A note on terminology: For purposes of brevity, this blog uses the terms ‘trans men’ or ‘transmasculine’ but can be taken as referring also to non-binary people and anyone assigned female at birth but who identifies differently.
Discussions around HIV treatment and prevention in the trans community have historically been focussed on the staggeringly high rates of HIV in trans women, particularly those who have sex with men. This is understandable given the severe burden of unmet need in this group. Worldwide, the HIV prevalence in trans women is reported to be 19% and trans women are estimated to be up to 66 times more likely than the general population to be HIV positive.[1] Despite this, some studies have begun to suggest that, though often completely missing from the discourse, trans men (i.e. those assigned female at birth) may in fact be equally at risk as trans women. This may be explained by trans men who have sex with men (MSM) being the receptive partner with the attendant higher risk of acquiring HIV.[2] In addition, the evidence base identifies potential increased risk of acquiring HIV in several subgroups of trans people, including young people, migrants, sex workers and people of the global majority. In 2021, it was reported that trans masculine individuals are almost seven times more likely to have HIV than other individuals over 15 years of age. This is lower compared to the figures for trans feminine individuals, however, are we seeing the true picture?
The fact that the previous paragraph contains such qualifiers as ‘some studies…suggest’, ‘may be equally at risk’ and ‘may be explained by’ is very telling. The existing data, whilst often cited, has severe limitations which require addressing as a matter of urgency if interventions are to be effective and people are to receive the care they need. Using data from the Public Health England (now UK Health Surveillance Agency) HIV surveillance team, the National Aids Trust produced the report, ‘Trans people and HIV: How can policy work improve HIV prevention, treatment and care for trans people in the UK?’, which discusses these data limitations in more detail. They highlight the fact that not only is UK-specific data lacking, but also that most of the evidence tends to focus on trans women, with little focus on trans men and even less on those who may identify outside binary gender categories. In the past, some have presumed that trans men almost exclusively have sex with cis-gendered women and are therefore not at risk of HIV, however, this is incorrect and yet again highlights a lack of understanding of trans men’s needs.
So, what DO we know about the specific needs of trans men? The Terrence Higgins Trust (THT) has a detailed online resource which covers a range of topics including safer sex, using PrEP and living with HIV. There are many interacting risk factors that put trans people at higher risk of HIV, from increased risk-taking behaviour related to psychosocial issues, to how they are treated by health services in general. A quote from the National Aids Trust report states: “Trans people often experience health services as discriminatory, ill-informed, and inaccessible. This results in inadequate healthcare and can result in trans people dropping out of care altogether." There are also issues with inconsistencies in sexual health services and access to PrEP for trans people across the UK. There are some praised clinics and charities across London and in Brighton for example, but unfortunately, a high standard is not upheld in all areas. Furthermore, some trans people feel that there is a lack of sexual health and PrEP information for trans and non-binary people and that cis gay men are prioritised. Resources such as the online information from THT can help to support healthcare providers to deliver accessible and non-judgemental care.
Another factor which may impact on the acquisition of HIV among trans men is gender affirming medical procedures, although this area is under-researched and very little attention has been paid to the HIV risk associated with the genital surgeries undertaken by trans men. Some trans people may be concerned about whether hormone therapy interacts with antiretroviral therapy (ART), i.e. PrEP and HIV treatment. While the British HIV Association (BHIVA) guidelines note that there are no known interactions between PrEP and gender-affirming hormones, testosterone does cause vaginal atrophy which may increase HIV risk depending on sexual behaviour. As with gender-affirming medical procedures, there is insufficient data in this area. Accessing appropriate care and reliable information around PrEP and gender affirming procedures is therefore crucial for trans men. However, we know that there are major inequalities and barriers to accessing PrEP in England for all those who even have the information and ability to request it. Alarmingly, two thirds of people who want PrEP are unable to access it and over half of those who can access it have to wait more than 12 weeks for an appointment.
To succeed in ending new HIV transmissions by 2030, it is essential that no population is left behind. Further work is needed to improve equity of provision of sexual health services and access to PrEP for underserved groups, and that a particular focus should be given to better understanding the needs of and risks facing trans men.
[1] Baral SD et al. ‘Worldwide burden of HIV in transgender women: a systematic review and meta-analysis’ Lancet Infect Dis. 2012; 13 (3): 214–222.
[2] Wansom T et al. ‘Transgender populations and HIV: unique risks, challenges and opportunities’ J Virus Erad. 2016.
