Work to improve the HIV care continuum for black transgender women should concentrate on HIV diagnosis

Less than half of black transgender women living with HIV in the United States are aware of their HIV status, but most of those who have been diagnosed report that they engage with care and take HIV treatment. Rates of viral suppression, however, are sub-optimal, according to an analysis published in the Journal of Acquired Immune Deficiency Syndromes.

Researchers from the University of Pittsburgh recruited participants at Black Pride events in six American cities from 2014 to 2017. Most participants were men who have sex with men, but this analysis focuses on a sub-sample of 422 transgender women. They were all assigned male sex at birth and currently identified as female or transgender. All were black and had sex with men.

Their average age was 30 years. Social challenges such as problems accessing healthcare, incarceration, homelessness, sex work and limited education were frequently reported.



An umbrella term for people whose gender identity and/or gender expression differs from the sex they were assigned at birth.

virological suppression

Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

continuum of care

A model that outlines the steps of medical care that people living with HIV go through from initial diagnosis to achieving viral suppression, and shows the proportion of individuals living with HIV who are engaged at each stage. 

statistical significance

Statistical tests are used to judge whether the results of a study could be due to chance and would not be confirmed if the study was repeated. If result is probably not due to chance, the results are ‘statistically significant’. 


A chemical messenger which stimulates or suppresses cell and tissue activity. Hormones control most bodily functions, from simple basic needs like hunger to complex systems like reproduction, and even the emotions and mood.

Researchers wished to characterise the HIV care continuum, as this has not previously been described in black transgender women.

HIV testing conducted as part of the study showed that 45% of participants were living with HIV (190 women). Just 41% of them (78) were aware of this.

Engagement with the next few stages of the care continuum was much better – 75 of the 78 diagnosed women were linked to care, 72 were retained in care and 65 were receiving HIV treatment. However, only 45 transgender women reported an undetectable viral load.

In percentages from stage to stage, the care continuum is therefore 41% diagnosed, 96% linked to care, 96% retained in care, 90% on treatment, 69% virally suppressed.

Only 24% of this group was diagnosed, in care and virally suppressed compared with the 90-90-90 target of 72.9%.

It appears that there are many barriers to transgender women learning their HIV status. The authors suggest that apprehension about receiving a diagnosis that will require them to use healthcare services where they may be stigmatised may be a factor. But once women take action to learn their status, most are ready to access HIV treatment and care.

The researchers examined factors that were associated with having undiagnosed HIV. In comparison with HIV-negative participants, undiagnosed participants were more likely to have been incarcerated (42% versus 32%) and to report being unable to access health care (54% vs 40%). After adjustment for other factors that could influence these results, these differences remained statistically significant.

Similarly, analysis of factors associated with not being virally suppressed showed that poor treatment outcomes were more common in those recently incarcerated (59% vs 29%), homeless (71% vs 39%), using multiple illicit drugs (50% vs 18%), reporting physical assault (73% vs 47%) and receiving hormone treatment (86% vs 47%). These differences were statistically significant.

The finding that women receiving hormones were less likely to be virally suppressed may reflect women prioritising hormonal therapies for gender reassignment over HIV treatment, especially in the face of economic challenges.

More broadly, the researchers say that their findings underscore “the need for trauma-informed care”. Interventions should address the multiple challenges that black transgender women face and address the fundamental causes of poor health.


Bukowski LA et al. Characterizing the HIV Care Continuum and Identifying Barriers and Facilitators to HIV Diagnosis and Viral Suppression among Black Transgender Women in the United States. Journal of Acquired Immune Deficiency Syndromes, online ahead of print, 2018. (Abstract.)