HIV Testing and PrEP Use in a National Probability Sample of Sexually Active Transgender People in the United States

Jae M. Sevelius, PhD; Tonia Poteat, PhD, PA-C, MPH; Winston E. Luhur, BS; Sari L. Reisner, ScD; Ilan H. Meyer, PhD


J Acquir Immune Defic Syndr. 2020;84(5):437-442. 

In This Article

Abstract and Introduction


Background: HIV testing and pre-exposure prophylaxis (PrEP) are effective HIV prevention strategies often underused by transgender people.

Methods: Recruitment occurred in 2 phases to identify transgender respondents in a probability sample of adults in the United States. Transgender respondents completed a self-administered paper or web-based survey designed to assess transgender population health. Sexually active respondents (HIV-negative and had sex in the 5 years previously, N = 190) and a subsample of those at risk for sexual HIV acquisition (sex with cisgender men or transgender women, n = 120) were included in analyses.

Results: Of the full sample of sexually active respondents, those who were transfeminine were less likely to be familiar with PrEP; most (72%) reported favorable attitudes toward PrEP. Of those at risk for HIV acquisition, 23% had never tested for HIV. Respondents of color were more likely than white respondents to meet Centers for Disease Control and Prevention recommendations for HIV testing. Respondents who met Centers for Disease Control and Prevention recommendations for HIV testing were more likely to report looking online for lesbian, gay, bisexual, and transgender or transgender-specific health information. Few respondents reported currently taking PrEP (3%); those who reported higher levels of nonaffirmation of their gender identity were less likely to currently use PrEP.

Discussion: These findings may indicate some success of HIV testing outreach programs that prioritize people at higher risk for acquiring HIV, focusing on those who are vulnerable to structural marginalization. Ongoing public health efforts are needed to increase HIV testing and PrEP awareness among transgender adults, who are disproportionately impacted by HIV.


Transgender people (individuals whose gender identity differs from sex assigned at birth) are disproportionately impacted by HIV,[1] with prevalence estimates of approximately 14% among transgender women and 3% among transgender men in the United States.[2,3] HIV prevention and treatment efforts, such as HIV testing and pre-exposure prophylaxis (PrEP), are effective HIV prevention strategies often underused in transgender populations. The Centers for Disease Control and Prevention (CDC) recommends that at-risk individuals get tested every 3–6 months,[4] but HIV testing remains lower among transgender people than other key populations.[5,6]

PrEP is an effective HIV prevention method when taken as prescribed.[7] To date, preexposure prophylaxis initiative (iPrEx) is the only clinical trial of PrEP that reported results specific to transgender women;[7] no clinical trials to date have reported data on transgender men. Although the results of iPrEx were initially reported without disaggregating transgender women from men who have sex with men, a subanalysis of iPrEx found no efficacy on an intention-to-treat basis among 339 transgender women enrolled,[8] likely because of low adherence. Furthermore, hormone use was associated with lower TFV-DP levels. Currently, high levels of adherence to oral PrEP are recommended for transgender women.[9,10] PrEP data in transgender men remain sparse. A recent online survey of 857 transmasculine individuals who have sex with men found that of those who were HIV-negative, 52.5% met PrEP indications and 33.3% reported lifetime PrEP use (21.8% current and 11.5% past).[11] In another recent study, of 439 transmasculine individuals who were eligible for PrEP, only 11% had received a PrEP prescription.[12]

Unique barriers and facilitators to HIV testing and PrEP uptake and adherence have been reported among transgender people.[13] HIV testing rates among transgender people are inadequate given their risk for HIV, suggesting that culturally tailored programs are needed.[14] PrEP knowledge has been demonstrated to be lower among transgender people than among cisgender men who have sex with men.[15,16] Attitudes toward PrEP are often mixed in studies of transgender people, with fear of negative interactions with hormones and HIV stigma inhibiting uptake.[17] Past and anticipated experiences of trans-related stigma and discrimination in health care settings are also significant barriers,[16,18] and facilitators include colocation of HIV testing and PrEP care with transition-related care, such as hormone prescription and monitoring.[19] Access to gender-affirming services has been shown to be critical in HIV-related and health-related interventions for transgender people.[20–22]

To date, studies of HIV testing and PrEP among transgender people have been conducted using convenience samples or have been restricted to small geographic regions. We present results from the first national probability sample in the United States to characterize HIV testing and PrEP attitudes and uptake among transgender individuals.