The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis

Abstract

Introduction: Transgender individuals are at risk for HIV. HIV risks are dynamic and there have been substantial changes in HIV prevention (e.g., pre-exposure prophylaxis [PrEP]). It is thus time to revisit HIV prevalence and burden among transgender individuals. The objective of this systematic review and meta-analysis was thus to examine worldwide prevalence and burden of HIV over the course of the epidemic among trans feminine and trans masculine individuals.

Methods: We conducted an updated systematic review by searching PsycINFO, PubMed, Web of Science, and Google Scholar, for studies of any research design published in in a peer-reviewed journal in any language that reported HIV prevalence among transgender individuals published between January 2000 and January 2019. Two independent reviewers extracted the data and assessed methodological quality. We then conducted a meta-analysis, using random-effects modelling, to ascertain standardized prevalence and the relative burden of HIV carried by transgender individuals by country and year of data collection, and then by geographic region. We additionally explored the impact of sampling methods and pre-exposure prophylaxis (PrEP).

Results: Based on 98 studies, overall standardized HIV prevalence over the course of the epidemic, based on weights from each country by year, was 19.9% (95% CI 14.7% - 25.1%) for trans feminine individuals (n = 48,604) and 2.56% (95% CI 0.0% - 5.9%) for trans masculine individuals (n = 6460). Overall OR for HIV infection, compared with individuals over age 15, was 66.0 (95% CI 51.4-84.8) for trans feminine individuals and 6.8 (95% CI 3.6-13.1) for trans masculine individuals. Prevalence varied by geographic region (13.5% - 29.9%) and sampling method (5.4% - 37.8%). Lastly, PrEP effects on prevalence could not be established.

Conclusion: Trans feminine and trans masculine individuals are disproportionately burdened by HIV. Their unique prevention and care needs should be comprehensively addressed. Future research should further investigate the impact of sampling methods on HIV prevalence, and monitor the potential impact of PrEP.

Fig 1. PRISMA flow chart describing the study selection process.

Fig 2. Forest plot of HIV prevalence in trans feminine individuals compared to all adults (age 15+).

The scale on the x-axis is log odds ratio. The percentages indicate the weight of each country by year within the meta-analysis. The numbers in the right column are the log odds ratios including their confidence intervals. We converted these log odds ratios into odds ratios, as described in Table 2.

Fig 3. Forest plot of HIV prevalence in trans masculine individuals compared to all adults (age 15+).

The scale on the x-axis is log odds ratio. The percentages indicate the weight of each country by year within the meta-analysis. The numbers in the right column are the log odds ratios including their confidence intervals. We converted these log odds ratios into odds ratios, as described in Table 3.

Fig 4. Forest plot of HIV prevalence in trans feminine individuals in the USA compared to all adults (age 15+) in the USA.

The 10 country-year including 18 studies above the line are studies where data were collected prior to the introduction of PrEP (2012). The 3 country-year including 6 studies below the line are studies where data were collected after the introduction of PrEP. The scale on the x-axis is log odds ratio. The percentages indicate the weight of each sample within the meta-analysis. The numbers in the right column are the log odds ratios including their confidence intervals.