When it comes to HIV care—as opposed to HIV infection or HIV risk—the biggest challenges for trans people are access and discrimination, which are entwined.

Theodore Gideonse, M.F.A., Ph.D., assistant professor of teaching, health, society, and behavior at the University of California, Irvine, spoke about HIV care issues in the trans community with Managed Healthcare Executive®.

What are the main challenges for trans people when it comes to HIV care?

American healthcare is obviously not designed to be easily accessible to people without health insurance, and trans people are more likely to be unemployed and/or financially precarious because of any combination of discrimination and mental health problems—most often brought on by discrimination and its subsequent trauma.

When trans people have the means to get healthcare, they face the challenge of finding care providers who are not just trans-friendly but are actually educated on trans health issues and know HIV care.

This is tough even when you are middle class, insured, and know how to navigate the systems. In major cities, this is easier but by no means easy. In Los Angeles, for instance, we have a more of such providers, and the county and state actually want to help, as opposed to states where the government is downright hostile. But unless you live in, say, Hollywood, you might have to travel three hours by bus to get to Hollywood if you can’t afford a car.

What can be done to meet some of these challenges?

I think it’s important to point out that a lot is already being done but many Americans don’t know or simply assume we wouldn’t ever be doing it.

Most importantly, the nearly 32-year-old Ryan White CARE Act has funded HIV/AIDS care for people who are under- or uninsured, so HIV care is not prohibitively expensive if you’re poor. In In fact, it’s free.

The Biden administration has stated that Ryan White funds can be used for gender affirming care and recommends that trans people get HIV treatment and hormone therapy in the same care setting. However, this information is not exactly put on billboards, so we need continued and expanded outreach to trans people about the services available of both HIV care and HIV prevention through PrEP (preexposure prophylaxis), which is covered by Ryan White funds.

That won’t matter, however, if the services aren’t available everywhere. Caregivers need to be trained on trans health issues, gender-affirming care, in addition to HIV care. I’d like to see governments provide incentives for caregivers to get that training, and I’d like to see these issues embedded in curriculums at medical, nursing and PA schools. Those schools shouldn’t be accredited without it being part of the curriculums.

What does the available data on HIV and trans people show?

It is discouraging in most ways but also encouraging in a least one detail. In 2019-20, the CDC surveyed a little over 1,600 transgender women in seven cities in the United States, and 42% reported being HIV positive. That’s outrageously high, but the survey also asked about treatment and 90% of those who reported being HIV positive said they were on antiretroviral drugs.

We don’t know how many of them are virally suppressed, and we’d all like to see 100% of them on medications. But 90%means they’re accessing care.

However, the survey didn’t include people not in those cities and obviously didn’t include people who weren’t comfortable being identified or self-identifying as transgender, so we need better information to know what’s really going on.