HIV and sexually transmitted infections disproportionately affect trans persons compared to the general population. The WHO estimates trans women are 49 times more likely to live with HIV than the general population, and trans men are 10 times more likely. Little is understood about the driving causes of this disconnect. This chapter aims to address the extent, burden, and characteristics of STI and HIV infections in trans persons, and to specifically characterize the factors that may explain why these differences exist. The stress factors that trans people face in societal and healthcare settings create an intersection of discrimination that falls within the realm of control of healthcare professionals. Therefore, improving STI trans education and a better understanding among physicians and trainees about STI epidemiology, clinical presentation, and care recommendations when treating trans patients is critical to achieving an excellent standard of care, increasing health and well-being, and reducing preventable sexually transmitted morbidity and mortality among trans patients
The burden of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) disproportionately affects trans persons. According to the World Health Organization (WHO), trans women and trans men are respectively 49 times and 10 times more likely to live with HIV compared to the general population [Reference Baral, Poteat and Strömdahl1]. Trans persons also face higher rates of STIs like gonorrhea, chlamydia, and syphilis. Minority stress factors like stigma and discrimination, as well as disparities in social determinants of health and in cultural sensitivity among healthcare professionals, contribute to disproportionate HIV and STI rates. Gender-affirming hormone treatments, procedures, and reproductive health needs should be considered when providing HIV/STI treatment for trans patients. This chapter aims to review: (1) epidemiology and clinical presentation of STI in trans persons; (2) behavioral and structural risk factors associated with HIV and STI acquisition in trans persons; and (3) specific screening and clinical management recommendations for HIV and STIs when caring for trans persons. We will discuss HIV and STIs individually, focusing on shared or unique features based on available data in trans men, trans women, and gender nonconforming populations.
37.2 Epidemiology and Clinical Presentation of HIV and STIs in Trans People
Prevalence and incidence of HIV and specific STIs in trans men and trans women are respectively summarized in Tables 37.1 and 37.2. We will discuss presentation and sequelae of each STI in detail. Unfortunately, the lack of visual pictures available at this time to accurately depict the presentation of cutaneous STI lesions in trans persons highlights the problem and need which this chapter seeks to address.
|HIV||0% to 8% seropositive international prevalence, 2021 [Reference Becasen, Denard, Mullins, Higa and Sipe3,Reference Sevelius25–Reference Drückler, Daans and Hoornenborg29]|
|HPV||24.4% prevalence in the US, 2007 [Reference Sevelius25]|
|Trichomoniasis||6.7% prevalence in the US, 2007 [Reference Sevelius25]|
|BV||8.9% prevalence in the US, 2007 [Reference Sevelius25]|
|HSV||2.1% to 80.7% lab-confirmed prevalence in Peru and the US [Reference Van Gerwen, Jani and Long12]|
|HPV||1.4% lab-confirmed prevalence in Boston, MA, US, 2015 [Reference Reisner, Vetters and White36]|
Globally, HIV infects almost two million adults every year, with an estimated global prevalence of 0.8% [Reference Frank, Carter and Jahagirdar2]. Trans persons have an estimated HIV infection prevalence of 9%, with trans women numbers being as high as 19% and trans men as high as 8% [Reference Becasen, Denard, Mullins, Higa and Sipe3]. The risk of HIV acquisition is 12 times higher in the trans populations than in general populations . Persons experiencing multiple intersectional minority status, such as racial/ethnic minorities, face disproportionately higher risks. For example, in the US, up to 60% of black trans women were living with an undiagnosed HIV infection in one estimate [Reference Bukowski, Chandler and Creasy5], with the prevalence of diagnosed HIV infection up to five times higher than white trans women [Reference Becasen, Denard, Mullins, Higa and Sipe3]. HIV infection numbers for gender nonbinary or nonconforming persons are scarce, but gender nonconformity has been associated as a risk factor for HIV infection [Reference Jobson, Tucker and de Swardt6].
Acute HIV infection may manifest with non-specific influenza or mononucleosis-like signs and symptoms, such as fever, pharyngitis, morbiliform eruption, or lymphadenopathy. Up to half of acute HIV infection may be asymptomatic [Reference Para, Gee and Davis7]. If left untreated, HIV infection undergoes about a 10-year clinical latency period, during which the immune system weakens as the CD4 T cell count depletes. Once below a threshold of 200 CD4 cells per unit, or the presence of an AIDS-defining illness, death usually occurs in 2–3 years due to opportunistic infections [Reference Para, Gee and Davis7]. The presentation of AIDS may be as broad as the list of complications is long, but in general a patient may present with fever, night sweats, and cachexia. Dermatologic conditions associated with chronic HIV/AIDS infection include seborrheic dermatitis, xerosis, folliculitis, and drug hypersensitivity reactions [Reference Borda, Perper and Keri8,Reference Chu and Selwyn9]. Screening for HIV infection should be offered to all patients. If diagnosed with HIV, all patients should establish care, begin antiretroviral therapy, and aim to achieve viral suppression [Reference Wood, Salas-Humara and Dowshen10].
37.2.2 Genital Herpes Simplex Infection
Genital herpes can be caused by a herpes simplex viral infection (HSV) type 2 or type 1. Globally, HSV-2 affected approximately 417 million people (11%) while genital HSV type 1 affected 140 million people in 2012 . HSV seroprevalence in trans persons ranged widely across studies, from 2% to 80% [Reference Van Gerwen, Jani and Long12].
Anogenital HSV typically presents as recurrent, erythematous, painful, grouped vesicles in external or internal genitalia, buttocks, or perianal region. The vesicles often would have ruptured upon presentation and present as clustered, crusted erosions or ulcers with scalloped border. Prodromal symptoms such as fever, headaches, fatigue, muscle aches, and localized tingling or erythema can occur prior to vesicle development [Reference Para, Gee and Davis7]. In persons living with HIV, a cutaneous HSV ulcer lasting for more than 1 month is considered an AIDS-defining condition. HSV can also mimic genital warts or squamous cell carcinoma in people living with HIV in a hypertrophic form, known as herpes vegetans or verrucous herpes. Disseminated herpes, meningitis, esophagitis, and retinal infections can also present in severe cases. In trans women, genital herpes has been reported on the neolabia and neovaginal lining after vaginoplasty [Reference Elfering, van der Sluis, Mermans and Buncamper13].
37.2.3 Human Papillomavirus
Human papillomavirus (HPV) has many different serotypes that can infect the genitals. Genital HPV is common among sexually active adults (around 40% prevalence by age 59). Trans persons are affected disproportionately by HPV infections, with prevalence as high as 88% [Reference Singh, Gratzer and Gorbach14]. Of note, rates of HPV infections are higher in trans men (24%) compared to trans women (1%) [Reference Workowski and Bolan15]. Importantly, the prevalence of neovaginal HPV infections has been reported as high as 20% in sexually active trans women who have undergone vaginoplasty [Reference van der Sluis, Bouman, Gijs and van Bodegraven16].
HPV can cause genital warts as well as premalignant and malignant lesions of the cervix, vulva, vagina, penis, anus, and oropharynx. Low-risk HPV strains (6 and 11) present as solitary or clustered, mamillated or verrucous papules. They are most often asymptomatic. Bleeding, ulceration, large size, induration, or recurrence despite treatment should raise concern for malignant transformation and warrant biopsy. Persistent infection of high-risk HPV strains (e.g. 16, 18, 31, 33) can lead to the development of premalignant lesions and malignancies of cervix, vulva, vagina, penis, anus, and oropharynx. Risk factors for the cancer-causing HR-HPV include number of sexual partners and HIV co-infection [Reference Yunihastuti, Teeratakulpisarn and Jeo17]. Because HPV can lead to premalignant and malignant lesions, it is important to discuss relevant HPV prevention, screening, diagnosis, and treatment in patients with anatomic organs at risk of cancer development, which may include trans men with a vagina, vulva, or cervix, trans women with penis, or trans women with neovagina. Neovaginal lining is commonly derived from penile skin. Prior to gender-affirming surgery, any lesions on the penis and surrounding tissue should be carefully examined and removed, as access to the neovagina is often complicated and lesions in the neovagina may be overseen and difficult to remove. See also Chapter 36 for more details.
37.2.4 Gonorrhea and Chlamydia
Neisseria gonorrhea and Chlamydia trachomatis are the two most commonly acquired sexually transmitted bacterial infections [Reference Workowski and Bolan15]. Depending on the anatomic site, trans men have gonorrhea infection prevalence ranges from 0% to 7% and trans women prevalence ranges from 2% to as high as 19% [Reference Van Gerwen, Jani and Long12]. Chlamydia infections affect trans men in a range from 1% to 11% prevalence and trans women from 3% to 25% [Reference Van Gerwen, Jani and Long12,Reference Sullivan, Phaswana-Mafuya and Baral18]. Both gonorrhea and chlamydia can infect rectal, pharyngeal, or urogenital sites.
Gonorrhea or chlamydia urethritis most commonly present with dysuria and mucopurulent penile discharge. If not treated, complications of gonorrhea and chlamydia infections include prostatitis and epididymitis. In trans men and people assigned female at birth, cervicitis is the most common complaint; however, many cases remain asymptomatic and unrecognized [Reference Para, Gee and Davis7,Reference Workowski and Bolan15]. Rectal gonorrhea and chlamydia infections may cause proctitis and many cases also remain asymptomatic. Asymptomatic STI presentations underscore the importance of screening any anatomical part that may be involved in sexual activity [Reference Para, Gee and Davis7]. Lymphogranuloma venereum, caused by chlamydia serovars L1 to L3, often presents asymptomatically or with proctitis [Reference Pathela, Blank and Schillinger19]. In transgender women, neovaginal chlamydia trachomatis infections have been reported after penile-inversion vaginoplasty and integrated peritoneum and urethral grafts. Symptoms include neovaginal discharge, malodor, and irritation [Reference Radix, Harris, Belkind, Ting and Goldstein20].
The global prevalence of primary and secondary Treponema pallidum infection is high, affecting about 18 million people in 2012 . Prevalence of syphilis in trans persons was estimated to range from 2% to 50% [Reference Van Gerwen, Jani and Long12,Reference Sullivan, Phaswana-Mafuya and Baral18,Reference Stephens, Bernstein and Philip22,Reference Fernandes, Zanini and Rezende23].
Syphilis can present in one of three classic stages: primary syphilis presents with painless ulcers at mucocutaneous sites, most commonly on the genitalia, but also at the oral mucosa and anus. Secondary syphilis presents with a broad variety of mucocutaneous signs and is known as the “great imitator,” which may include palmoplantar eruption with copper-colored oval scaly macules; non-pruritic truncal maculopapular to papulosquamous eruption; condyloma latum resembling genital warts; mucous patches with shallow ulcers on mucous membranes; and moth-eaten patchy scalp hair loss. Systemic symptoms such as fever, malaise, myalgia, and lymphadenopathy may also be present [Reference Para, Gee and Davis7]. If left untreated, signs and symptoms of syphilis may resolve spontaneously and become latent syphilis. Tertiary syphilis, which develops in about one-third of untreated patients, presents with granulomatous necrotic nodules or gummas in the skin or liver, syphilitic aortitis or aortic aneurysm, and neurologic complications such as tabes dorsalis, generalized paresis, strokes, and dementia [Reference Workowski and Bolan15]. Ocular syphilis and neurosyphilis may develop across all syphilis stages. These patients can present with uveitis, meningitis, focal neurologic deficits, and cranial nerve dysfunctions.
Trichomoniasis, caused by the protozoa Trichomonas vaginalis, is a common cause of vaginitis and typically presents with copious yellow–green, frothy discharge, dyspareunia, odor, and pruritus [Reference Para, Gee and Davis7]. The most common global non-viral STI is trichomoniasis [Reference Van Gerwen, Jani and Long12]. Little data or screening guidelines exist on how trichomoniasis affects trans persons, with prevalence in trans men as high as 7%, but given its general population prevalence and its potential to amplify HIV transmission, physicians should screen for and treat trichomoniasis when appropriate [Reference Van Gerwen, Jani and Long12].
37.2.7 Bacterial Vaginosis
As with other bacterial infections, bacterial vaginosis (BV) can be largely asymptomatic, but may present with urethritis, vaginitis, and a “fishy” odor. BV is due to an overgrowth of polymicrobial anaerobes in the setting of a loss of normal vaginal flora. Little data exists on BV in trans women, but in trans men who have not undergone gender-affirming genital surgery, BV prevalence can be as high as 9%. Given the relationship between preoperative BV and trichomonas and postoperative vaginal cuff cellulitis after hysterectomies, screening and metronidazole therapy can be considered [Reference Soper, Bump and Hurt24].
37.3 Risk Factors Associated with HIV and STI Infection
In this section, we will discuss risk factors and models that contribute to the disproportionate HIV and STI risks faced by transgender people. Minority stress, victimization, mental health conditions, and substance use have been linked to increased risk of HIV and STI acquisition among trans persons [Reference Reisner, White Hughto, Pardee and Sevelius37]. Understanding the context in which HIV and STI acquisition occur will enable more effective engagement in safer sex practices as well as HIV/STI screening and prevention. Among transgender persons, known risks factors for HIV and STI acquisition include sex with cisgender men, unprotected receptive vaginal or anal intercourse, commercial sex, co-infection with other STI, and substance use [Reference Nuttbrock, Hwahng and Bockting38,Reference Operario and Nemoto39]. We will broadly address these risk factors in terms of the syndemic between HIV and STI, as well as discuss the implications of victimization, sex work, healthcare engagement, and intersectionality.
37.3.1 Syndemic between HIV and STI
Syndemic theory is a useful framework to understand how disease acquisition can be linked by multiple factors that exacerbate each other, such as between HIV and other STI [Reference Gandhi, Spinelli and Mayer40]. The syndemic concept is increasingly recognized as a crucial driver of the disproportionate HIV and STI rates faced by trans persons. Trans persons diagnosed with syphilis in Peru, for example, had a 66.7% co-infection rate with HIV and 16.7% co-infection rate with anal gonorrhea [Reference Kojima, Park and Konda33]. Shared risk factors between HIV and STI acquisition include substance use, mental health disorders, violence, and victimization [Reference Operario and Nemoto39]. Syndemic factors in trans persons, such as binge drinking, substance use, anxiety, depression, childhood abuse, and intimate partner violence, all have been associated with higher risks of lifetime unprotected receptive anal intercourse and STI diagnoses and higher number of recent sexual partners [Reference Brennan, Kuhns and Johnson41]. Systemic discrimination, race, transphobia, violence, economic marginalization, housing instability, and stigma are additional factors that contribute to disproportionate HIV and STI burden in trans persons [Reference Neumann, Finlayson, Pitts and Keatley42]. Minority stress factors, such as internalized stigma and experienced or anticipated discrimination due to transphobia, also leads to disproportionate rates of depression and anxiety, which feed into each other to influence risky behaviors and affect HIV/STI outcomes [Reference Meyer43,Reference Hendricks and Testa44]. Trans persons may experience higher levels of suicidality, emotional distress, isolation, and depression, which may undermine motivations to practice safer sex behaviors and can increase motivations for unprotected receptive intercourse as a means for cognitive or emotional release or for seeking emotions of intimacy [Reference Operario and Nemoto39]. Higher rates of substance use also contribute to the risk of unprotected receptive intercourse due to impaired behavioral cognition [Reference Operario and Nemoto39]. In sum, multiple broad and intersecting sets of risk factors contribute to disproportionate HIV/STI risks in trans persons.
Victimization from threats, assaults, harassment, and violence – often related to gender identity – is disproportionately experienced by trans persons as compared with the general population [Reference Clements-Nolle, Marx, Guzman and Katz27,Reference Brennan, Kuhns and Johnson41]. Trans persons who experience intimate partner violence and polysubstances have increased sexual risk outcomes like unprotected receptive anal intercourse (URAI) [Reference Brennan, Kuhns and Johnson41]. Trans persons also experience high levels of physical and sexual violence [Reference Risser, Shelton and McCurdy45], which are often motivated by gender-based discrimination [Reference Bockting and Avery46]. Many trans persons report intimate partner violence at home, 50% among primary partners and 22% with casual partners [Reference Risser, Shelton and McCurdy45]. Consequently, many trans persons report being uncomfortable and unsafe in public settings [Reference Risser, Shelton and McCurdy45]. A history of victimization from violence contributes to higher burden of mental health disorders [Reference Thompson, Dutta and Bhattacharjee47]. Furthermore, trauma from intimate partner violence has a direct effect on depression [Reference Bukowski, Hampton and Escobar-Viera48], which may further exacerbate behaviors that increase risk of STI acquisition. In terms of links between discrimination and STI acquisition risk factors, there is an association between exposure to transphobia and unprotected receptive anal intercourse [Reference Sugano, Nemoto and Operario49]. Finally, transgender youth experience depression, trauma, stigma, low self-esteem, substance use, victimization, all of which influence sexual risk behaviors for HIV/STI acquisition such as unprotected receptive anal intercourse [Reference Brennan, Kuhns and Johnson41,Reference Operario and Nemoto50].
37.3.3 Sex Work
Sex work is an independent risk factor for increased HIV infection among trans persons [Reference Brennan, Kuhns and Johnson41,Reference Wilson, Garofalo and Harris51]. Trans women are more likely to engage in sex work than trans men, with prevalence estimates of 38–57% and 13–23%, respectively [Reference Becasen, Denard, Mullins, Higa and Sipe3,Reference Stephens, Bernstein and Philip22]. For some trans women, sex work provides financial means and provides affirmation of their gender identity [Reference Poteat, Scheim, Xavier, Reisner and Baral52]. Gender affirmation plays complex social, medical, legal, and sexual health roles in the lives of trans persons [Reference Reisner, White Hughto, Pardee and Sevelius37]. Seeking gender affirmation from sexual partners can also sometimes override safer sex practices [Reference Sevelius25]. On the other hand, social gender affirmation may be associated with lower likelihood of unprotected receptive anal intercourse [Reference Reisner, White Hughto, Pardee and Sevelius37].