Estimating HIV Prevalence and Risk Behaviors of Transgender Persons in the United States: A Systematic Review

Jeffrey H. Herbst; Elizabeth D. Jacobs; Teresa J. Finlayson; Vel S. McKleroy; Mary Spink Neumann; Nicole Crepaz


AIDS and Behavior. 2008;12(1):1-17. 

In This Article

Abstract and Introduction

Transgender populations in the United States have been impacted by the HIV/AIDS epidemic. This systematic review estimates the prevalence of HIV infection and risk behaviors of transgender persons. Comprehensive searches of the US-based HIV behavioral prevention literature identified 29 studies focusing on male-to-female (MTF) transgender women; five of these studies also reported data on female-to-male (FTM) transgender men. Using meta-analytic approaches, prevalence rates were estimated by synthesizing weighted means. Meta-analytic findings indicated that 27.7% (95% confidence interval [CI], 24.8-30.6%) of MTFs tested positive for HIV infection (four studies), while 11.8% (95% CI, 10.5-13.2%) of MTFs self-reported being HIV-seropositive (18 studies). Higher HIV infection rates were found among African-American MTFs regardless of assessment method (56.3% test result; 30.8% self-report). Large percentages of MTFs (range, 27-48%) reported engaging in risky behaviors (e.g., unprotected receptive anal intercourse, multiple casual partners, sex work). Prevalence rates of HIV and risk behaviors were low among FTMs. Contextual factors potentially related to increased HIV risk include mental health concerns, physical abuse, social isolation, economic marginalization, and unmet transgender-specific healthcare needs. Additional research is needed to explain the causes of HIV risk behavior of transgender persons. These findings should be considered when developing and adapting prevention interventions for transgender populations.

In the US, HIV/AIDS continues to have a devastating impact on vulnerable and marginalized populations (Wolitski et al. 2006). Although no national surveillance data are currently available on the incidence or prevalence of HIV/AIDS within the US transgender population, data collected by local jurisdictions suggest disproportionately high rates of HIV infection among transgender persons. In 2002, the State of California began recording male-to-female (MTF) and female-to-male (FTM) as gender reporting options in publicly-funded HIV counseling and testing sites (California Department of Health Services 2005; HIV Epidemiology Program 2006). Despite accounting for a small proportion of the population, data collected in 2003 revealed that self-identified transgender clients had a much higher rate of HIV diagnoses (6.3%) than other risk categories, including men who have sex with men (MSM; 4.2%) or partners of people living with HIV (4.8%) (California Department of Health Services 2006). These data also revealed that African American transgender clients had a substantially higher rate of HIV diagnoses (28.6%) than all other racial or ethnic groups (California Department of Health Services 2006). In 2006, the estimated prevalence of HIV among non-injecting MTFs living in San Francisco was 22.8%, a rate comparable to that estimated for MSM (24.3%) (San Francisco Department of Public Health 2006). Several HIV seroprevalence studies conducted in Europe and Asia also report high rates of HIV infection among MTF transgender persons (Pisani et al. 2004; Setia et al. 2006; Spizzichino et al. 2001; Wiessing et al. 1999; Zehender et al. 2004). Together, these data suggest that transgender populations, particularly MTFs, appear to be greatly impacted by the HIV epidemic.

The term "transgender" is an umbrella term that includes persons whose gender identity, expression, or behavior does not conform to societal gender norms associated with sex at birth (Center for AIDS Prevention Studies 2001). Transgender people experience a gender identity that is different than their anatomic sex; they may seek to alter their physical appearance by undergoing cosmetic procedures, using hormones, or having sex reassignment surgery. Other persons do not choose a physical transition, but rather express their gender identity through varied presentations and behaviors (Lombardi and van Servellen 2000b). Different labels have been used to describe gender-variant persons, including MTF, FTM, transsexual, cross-dresser, transvestite, drag queen/king, gender queer, and others (Keatley 2006).

Over the past decade, a small but growing literature has documented behaviors of transgender persons that can ultimately lead to the acquisition or transmission of sexually transmitted diseases (STDs), including HIV (Bockting and Avery 2005; Winningham and Seal 2003; Xavier et al. 2004). Transgender persons often engage in numerous risky sex behaviors, such as having multiple sex partners or unprotected sex, frequently within the context of commercial sex work (Shankle 2006). Needle injection practices may also increase risk for HIV through unsafe injection of recreational drugs or substances to alter gender presentation (i.e., hormones and silicone) (Bockting and Kirk 2001; Lombardi and van Servellen 2000a; Shankle 2006). Since no effective evidence-based HIV prevention interventions have been identified for transgender persons (Centers for Disease Control and Prevention [CDC] 1999; Lyles et al. 2007), there remains an urgent need to better understand both sex and injection risk behaviors, and the contextual factors underlying these risk behaviors. Once understood, these factors can be used to inform the development of new interventions or the adaptation of existing evidence-based interventions to meet the unique HIV prevention needs of transgender populations (McKleroy et al. 2006; Solomon et al. 2006).

This paper presents a systematic review of the US-based HIV behavioral prevention literature focusing on transgender populations. The goals of this paper are to use meta-analytic techniques to estimate the prevalence of HIV infection among MTF and FTM transgender persons and to estimate the prevalence of HIV risk behaviors. This paper also seeks to identify individual, interpersonal, and structural/societal factors that may lead transgender persons to engage in behaviors related to increased risk of HIV transmission or acquisition.


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