HIV This Week

Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N; for the HIV/AIDS Prevention Research Synthesis Team. Estimating HIV Prevalence and Risk Behaviors of Transgender Persons in the United States: A Systematic Review. AIDS Behav 2007 ; 12(1):1-17.

Transgender populations in the United States have been affected by the HIV epidemic. This systematic review estimates the prevalence of HIV infection and risk behaviours of transgender persons. Comprehensive searches of the US-based HIV behavioural prevention literature identified 29 studies focusing on male-to-female transgender women; five of these studies also reported data on female-to-male 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 male-to-female transgender women tested positive for HIV infection (four studies), while 11.8% (95% CI, 10.5-13.2%) of male-to-female transgender women self-reported being HIV-seropositive (18 studies). Higher HIV infection rates were found among African-American male-to-female transgender women regardless of assessment method (56.3% test result; 30.8% self-report). Large percentages of male-to-female transgender women (range, 27-48%) reported engaging in risky behaviours (e.g., unprotected receptive anal intercourse, multiple casual partners, sex work). HIV prevalence and risk behaviours were low among female-to-male transgender men. 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 behaviour of transgender persons. These findings should be considered when developing and adapting prevention interventions for transgender populations.

Editors’ note: This systematic review highlights marked differences in HIV prevalence by self-report versus actual HIV testing and in HIV prevalence and risk behaviour between male-to-female transgender women and female-to-male transgender men. In the four studies that included HIV testing, HIV prevalence in transgender women exceeded that of men who have sex with men in 5 US cities and was highest among African-American transgender women. Prevention programmes encouraging transgender persons to practice safer sex behaviours within different types of sexual relationships risk failure if they do not address the individual, interpersonal, and structural/societal contexts influencing their sexual and injecting behaviour.

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Myer L, Rebe K, Morroni C. Missed opportunities to address reproductive health care needs among HIV-infected women in antiretroviral therapy programmes. Trop Med Int Health. 2007; 12(12):1484-9.

 

Myer and colleagues investigate the delivery of reproductive health care services in an antiretroviral therapy programme in Cape Town, South Africa. A cross-sectional survey was conducted among 227 consecutive women attending a hospital-based antiretroviral therapy outpatient service who had been on antiretroviral therapy for at least one month. Semi-structured interviews investigating reproductive health issues and services received were conducted in participants' home language by a trained interviewer. Sixty-seven per cent of the women were younger than 30 years and 75% were sexually active. The use of both condoms (70%) and hormonal contraceptives (31%) decreased with age, while the prevalence of sterilization (13%) increased with age. Few women knew about emergency contraception (7%) or termination of pregnancy (13%). Approximately 45% of women had had a Papanicolau smear, and this was constant across all age groups. One in 10 women had experienced verbal or physical abuse by an intimate partner since their HIV diagnosis. More than 80% of women had discussed the use of condoms and other forms of contraception with a health care provider since their HIV diagnosis, but less than 5% had discussed emergency contraception or termination of pregnancy, and no woman had discussed issues of partner violence. These data delineate the large unmet need for reproductive health services among HIV-infected women receiving antiretroviral therapy in this setting. While issues related to condom and contraceptive use are relatively well addressed, reproductive health services related to unintended pregnancy and partner violence appear to be neglected. The integration of a broad range of reproductive health services into antiretroviral therapy programmes requires urgent attention in both research and policy-making circles.

Editors’ note: Systematic investigations of the reproductive health needs of women on antiretroviral treatment in sub-Saharan Africa are rare. Most antiretroviral programmes focus on condoms and sexual risk reduction counselling to prevent ongoing sexual transmission and on contraception to prevent unwanted pregnancies and danger to the foetus posed by some antiretroviral drugs. Often they do not address comprehensive reproductive health care needs including emergency contraception, termination of pregnancy, gender-based violence, and screening to prevent cervical cancer, which is itself an AIDS-defining condition. Creating one-stop services by integrating reproductive health fully into antiretroviral programmes supports the sexual and reproductive health and rights of women living with HIV. Such integration is urgently needed both in urban settings where it may be easier to accomplish and in rural settings across sub-Saharan Africa.