What transgender and gender-diverse people should know about screening for STIs and Hepatitis C

Seeking health care can be overwhelming and time-consuming. But when it comes to your sexual health, the extra effort is worth it.

If you skip routine care, you’re missing out on the opportunity to screen (or test) for sexually transmitted infections (STIs), including HIV, and hepatitis C. The good news is that understanding your risk and screening recommendations may not be as complicated as you might think. Here's what you need to know about screening and how to find the care you need to stay healthy.

STI screening should be based on your anatomy and sexual behaviors

Health experts recommend routine STI testing for all people based on their anatomy and sexual behaviors. That includes transgender, gender nonconforming, and nonbinary people.

"Individuals' risks are directly tied to their sexual practices," explains Marcus Sandling, MD, a New York-based infectious disease specialist and primary care physician dedicated to LGBTQ+ health and HIV prevention. "If patients have more than one partner, or if they're inconsistently using condoms, or their primary partner is having other partners, then they should be having appropriate screenings at regular intervals."

"I use the term 'inconsistent condom use' because you can use them 95 percent of the time, and that's great, but it's still inconsistent," adds Dr. Sandling.

If you are sexually active, your healthcare provider (HCP) should talk to you about your sexual history to help determine what STI testing might be necessary for you. Most sexually active people will need routine screening tests for HIV, hepatitis B and C, gonorrhea, and chlamydia. Depending on additional risk factors or symptoms, your HCP may recommend testing for syphilis, herpes, or other STIs. (Everyone should be screened for syphilis at least once in their life.) Symptoms that indicate the need for testing include unusual bleeding or discharge, pain during sex or urination, or sores.

Where you might be in your gender-affirmation process can also help your HCP understand and advise what tests you need.

The correct frequency of testing for each person will depend on risk factors. Sandling suggests STI screening at least once a year for people in mutually monogamous relationships (meaning partners are only sexually active with each other). With more risk factors—such as multiple partners, a partner with multiple partners, or inconsistent condom use—the recommendation would be to screen more frequently, such as every three months.

Make sure you're screening the appropriate body parts

Asking generally to be screened for STIs may not provide you with the full range of care you need. Routine screening as a baseline does not always include all STIs.

"If you walked into urgent care and said you want to get STI testing and they say, 'OK, here's a cup to pee in'—and you're aware that you also engage in anal intercourse or oral sexual activity—you should ask them for that additional testing," explains Sandling. The key is to have that detailed discussion with your HCP about your risk factors.

"The simplest way I tell people to think about it is this: If you're using it, check it," says Sandling.

In other words, if you're engaging in oral sexual activity, you should get a throat swab. If you're having receptive anal intercourse, you should get a rectal swab. Testing for oral gonorrhea, for example, will use a swab, whereas testing for vaginal gonorrhea may use a swab or a urine test. Other STIs, like syphilis, are more systemic, which means they can be screened with a blood test.

Keep in mind that some providers who are not experienced in treating gender-diverse individuals may make assumptions about your sexual behaviors. This is a frustrating reality that can put your health at risk by leading you to be screened inadequately or by causing you to skip screening entirely. For this reason, it’s important to find an HCP you trust so you can have an honest and open conversation about your sexual behaviors. It’s also important to talk to your sexual partners about their risks and screening behaviors, too, so you have as complete a picture as possible.

HIV screening is based on your risk, which is generally higher in transgender women

Each person’s risk for HIV is highly personal and based on their behaviors and risk factors. But generally speaking, the rate of HIV is significantly higher among the gender-diverse population. This is a result of many factors, including:

• Many transgender people face discrimination and stigma that can create barriers to education, employment, and safe housing.
• Certain behaviors often help transgender people cope with discrimination, stigma, or economic uncertainty. These include elevated rates of injecting hormones or drugs, having sex without the use of condoms or medicines to prevent HIV, and engaging in commercial sex work.
• The fact that few HCPs are knowledgeable in transgender health can also lead to limited health care access and negative encounters with the healthcare system. This can prevent people from seeking care they need.

According to a 2019 review of research published in the American Journal of Public Health, an estimated 14.1 percent of transgender women and 3.2 percent of transgender men had lab-confirmed HIV infections. Rates of HIV among Black transgender women were the highest, at 44.2 percent, compared to 6.7 percent among white transgender women. The estimated HIV prevalence among adults in the United States overall is less than 0.5 percent.

The CDC recommends that everyone over age 13 get screened for HIV at least once, with additional screening based on risk factors. Testing at least once a year may be appropriate if you're at a higher risk, which may mean:

• You've had new or multiple sex partners since your last test
• You have unprotected anal or vaginal sex
• You’ve had anal or vaginal sex with someone who has tested positive for HIV
• You've been diagnosed with an STI
• You engage in risky sexual behaviors (like transactional sex or sex work)
• You inject drugs or share needles for hormones
• You live in an area with high HIV prevalence

Sandling suggests using the time intervals for screening discussed above, with more frequent screening if you have multiple partners or inconsistent condom use.

Anyone who is at high risk of HIV infection may benefit from PrEP (also known as pre-exposure prophylaxis). This is a type of medicine that can help prevent HIV from sex or injection drug use. Transfeminine people may be particularly good candidates, given overall risk. When taken consistently and correctly, PrEP can significantly lower risk. It is not thought to interact with feminizing hormones.

Screening for hepatitis C also depends on your risk, which may be elevated in transgender women

Hepatitis C is a liver infection that is spread through contact with blood from someone infected with the virus. Many expert groups, including the U.S. Preventive Services Task Force, recommend screening for hepatitis C at least once in your life. More frequent testing is recommended based on risk factors, such as having HIV or using injection drugs or sharing needles.

Certain groups of transgender women have been found to have higher rates of hepatitis C, according to a 2021 study published in the journal PLoS ONE. This higher prevalence could be because transgender women may be more likely to share needles when self-injecting hormones or fillers. They also tend to have higher rates of HIV, homelessness, incarceration (being in jail or prison), or substance use. If you've received any medical procedures outside of a clinical setting, Sandling suggests screening for hepatitis C.

Sandling’s practice typically does higher than average screening for hepatitis C. "The reason we do it in our office is because we have seen some clusters of sexual transmission of hepatitis C among men who have sex with men and transgender women," he notes.

These factors cannot be generalized to all transgender women, however, so it’s important to have that conversation with your HCP about your risk factors and behaviors to arrive at a screening routine that makes sense for you.

Seek affirming, evidence-based screening

To ensure that your sexual health is being appropriately addressed with recommended screening, it’s important to locate an affirming and experienced HCP. Sandling suggests starting with your state's local health department or local Planned Parenthood clinics. (Call Planned Parenthood ahead of time to ensure they offer the services you seek.) These providers tend to be more comfortable having detailed conversations about risk factors and screening and may have more experience addressing the sexual health needs of gender-diverse people. You can also check local LGBTQIA+ organizations for their recommendations, or search the online directories from TransPulse, OutCare, GLMA, or Included Health for options.

"The most important thing is to understand your own individual risk and to find a provider who can help serve you in the most affirming way possible," Sandling says. "Know that your risk will not go away just because you're not thinking about it."