Stigma,Discrimination,and Mental Health Outcomes Among Transgender Women With Diagnosed HIV Infection in the United States,2015-2018

Abstract

Objective:

Transgender women with diagnosed HIV experience social and structural factors that could negatively affect their overall health and HIV-related health outcomes. We describe estimates from the Centers for Disease Control and Prevention Medical Monitoring Project (MMP) of sociodemographic characteristics, HIV stigma, discrimination, and mental health outcomes among transgender women with diagnosed HIV.

Methods:

We analyzed pooled data of all transgender women with diagnosed HIV (N = 217) from the 2015 through 2018 MMP cycles. We reported unweighted frequencies, weighted percentages, and 95% CIs for all characteristics. We post-stratified data to known population totals by age, race and ethnicity, and sex at birth from the National HIV Surveillance System.

Results:

Approximately 46% of transgender women with diagnosed HIV identified as Black or African American, 67% lived at or below the federal poverty level, 18% had experienced homelessness in the past year, 26% experienced mild to severe symptoms of depression, 30% experienced mild to severe anxiety symptoms, 32% reported physical violence by an intimate partner, and 30% reported forced sex during their lifetime. Despite 80% being very satisfied with their current HIV care, 94% experienced current HIV stigma and 20% experienced health care–related discrimination since being diagnosed with HIV. Among transgender women with diagnosed HIV who experienced discrimination, 46% and 51% experienced health care discrimination attributed to their gender and sexual orientation or sexual practices, respectively.

Conclusions:

Our findings underscore a need to address unmet ancillary services, such as housing, intimate partner violence, and mental health needs, and the need for strategies to reduce experiences with HIV stigma and discrimination in care for transgender women with diagnosed HIV in the United States.

Keywords

transgender women HIV stigma discrimination Medical Monitoring Project

Transgender women in the United States experience substantial health disparities, in part due to social and structural factors, including homelessness,^1,2 poverty,^2,3 lack of health insurance,⁴ and lack of access to health care and preventive services. These social and structural disadvantages are often related to stigma and discrimination.^1,5-8 Transgender women also experience HIV-related disparities. For example, from 2014 to 2018, the proportion of transgender women with diagnosed HIV infection increased 24%; in contrast, among cisgender men and cisgender women, respectively, comparative increases were 11% and 6%.⁹ An estimated 14% of transgender women in the United States have diagnosed HIV; a higher percentage of Black or African American (44%) and Hispanic/Latina (26%) transgender women have diagnosed HIV compared with transgender women in other racial and ethnic groups.¹ Therefore, HIV treatment and care efforts for transgender women with HIV must address social and structural factors to reduce these disparities and improve health outcomes.

Transgender women with diagnosed HIV experience HIV stigma and health care discrimination due to the convergence of multiple marginalized social identities, which include their HIV status and gender identity.¹⁰ Stigma is a complex and dynamic social process, where societal beliefs and attitudes reject and interpret “selective” human differences as inferior or of lower social value as a form of social control.^10-12 Discrimination is the behavior that results from stigma, which translates into the act of treating people unfairly due to their human differences.¹¹ Transgender women experience discrimination at health care settings from physicians, health care providers, and other staff. Examples of health care discrimination include not receiving transition-related health care, being asked invasive questions about being transgender, and having to teach the health care provider about transgender people to receive appropriate care.⁶ Stigma and discrimination in health care settings are associated with poor mental health and HIV treatment and care outcomes,^13-16 including low adherence to antiretroviral therapy (ART) and reduced viral suppression.^13,16,17

Disproportionate experiences with stigma, health care discrimination, and poor mental health outcomes have been reported among transgender women in the United States.^6,15,18-21 However, limited studies are available on transgender women from population-based samples of people with diagnosed HIV.^2,13,22 Here, we describe sociodemographic characteristics, HIV stigma, health care discrimination, and mental health outcomes among transgender women with diagnosed HIV using data from the Centers for Disease Control and Prevention’s (CDC’s) Medical Monitoring Project (MMP).^23,24 Our results could inform future interventions and strategies to address stigma and discrimination and improve HIV-related health outcomes for transgender women with diagnosed HIV.

Methods

MMP Design and Data Collection

The MMP is an annual, cross-sectional survey designed to produce nationally representative estimates of behavioral and clinical characteristics among adults with diagnosed HIV in the United States. Briefly, MMP uses a 2-stage sampling method. In the first stage, 16 states and Puerto Rico were sampled from all 50 states, the District of Columbia, and Puerto Rico. In the second stage, simple random samples of people with diagnosed HIV aged ≥18 years were drawn annually for each participating jurisdiction from the National HIV Surveillance System, a census of people with diagnosed HIV in the United States. This analysis was conducted in 2020, using combined annual data from the 2015 through 2018 MMP cycles. For each annual cycle, interview and medical record data were collected from June of each cycle year through May of the following year. The MMP had response rates of 100% at the jurisdiction level and from 40% to 46% at the person level. MMP data collection is a part of routine public health surveillance and, thus, determined to be non-research by CDC.²⁵ Participating jurisdictions obtained local institutional review board approval to collect data when required. Informed consent was obtained from all participants.

People were classified as transgender women if they reported that their sex assigned at birth was male and their gender was female or transgender (N = 217). From MMP data, we calculated weighted percentages of transgender women among all adults with diagnosed HIV by yearly cycle as follows: 1.23% (95% CI, 0.72%-1.74%) in 2015, 1.05% (95% CI, 0.69%-1.41%) in 2016, 1.51% (95% CI, 1.06%-1.97%) in 2017, and 1.63% (95% CI, 1.26%-2.01%) in 2018.

Measures

The MMP survey used 10 items, with responses measured on a 5-point Likert scale (from 1 [strongly disagree] to 5 [strongly agree]), to measure HIV stigma that encompassed 4 domains: personalized stigma, disclosure concerns, negative self-image, and public attitudes.²⁶ The personalized stigma domain measures the perceived negative experiences of other people knowing of their HIV status. The disclosure concerns domain is related to feelings of worry and being careful about disclosing their HIV status. The negative self-image domain measures the internalized stigma, feelings of guilt, blame, or shame due to HIV status. The public attitudes domain measures concerns about how others view people with HIV.²⁷ Other studies that used MMP data have previously used the HIV stigma scale for transgender women with diagnosed HIV.^28,29 In addition, in a national community-based research study that used this HIV stigma scale for transgender women with HIV, Cronbach α values ranged from 0.76 to 0.88 for the 4 domains.³⁰ Respondents experienced overall stigma if they responded with “somewhat agree” or “strongly agree” to any of the 10 items. Respondents experienced any stigma within each domain if they responded with “somewhat agree” or “strongly agree” to any of the items within that domain.

The MMP measured discrimination by using 3 yes/no questions about discrimination experienced in the health care system since the person first tested positive³¹; these questions had been asked only during the 2015 through 2017 MMP cycles. Respondents experienced any discrimination in the health care system if they responded “yes” to any of the following 3 questions: (1) Since testing positive for HIV, has anyone in the health care system exhibited hostility or a lack of respect for you? (2) Since testing positive for HIV, has anyone in the health care system given you less attention than other patients? (3) Since testing positive for HIV, has anyone in the health care system refused you service? If respondents reported discrimination, they were asked whether they attributed the discrimination to their gender and/or their sexual orientation/sexual practices.

We categorized generalized anxiety disorder and depression symptoms in the previous 2 weeks based on clinically meaningful cutoff points from the Generalized Anxiety Disorder 7-item scale³² and the Patient Health Questionnaire 8-item scale,³³ respectively. Respondents were categorized as having “severe anxiety” if they had a score of ≥15 according to the Generalized Anxiety Disorder 7-item scale and were categorized as having “mild to moderate anxiety” if they had a score of 5 through 14. Respondents were categorized as having “severe depression” if they had a score of ≥15 according to the Patient Health Questionnaire 8-item scale and as having “mild to moderate depression” if they had a score of 5 through 14.

Respondents were categorized as experiencing physical violence by an intimate partner if they had been slapped, punched, shoved, kicked, choked, or otherwise physically hurt by a romantic or sexual partner. Respondents were categorized as experiencing forced sex if they had been threatened with harm or physically forced to have unwanted vaginal, anal, or oral sex. The MMP adapted the physical violence and forced sex questions from the National Intimate Partner Violence Survey.³⁴

The MMP used 1 item to measure sexual identity among respondents: “Do you think of yourself as,” with response options of “lesbian or gay”; “straight, that is, not gay”; “bisexual”; or “something else.” All examined covariates were collected via interview and were measured during the past 12 months, except where otherwise noted. Household poverty level was defined based on US Department of Health and Human Services guidelines.³⁵ For example, a single person with no other people in the family or the household who had an annual income ≤$11 880 was considered at or below the federal poverty level. Respondents were categorized as experiencing homelessness if they lived on the street, in a shelter, in a single-room occupancy hotel, or in a car. Health insurance coverage was categorized as having any private health insurance, public health insurance only, or Ryan White HIV/AIDS Program (hereinafter, Ryan White) coverage, or AIDS Drug Assistance Program only/uninsured. Respondents who had Ryan White or AIDS Drug Assistance Program coverage only and respondents who had no health insurance were combined because of small sample sizes and because both categories indicated a need for health insurance. Respondents were categorized as having an unmet need for ancillary services if they reported a need but did not receive any of a range of services (eg, substance use counseling or treatment, adherence support counseling, dental care).³⁶

Statistical Analysis

We conducted our data analyses in 2020. We reported unweighted frequencies, weighted percentages, and 95% CIs for demographic characteristics, mental health outcomes, and experiences of violence victimization, stigma, and discrimination. The MMP used weighted data based on known probabilities of selection at state or territory and person levels, adjusted for nonresponse.^23,37 For the nonresponse adjustment, the MMP based weighting classes on variables related to person-level responses, which were assessed annually; more details on the variables used to create weighting classes are described elsewhere.³⁸ We post-stratified the data to known population totals by age, race and ethnicity, and sex assigned at birth from the National HIV Surveillance System. We conducted the data analysis using weighting procedures that accounted for the complex sample design using the survey procedures in SAS version 9.4 (SAS Institute, Inc).

Results

We found that 46.1% of transgender women with diagnosed HIV identified as non-Hispanic Black or African American (Table 1). More than one-fourth (26.2%) of transgender women with diagnosed HIV experienced mild to severe symptoms of depression, and nearly one-third (30.0%) experienced symptoms of mild to severe anxiety in the 2 weeks before the interview (Table 2). Almost 1 in 10 transgender women (9.2%) reported having an unmet need for mental health services in the 12 months before they were interviewed.

Table 1.

Sociodemographic characteristics among transgender women with diagnosed HIV in the United States, Medical Monitoring Project, 2015-2018^a

Characteristic	Transgender women, no. (N = 217)^b	% (95% CI)^c
Age, y
18-34	61	28.3 (20.4-36.2)
35-44	47	23.9 (16.3-31.6)
45-54	67	31.3 (23.2-39.3)
≥55	42	16.5 (11.0-22.0)
Race and ethnicity
Black, non-Hispanic	101	46.1 (36.7-55.5)
Hispanic or Latino	69	34.4 (25.4-43.5)
Other^d	27	11.7 (7.2-16.2)
White, non-Hispanic	20	7.8 (3.9-11.6)
Education
<High school	59	26.3 (19.6-33.0)
High school diploma or equivalent	80	34.8 (27.9-41.7)
>High school	78	38.9 (30.9-46.9)
Sexual orientation
Bisexual	20	10.7 (4.6-16.8)
Lesbian or gay	66	31.2 (23.3-39.2)
Something else	52	22.3 (16.3-28.3)
Straight, that is, not gay	77	35.7 (27.4-44.0)
Annual household income, past calendar year, $
<20 000	152	73.9 (66.0-81.9)
≥20 000	44	26.1 (18.1-34.0)
Household poverty level^e
Above federal poverty level	57	32.8 (24.5-41.1)
At or below federal poverty level	139	67.2 (58.9-75.5)
Experienced homelessness^f
Yes	43	17.6 (12.2-22.9)
No	174	82.4 (77.1-87.8)
Incarcerated >24 hours
Yes	29	12.0 (7.7-16.3)
No	188	88.0 (83.7-92.3)
Health insurance
Any private health insurance	43	23.9 (16.3-31.5)
Public health insurance only	138	57.2 (48.2-66.2)
Uninsured or only Ryan White HIV/AIDS program coverage	35	18.9 (11.6-26.2)
Unmet need for ancillary services^g
Yes	133	59.5 (51.6-67.4)
No	83	40.5 (32.6-48.4)

All variables measured were self-reported by respondents during the past 12 months except where otherwise noted. Data sources: Beer et al²³ and Centers for Disease Control and Prevention.²⁴

Numbers are unweighted.

Percentages and corresponding 95% CIs are weighted percentages.

Other includes American Indian/Alaska Native, Asian, Native Hawaiian/Other Pacific Islander, or multiple races and ethnicities.

Poverty guidelines are as defined by the US Department of Health and Human Services.³⁵

Experienced homelessness includes living on the street, in a shelter, in a single-room occupancy hotel, or in a car.

An unmet need is defined as needing but not receiving any of the following ancillary services: HIV case management services; adherence support services; medicine through the AIDS Drug Assistance Program; patient navigation services; HIV peer group support; dental care; drug or alcohol counseling or treatment; mental health services; transportation assistance; shelter or housing services; Supplemental Nutrition Assistance Program or Special Supplemental Nutrition Program for Women, Infants, and Children; meal or food services; or domestic violence services.

Table 2.

Mental health outcomes and experiences with violence among transgender women with diagnosed HIV in the United States, Medical Monitoring Project, 2015-2018^a

Mental health outcome or experience with violence	Transgender women, no. (N = 217)^b	% (95% CI)^c
Depression symptoms, past 2 weeks^d
No depression (0-4)	156	73.8 (66.7-80.9)
Mild–moderate depression (5-14)	29	13.1 (8.3-18.0)
Severe depression (≥15)	29	13.1 (7.3-18.9)
Anxiety symptoms, past 2 weeks^e
No anxiety (0-4)	143	70.0 (62.7-77.2)
Mild–moderate anxiety (5-14)	45	18.4 (13.2-23.6)
Severe anxiety (≥15)	25	11.7 (6.1-17.2)
Received mental health services, past 12 months
Received this service	97	43.5 (35.1-52.0)
Needed, but did not receive this service	21	9.2 (4.9-13.5)
Did not need and did not receive this service	96	47.3 (38.7-55.9)
In past 12 months, ever slapped, punched, shoved, kicked, choked, or otherwise physically hurt by a romantic or sexual partner
Yes	20	9.2 (5.0-13.3)
No	195	90.8 (86.7-95.0)
In lifetime, ever slapped, punched, shoved, kicked, choked, or otherwise physically hurt by a romantic or sexual partner
Yes	78	32.1 (25.3-38.8)
No	137	67.9 (61.2-74.7)
In past 12 months, ever threatened with harm or physically forced to have unwanted vaginal, anal, or oral sex
Yes	11	4.6^f (1.6-7.6)
No	201	95.4 (92.4-98.4)
In lifetime, ever threatened with harm or physically forced to have unwanted vaginal, anal, or oral sex
Yes	71	30.4 (23.7-37.0)
No	142	69.6 (63.0-76.3)

All variables measured were self-reported by respondents during the past 12 months except where otherwise noted. Data sources: Beer et al²³ and Centers for Disease Control and Prevention.²⁴

Numbers are unweighted.

Percentages and corresponding 95% CIs are weighted percentages.

Responses to items on the Patient Health Questionnaire 8-item scale were used to categorize depression according to criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR).^33,65

Responses to the Generalized Anxiety Disorder 7-item scale were used to categorize anxiety according to criteria from the DSM-IV-TR.^32,65

The coefficient of variation may be >0.30 and may be unstable.

Nearly all transgender women with diagnosed HIV experienced some aspect of HIV-related stigma (93.6%) (Table 3). More than half (51.7%) experienced personalized stigma, 86.9% experienced HIV disclosure stigma, 27.4% experienced stigma related to negative self-image, and 69.3% experienced stigma related to perceived public attitudes about people with HIV. Nearly 1 in 5 transgender women (19.8%) experienced discrimination in a health care setting since testing positive for HIV. Among those who reported any discrimination, health care–related discrimination attributed to gender and sexual orientation/sexual practices was also high (45.8% and 50.8%, respectively). Despite the high prevalence of experiencing any discrimination in the health care system, 80.1% of transgender women with diagnosed HIV were very satisfied with their current HIV care and 15.5% were somewhat satisfied.

Table 3.

Stigma and discrimination among transgender women with diagnosed HIV in the United States, Medical Monitoring Project, 2015-2018^a

Stigma or discrimination	No. of transgender women (N = 217)^b	% (95% CI)^c
Any HIV stigma
Yes	203	93.6 (89.2-98.0)
No	11	6.4^d (2.0-10.8)
Any personalized stigma
Yes	120	51.7 (44.2-59.2)
No	93	48.3 (40.8-55.8)
I have been hurt by how people reacted to learning I have HIV
Yes	90	39.1 (31.7-46.5)
No	123	60.9 (53.5-68.3)
I have stopped socializing with some people because of their reactions to my HIV status
Yes	80	34.5 (27.9-41.2)
No	134	65.5 (58.8-72.1)
I have lost friends by telling them I have HIV
Yes	67	27.9 (21.2-34.7)
No	14	72.1 (65.3-78.8)
Any disclosure stigma
Yes	189	86.9 (81.2-92.7)
No	25	13.1 (7.3-18.8)
I am very careful who I tell that I have HIV
Yes	182	83.9 (77.9-89.9)
No	32	16.1 (10.1-22.1)
I worry that people who know I have HIV will tell others
Yes	135	62.7 (55.0-70.3)
No	79	37.3 (29.7-45.0)
Any negative self-image stigma
Yes	56	27.4 (19.8-35.1)
No	157	72.6 (64.9-80.2)
I feel that I am not as good a person as others because I have HIV
Yes	42	17.5 (12.3-22.7)
No	172	82.5 (77.3-87.7)
Having HIV makes me feel unclean
Yes	46	23.3 (16.0-30.6)
No	167	76.7 (69.4-84.0)
Having HIV makes me feel that I’m a bad person
Yes	20	9.4 (5.3-13.5)
No	194	90.6 (86.5-94.7)
Any public attitudes stigma
Yes	150	69.3 (61.9-76.6)
No	62	30.7 (23.4-38.1)
Most people think that a person with HIV is disgusting
Yes	95	42.3 (34.8-49.8)
No	116	57.7 (50.2-65.2)
Most people with HIV are rejected when others find out
Yes	140	65.4 (58.0-72.7)
No	73	34.6 (27.3-42.0)
Discrimination
Ever experienced discrimination in the health care system since testing positive for HIV (2015-2017 only)
Yes	33	19.8 (12.7-26.9)
No	113	80.2 (73.1-87.3)
Since testing positive for HIV, has anyone in the health care system exhibited hostility or a lack of respect for you? (2015-2017 only)
Yes	31	19.1 (12.0-26.1)
No	115	80.9 (73.9-88.0)
Since testing positive for HIV, has anyone in the health care system given you less attention than other patients? (2015-2017 only)
Yes	20	12.5 (6.6-18.4)
No	126	87.5 (81.6-93.4)
Since testing positive for HIV, has anyone in the health care system refused you service? (2015-2017 only)
Yes	9	5.5^d (1.8-9.3)
No	136	94.5 (90.7-98.2)
Among those who experienced discrimination, discrimination occurred because of gender (2015-2017 only)
Yes	15	45.8 (26.3-65.3)
No	17	54.2 (34.7-73.7)
Among those who experienced discrimination, discrimination occurred because of sexual orientation/sexual practices (2015-2017 only)
Yes	18	50.8 (31.1-70.5)
No	14	49.2 (29.5-68.9)
Satisfaction with current HIV care
Very satisfied	164	80.1 (74.7-85.6)
Somewhat satisfied	33	15.5 (10.5-20.4)
Very/somewhat dissatisfied	11	4.4 (1.9-6.9)

All variables measured were self-reported by respondents during the past 12 months except where otherwise noted. Data sources: Beer et al²³ and Centers for Disease Control and Prevention.²⁴

Numbers are unweighted.

Percentages and corresponding 95% CIs are weighted percentages.

Because coefficient of variation is >0.30, estimate may be unstable.

Discussion

In this analysis, we found high levels of HIV stigma, discrimination, and poor mental health outcomes among transgender women with diagnosed HIV in the United States. However, most transgender women with diagnosed HIV also reported a high satisfaction level with their current HIV care, which is notable and encouraging. This finding could suggest that HIV care settings are providing needed care for transgender women with diagnosed HIV. By contrast, nearly 20% of respondents also reported health care–related discrimination. It is possible that the reported experiences with health care–related discrimination occurred in the past and/or outside their current HIV health care setting. In addition, it could reflect the resilience of transgender women and the role of peer support in overcoming experiences of discrimination.^6,30,39 Reducing stigma and discrimination toward transgender women with diagnosed HIV should be prioritized, as it could ameliorate the general well-being and HIV outcomes of this population.

The high levels of HIV stigma reported by transgender women with diagnosed HIV included personalized stigma, HIV disclosure stigma, and stigma related to public attitudes toward people with HIV. Experiences of HIV stigma among transgender women with diagnosed HIV could derive from devaluing attitudes and beliefs toward people with HIV. Experiences of stigma could also be attributed to public views on identities such as gender and race and ethnicity of people with HIV.^10,29,40 These results, which are consistent with the literature,^20,21,41,42 are important because experiences with stigma can negatively affect both the physical and mental health of transgender women and limit their access to employment, housing, and health care resources.^{10,14,41,43,44} The HIV stigma scale used in our study to measure 4 domains of HIV stigma experiences is also used by the National HIV/AIDS Strategy to monitor the prevalence of stigma among people with HIV.⁴⁵ Thus, the estimates from our study could provide a benchmark to monitor progress in decreasing the prevalence of HIV stigma among transgender women with diagnosed HIV in the United States.

In studies of patients with HIV, experiences with stigma are associated with low ART adherence, reduced viral suppression, and decreased access to HIV care.^{5,10,22,42,46,47} Strategies to reduce experiences with stigma could include multilevel approaches that address negative attitudes and beliefs about people with HIV and transgender women.^14,46 Lack of awareness and cultural humility—that is, having an other-oriented interpersonal position characterized by respect and lack of superiority toward the cultural background and experiences of individuals⁴⁸—among staff and health care providers could increase experiences with stigma toward transgender women with diagnosed HIV. Although no evidence-based interventions have been designed to reduce experiences with HIV-related stigma among transgender women with diagnosed HIV, a systematic review focused on education training for medical students and residents on transgender health care. Training improved attitudes toward transgender patients and increased knowledge and skills needed for providing competent care to transgender people.⁴⁹

Among the transgender women with diagnosed HIV who reported experiences with health care–related discrimination since testing positive for HIV, nearly half reported that the discrimination was attributed to their gender identity and sexual orientation/sexual practices, which is consistent with other studies.^{1,6,7,15,21,50,51} These findings indicate a multilayered experience of discrimination, which may be based on beliefs, attitudes, and prejudice of health care facility staff and providers. In addition, groups who are socially marginalized, such as transgender women, experience discrimination outside health care systems that could impede access to care.^52,53 Discrimination attributed to HIV and gender identity status could increase barriers to care and lead to poor health outcomes among transgender women with diagnosed HIV.^10,50,54 These experiences can also impede access to treatment and care in this population.^7,14,55,56

Improving knowledge of health care providers through transgender cultural competency training and gender affirmation models in health care settings could reduce the stigma experienced by transgender women in health care settings.^7,14,21,57 The CDC website⁵⁸ has information, educational materials, and tools for health care providers, whole care teams, and social service providers on delivering care for transgender patients, including transgender women with HIV. These tools, when used consistently and appropriately, can reduce the number of experiences with discrimination among transgender women with diagnosed HIV.⁵⁸ Results from a qualitative study of transgender women suggested that systemic changes in health care settings, such as inclusion of transgender people in service delivery, peer support, safe spaces, and education training developed and delivered by transgender people, could also improve health care services for this population.³⁹

We found that about 1 in 4 transgender women with diagnosed HIV experienced symptoms of depression and anxiety, which aligns with the literature.^{16,17,21,41,43,59} Transgender women with diagnosed HIV experienced levels of symptoms of depression (26.2% vs 18.0%) and anxiety (30.1% vs 21.7%) that were higher than among all adults with diagnosed HIV during 2018.³⁶ Although not examined in our study, an association between symptoms of anxiety and depression and experiences of multiple domains of HIV stigma has been found in other studies.^29,40 The self-reported mental health symptoms of anxiety and depression among our cohort could be attributed to high levels of socioeconomic challenges, including homelessness, poverty, and exposure to violence victimization.¹⁷ In addition, the transgender women with diagnosed HIV in our study reported substantial unmet needs for mental health services. High levels of anxiety and depression and unmet needs for mental health services highlight the need to improve the delivery of mental health services for transgender women with diagnosed HIV. Experiences with anxiety and depression are associated with poor HIV-related health outcomes, such as lower ART prescription, adherence, and viral suppression.^16,17,42,46 Screening for and addressing the mental health needs of transgender women in HIV treatment and care are critical for improving their overall health and well-being.

In our examination of the sociodemographic characteristics of transgender women with diagnosed HIV, a greater percentage of transgender women with diagnosed HIV identified as Black or African American and Hispanic/Latina than other races and ethnicities, and most experienced socioeconomic challenges, including living below the federal poverty level, having a past-year income of <$20 000, and experiencing homelessness. We also found that transgender women with diagnosed HIV experienced levels of social and structural factors associated with poor health outcomes that were higher than shown among all adults with diagnosed HIV. Specifically, transgender women with diagnosed HIV had prevalences of homelessness (17.6% vs 10.0%), incarceration (12.0% vs 4.7%), and income below the federal poverty level (67.2% vs 43.0%) that were higher than those reported among all adults with diagnosed HIV.^36,50 More than half reported unmet needs for ancillary services, which included shelter or housing services and domestic violence services. These findings support the findings of previous studies on unmet service needs among transgender women with diagnosed HIV and highlight the importance of integrating these services with HIV care.^2,4,6,54 In addition, our findings add to the literature by providing estimates for this key population that were drawn from a nationally representative sample of adults with diagnosed HIV.^{1,6,7,19,22,50,60}

Among transgender women with diagnosed HIV, we found that nearly 70% had a lifetime experience with physical violence by an intimate partner and/or forced sex. Specifically, we found prevalences of lifetime physical violence by an intimate partner (32.1% vs 27.5%) and lifetime forced sex (30.4% vs 17.4%) among transgender women with diagnosed HIV that were higher than reported in all adults with diagnosed HIV.³⁶ Transgender women with diagnosed HIV may experience homelessness, unmet housing needs, and income needs as a result of housing and employment discrimination,^6,60 increasing their risk for and experiences with violence and forced sex.^5,61 Socioeconomic challenges, including unemployment and homelessness, and experiences with physical violence and/or forced sex are associated with poor health outcomes.^60,62 Training health care providers to incorporate screening for employment and housing needs and linking women to appropriate services may assist with addressing these socioeconomic challenges and improving health outcomes among transgender women with diagnosed HIV.^50,54,62 Health care providers should also include screening for and linkage to services that address intimate partner violence into health care visits for this population.

Limitations

Our study had 5 limitations. First, the measures used in our study were self-reported, which could have led to an over- or underestimation as a result of recall bias and social desirability bias. Although the MMP used the 2-step method to measure transgender identity, some respondents may not have identified themselves as transgender women, possibly because of fear of stigma. To measure symptoms of anxiety and depression among respondents, the MMP used the Generalized Anxiety Disorder 7-item scale and the Patient Health Questionnaire 8-item scale, which are not equivalent to a clinical diagnosis; however, these measures are linked to the diagnostic criteria used in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV text revision) and showed good criterion validity.^32,33,63-65 Second, 95% CIs for some variables were unstable because of small sample sizes. Because of the small sample size, our ability to examine relationships among sociodemographic characteristics, stigma, discrimination, and mental health outcomes was limited. Third, the stigma measures in this study were focused only on HIV-related stigma and did not measure intersectional stigma, which is stigma due to the convergence of multiple social statuses.¹⁰ The MMP only measured discrimination in health care settings. Broader measures, such as the Everyday Discrimination Scale,⁶⁶ could assess experiences of discrimination beyond health care settings. Fourth, the study estimates could vary by geographic area. Fifth, qualitative research exploring the insights of transgender women with diagnosed HIV on the interpersonal and structural factors and the underlying mechanisms of stigma and discrimination in health care settings was beyond the scope of our study.

Conclusions

Our study reported the national estimates of HIV stigma, discrimination, and mental health outcomes among transgender women drawn from a nationally representative sample of people with diagnosed HIV in the United States. Many experienced stigma and discrimination. Our results could inform future interventions and strategies to address stigma and discrimination; addressing stigma and discrimination could lead to improved HIV-related health and overall physical and mental health outcomes for transgender women with diagnosed HIV. About one-fourth of transgender women with diagnosed HIV reported symptoms of anxiety and depression, and 1 in 10 reported unmet mental health needs. Our results suggest a need to integrate mental health needs into HIV treatment and care services to improve the mental health of transgender women with diagnosed HIV. Our findings underscore the need for transgender-sensitive health care settings and providers so that health disparities among transgender women, who are disproportionately affected by HIV in the United States, can be decreased. Future research should explore the associations among stigma, discrimination, and mental health outcomes and the HIV care continuum outcomes among transgender women with diagnosed HIV.

Footnotes

Acknowledgements

The authors thank MMP participants, project area staff, and MMP provider and community advisory board members. We also acknowledge the contributions of the Clinical Outcomes Team and Behavioral and Clinical Surveillance Branch at CDC.

Disclaimer

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Krishna Kiran Kota, PhD, MS

Donna Hubbard McCree, PhD, MPH, RPh

References

Becasen

Denard

Mullins

Higa

Sipe

TA.

Estimating the prevalence of HIV and sexual behaviors among the US transgender population: a systematic review and meta-analysis, 2006-2017. Am J Public Health. 2019;109(1):e1-e8. doi:10.2105/AJPH.2018.304727

Mizuno

Frazier

Huang

Skarbinski

Characteristics of transgender women living with HIV receiving medical care in the United States. LGBT Health. 2015;2(3):228-234. doi:10.1089/lgbt.2014.0099

Carpenter

Eppink

Gonzales

Transgender status, gender identity, and socioeconomic outcomes in the United States. ILR Rev. 2020;73(3):573-579. doi:10.1177/0019793920902776

Frank

Restar

Kuhns

, et al. Unmet health care needs among young transgender women at risk for HIV transmission and acquisition in two urban U.S. cities: the LifeSkills Study. Transgend Health. 2019;4(1):1-8. doi:10.1089/trgh.2018.0026

Poteat

Radiz

. HIV prevention, care, and treatment for transgender communities of color. In: Ojikutu

Stone

, eds. HIV in US Communities of Color. Springer International; 2021:191-206.

James

Herman

Rankin

Keisling

Mottet

Anafi

The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality; 2016.

Sevelius

Chakravarty

Neilands

, et al. Evidence for the model of gender affirmation: the role of gender affirmation and healthcare empowerment in viral suppression among transgender women of color living with HIV. AIDS Behav. 2021;25(suppl 1):64-71. doi:10.1007/s10461-019-02544-2

Salazar

Crosby

Jones

Kota

Hill

Masyn

KE.

Contextual, experiential, and behavioral risk factors associated with HIV status: a descriptive analysis of transgender women residing in Atlanta, Georgia. Int J STD AIDS. 2017;28(11):1059-1066. doi:10.1177/0956462416686722

Centers for Disease Control and Prevention. Diagnoses of HIV infection in the United States and dependent areas, 2018 (updated). HIV Surveill Rep. 2020;31:1-119. Accessed October 11, 2020. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2018-updated-vol-31.pdf

10.

Turan

Hatcher

Weiser

Johnson

Rice

Turan

JM.

Framing mechanisms linking HIV-related stigma, adherence to treatment, and health outcomes. Am J Public Health. 2017;107(6):863-869. doi:10.2105/AJPH.2017.303744

11.

Link

Phelan

JC.

Stigma and its public health implications. Lancet. 2006;367(9509):528-529. doi:10.1016/S0140-6736(06)68184-1

12.

Phelan

Link

Dovidio

JF.

Stigma and prejudice: one animal or two?

Soc Sci Med. 2008;67(3):358-367. doi:10.1016/j.socscimed.2008.03.022

13.

Mizuno

Beer

Huang

Frazier

EL.

Factors associated with antiretroviral therapy adherence among transgender women receiving HIV medical care in the United States. LGBT Health. 2017;4(3):181-187. doi:10.1089/lgbt.2017.0003

14.

White Hughto

Reisner

Pachankis

JE.

Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med. 2015;147:222-231. doi:10.1016/j.socscimed.2015.11.010

15.

Bradford

Reisner

Honnold

Xavier

Experiences of transgender-related discrimination and implications for health: results from the Virginia Transgender Health Initiative Study. Am J Public Health. 2013;103(10):1820-1829. doi:10.2105/AJPH.2012.300796

16.

Gokhale

Weiser

Sullivan

Luo

Shu

Bradley

Depression prevalence, antidepressant treatment status, and association with sustained HIV viral suppression among adults living with HIV in care in the United States, 2009-2014. AIDS Behav. 2019;23(12):3452-3459. doi:10.1007/s10461-019-02613-6

17.

Beer

Tie

Padilla

Shouse

; Medical Monitoring Project. Generalized anxiety disorder symptoms among persons with diagnosed HIV in the United States. AIDS. 2019;33(11):1781-1787. doi:10.1097/QAD.0000000000002286

18.

Maksut

Sanchez

Wiginton

, et al. Gender identity and sexual behavior stigmas, severe psychological distress, and suicidality in an online sample of transgender women in the United States. Ann Epidemiol. 2020;52:15-22. doi:10.1016/j.annepidem.2020.07.020

19.

Grant

Mottet

Tanis

Harrison

Herman

Keisling

Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011.

20.

King

White Hughto

Operario

Transgender stigma: a critical scoping review of definitions, domains, and measures used in empirical research. Soc Sci Med. 2020;250:112867. doi:10.1016/j.socscimed.2020.112867

21.

Valentine

Shipherd

JC.

A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States. Clin Psychol Rev. 2018;66:24-38. doi:10.1016/j.cpr.2018.03.003

22.

Klein

Psihopaidas

Xavier

Cohen

SM.

HIV-related outcome disparities between transgender women living with HIV and cisgender people living with HIV served by the Health Resources and Services Administration’s Ryan White HIV/AIDS Program: a retrospective study. PLoS Med. 2020;17(5):e1003125. doi:10.1371/journal.pmed.1003125

23.

Beer

Johnson

Fagan

, et al. A national behavioral and clinical surveillance system of adults with diagnosed HIV (The Medical Monitoring Project): protocol for an annual cross-sectional interview and medical record abstraction survey. JMIR Res Protoc. 2019;8(11):e15453. doi:10.2196/15453

24.

Centers for Disease Control and Prevention. Surveillance reports. Accessed August 26, 2020. https://www.cdc.gov/hiv/statistics/systems/mmp/resources.html#Surveillance%20Reports

25.

Centers for Disease Control and Prevention. Distinguishing public health research and public health nonresearch. July 29, 2010. Accessed October 13, 2020. https://stacks.cdc.gov/view/cdc/24235

26.

Wright

Naar-King

Lam

Templin

Frey

Stigma scale revised: reliability and validity of a brief measure of stigma for HIV+ youth. J Adolesc Health. 2007;40(1):96-98. doi:10.1016/j.jadohealth.2006.08.001

27.

Berger

Ferrans

Lashley

FR.

Measuring stigma in people with HIV: psychometric assessment of the HIV stigma scale. Res Nurs Health. 2001;24(6):518-529. doi:10.1002/nur.10011

28.

Baugher

Beer

Fagan

, et al. Prevalence of internalized HIV-related stigma among HIV-infected adults in care, United States, 2011-2013. AIDS Behav. 2017;21(9):2600-2608. doi:10.1007/s10461-017-1712-y

29.

Beer

Tie

McCree

, et al. HIV stigma among a national probability sample of adults with diagnosed HIV—United States, 2018-2019. AIDS Behav. 2022;26(suppl 1):39-50. doi:10.1007/s10461-021-03414-6

30.

Lacombe-Duncan

Warren

Kay

, et al. Mental health among transgender women living with HIV in Canada: findings from a national community-based research study. AIDS Care. 2021;33(2):192-200. doi:10.1080/09540121.2020.1737640

31.

Schuster

Collins

Cunningham

, et al. Perceived discrimination in clinical care in a nationally representative sample of HIV-infected adults receiving health care. J Gen Intern Med. 2005;20(9):807-813. doi:10.1111/j.1525-1497.2005.05049.x

32.

Spitzer

Kroenke

Williams

Lowe

A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097. doi:10.1001/archinte.166.10.1092

33.

Kroenke

Strine

Spitzer

Williams

Berry

Mokdad

AH.

The PHQ-8 as a measure of current depression in the general population. J Affect Disord. 2009;114(1-3):163-173. doi:10.1016/j.jad.2008.06.026

34.

Smith

Zhang

Basile

, et al. The National Intimate Partner and Sexual Violence Survey: 2015 data brief—updated release. November 2018. Accessed February 9, 2021. https://www.cdc.gov/violenceprevention/pdf/2015data-brief508.pdf

35.

US Department of Health and Human Services, Office of the Assistant for Planning and Evaluation. Computations for the 2016 poverty guidelines. 2016. Accessed October 12, 2020. https://aspe.hhs.gov/computations-2016-poverty-guidelines

36.

Centers for Disease Control and Prevention. Behavioral and clinical characteristics of persons with diagnosed HIV infection—Medical Monitoring Project, United States, 2018 cycle (June 2018–May 2019). HIV Surveill Special Rep. 2020;25:1-38. Accessed October 13, 2020. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-25.pdf

37.

Groves

RM.

Nonresponse rates and nonresponse bias in household surveys. Public Opin Q. 2006;70(5):646-675. doi:10.1093/poq/nfl033

38.

Centers for Disease Control and Prevention. Diagnoses of HIV infection in the HIV surveillance report, 2018 (preliminary). HIV Surveill Rep. 2019;30:1-129. Accessed February 3, 2022. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2018-preliminary-vol-30.pdf

39.

Lacombe-Duncan

Logie

Newman

Bauer

Kazemi

A qualitative study of resilience among transgender women living with HIV in response to stigma in healthcare. AIDS Care. 2020;32(8):1008-1013. doi:10.1080/09540121.2020.1728212

40.

Williams

Cook

Brumback

, et al. The relationship between individual characteristics and HIV-related stigma in adults living with HIV: Medical Monitoring Project, Florida, 2015-2016. BMC Public Health. 2020;20(1):723. doi:10.1186/s12889-020-08891-3

41.

Operario

Yang

M-F

Reisner

Iwamoto

Nemoto

Stigma and the syndemic of HIV-related health risk behaviors in a diverse sample of transgender women. J Community Psychol. 2014;42(5):544-557. doi:10.1002/jcop.21636

42.

Sevelius

Patouhas

Keatley

Johnson

MO.

Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med. 2014;47(1):5-16. doi:10.1007/s12160-013-9565-8

43.

Kota

Salazar

Culbreth

Crosby

Jones

Psychosocial mediators of perceived stigma and suicidal ideation among transgender women. BMC Public Health. 2020;20(1):125. doi:10.1186/s12889-020-8177-z

44.

Yang

Manning

van den Berg

Operario

Stigmatization and mental health in a diverse sample of transgender women. LGBT Health. 2015;2(4):306-312. doi:10.1089/lgbt.2014.0106

45.

US Department of Health and Human Services. HIV National Strategic Plan for the United States: a roadmap to end the epidemic 2021-2025. 2021. Accessed February 2, 2022. https://files.hiv.gov/s3fs-public/HIV-National-Strategic-Plan-2021-2025.pdf

46.

Seeley

Blanc

AK.

Reducing stigma and discrimination: new evidence and its implications. AIDS. 2020;34(suppl 1):S1-S4. doi:10.1097/QAD.0000000000002647

47.

Reisner

Jadwin-Cakmak

White Hughto

Martinez

Salomon

Harper

. Characterizing the HIV prevention and care continua in a sample of transgender youth in the U.S. AIDS Behav. 2017;21(12):3312-3327. doi:10.1007/s10461-017-1938-8

48.

Hook

Davis

Owen

Worthington

Utsey

SO.

Cultural humility: measuring openness to culturally diverse clients. J Couns Psychol. 2013;60(3):353-366. doi:10.1037/a0032595

49.

Dubin

Nolan

Streed

Jr Greene

Radix

Morrison

SD.

Transgender health care: improving medical students’ and residents’ training and awareness. Adv Med Educ Pract. 2018;9:377-391. doi:10.2147/AMEP.S147183

50.

Baguso

Turner

Santos

, et al. Successes and final challenges along the HIV care continuum with transwomen in San Francisco. J Int AIDS Soc. 2019;22(4):e25270. doi:10.1002/jia2.25270

51.

Baugher

Beer

Fagan

Mattson

Shouse

; Medical Monitoring Project. Discrimination in healthcare settings among adults with recent HIV diagnoses. AIDS Care. 2019;31(9):1077-1082. doi:10.1080/09540121.2018.1545988

52.

McCree

Beer

Jeffries

Tie

Fagan

Crim

SM.

Sociodemographic correlates of self-reported discrimination in HIV health care settings among persons with diagnosed HIV in the United States, Medical Monitoring Project, 2018-2019. J Acquir Immune Defic Syndr. 2021;88(5):457-464. doi:10.1097/QAI.0000000000002788

53.

Pitasi

Chavez

DiNenno

, et al. Stigmatizing attitudes toward people living with HIV among adults and adolescents in the United States. AIDS Behav. 2018;22(12):3887-3891. doi:10.1007/s10461-018-2188-0

54.

Padilla

Frazier

Carree

Luke Shouse

Fagan

Mental health, substance use and HIV risk behaviors among HIV-positive adults who experienced homelessness in the United States—Medical Monitoring Project, 2009-2015. AIDS Care. 2020;32(5):594-599. doi:10.1080/09540121.2019.1683808

55.

Bockting

MacCrate

Israel

Mantell

Remien

RH.

Engagement and retention in HIV care for transgender women: perspectives of medical and social service providers in New York City. AIDS Patient Care STDS. 2020;34(1):16-26. doi:10.1089/apc.2019.0067

56.

Katz

Ryu

Onuegbu

, et al. Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis. J Int AIDS Soc. 2013;16(3 suppl 2):18640. doi:10.7448/IAS.16.3.18640

57.

Kattari

Walls

Speer

Kattari

Exploring the relationship between transgender-inclusive providers and mental health outcomes among transgender/gender variant people. Soc Work Health Care. 2016;55(8):635-650. doi:10.1080/00981389.2016.1193099

58.

Centers for Disease Control and Prevention. HIV prevention and care for the transgender population. 2020. Accessed October 7, 2020. https://www.cdc.gov/hiv/clinicians/transforming-health/index.html

59.

Ogburn

Schoenbach

Edmonds

, et al. Depression, ART adherence, and receipt of case management services by adults with HIV in North Carolina, Medical Monitoring Project, 2009-2013. AIDS Behav. 2019;23(4):1004-1015. doi:10.1007/s10461-018-2365-1

60.

Wilson

Turner

Arayasirikul

, et al. Housing and income effects on HIV-related health outcomes in the San Francisco Bay Area—findings from the SPNS Transwomen of Color initiative. AIDS Care. 2018;30(11):1356-1359. doi:10.1080/09540121.2018.1489102

61.

Poteat

Wirtz

Radix

, et al. HIV risk and preventive interventions in transgender women sex workers. Lancet. 2015;385(9964):274-286. doi:10.1016/S0140-6736(14)60833-3

62.

Aidala

Wilson

Shubert

, et al. Housing status, medical care, and health outcomes among people living with HIV/AIDS: a systematic review. Am J Public Health. 2016;106(1):e1-e23. doi:10.2105/AJPH.2015.302905

63.

Kroenke

Spitzer

Williams

Monahan

Lowe

Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146(5):317-325. doi:10.7326/0003-4819-146-5-200703060-00004

64.

Kroenke

Spitzer

Williams

Lowe

The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry. 2010;32(4):345-359. doi:10.1016/j.genhosppsych.2010.03.006

65.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Text Revision: DSM-IV-TR. 4th ed. American Psychiatric Association; 2000.

66.

Williams

Yan

Jackson

Anderson

NB.

Racial differences in physical and mental health: socio-economic status, stress and discrimination. J Health Psychol. 1997;2(3):335-351. doi:10.1177/135910539700200305