HIV care outcomes among transgender persons with HIV infection in the United States, 2006-2021.

OBJECTIVES: HIV prevalence is an estimated 14% among transgender women (TW) and 3% among transgender men (TM). HIV care is vital for viral suppression but is hindered by transphobia and HIV stigma. We assessed HIV care outcomes among transgender persons (TG) with HIV in the United States. DESIGN: Systematic review and meta-analysis of peer-reviewed journal articles. METHODS: We searched multiple electronic databases and Centers for Disease Control and Prevention's HIV Prevention Research Synthesis database for 2006-September 2020. Eligible reports were US-based studies that included TG and reported HIV care outcomes. Random-effects models were used to calculate HIV care outcome rates. The protocol is registered with PROSPERO (CRD42018079564). RESULTS: Few studies reported outcomes for TM; therefore, only TW meta-analysis results are reported. Fifty studies were identified having low-to-medium risk-of-bias scores. Among TW with HIV, 82% had ever received HIV care; 72% were receiving care, and 83% of those were retained in HIV care. Sixty-two percent were currently virally suppressed. Among those receiving HIV care or antiretroviral therapy (ART), 67% were virally suppressed at last test. Sixty-five percent were linked to HIV care 3 months or less after diagnosis. Seventy-one percent had ever been prescribed ART. Approximately 66% were taking ART, and 66% were ART-adherent. Only 56% were currently adherent the previous year. CONCLUSIONS: HIV care outcomes for TW were not ideal, and research gaps exists for TM. High heterogeneity was observed; therefore, caution should be taken interpreting the findings. Integrating transgender-specific health needs are needed to improve outcomes of transgender persons across the HIV care continuum.

Estimating the Prevalence of HIV and Sexual Behaviors Among the US Transgender Population: A Systematic Review and Meta-Analysis, 2006-2017.

Background. Transgender women (transwomen) in the United States have been shown to have high HIV risk with Black and Hispanic transwomen being particularly vulnerable. Growing research on transgender men (transmen) also shows increased HIV risk and burden, although not as much is known for this transgender population.Objectives. This systematic review estimates the prevalence of self-reported and laboratory-confirmed HIV infection, reported sexual and injection behaviors, and contextual factors associated with HIV risk of transgender persons living in the United States.Search Methods. We searched the HIV Prevention Research Synthesis database and MEDLINE, EMBASE, PsycINFO, CINAHL, and Sociological Abstracts databases from January 2006 to March 2017 and January 2006 to May 2017, respectively. Additional hand searches were conducted in December 2017 to obtain studies not found in the literature searches.Selection Criteria. Eligible reports were published US-based studies that included transgender persons and reported HIV status.Data collection and analysis. Data were double-coded and quality assessed. We used random-effects models employing the DerSimonian-Laird method to calculate overall prevalence of HIV infection, risk behaviors, and contextual factors for transwomen, transmen, and race/ethnicity subgroups.Main Results. We reviewed 88 studies, the majority of which were cross-sectional surveys. Overall laboratory-confirmed estimated prevalence of HIV infection was 9.2% (95% confidence interval [CI] = 6.0%, 13.7%; κ = 24). Among transwomen and transmen, HIV infection prevalence estimates were 14.1% (95% CI = 8.7%, 22.2%; κ = 13) and 3.2% (95% CI = 1.4%, 7.1%; κ = 8), respectively. Self-reported HIV infection was 16.1% (95% CI = 12.0%, 21.2%; κ = 44), 21.0% (95% CI = 15.9%, 27.2%; κ = 30), and 1.2% (95% CI = 0.4%, 3.1%; κ = 7) for overall, transwomen, and transmen, respectively. HIV infection estimates were highest among Blacks (44.2%; 95% CI = 23.2%, 67.5%; κ = 4). Overall, participation in sex work was 31.0% (95% CI = 23.9%, 39.0%; κ = 39). Transwomen (37.9%; 95% CI = 29.0%, 47.7%; κ = 29) reported higher participation in sex work than transmen (13.1%; 95% CI = 6.6%, 24.3%; κ = 10; P = .001). Most outcomes indicated high heterogeneity in the overall and subgroup analyses.Conclusions. The availability of more data allowed us to calculate estimates separately for transwomen and transmen. HIV prevalence estimates for US transwomen were lower than previous estimates, but estimates for HIV prevalence and participation in sex work were higher when compared with transmen. Evidence gaps remain for transmen and the syndemic relationship of HIV, risky behaviors, and contextual factors specific to the transgender experience.Public Health Implications. This study highlights gender disparities for HIV and risky sexual behavior, as well as evidence gaps that exist for transmen. Tailored programs and services for the transgender population need to be developed to encourage use of and access to HIV prevention services.