Quality of life and sexual health among transgender people and people living with HIV in Sweden

Background: The overarching objective of public health policy in Sweden has a clear focus on equitable health throughout the population and includes a commitment to reduce avoidable health inequalities. Trans (transgender) people constitute a population that is highly affected by social and health inequalities. People living with HIV in the era of effective antiretroviral therapy (ART) with full access to treatment can live long, fulfilling and productive lives, yet social conditions such as stigma and discrimination continue to contribute to negative health outcomes.

Aim: This project studies quality of life (QoL) and sexual health in two populations: trans people and people living with HIV.

Methods: Data for this thesis is derived from two large cross-sectional studies, targeting people living with HIV (Paper I–II) and trans people (Paper III–IV). In 2013-2014, a nationwide representative study was conducted in 17 infectious disease clinics and needle exchange programs across Sweden (Paper I–II) (n=1097). For studies III–IV, data was collected via a web-based survey targeting trans people in Sweden in 2015 (n=796).

Results: In Paper I, we found that QoL among people living with HIV included in the study was high overall. Lower QoL was associated with having comorbidities, internalized stigma, hopelessness and experiencing negative changes to sex life after HIV diagnosis. In Paper II, we examined the direct and indirect associations between sexual satisfaction and contributing factors among people living with HIV. Sexual dissatisfaction was reported among 49% of respondents. Path analyses revealed that, among both women and men, negative changes to sex life after the HIV diagnosis were directly associated with sexual dissatisfaction. In addition, not being involved in an intimate relationship and perceiving the obligation to disclose HIV status to sexual partners as a barrier to finding a long-term partner were indirectly associated with sexual dissatisfaction. In Paper III, it was found that self-rated health, self-reported disability and QoL among trans people included in the study were associated with experiencing negative or incompetent healthcare experiences. In addition, poorer health outcomes were associated with limited access to legal gender recognition and with identifying as non-binary. The results from Paper IV indicated that sexual satisfaction was relatively low among respondents (46%) and was associated with having multiple current sexual partners, satisfaction with partner relationship, absence of negative mood symptoms, possibilities to discuss sexual matters in healthcare context and no history of sex in exchange for money. In addition, results revealed generally low condom use and HIV testing, both motivated by low risk perception, lack of knowledge of trans-friendly clinics and sexual practices that do not require a condom.

Conclusions: Despite good treatment outcomes and generally high QoL, people living with HIV face stigma, poor mental health and various sexual health challenges that have a bearing on people’s QoL and sexual satisfaction. Factors related to trans people’s health and QoL are similar to those of the general population in addition to trans-related distal factors such as legal gender recognition and experiences of healthcare incompetence in trans-related issues.

List of scientific papers

I. Zeluf-Andersson G, Eriksson LE, Schönnesson LN, Höijer J, Månehall P, Ekström AM. Beyond viral suppression: the quality of life of people living with HIV in Sweden. AIDS Care. 2018.
https://doi.org/10.1080/09540121.2018.1545990

II. Schönnesson LN, Zeluf G, Garcia-Huidobro D, Ross MW, Eriksson LE, Ekström AM. Sexual (dis)satisfaction and its contributors among people living with HIV infection in Sweden. Arch Sex Behav. 2018; 47(7):2007.
https://doi.org/10.1007/s10508-017-1106-2

III. Zeluf G, Dhejne C, Orre C, Nilunger Mannheimer L, Deogan C, Höijer J, Ekéus Thorson A. Health, disability and quality of life among trans people in Sweden–a web-based survey. BMC Public Health. 2016;16(1):903.
https://doi.org/10.1186/s12889-016-3560-5

IV. Zeluf-Andersson G, Dhejne C, Deogan C, Nilunger Mannheimer L, Ekéus Thorson A. Sexual health and sexual satisfaction in a population of self-identified trans people. [Manuscript]