HIV is a virus that alters the immune system and increases the impact of other infections. Transgender people are at a higher risk for acquiring HIV due to multiple risk factors. Gender-affirming surgery may help mental health as well as HIV treatment outcomes.

Without treatment, HIV can progress to AIDS. Fortunately, due to medical advances and treatments, many experts consider HIV as a manageable condition.

Both the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) note that transgender people have a higher risk of HIV than others. A number of factors contribute toward an increased risk of HIV among transgender people as well as having less access to adequate treatment.

Gender-affirming surgery, also known as gender-confirming surgery or gender-reassignment surgery, refers to surgical procedures that help a person’s body conform to their gender identity. Evidence suggests that access to gender-affirming surgery may improve adherence to HIV treatment.

In this article, we will discuss the associations between HIV and gender-affirming surgery and suggest prevention and treatment options.

Transgender women, who are at a higher risk of HIV, holding a ribbon to promote World AIDS Day.Share on Pinterest
PRAKASH MATHEMA/AFP via Getty Images

According to the Department of Health and Human Services (HHS), approximately 1.2 million people in the United States are living with HIV. Evidence also suggests that transgender people are at a higher risk of HIV infection.

Data from the CDC adds that nearly 1 million people in the U.S. are transgender. Of these individuals, 9.2% are living with HIV. Evidence adds that in 2018, 2% of new HIV diagnoses in the U.S. were among transgender people.

A 2019 study indicates that roughly 25–35% of transgender and gender nonbinary people report undergoing some form of gender-confirming surgery.

There are several challenges that place transgender people at a higher risk of contracting HIV. Stigma, discrimination, and a lack of knowledge about transgender issues all contribute toward this. Additionally, certain risk factors surrounding gender-affirming surgery also exist.

Gender-affirming surgery and other transitioning procedures can be costly and can negatively affect a person’s economic standing. Evidence also notes that transgender people may be at a higher risk of unemployment and poverty. As a result, this may cause transgender people to rely on sex work, which can increase the risk of acquiring HIV.

Following gender-affirming surgery, transgender people are likely to have a reduction in gender and body incongruence and improvements in mental health. As a result, this will likely increase the frequency of sexual activities and sexual partners, which may again increase their risk of contracting HIV.

As well as more frequent sex, transgender people may also participate in sexual activities that can increase the risk of exposure to HIV. For example, low self-esteem and marginalization may mean that transgender women are more likely to participate in anal sex and may be less insistent on using barrier methods, such as condoms.

While more research is necessary, some evidence also suggests that surgical procedures to affirm gender identities, such as genital surgery, may increase the risk of HIV. This may be due to the tissue being more susceptible to bleeding or infection.

Evidence from the CDC notes that gender-affirming medical treatment may improve the uptake of HIV treatment and prevention. Unmet surgical needs may result in interruptions to HIV treatments.

Taking HIV medication can help with viral suppression, which refers to having an undetectable viral load. Maintaining viral suppression can help a person to stay healthy, have less risk of potentially transmitting HIV, and improving quality of life.

Research presented at the Conference on Retroviruses and Opportunistic Infections 2021 notes that viral suppression was more likely among those who had access to gender-affirming surgery.

The results state that viral suppression among people who received gender-affirming surgery improved and was comparable with levels in cisgender men. Evidence also notes that those who received both top and bottom gender-affirming surgery saw the greatest improvement in viral suppression.

The researchers suggest that the increase in viral suppression may be due to gender-affirming surgery reducing stigma and other possible barriers to HIV care. Additionally, surgery may increase self-care practices, support engagement with the healthcare system, and enable providers to better monitor HIV outcomes.

To reduce the risk of acquiring HIV, people may want to consider implementing strategies such as:

  • Taking medications. Using medications such as pre-exposure prophylaxis, or PrEP, prior to any sexual contact can reduce the risk of HIV infection.
  • Practicing safer sex. It is important that people use condoms to help prevent the transmission of HIV, particularly with anal sex or penetrative sex with a person following bottom surgery.
  • Reducing the number of sexual partners. Minimizing the amount of sexual partners can reduce the risk of contracting HIV.
  • Using licensed a professional. Discrimination and barriers to healthcare may result in people turning to unlicensed professionals, who may increase the risk of exposure through unsanitary medical equipment or reusing needles for hormone therapy.

Most evidence indicates that transgender people experience difficulties in accessing treatment. This is likely due to the stigma and discrimination they may face.

Those with health insurance can seek HIV testing or treatment from their primary physician for free or at a reduced cost.

For those without health insurance, resources are available that can help provide affordable testing and treatments. There are also projects that aim to support health departments to implement strategies to increase access to care and improve outcomes for those living with HIV.

While there is currently no effective cure for HIV, treatments exist that can stop disease progression, control symptoms, and improve the quality of life.

It is advisable for people to start antiretroviral therapy as soon as possible after their HIV diagnosis. Successful therapy can prevent people from developing advanced HIV and reduces the risk of transmitting the virus to others.

Evidence also notes that there are no known drug interactions between HIV medication and hormone therapy. Therefore, people can safely take these medications before, during, or after gender-affirming procedures.

While there are potential complications, it is possible for people with HIV to undergo gender-affirming surgery. Proper use of medications and protective measures can reduce the risk of any postoperative infections or transmission to medical staff.

HIV is a lifelong condition, so it is important for people to regularly check in with their healthcare team to ensure they are receiving optimal support and treatment.

Living with HIV can also be very distressing due to the chronic nature of the condition and the stigmatization that surrounds it. Therefore, it is also essential that people receive additional support for their mental well-being.

If a person has any concerns or notices any symptoms worsening, it is advisable that they contact their doctor.

Due to a variety of factors, such as stigmatization, discrimination, and economic instability, transgender people are at a higher risk of acquiring HIV. They may also experience a number of barriers and disparities that prevent them from accessing adequate care and support.

Some transgender people may consider undergoing gender-affirming surgery to align their outward appearance with their gender identity. In some cases, this may increase the risk of HIV due to potential higher risk behaviors. However, evidence also notes that following surgery, people are more likely to adhere to HIV medication and better manage the condition.