Disproportionate HIV Risk Among Transgender People Continues

Compared with the general population of individuals over age 15, transmasculine individuals are almost 7 times more likely to have HIV, and transfeminine individuals are 66 times more likely to have HIV.

Transgender individuals are still disproportionately burdened by HIV and the unique prevention and care needed for these groups should be comprehensively addressed, a meta-analysis published in PLoS ONE said.

According to the review authors, current evidence suggests that pre-exposure prophylaxis (PrEP) has played no role in reducing HIV among transgender individuals, not due to lack of efficacy, but lack of availability.

Researchers conducted a systematic review by first collecting various studies on HIV prevalence among transgender individuals published between January 2000 and January 2019. Using random-effects modeling, they then conducted a meta-analysis to evaluate standardized prevalence and relative burden of HIV on transgender individuals by country and year of data collection, and then by geographic region. They also analyzed the impact of sampling methods and PrEP.

The meta-analysis pulled data from 98 studies, with 48,604 transfeminine and 6460 transmasculine individuals. Overall standardized HIV prevalence over the course of the epidemic, adjusted for each country by year, was 19.9% (95% CI, 14.7%-25.1%) for transfeminine individuals and 2.56% (95% CI, 0.0%-5.9%) for transmasculine individuals. The overall odds ratio (OR) for HIV infection was 66.0 (95% CI, 51.4-84.8) for transfeminine individuals and 6.8 (95% CI, 3.6-13.1) for transmasculine individuals, compared with the general population of individuals over age 15.

“Using a larger pooled sample than ever compiled before, we ascertained that trans masculine individuals almost seven times more likely to have HIV, and trans feminine individuals are 66 times more likely to have HIV, than other individuals over 15 years of age,” the authors said. “Additionally, based on data from 34 countries across major geographic regions, we found support for the contention that the disproportionate burden for HIV carried by transgender individuals is a worldwide phenomenon, and that some regions, such as Africa and Latin America, may be impacted more than others.”

Prevalence varied by geographic region (13.5%-29.9%) and sampling method (5.4%-37.8%), and PrEP effects on prevalence could not be established.

Instead, researchers discovered a higher HIV prevalence rate following the introduction of PrEP. However, only 6 studies were conducted following the introduction of PrEP and these used smaller sample sizes and possibly less representative.

“It is possible that no reduction in prevalence due to PrEP is the result of PrEP not yet reaching trans individuals,” the authors explained. “The inclusion of transgender individuals in PrEP trials has been low and access to PrEP for transgender individuals has been limited.”

However, a study showed high interest among transgender women to be involved in trials.

“Discrimination, judgment, insensitivity, and a lack of understanding from health care providers prevents many transgender individuals from accessing HIV prevention, testing, treatment, and care services,” the authors stated. “Gender affirming care is not simply the provision of hormones and gender-affirming surgeries; it also includes using patients’ preferred names and pronouns, respecting diversity in gender identities and expressions, employing inclusive intake forms, displaying images that are welcoming to transgender individuals, and creating safe spaces where transgender individuals can be themselves.”

Although transgender people may be affected by HIV in some regions more than others, the authors argued it is important to understand all levels of HIV risk in all areas in order to target individual risk factors.

“In sum, this systematic review and meta-analyses have served to update our understanding of HIV prevalence over the course of the epidemic as well as HIV burden in both trans feminine and trans masculine individuals using a larger sample than ever before, and has shown that, worldwide, both carry a substantially higher burden of HIV than other individuals over 15 years of age,” the authors said.

The review also showed the need for analyses by country and year and that sampling methods could impact prevalence rates.

“We recommend integrating HIV prevention and care services in broader gender-affirming care services,” the authors said. “This includes actively making PrEP available to transgender individuals.”


Stutterheim SE, van Dijk M, Wang H, Jonas KJ. The worldwide burden of HIV in transgender individuals: an updated systematic review and meta-analysis. PLoS ONE. Published online December 1, 2021. doi:10.1371/journal.pone.0260063

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