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Worldwide burden of HIV in transgender women: a systematic review and meta-analysis

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Summary

Background

Previous systematic reviews have identified a high prevalence of HIV infection in transgender women in the USA and in those who sell sex (compared with both female and male sex workers). However, little is known about the burden of HIV infection in transgender women worldwide. We aimed to better assess the relative HIV burden in all transgender women worldwide.

Methods

We did a systematic review and meta-analysis of studies that assessed HIV infection burdens in transgender women that were published between Jan 1, 2000, and Nov 30, 2011. Meta-analysis was completed with the Mantel-Haenszel method, and random-effects modelling was used to compare HIV burdens in transgender women with that in adults in the countries for which data were available.

Findings

Data were only available for countries with male-predominant HIV epidemics, which included the USA, six Asia-Pacific countries, five in Latin America, and three in Europe. The pooled HIV prevalence was 19·1% (95% CI 17·4–20·7) in 11 066 transgender women worldwide. In 7197 transgender women sampled in ten low-income and middle-income countries, HIV prevalence was 17·7% (95% CI 15·6–19·8). In 3869 transgender women sampled in five high-income countries, HIV prevalence was 21·6% (95% CI 18·8–24·3). The odds ratio for being infected with HIV in transgender women compared with all adults of reproductive age across the 15 countries was 48·8 (95% CI 21·2–76·3) and did not differ for those in low-income and middle-income countries compared with those in high-income countries.

Interpretation

Our findings suggest that transgender women are a very high burden population for HIV and are in urgent need of prevention, treatment, and care services. The meta-analysis showed remarkable consistency and severity of the HIV disease burden among transgender women.

Funding

Center for AIDS Research at Johns Hopkins and the Center for Public Health and Human Rights at the JHU Bloomberg School of Public Health.

Introduction

The term transgender is used most often to refer to people whose gender identity or expression differs from their birth sex.1 Gender presentations and social categories vary greatly across cultures, and many different terms are used to describe individuals who live between or outside a male-female binary.2, 3, 4 For the purposes of this report, the terms male and female will be used to refer to biological sex, and the term man and woman will be used to refer to gender identity or expression. Transgender women, defined here as people who were assigned male at birth but who identify as women, have long been known to be at high risk for HIV acquisition and transmission. As of 2012, there remains a poor understanding of the burden of HIV among transgender women because of the limited inclusion of these populations in national HIV surveillance systems. In the few countries where epidemiological data for transgender women have been obtained, results have shown a disproportionate risk for HIV infection.

A 2008 meta-analysis by Herbst and colleagues5 at the US Centers for Disease Control and Prevention (CDC) identified 22 studies that reported HIV infection rates for transgender women. The average prevalence was 27·7% (range 16–68%) from the four studies that reported laboratory-confirmed HIV infections. African American transgender women had twice the prevalence of HIV infection (56·3%) than did those who were white (16·7%) or Hispanic (16.1%). When the results were averaged across the 18 studies where respondents self-reported their HIV serostatus, the average dropped to 11·8% (range 3–60%). Although selection bias might account for the difference in HIV prevalence between studies with self-reported HIV status and those with biologically confirmed HIV, CDC has reported that as many as 73% of the transgender women who tested HIV-positive were unaware of their status. Therefore, the difference in HIV prevalence between studies that used laboratory markers and those with only self-report provide support for the hypothesis that many transgender women might not be aware of their HIV status.5

One international systematic review and meta-analysis of HIV risk in a subset of transgender women was done by Operario and colleagues in 2008.6 This study compared HIV prevalence in transgender women sex workers versus transgender women who do not engage in sex work, male sex workers, and female sex workers. The investigators identified 25 studies including 6405 participants (3159 transgender women—2139 categorised as sex workers and 1020 categorised as non-sex workers—1633 male sex workers, and 1613 female sex workers) recruited from 14 countries on five continents. Although most studies were done in the USA, study populations also included transgender women in Spain, Singapore, Israel, Netherlands, Brazil, Belgium, Indonesia, Australia, Thailand, Uruguay, India, and Italy. Most sites were large metropolitan cities and all used convenience samples. Participants were recruited at venues that included HIV testing clinics, medical and community-based organisations serving transgender populations, street locations, and social and workplace venues. Six of the 25 studies established HIV status on the basis of self-report.

Overall crude HIV prevalence was 27·3% in transgender women engaging in sex work, 14·7% in those not engaging in sex work, 15·1% in male sex workers, and 4·5% in female sex workers. There was a significant difference in HIV prevalence in transgender women sex workers compared with all other pooled groups (odds ratio [OR] 1·46, 95% CI 1·02–2·09) and a significant difference between transgender sex workers and female sex workers (4·02, 1·60–10·11). Transgender sex workers were therefore more than four times more likely to be living with HIV than were female sex workers. Studies done outside of the USA showed higher HIV prevalence in transgender sex workers than in all other groups (OR 1·90, 95% CI 1·52–2·37), although studies within the USA did not show this difference (OR 1·24, 95% CI 0·72–2·12). These data highlight the disproportionate burden of HIV infections in transgender women sex workers compared with female sex workers.

We did a global systematic review to better assess the relative HIV burden among all transgender women worldwide. We then completed a meta-analysis comparing the burdens of HIV infection in these populations to those of adults of reproductive age in their countries to characterise the size of the burden of HIV borne by these women.

Section snippets

Search strategy and selection criteria

We searched PubMed, Embase, Global Health, Scopus, PsycINFO, Sociological Abstracts, Cumulative Index to Nursing and Allied Health Literature, Web of Science, POPLine, and LexisNexis. The WHO publications database was searched, as well as the National Library of Medicine's Meeting Abstracts database. Searches were done in February, 2011, and repeated in November, 2011. Conference abstracts were searched from the online archives of the International AIDS Conference, the Conference on HIV

Results

Figure 1 shows our study design. Across 15 countries with data that were included in this review, the pooled HIV prevalence was 19·1% (95% CI 17·4–20·7) for transgender women (table 1).11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48 In transgender women sampled in low-income and middle-income countries, HIV prevalence was 17·7% (95% CI 15·6–19·8); in high-income countries, HIV prevalence was

Discussion

Our findings suggest that transgender women are a very high burden population for HIV and are in urgent need of prevention, treatment, and care services. The findings of the meta-analysis of HIV infection rates are remarkable for the severity and consistency of disease burdens across these populations. This was true in all regions including Europe, Central and South America, Asia-Pacific, and the USA, and when stratified by income level of the country. Pooled ORs for HIV ranged from a low of

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