Syndemics and HIV Risk Among Transgender Women, by Race and Ethnicity

Visual summary. CDC

Transgender women are disproportionately affected by HIV, with severe racial and ethnic disparities. Syndemic theory holds that epidemics are driven by diseases and social conditions together — here, structural conditions such as homelessness and incarceration, and psychosocial ones such as sexual violence and drug use, which can jointly raise HIV risk. No earlier study had examined racial and ethnic differences in these conditions in a population-based sample of transgender women.

The study

CDC's National HIV Behavioral Surveillance Among Transgender Women recruited participants in 2019–2020 in Atlanta, Los Angeles, New Orleans, New York City, Philadelphia, San Francisco and Seattle, using respondent-driven sampling. This analysis included 1,348 women — 546 Black, 176 White and 626 Hispanic — and counted six syndemic conditions into a syndemic score:

The outcome was condomless anal intercourse (CAI).

Who faced what

Most participants (68.9%) were 30 or older.

What went with condomless sex

• More conditions, more CAI — for every group. The link was significantly stronger for White participants than for Black or Hispanic participants.
• Individually, only exchange sex and polydrug use were linked to CAI among Black participants; among White and Hispanic participants, every condition was except psychological distress.
• Combinations mattered differently by group. The few "superadditive" pairs — raising CAI more than the two conditions would separately — were mostly structural:

Estimated condomless anal intercourse by syndemic score and race and ethnicity. CDC

Interactions between pairs of syndemic conditions on condomless anal intercourse, by race and ethnicity. CDC

Why the differences?

• Drug use may be higher among White participants because the opioid epidemic has hit White people disproportionately.
• Lower reported distress among Black participants might reflect John Henryism — a high-effort, active way of coping with stress often used by Black people, linked to physical problems such as hypertension and possibly to under-reporting of mental health problems — or a measure that misses how distress shows up in this group.
• More exchange sex among Black and Hispanic women may reflect economic marginalization from discrimination, and more incarceration the disproportionate impact of mass incarceration.

The study's conceptual model. CDC

What it means

Syndemic conditions and CAI were common in every group, so HIV prevention for transgender women must tackle both structural and psychosocial conditions — including housing and poverty — and be tailored:

Culturally tailored programs that address social and structural barriers to status-neutral HIV services — patient navigation or case management, housing and employment help, mental health services — have increased engagement in care among transgender women of color with HIV.

Limits

The survey was cross-sectional, so it can't show what came first; results may not apply outside these cities or to all transgender women in them; the White group was small; and some women may have been protected during CAI by preexposure prophylaxis or effective HIV treatment, which the analysis couldn't account for fully.

Sources

Based on Hershow RB, Trujillo L, Olansky E, et al., "Structural and Psychosocial Syndemic Conditions and Condomless Anal Intercourse Among Transgender Women — National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019–2020," MMWR Supplements volume 73, number 1, Centers for Disease Control and Prevention; a work of the United States government in the public domain.