HIV prevalence and behavioral and psychosocial factors among transgender women and cisgender men who have sex with men in 8 African countries: A cross-sectional analysis

Abstract

IntroductionSub-Saharan Africa bears more than two-thirds of the worldwide burden of HIV; however, data among transgender women from the region are sparse. Transgender women across the world face significant vulnerability to HIV. This analysis aimed to assess HIV prevalence as well as psychosocial and behavioral drivers of HIV infection among transgender women compared with cisgender (non-transgender) men who have sex with men (cis-MSM) in 8 sub-Saharan African countries.Methods and findingsRespondent-driven sampling targeted cis-MSM for enrollment. Data collection took place at 14 sites across 8 countries: Burkina Faso (January–August 2013), Côte d’Ivoire (March 2015–February 2016), The Gambia (July–December 2011), Lesotho (February–September 2014), Malawi (July 2011–March 2012), Senegal (February–November 2015), Swaziland (August–December 2011), and Togo (January–June 2013). Surveys gathered information on sexual orientation, gender identity, stigma, mental health, sexual behavior, and HIV testing. Rapid tests for HIV were conducted. Data were merged, and mixed effects logistic regression models were used to estimate relationships between gender identity and HIV infection. Among 4,586 participants assigned male sex at birth, 937 (20%) identified as transgender or female, and 3,649 were cis-MSM. The mean age of study participants was approximately 24 years, with no difference between transgender participants and cis-MSM. Compared to cis-MSM participants, transgender women were more likely to experience family exclusion (odds ratio [OR] 1.75, 95% CI 1.42–2.16, p < 0.001), rape (OR 1.95, 95% CI 1.63–2.36, p < 0.001), and depressive symptoms (OR 1.30, 95% CI 1.12–1.52, p < 0.001). Transgender women were more likely to report condomless receptive anal sex in the prior 12 months (OR 2.44, 95% CI 2.05–2.90, p < 0.001) and to be currently living with HIV (OR 1.81, 95% CI 1.49–2.19, p < 0.001). Overall HIV prevalence was 25% (235/926) in transgender women and 14% (505/3,594) in cis-MSM. When adjusted for age, condomless receptive anal sex, depression, interpersonal stigma, law enforcement stigma, and violence, and the interaction of gender with condomless receptive anal sex, the odds of HIV infection for transgender women were 2.2 times greater than the odds for cis-MSM (95% CI 1.65–2.87, p < 0.001). Limitations of the study included sampling strategies tailored for cis-MSM and merging of datasets with non-identical survey instruments.ConclusionsIn this study in sub-Saharan Africa, we found that HIV burden and stigma differed between transgender women and cis-MSM, indicating a need to address gender diversity within HIV research and programs.

Achieving the first 90 for key populations in sub‐Saharan Africa through venue‐based outreach: challenges and opportunities for HIV prevention based on PLACE study findings from Malawi and Angola

“…Providing HIV/AIDS information via an outreach strategy could help facilitate such scale up based on our finding that outreach worker‐led education was associated with increased recent HIV testing for FSW and MSM—an observation among the first of its kind from SSA. The fact that this association was not observed among TGW people warrants further study, and may reflect the scarcity of TGW‐tailored outreach services in SSA .…”

High HIV prevalence and associated risk factors among transgender women in China: a cross‐sectional survey

“…A global meta‐analysis places HIV prevalence among transgender women at 19.1%, with the odds of infection 48.8 times that of other adults . Even in sub‐Saharan Africa, the region of the world with the highest burden of HIV infection among the general population, transgender women have significantly higher HIV prevalence . In the few Asian countries with data on transgender women, surveys have also demonstrated high prevalence of HIV, for example, in Indonesia (26.1%), Thailand (12.5%), Vietnam (18.0%) and Cambodia (5.7%) .…”

“…International research indicates that stigma and discrimination towards transgender women leads to biological, behavioural, social, cultural and economical vulnerabilities for HIV that vary across countries and regions . For example, in several African countries, depression, condomless receptive anal sex, law enforcement stigma and violence were significantly associated with HIV . In the United States and Peru , race, multiple sexual partners, condomless receptive anal or vaginal sex, non‐prescribed injection of hormones or drugs, sharing drug paraphernalia, engaging in commercial sex work and history of sexually transmitted infections (STI) were associated with HIV .…”

Accuracy of Self-Reported HIV Status Among African Men and Transgender Women Who Have Sex with Men Who were Screened for Participation in a Research Study: HPTN 075

“…MSM and transgender women in Africa are at high risk of HIV infection [8–11]. Criminalization of homosexuality in many countries, stigma, and fear of social harms have limited uptake of HIV prevention and treatment services among African MSM [7, 12, 13].…”