Persons left behind: transgender women

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

Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Lancet Infect Dis. 2012 Dec 20. pii: S1473-3099(12)70315-8. [Epub ahead of print]

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.

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Editor’s notes: This paper systematically reviews studies on the prevalence of HIV infection among transgender women in different countries from three continents. Results unfortunately show that there is a dramatic consistency in HIV prevalence data, which reach peaks often above 20%, irrespective of the financial context of the countries where transgenders live. In addition, there is a common theme: risk factors including stigma, discrimination and marginalisation are all factors which dramatically increase the risk of becoming infected by HIV. Not only are transgender women probably the group with the highest risk of acquiring the infection, but they are also in urgent need of prevention, possibly including pre- and post-exposure prophylaxis, and of tailored support and care. But these might not be enough, if marginalisation is supported in some countries with a legal environment contradicting international human rights frameworks.

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