HIV Incidence, Mortality Rates Vary by Race, Region Among Transgender Women


Research showed that HIV incidence and mortality rates were highest among transgender women who were Black or Latinx or lived in the southern United States.

Among transgender women in the United States, HIV incidence and mortality were found to be high at 5.5 cases and 3.3 deaths per 1000 person-years, respectively.

These findings were published in The Lancet HIV.

The multisite cohort study was conducted across 2 modes. The first was a site-based, technology-enhanced mode conducted in 6 cities: Atlanta, Baltimore, Boston, Miami, New York City, and Washington, DC. The second was a digital mode conducted across 72 eastern and southern US cities, which were matched to the 6 site-based cities by population size and demographics.

Between March 2018 and August 2020, the authors enrolled 1312 transgender women into the cohort, with 734 (56%) in the site-based mode and 578 (44%) in the digital mode.

At the 24-month assessment, 633 (59%) of 1076 eligible participants chose to continue with the study, and 1084 (83%) of 1312 participants were retained based on the study definition of loss to follow-up, regardless of their choice to continue with the study. By May 2022, the cohort participants contributed and accumulated 2730 person-years to the analytical data set.

The analysis showed that overall HIV incidence was 5.5 (95% CI, 2.7–8.3) per 1000 person-years, with higher incidence among Black participants and participants living in the South. All incidence and mortality values had a 95% CI.

Based on race or ethnicity, HIV incidence was 19.3 (95% CI, 8.4-30.2) per 1000 person-years for Black participants, 9.9 (3.2-23.1) for Latinx participants, and 1.6 (0.3-4.7) for White participants.

The overall mortality rate was 3.3 (95% CI, 1.5-6.3) per 1000 person-years, with 9 participants dying during the study. Mortality was higher among Latinx participants with a mortality rate of 9.9 (3.2-23.1), compared with 4.8 (1.0-14.1) among Black participants and 3.2 (1.2-7.0) among White participants.

HIV incidence and mortality were both highest in the southern United States, with an incidence rate of 10.3 (95% CI, 4.5-20.3) and mortality rate of 7.7 (2.8-16.8) per 1000 person-years. The mid-Atlantic region followed, with identical incidence and mortality rates of 4.8 (1.0-14.1). The north region had the lowest rates at 3.0 (0.8-7.7) for incidence and 0 (0.0-2.8) for mortality.

When separated by mode, HIV incidence was higher in the site-based mode, with 8.7 (95% CI, 4.0-13.5) cases per 1000 person-years in the site-based mode and 1.6 (0.2-5.8) cases per 1000 person-years in the digital mode.

“Identical predictors of HIV seroconversion and death included residence in southern cities, sexual partnerships with cisgender men, and use of stimulants,” the authors added. “Participation in the digital cohort and seeking care for gender transition were inversely associated with both outcomes.”

According to the authors, these findings show the importance of prioritizing transgender women more in national HIV prevention strategies, especially Black and Latinx transgender women. They also said national strategies such as colocated service delivery, increased prescribing authority for pharmacists and other providers, and telehealth may help reduce barriers to HIV prevention strategies. Additionally, interventions delivered both in person and digitally to support safety, housing, employment, and substance use treatment alongside HIV prevention have the potential to change the trajectories of the HIV epidemic and premature death among transgender women.

“As HIV research and interventions are increasingly delivered online, differences by mode highlight the need for continued community and location-based efforts to reach the most marginalised transgender women,” the authors said. “Our findings underscore community calls for interventions that address social and structural contexts that affect survival and other health concerns alongside HIV prevention.”


Wirtz AL, Humes E, Althoff KN, et al; American Cohort to Study HIV Acquisition Among Transgender Women (LITE) Study Group. HIV incidence and mortality in transgender women in the eastern and southern USA: a multisite cohort. Lancet HIV. Published online February 28, 2023. doi:10.1016/S2352-3018(23)00008-5

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