Global burden of HIV infection among Transgender Women: A Systematic Review and Meta-Analysis By Stefan Baral, Tonia Poteat, Andrea L Wirtz, Thomas Guadamuz, Susanne Stromdahl, Chris Beyrer Center for Public Health and Human Rights Johns Hopkins School of Public Health

Background Transgender people exist on every continent. Epidemiologic studies have generally included Male to Female Transgenders (TG) as a subpopulation of men who have sex with men (MSM) in HIV research Some biological risk factors are shared between TG women and MSM There is a limited understanding of the burden of HIV among TG

Systematic Review Protocol Inclusion Criteria Published January 1, 2000 to November 30, 2011 in English, French, Spanish PubMed, EMBASE, Global Health, SCOPUS, PsycINFO, Sociological Abstracts, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Science, and POPLine Following search terms medical subject headings (MeSH) terms for HIV or AIDS, and terms associated with transgender ( transgender* OR “travesty” OR “koti” OR “hijra” OR “MTF” or “male to female transgender” OR transsexual* OR transvest* OR “mahuvahine” OR “mahu” OR “waria” OR katoey OR “cross dresser” OR “bantut” OR “nadleehi” OR “mahu” OR “berdache” OR “xanith”). Title search Completed by two reviewers with a third acting as tie-breaker Duplicate titles removed and excluding non-scientific journals. These were retained for abstract review. Abstract review Full text review and Data Abstraction Completed by two abstractors with a third acting as tie-breaker

Methods Meta-Analysis Characterize the increased odds of living with HIV for male-to- female transgender as compared to other people in each country TG HIV Prevalence All estimates from a country were pooled and weighted by sample size to achieve prevalence estimate Background HIV Prevalence UNAIDS data from Men and Women 15+ living with HIV as numerator in each country Denominator was calculated by using US Census Bureau Data for all men and women 15-49 in that country separately Heterogeneity testing done with DerSimonian and Laird’s Q test Random Effects Modeling Assumption that the HIV prevalence in one country is independent of the HIV prevalence in other countries

Systematic Review Results 1512 citations were retrieved 877 unique titles 414 abstract reviews 145 full text reviews 39 studies that met inclusion criteria 11066 Transgender women included in meta-analysis 10 Low and Middle Income Countries 5 High Income Countries

Results The pooled global HIV prevalence was 19.1% (95% CI 17.4-20.7) In 7,197 TG from 10 LMIC, HIV prevalence was 17.7%(95%CI 15.6-19.8) In 3,869 TG from 5 HIC, HIV prevalence was 21.6%(95% CI 18.8-24.3)

Meta-Analysis of HIV Prevalence Data among TG women compared to all adults

Limitations There were only data available for 15 Countries meeting inclusion criteria Studies only available from countries with concentrated and male-predominant HIV epidemics Note: each of these countries have expanding epidemics Significant heterogeneity of study results and methods Pooling of results masks wide geographical variations within a country such as India

Conclusions Male to female TG persons are at very high risk for HIV infection in both low and high income countries They are some 50 times more likely to have HIV infection than other adults of reproductive age in the 15 countries for which data were available TG are an understudied but very at risk group for HIV and are clearly in urgent need of HIV services Virtually no data from the generalized epidemics of the world