further studies by Reif, Wilson, and McAllaster (2014),

found that quality health clinics in certain areas of South Carolina are hard to come by.

Individuals often have to travel a great distance in order to have access to HIV care (Reif,

Wilson, & McAllaster, 2014). Once they reach their destination, they are faced with long wait
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times, even if they have an appointment (Reif, Wilson, & McAllaster, 2014). In addition, many

individuals also rely on public transportation in order to access these health care facilities,

however, the public transportation in South Carolina can at times be unreliable (Reif, Wilson, &

McAllaster, 2014).

Current Hypotheses

Currently, it is known that HIV is caused by a virus that is transmitted through sexual

contact with an HIV positive person and through bodily fluids such as blood, semen, and vaginal

fluids (HIV, 2017b). Furthermore, researchers know that transgender individuals are also at a

higher risk for contracting HIV due to risky sexual behaviors that are related to their occupation

(Trans Equality, 2016). Data also shows that the southern part of the United States has higher

rates of HIV due to stigma and lack of quality health care (CDC, 2017g).

Gaps in Knowledge

As previously discussed, there is very little data to be found regarding the mortality rates

of HIV infected individuals. According to the CDC (2017i), transgender men are the most

underrepresented and understudied group amongst the transgender population. The CDC (2017i)

states that further studies need to be made about the risky behaviors that put transgender men at

risk for HIV. Furthermore, physicians and other healthcare professionals still do not know how

to effectively treat transgender patients (CDC, 2017b). Physicians cannot successfully treat

transgender individuals if they do not understand how their post-gender reassignment surgeries

bodies work. In addition, the CDC (2017b) states that most HIV prevention programs are

originally made for cisgender individuals and are slightly modified to fit the needs of the

transgender population. However, this may pose a problem because a program that works for a
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cisgender population may not always translate successfully when applied to transgender

individuals.

Areas for Further Epidemiological Research

Researchers and epidemiologists must study transgender individuals as their own

subcategory. Many organizations are still putting transgender individuals in the gay or lesbian

category and that is not entirely representative of the transgender population (SFAF, 2009). Also,

more research needs to be done regarding the risk behaviors of transgender men in order to

reduce the prevalence of HIV within this subgroup. Although medicine exists to prolong life

expectancy and the transition into AIDS, there is currently no known cure for HIV. In order to

fully eradicate the HIV issue at hand, researchers need to be focused on finding a cure.
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References

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Appendix A

Annenberg Learner. (2017)’s Structure of HIV Virus

https://www.learner.org/courses/biology/textbook/hiv/hiv_4.html

Appendix B

AIDS Info. (2017)’s The Stages of HIV Infection.


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https://aidsinfo.nih.gov/images/factsheet/HIVProgression800.jpg

Appendix C

Avert (2017)’s HIV Modes Of Transmission Infographic

https://www.avert.org/sites/default/files/styles/responsive_articlecustom_user_desktop_1x/public

/YOU_CAN_GET_HIV.png?itok=V1CdDMGP&timestamp=1500022685

Appendix D

Trans Equality. (2016)’s Graph of Participation in the Sex Trade By Gender Identity
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http://www.transequality.org/sites/default/files/Meaningful%20Work-

Full%20Report_FINAL_3pdf

Appendix E

Centers for Disease Control and Prevention. (2017h)’s HIV in the United States By Geographic

Distribution
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https://www.cdc.gov/hiv/images/statistics/lifetime-risk-us-map-2014-900x512.png

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