1. 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

2. 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

3. 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

4. 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 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

5. 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

6. 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 )
In 3,869 TG from 5 HIC, HIV prevalence was 21.6%(95% CI )

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

8. 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

9. 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