Over a decade ago, psychologist and researcher Jae Sevelius had an idea: The behaviors that might put transgender people at particularly high risk of getting HIV stem from the fact that their gender wasn’t being affirmed as they needed.
If that could happen more easily for people — with good medical care, but also through validation from family, friends, and society — they’d be healthier overall, and less likely to engage in risky behavior that could put them at risk of an HIV infection, Sevelius argued, identifying this underlying system as the gender affirmation framework.
A study of more than 8,000 trans and nonbinary people published Thursday in The Lancet HIV supports this idea. At two prominent LGBTQ+ community health centers in the U.S., patients who received gender-affirming hormones were 37% less likely to be infected with HIV than those who were not taking hormones. And if they already were infected, they were 44% less likely to have transmissible levels of the virus in their blood.
“This has been a strong hypothesis for a while,” said Diana Tordoff, a Stanford University epidemiologist focused on LGBTQ+ health equity, who was not involved in the study. “It’s really nice to see a very thoughtful, well-done study confirming this, with a pretty significant effect size.”
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It’s a critical confirmation, arriving at a time when both research and clinical care for trans people has been hamstrung by government action that denies variations in sex, attempts to dramatically curb young people’s access to care, discontinues the inclusion of trans identities in federal health surveillance data, and terminates innumerable research grants on LGBTQ+ health.
“It’s a very difficult time. More than ever, we need to do this research,” said study author Sari Reisner, a social and psychiatric epidemiologist at the University of Michigan School of Public Health.
Even before the Trump administration took over, there’s long been an underinvestment in trans health, Reisner said. Data on trans people and HIV has been limited, mostly focusing on transgender women, with little longitudinal data.
The new study spans 2013 to 2019, following patients with a diverse array of gender identities and racial backgrounds at Callen-Lorde Community Health Center in New York, and Fenway Health in Boston. Black, Hispanic, and multiracial trans participants had disproportionately high rates of HIV, which the authors hypothesized was related to structural barriers like lower socioeconomic status.
These two centers specialize in providing gender-affirming care and treating LGBTQ+ people, which the authors cite as a limitation of the study. Repeating the study across less-specialized clinics likely wouldn’t change the results, but it would be a harder study to execute, said Kellan Baker, the executive director of the Institute for Health Research and Policy at Whitman-Walker. (Baker was part of early discussions getting the cohort study off the ground, but did not participate further.) First, it requires a level of trust between patients and their clinicians. Logistically, it requires electronic medical records that can capture gender identity information and trained staff members who can talk about hormones and HIV prevention.
This is the second paper to draw from this cohort showing the benefits of hormones. Earlier in March, Reisner and colleagues showed that patients who took hormones had a much lower risk of experiencing moderate-to-severe depressive symptoms than those not on hormones.
Neither study investigates exactly why the associations occurred. In addition to exploring those mechanics in a future study, Reisner would also like to look at how social, psychological, and legal dimensions of gender-affirmation affect HIV risk among trans people.
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Among the participants, only 3.1% without HIV had a current prescription for pre-exposure prophylaxis (PrEP). That’s “surprisingly low,” Reisner said. He’d also like to study uptake of this effective, preventative medication among trans communities, and whether it’s increased over time.
But pursuing new studies will be challenging. Like many researchers, Reisner has lost all of his existing grants from the National Institutes of Health. While the team that worked on this study is still pursuing other publications based on the cohort, the future is murky after that.
Thinking back to the gender affirmation framework, experts worry that the same forces making research more difficult will also have severe effects on the health of trans people.
“The administration and its policies cannot erase transgender people,” Baker said. “They can make their lives a lot harder. And in the context of HIV prevention and treatment, this administration’s policies can kill people.”
