Recently we took a close look at the progress that has been made in the overall percentage of people diagnosed with HIV who have achieved viral suppression in the United States. The overall results showed improvement but hid the fact that some populations are at risk of being left behind. We saw this among youth and people who inject drugs and, sadly, we also see it among transgender women. In this blog we’ll examine the National HIV/AIDS Strategy (NHAS) indicator that is used to monitor the progress of viral suppression among transgender women.

Transgender Women

Transgender women are disproportionately impacted by HIV. A 2013 report found that about 22% of transgender women were living with HIV in the United States. Black/African American transgender women are more likely to have HIV than transgender women of other races and ethnicities.

Transgender women often experience rejection from family and friends. The stigma and discrimination experienced by transgender women can lead to unemployment, poverty, homelessness, mental health problems, substance use, and other adverse conditions. All of these contribute to the many health-related disparities experienced by transgender women and are important challenges to address in order to provide HIV care and treatment.

Why Focus on Viral Suppression?

While recent scientific studies have not focused specifically on the impact of viral suppression on transgender women, they have shown that taking HIV medications to achieve and maintain viral suppression improves the health of people living with HIV. Studies have also shown the prevention effectiveness of viral suppression to reduce the risk for sexual transmission of HIV. This means that people living with HIV who take HIV medications daily as prescribed and achieve and then maintain an undetectable viral load for at least six months have effectively no risk of sexually transmitting the virus to an HIV-negative partner.

Modeling of various prevention strategies has shown that increasing viral suppression among people living with HIV may be the single most effective strategy for preventing new infections and ending the epidemic in the United States.

What the Data Tells Us

The NHAS indicator for increasing viral suppression among transgender women in HIV medical care is slightly different from the other NHAS viral suppression indicators. This indicator measures viral suppression among transgender women who are receiving HIV medical care through the Health Resources and Services Administration’s (HRSA) Ryan White HIV/AIDS Program. The other viral suppression indicators measure viral suppression for all people in the United States who have been diagnosed with HIV, using a different data set from CDC. NHAS uses the HRSA Ryan White HIV/AIDS Program data for this indicator due to the limited availability of data about the overall population of transgender women living with HIV in the United States.

The data for the transgender women viral suppression indicator comes from the HRSA Ryan White HIV/AIDS Program Services Report (RSR), which is the primary source of annual, client-level data reported by more than 2,000 grant recipients and subrecipients of the Ryan White HIV/AIDS Program (RWHAP). RSR data are published annually by HRSA in the Ryan White HIV/AIDS Program Annual Client-Level Data Report.

The NHAS indicator for viral suppression is defined as having a viral load result of <200 copies/mL at the most recent viral load test among people living with HIV. The HRSA RSR monitors viral suppression among RWHAP clients who have received at least one Outpatient Ambulatory Health Services visit and at least one viral load test from a provider during the measurement year. According to the latest RSR data released in the RWHAP Annual Client-Level Data Report in November 2017:

• 79.0% of transgender women in RWHAP HIV medical care were virally suppressed in 2016. That means that we have exceeded our 2016 target (74.7%). Even though the result (79.0%) exceeded the 2016 target, it was below the national average of 84.9% for Ryan White HIV/AIDS Program clients.
• Great improvements have been made in the percentage of transgender women who are virally suppressed. In 2010, the percentage was 62.2% and has increased nearly 17 percentage points to 79.0% in 2016.
• We are moving in the right direction, but still have a way to go toward reaching the NHAS 2020 target of 90%.

Where Do We Go From Here?

Long-standing disparities represent significant challenges to preventing new HIV infections and achieving health equity in the United States. There is a lack of data available about transgender women, which limits the ability to effectively provide appropriate patient-centered healthcare. We need to improve already existing methods and identify new methods to collect data in a way that will assist us in providing efficient, effective, and impactful services to all transgender women with HIV. We need to work toward creating a future that does not allow stigma, discrimination, and violence against transgender women or any other person. We need to work toward creating a future where new HIV infections are rare, and when they do occur, each and every person regardless of their gender or gender identity has access to and gets the full benefits of culturally competent HIV care and treatment to achieve and maintain viral suppression, and, ultimately one day, can be cured. We stand at a moment where a huge battle can be won in the fight against HIV and we must make sure transgender women are not left behind as we continue to make progress on our national goals.

In our final post in the NHAS Indicators series, we will look at our national progress toward reducing the death rate among people with diagnosed HIV. Stay tuned…