National estimates of HIV prevalence tell us how many people are living with HIV in Canada at a specific point in time. These estimates include information on how many people with HIV in Canada are women or men, but they do not currently provide information on how many of these people identify as trans. A greater understanding of HIV prevalence can help us better advocate and plan for HIV prevention, testing and treatment and care services for trans people. This article summarizes a systematic review on the global and regional prevalence of HIV in trans people.1
HIV and trans people
Trans people is an umbrella term describing those whose gender identity/expression is different from the sex they were assigned at birth. Trans people are diverse and use different terms to identify themselves, including the following:
- trans woman: a person who was assigned a male sex at birth and has a female gender identity/feminine gender expression
- trans man: a person who was assigned a female sex at birth and has a male gender identity/masculine gender expression
Trans people face many barriers to engaging in HIV prevention, testing, treatment and care.2,3,4 These can include social and structural barriers such as transphobia, stigma and discrimination and lack of access to services and care providers able to address trans-specific needs. To date, research on HIV and trans people has focused more on trans women than on trans men.
What kind of research did the systematic review include?
The systematic review combined data on HIV among trans people from different countries to develop global and regional estimates of HIV prevalence. In the absence of national data in Canada, these broader estimates can provide us with a general understanding of HIV prevalence among trans people in this country.
Ninety-three articles were included in the review, including one study from Canada. A study was included if it:
- was published between 2000 and 2019
- provided HIV prevalence information on trans women or trans men
- determined HIV status through a laboratory-confirmed test (that is, the study did not use participant self-report to determine HIV status)
- provided information on the study’s setting/location
- provided a time frame for data collection
- reported on HIV prevalence or frequency of HIV diagnosis within the total study sample
- had a sample size of at least 40 individuals for the studies with trans women (this criterion was not applied to studies with trans men, as these studies had smaller samples and having a participant minimum would have excluded many studies)
Characteristics of the studies in the review included the following:
- There were 78 studies on trans women, four studies on trans men and 16 studies on both trans women and trans men.
- Studies on trans women included a total of 48,604 individuals from 34 countries. Studies on trans men included a total of 6,460 individuals from five countries.
What is the prevalence of HIV in trans people?
The review examined HIV prevalence among trans people as well as the likelihood of being HIV-positive among trans people compared with among people in the general population over age 15. In general, trans women had a higher HIV prevalence than trans men, and both groups were more likely to have HIV than people in the general population.
The overall prevalence of HIV among trans people in the review was 19.9% for trans women and 2.6% for trans men. Compared with the general population, there was a greater likelihood of being HIV-positive among both trans women (odds ratio [OR] = 66.0) and trans men (OR = 6.8).
By geographic region
The review looked at HIV prevalence among trans women in four regions: Africa, Asia, Latin America and Global North. Global North included studies from Canada, the United States, Australia, Italy and Spain. The four studies in the review that focused on trans men represented only five countries, and the review did not calculate prevalence by region for trans men.
HIV prevalence for trans women in each region was as follows:
- Africa – 29.9%; they were 22 times more likely to have HIV than the general population (OR = 21.5)
- Asia – 13.5%; they were 68 times more likely to have HIV than the general population (OR = 68.0)
- Latin America – 25.9%; they were 96 times more likely to have HIV than the general population (OR = 95.6)
- Global North – 17.1%; they were 48 times more likely to have HIV than the general population (OR = 48.4)
Association between PrEP and HIV prevalence
The review also examined if pre-exposure prophylaxis (PrEP) use has had an impact on HIV prevalence among trans women. Using data from the US studies in the review, the authors calculated HIV prevalence before and after the introduction of PrEP in the United States in 2012.
Before the introduction of PrEP, HIV prevalence was 18.4% among trans women in the US-based studies, while after the introduction of PrEP, HIV prevalence was 23.7%. Trans women were more likely to be living with HIV than people in the general population over 15 years both before (OR = 53.5) and after (OR = 58.0) the introduction of PrEP. On the basis of these results, the authors concluded PrEP did not have an effect on HIV prevalence among trans women. They suggested that this finding may be due to the fact that data from fewer studies were available after the introduction of PrEP, and as a result there may have been a less representative sample from which to calculate prevalence in this period. Another possible explanation suggested by the authors is that trans people have had limited access to PrEP to date and there has been limited inclusion of trans people in PrEP trials. Further efforts are needed to ensure trans people are aware of and able to access PrEP.
What are the implications of the review for service providers?
This systematic review confirms that there is a high prevalence of HIV among trans people globally, a finding consistent with past systematic reviews looking at HIV among trans people. It also confirms the increased burden of HIV among trans people compared with individuals in the general population, with trans women having higher odds of being HIV-positive than trans men. Although these findings are not specific to the Canadian context, in finding a high HIV prevalence across many different regions, the review demonstrates a consistently increased burden of HIV among trans people regardless of location. The review also found that PrEP did not have an effect on HIV prevalence rates among trans women.
There are a number of steps service providers can take to better address HIV in trans people through their programs and services, including:
- developing their knowledge and cultural competency in working with trans people and delivering services that are welcoming, safe, appropriate and gender affirming for trans people3,4,5,6
- examining existing services to identify to what extent they are appropriate, safe and relevant for trans people, and how they can be made more welcoming to trans people (e.g., engaging trans people in program development and as workers in service delivery)3,5
- creating trans-specific services to address the needs of trans people (e.g., co-locating HIV and other trans health services for more comprehensive care, and recognizing that trans women and trans men may have different needs)4,5
- promoting greater awareness of PrEP among trans people and supporting adherence for those on PrEP (e.g., addressing barriers to PrEP access and use and trans-specific concerns related to PrEP such as potential interactions between PrEP and hormone therapy)3,6
- addressing social determinants of health like housing and food security that may present barriers to trans people engaging in health and HIV-related services5
- advocating for improvements in data collection to include categories related to gender identity on, for example, intake forms or client surveys, to further increase understanding of trans people in the context of HIV4
When considering this review, it is important to remember that:
- HIV prevalence was calculated using the studies available at the time the review was done. The sample of people in the collection of included studies may not be a representative sample of trans people globally or in particular regions. More accurate reporting of HIV diagnoses among trans people within surveillance systems is needed to improve our understanding of HIV among trans people.
- HIV-related research to date has focused more on trans women than trans men. This means the review included far fewer studies on trans men than trans women and could not analyze HIV prevalence by region or the impact of PrEP on prevalence in trans men. In addition to some studies that included both trans women and trans men, there were only four studies that focused specifically on trans men and there is potential for sample size bias in these studies. Studies on trans women were excluded if they had fewer than 40 participants but this criterion was not used for studies of trans men, as it would have eliminated most studies on trans men.
What is a systematic review?
Systematic reviews are important tools for informing evidence-based programming. A systematic review is a critical summary of the available evidence on a specific topic. It uses a rigorous process to identify all the studies related to a specific research question. Relevant studies can then be assessed for quality and their results summarized to identify and present key findings and limitations. If studies within a systematic review contain numerical data, these data can be combined in strategic ways to calculate summary (“pooled”) estimates. Combining data to produce pooled estimates can provide a better overall picture of the topic being studied. The process of pooling estimates from different studies is referred to as a meta-analysis.
The Epidemiology of HIV in Canada – fact sheet
Research Update: HIV health and healthcare findings from the 2015 U.S. Transgender Survey
HIV prevention and trans people: What the Trans PULSE Project can tell us
- Stutterheim SE, van Dijk M, Wang H et al. The worldwide burden of HIV in transgender individuals: an updated systematic review and meta-analysis. PLoS One. 2021 Dec 1;16(12):e0260063. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0260063
- Munro L, Marshall Z, Bauer G et al. (Dis)integrated care: barriers to health care utilization for trans women living with HIV. Journal of the Association of Nurses in AIDS Care. 2017 Oct;28(5):708-22.
- Lacombe-Duncan A, Kia H, Logie CH et al. A qualitative exploration of barriers to HIV prevention, treatment and support: perspectives of transgender women and service providers. Health and Social Care in the Community. 2021 Sep;29(5):e33-46.
- Scheim AI, Travers R. Barriers and facilitators to HIV and sexually transmitted infections testing for gay, bisexual, and other transgender men who have sex with men. AIDS Care. 2017 Aug;29(8):990-5. Available from: https://www.tandfonline.com/doi/full/10.1080/09540121.2016.1271937
- Everhart AR, Boska H, Sinai-Glazer H et al. “I’m not interested in research; I’m interested in services”: how to better health and social services for transgender women living with and affected by HIV. Social Science and Medicine. 2022 Jan;292:114610. Available from: https://www.sciencedirect.com/science/article/pii/S0277953621009424?via%3Dihub
- Poteat T, Wirtz AL, Reisner S. Strategies for engaging transgender populations in HIV prevention and care. Current Opinion in HIV and AIDS. 2019 Sep;14(5):393-400.
About the author(s)
Erica Lee is CATIE’s manager, website content and evaluation. Since earning her Master of Information Studies, Erica has worked in the health library field, supporting the information needs of frontline service providers and service users. Before joining CATIE, Erica worked as the Librarian at the AIDS Committee of Toronto (ACT).