In this study of a multi-ethnic sample of transgender women in San Francisco, 41% reported HIV positive status and 13% had another sexually transmitted infection during the past year. Approximately one-third (34%) of the sample reported having had unprotected sex with a male primary partner during the past 3 months; by contrast, only 6% reported having had unprotected sex with a non-primary partner during the past 3 months. Factors associated with unprotected sex with a primary partner included living with the partner, drug use, alcohol use, and education level. In addition, self-efficacy to use condoms was associated with lower unprotected sex with a primary partner, and perceived discrimination was associated with higher unprotected sex with a primary partner.
A concern identified in this study was the relatively high prevalence of unprotected sex in HIV discordant partnerships. Over one-third (35%) of transgender women in discordant partnerships reported having any unprotected sex with their male primary partner during the past 3 months, highlighting substantial risk for HIV transmission. Sex with outside partners during the past 3 months was reported by transgender women in HIV-negative concordant (16%), HIV-discordant (13%), and HIV-positive discordant (27%) relationships. Transgender women in HIV-positive concordant relationships were more likely to have had unprotected sex with outside partners.
Findings from this research underscore a need for prevention interventions to address the relationship context for HIV transmission in transgender women and their male primary partners. Several couples-focused HIV interventions have been shown to reduce risk behavior in members of a committed relationship [13
]. Couples-focused intervention modalities include couples HIV testing [29
] and couples behavioral counseling [31
]. Although HIV prevention programs involving both members of a committed relationship might require additional effort compared with programs that involve one member only, couples-focused interventions offer an opportunity for both members to discuss their perceptions and attitudes toward HIV, develop mutual risk-reduction goals, and reinforce one another’s behaviors.
One emerging challenge in couples-focused HIV interventions is the potential need to counsel partners to reduce sexual risk with concurrent partners outside of the primary partnership. Although the reasons for the high prevalence of concurrency among partners in a primary relationship are unclear, previous studies of transgender women and men who have sex with transgender women have described how social stigma, lack of relationship legitimacy (e.g., legal marriage), and a limited partner selection pool influenced partner choice and sexual risk behaviors [4
]. High prevalence of extra-relationship sex partners has also been reported in several studies of MSM couples, and has been described as a factor contributing to HIV and other STI transmission in MSM [34
]. For example, in a study of 200 MSM couples in San Francisco, 52% reported having ‘open relationships’ whereby partners implicitly or explicitly permitted one another to have sex with other people [35
]. Many MSM couples who reported having open relationships developed explicit agreements about practicing safer sex with all outside partners, referred to as negotiated safety [36
]. However, in the absence of such agreements and negotiated safety practices, partners may experience increased risk for HIV or other STIs. To address HIV risk in couples that do not practice monogamy, it is important for interventions to explicitly acknowledge and distinguish between sex within the primary relationship versus sex with outside partners, and to encourage the formulation of explicit agreements about safer sex in both contexts. Another challenge in couples-focused HIV interventions is to encourage disclosure of HIV-positive status if partners had not already done so. Protocols to facilitate disclosure of concurrent sex partnerships or HIV-positive status need to be developed with extreme sensitivity, in order to minimize risk for interpersonal partner conflict.
Other factors associated with unprotected sex with a primary partner, identified here, should be taken into account when designing interventions for transgender women. These factors include length of relationship, which might confer a sense of complacency regarding HIV, and alcohol and drug use, behaviors which might undermine perceptions of risk and intentions to practice safer sex. Interventions should also aim to improve condom use self-efficacy, which fosters a sense of control in negotiating safer sex, and address perceived discrimination in transgender women, which might contribute to a heightened need for intimacy and affirmation from sex partners [2
Limitations to this study must be acknowledged. First, convenience sampling approaches prevent generalization to a wider population. Second, the sample included only transgender women who were comfortable about disclosing their gender history, and so we cannot draw inferences about transgender women who are less open. Third, the sample had a predominantly low socioeconomic background, thereby minimizing generalizability to more affluent transgender women. Fourth, use of cross-sectional surveys does not permit inferences about temporal associations and causal pathways between measured factors. Fifth, use of self-report surveys might have introduced social desirability biases. Sixth, HIV status might be underreported due to our inability to provide HIV testing. Seventh, analyses do not permit inference about the directionality of risk for HIV transmission—that is, whether transwomen are at greater risk of HIV infection by their male primary partners or vice versa. In light of the high prevalence of concurrency, it might be useful to conceptualize risk for transmission as bidirectional and influenced by broader sexual networks.
In conclusion, we have observed high rates of unprotected sex among transgender women and their male primary partners, particularly among those in serodiscordant partnerships. Couples-focused prevention interventions may be warranted to reduce risk for HIV transmission. HIV risk among transgender women appears contextualized in a broader context of co-occurring public health problems, including high rates of substance use, depression, and socioeconomic hardship, which might affect motivations and behaviors in the context of primary relationships. In addition to addressing the risk for HIV transmission in transgender women, interventions for other co-occurring public health and psychological issues observed in this population warrant equally urgent response.