"Due to the lack of tracking, there might be an epidemic out of control and we don't know about it, nor do we have the resources to address it if we need to," warns Jason Farrell, executive director of the Positive Health Project, an AIDS outreach program in New York. "Some advocates think that the rates of infection may be going up in the transgender community, but there's no way to know because there's no tracking whatsoever of transgenders now."

In the last 10 years, HIV prevalence rates amongst intravenous drug users have dropped dramatically, according to David A. Hansell, associate commissioner for HIV services for the New York Department of Health, and many researchers believe outreach to drug users and widespread use of needle exchange programs have been partially responsible for the decline. But rates of transmission in the transgender population have remained staggeringly high, and may be continuing to rise, according to recent health studies. Researchers are now asking whether black-market hormones could be at least partly responsible for high HIV infection rates.

"Clearly, sharing of hormone needles is a possible route of transmission because with any injection there's a possible risk," Hansell says. "It's one of the risks that people need to be educated about so they avoid it."

Health departments in New York, Los Angeles, Boston and San Francisco are exploring the issue. Finding that the rates of infection in the group were phenomenally high in Los Angeles County, the city's Community HIV Prevention Planning Committee recently designated the transgender population as one of its highest priorities for HIV prevention efforts. Dr. Paul Simon, a medical epidemiologist with the Los Angeles County Department of Health Services, is one of several researchers who conducted a survey of 244 male-to-female transsexuals in 1998 and 1999. The results of the study were published in a December 2000 issue of the journal "AIDS."

The findings stunned Simon and his researchers. Twenty-two percent of those in the study group were HIV-positive (while only a fraction of 1 percent of the general population in the United States is thought to be HIV-positive today). They conducted a follow-up study and determined that in a group of 100 transsexuals, the chance of getting infected was 3.4 percent.

"That's as high as what we were seeing among gay and bisexual men in the 1980s at the peak of the epidemic," says Simon. "It's a very high rate of HIV infection."

As a group, transsexuals face several risk factors. Although most transgender people do not think of themselves as gay, most engage in anatomically homosexual sex. And among male-to-female transsexuals, the group reported a high rate of unprotected anal sex (47 percent reported having unprotected receptive anal sex in the last six months). Recent public health studies also reveal that sexual partners of transsexuals tend to identify as straight, providing anecdotal evidence that safe-sex education that is widely available in the gay community may not be reaching them.

When asked about needles, 69 percent reported that they had injected hormones at some point in their lives; 44 percent in the previous six months alone. Of those who had recently injected hormones, 72 percent said they got their needles off the streets. But Simon says it is unclear what role black market needles played, since unsafe sex and drug use are also dangers (8 percent reported using intravenous drugs in the last six months). Sharing hormone needles may be less risky than sharing drug needles, he added, because transsexuals do not typically draw blood directly back into the needle, as drug users do.

Female and male hormones come in various forms -- pills, patches and liquid -- but many transsexuals prefer injections to the other methods because liquid hormones supposedly take effect faster. Hormone needles are about twice the length and width of the needles used to shoot heroin, which is usually diluted with water before it is injected. But just like drug syringes, hormone needles are not readily available in pharmacies without a prescription, and are sometimes even harder to come by than clean drug needles on the streets.

The San Francisco and New York health departments have both studied HIV risk factors in the transgender population. Of 94 transgender people surveyed for the 1999 "Transgender Needs Assessment" for the New York City HIV Prevention Planning Group, 90 percent of respondents said they had a history of using hormones. Of those, 40 percent said they had gotten them off the black market.

"A small number reported sharing, but when people are accessing hormones from the black market there's no way of knowing if they're using syringes that have been used before," says Kelly McGowan, author of the report. "It was definitely discussed as a perceived risk factor, particularly amongst female-to-males."

In San Francisco, however, researchers found little needle sharing. Out of 500 transsexuals surveyed, only three men who were taking hormones to become women, and one woman trying to become a man, reported sharing needles in the last six months. Of the transgenders who inject hormones, 84 percent reported that they had obtained their needles from safe sources in the last six months.

Kristen Clements, an epidemiologist with the San Francisco Department of Public Health and the chief investigator for that city's report, says the divergence might reflect the two cities' different approaches to needle exchange and transgender lifestyles. In San Francisco, several health clinics provide free hormone syringes and free and low-cost hormone therapy in a safe, medical setting, with hours set aside exclusively for transsexuals.

"I can guarantee you that if someone is grappling with gender identity, they're going to get hormone needles off the street," Clements says. "But we take that seriously here, and we provide needles."

By comparison, the 1999 "Gay and Lesbian Health Report" by the New York City Department of Public Health found that "members of the transgender community report barriers to accessing body altering drugs and procedures."

When asked if he knew of any clinics in New York City that offer low-cost or free hormone therapy for transitioning adults, Farrell just laughed, shaking his head. "That's San Francisco," he says. (Indeed, San Francisco is currently considering a proposal to add sex changes to the list of medical procedures covered by city employees' health plans.) Farrell adds that he knew of only two needle exchange programs in New York that specifically do outreach to the transgender community -- his own and Streetworks, a program for adolescent transsexuals.

However, on Jan. 1, New York state implemented a new policy of needle deregulation. For three years, it will make syringes available to adults without a prescription, through licensed pharmacies, healthcare facilities and certain healthcare practitioners who voluntarily register with the state.

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