Center for Public Health and Human Rights Johns Hopkins School of Public Health

1. Global burden of HIV infection among Transgender Women: A Systematic Review and Meta-AnalysisBy 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 • Completed by two reviewers with a third acting as tie-breaker • 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 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

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 15.6-19.8) • In 3,869 TG from 5 HIC, HIV prevalence was 21.6%(95% CI 18.8-24.3)

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