We all have more strength within us than we realize. We often become aware of those strengths when we are tested by the hard times in life. Some of the strongest people I have ever known in my own life have been transgender women. These women have had to endure so much stigma, discrimination, and aggression in their lives. Despite the adversity they have faced, these resilient women have remained strong, fierce, and true to themselves.
But these experiences can take a toll on the health of transgender women, in some cases even costing them their lives. The stigma and discrimination experienced by transgender people can lead to poverty, homelessness, substance use, mental health problems, and other adverse conditions. They explain many of the health-related disparities experienced by transgender women and are important reasons that too many transwomen are at risk for HIV, are already living with HIV, and are not fully benefiting from HIV care and treatment.
The prevalence of HIV among transgender women is extremely high. A 2013 study combined data from multiple studies and found that about 22% of transgender women were living with HIV. Race/ethnicity affects outcomes among transgender women, like it does for other populations. Black/African American transgender women are more likely to have HIV than transgender women of other races/ethnicities.
Transgender women living with HIV also tend to do more poorly on key health measures than do non-transgender (cisgender) people. According to 2015 data from the Ryan White HIV/AIDS Program (RWHAP), transgender women were less likely to have a suppressed viral load — 77% of transgender women had a suppressed viral load, compared to 83% for all of people receiving RWHAP medical care. That’s not good; but the news isn’t all bad. We are seeing progress. From 2011 to 2015, viral suppression improved by 12 percentage points (from 65% to 77%) among transgender women receiving RWHAP medical care. This change was not enough, however, to erase the disparity that exits for transgender women compared to all people in RWHAP medical care.
The National HIV/AIDS Strategy includes transgender women as a key population because of the high prevalence of HIV and its impact on this population. Last year, as promised when the updated Strategy was released in 2015, we introduced a developmental indicator [PDF 367.35 KB] that focused on improving viral suppression among transgender women. A cross-agency work group, with advice from transgender women and other experts and stakeholders, developed this indicator. The indicator sets the goal that at least 90% of transgender women in RWHAP will be virally suppressed by 2020. Encouragingly, in last year’s National HIV/AIDS Strategy Progress Report [PDF 1,469.73 KB] the annual target for that new indicator (72%) was actually exceeded (77%). However, we still have a way to go to get to the 90% goal.
Today’s observance of National Transgender HIV Testing Day reminds all of us that we need to recognize and work hard to address the effects of HIV, stigma, and discrimination on the lives of transgender people. A number of federally funded programs are supporting efforts to improve HIV prevention, medical care, and treatment for transgender women:
With funding from the Secretary’s Minority AIDS Initiative Fund (SMAIF), last year the Health Resources and Services Administration (HRSA) launched a leadership training initiative for people of color who are living with HIV that emphasized the inclusion of transgender women of color. This program builds on their strengths of people living with HIV to support them in being effective leaders on planning bodies, care teams, boards of directors, and in community-based organizations and other settings.
Transgender people are part of CDC’s Act Against AIDS campaigns that are designed to speak with a wide range of audiences. For example, transgender women are featured in Doing It, which encourages all adults to get tested for HIV and know their status, and includes images and testimonial videos featuring transgender leaders. The experiences of transgender women are portrayed as well in HIV Treatment Works, which encourages people living with HIV to stay in medical care, and tells one transgender woman’s story of staying healthy while living with HIV.
CDC recently announced that seven community-based organizations were awarded funds work with young transgender persons of color (PS17-1704). These organizations will implement comprehensive HIV prevention programs to reduce morbidity, mortality, and related health disparities among young transgender persons of color and their partners who are at high risk of acquiring HIV.
Last year, RWHAP concluded a multi-year, multi-site demonstration and evaluation of HIV service delivery interventions for transgender women of color, Enhancing Engagement and Retention in Quality HIV Care for Transgender Women of Color Initiative. This project should yield lessons and tools that improve results for transgender women of color. While we wait for the final results to come out of this project, you can find useful information and resources about improving care for transgender persons on the TARGET Center website.
Each of these, and many other state- and community-led activities, seek to recognize and build upon the resilience, wisdom, skills, experiences, and the many strengths of transgender women. These traits and assets have not always been gained easily. The experiences that built them have not always been pretty, and they should not have happened in the first place. We need to work toward creating the future that does not allow the stigma, the discrimination, and the violence to continue. But that’s not the world we live in today.
It’s an old saying that adversity makes you stronger. The transwomen I’ve known have shown me that. They persevered. They kept on fighting. And as a result, they emerged stronger and wiser, having gained a wealth of experience, knowledge, skills, and abilities. These hard-won attributes and strengths are resources that can help transgender women, and all of us, move closer toward the vision of the future that we share. A future that is free from stigma and discrimination. One where new HIV infections are rare, and when they do occur, each and every person regardless of their gender or gender-identify has access to and gets the full benefits of culturally competent HIV care and treatment, and, ultimately one day, can be cured.
Author: Richard Wolitski