The Federal Government Undermines its Own HIV Targets by Restricting Gender-Affirming Care for Youth

During his first term in office, President Trump vowed in a 2019 State of the Union speech to “eliminate the HIV epidemic in the United States within 10 years.” With the support of Congress, he initiated the Ending the HIV Epidemic (EHE) program to provide additional funding to the Department of Health and Human Service (HHS) with the ambitious goal of constraining new HIV transmissions by 90 percent before 2030.

The EHE strategy embraces a coordinated and comprehensive approach to both HIV prevention and treatment. For people vulnerable to acquiring HIV, EHE aims to increase access to routine HIV testing and use of Pre-Exposure Prophylaxis (PrEP), medications that effectively prevent HIV transmission. On the treatment side, EHE endorses timely provision of antiretroviral therapy, which allow people living with HIV to lead long, fulfilled lives.

Yet one year into his second presidency, President Trump has advanced a flurry of policies that directly conflict with these goals. For example, his administration proposed a 2026 budget that would end HIV prevention and surveillance programs at the Centers for Disease Control and Prevention, as well as eliminate housing, behavioral health, and research programs dedicated to people living with HIV.

But the federal government is also undermining its own HIV targets in less direct ways.

Last July, the Department of Justice began investigating health care providers under a theory that gender-affirming care (GAC) for youth is “fraud.” In December, HHS Secretary Robert F. Kennedy Jr. declared that GAC for youth was no longer considered a safe or effective standard of medical care, a statement that has been challenged in court. One day later, the HHS published two proposed regulations that would respectively ban the use of federal dollars on GAC for youth under the age of 18, as well as some 18-year-old adults, and prohibit hospitals that provide GAC to transgender youth from participating in either Medicare or Medicaid. 

Under the administration’s pressure, many health care providers have limited or altogether stopped their provision of GAC. These decisions have caused extreme distress to transgender youth and their families, with advocates condemning the federal government’s policies as downright cruel.

In this post, I will highlight a contradiction of recent attacks: The federal government cannot achieve its longstanding HIV goals without promoting access to GAC for transgender youth. I lay out this argument in three parts. First, HIV disproportionately impacts transgender people. Second, GAC is essential to improving HIV outcomes among transgender people. And finally, transgender people who receive GAC during youth are protected against negative HIV outcomes as adults.

Transgender people are disproportionately affected by HIV.

The percentage of transgender people living with HIV is three times higher than the percentage of the general U.S. population living with HIV, for multiple social and structural reasons. The prevention of HIV transmission relies on a person’s ability to obtain and maintain a prescription for PrEP, and the treatment of HIV requires consistent access to antiretroviral therapy. However, many transgender people have reported hesitance to seek health care because of stigma, discrimination, and past mistreatment from health care providers.

Both prevention and treatment of HIV can also be expensive. Although the list price for generic PrEP medication is nearly $2,000 less per month than for branded formulations, branded formulations account for half of all PrEP prescriptions annually. Multiple factors contribute to this pattern, including incentives for distributors to provide more expensive drugs. But these high-cost medications can be especially burdensome for transgender people, who live in poverty and experience uninsurance at an elevated rate compared to the general U.S. population.

Gender-affirming care is needed for positive HIV outcomes among transgender people.

GAC is documented to build patients’ comfort with health care providers, which promotes HIV testing and PrEP use among transgender people by overcoming medical mistrust. As a result, a publication last year from a large study called LEGACY showed that transgender people who received GAC were 37 percent less likely to test positive with HIV than transgender people who did not receive gender-affirming care.

GAC also increases quality of life and reduces depression; in turn, these positive mental health outcomes improve adherence to antiretroviral medication regimens. Indeed, the LEGACY study showed that transgender people living with HIV were 44 percent less likely to have transmissible levels of HIV if they received GAC than if they did not receive gender-affirming care. And transgender people living with HIV were more likely to have untransmissible levels of HIV in their blood the longer they remained in GAC.

Transgender youth who cannot access gender-affirming care face increased vulnerability to HIV as adults.

Although the federal government has focused its attacks on GAC for transgender youth, they will ultimately worsen HIV outcomes for transgender people across all age groups because transgender youth who cannot access GAC face magnified vulnerability to HIV during adulthood. Compared to youth in the general U.S. population, transgender youth struggle with disproportionate rates of mental health problems, including depression, self-harm, and suicide attempts. These problems are exacerbated by their increased likelihood of facing school violence and unstable housing.

But a large body of research has demonstrated that GAC mitigates mental health problems in transgender youth with the result of saving lives. In fact, multiple studies have shown that GAC is more effective at protecting against mental health problems the earlier that transgender youth start it, likely in part by preventing unwanted puberty. Without access to GAC during youth, transgender people suffering from mental distress are likely to see those problems persist into adulthood, increasing the likelihood of life circumstances associated with negative HIV outcomes.

In conclusion, strong evidence confirms that GAC during youth is central to improved HIV outcomes among transgender people throughout their lives. And ending the HIV epidemic requires effective prevention and treatment for transgender people specifically because they are more vulnerable to poor HIV outcomes than the general population.

President Trump’s vision of “eliminat[ing] the HIV epidemic” has been an important one. If he was serious about reaching this public health achievement, his current administration would cease attacks against GAC for transgender youth immediately, and it would expand access to this important care instead.