Having receptive anal sex carries the greatest HIV risk compared to other sexual behaviours (such as insertive anal sex, and insertive and receptive vaginal sex).

Unless a transgender woman has had gender reassignment surgery, she will not have a vagina so she will not be able to have receptive vaginal sex. If she has sex with men she will only be able to have anal sex – and this may be insertive or receptive. If she struggles to use condoms with partners or access PrEP she is at high risk of HIV. 

Just like other women, transgender women also experience gender-based violence and gender inequality, both of which increase HIV risk. In some circumstances, if a trans women doesn’t ‘pass’ as female, violence (including sexual violence) can be even worse than other women experience as a form of punishment for not acting and behaving like a man.

Transgender women need the same non-judgemental, easily accessible HIV services as any other at-risk group. This means providing HIV prevention services, such as condoms and lubricants, plus PrEP and PEP if available. It means providing HIV and STI testing and good links to treatment, adherence support and treatment monitoring. 
 

It is essential to ensure such services treat transgender women as women – using their chosen names and correct pronouns (such as ‘she/her’) – not as men who have sex with men.

Other support to consider includes:

- gender-based violence services, particularly in relation to rape and intimate partner violence, tailored to the experiences of transgender women, not gay men

- needle and syringe programmes for trans women who inject hormones or drugs (if legal) 

- tailored livelihood support for trans sex workers interested in other employment

- safe housing plus food support for trans women who have been made homeless

- tailored counselling and support to improve mental health and well-being. 

The best way to provide transgender women with services is to work with community representatives who can advise on what trans women want and need, and how best to deliver this support.