High mortality among U.S. transgender women appeared to be related to social vulnerability rather than HIV, despite the low use of pre-exposure prophylaxis (PrEP), according to newly published results from a cohort study. Preventable and violent deaths in this population highlight important targets for further study and intervention.
About This Study
“HIV incidence and mortality in transgender women in the eastern and southern USA: a multisite cohort study” was published online on Feb. 28, 2023, in The Lancet HIV. The lead author is Andrea L. Wirtz, Ph.D., of the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health of Johns Hopkins University in Baltimore, Maryland.
A related commentary, “Social determinants of transgender women's health” by Carlos F Cáceres, M.D., Ph.D. , and Ximena Salazar, Ph.D., of the Center for Interdisciplinary Studies in Sexuality, AIDS, and Society at Universidad Peruana Cayetano Heredia in Lima, Peru, was published in the same issue.
Key Research Findings
The aim of this multisite cohort study was to estimate the incidence of HIV in transgender women in the eastern and southern U.S. The researchers also gathered mortality data during the follow-up period and those results are reported here as well.
Nine of 1,312 transgender women died during the study period: one each due to homicide and suicide, two from overdose, and the remainder for other or unknown causes. Participants, followed for at least 24 months, during 2018-2022, contributed 2,730 person-years (PYs) of follow-up, resulting in a mortality rate of 3.3/1,000 PY. That rate was higher among Latinx participants (who comprised 9% of all participants). All but one deceased participant had been unemployed (vs. 41% of all participants), a third had been homeless (vs. 11% overall), and two-thirds had engaged in sex work (vs. 38% overall).
The HIV incidence rate was 5.5/1,000 PY but was higher among non-Latinx Black women (who comprised 13% of all participants) and those living in the U.S. South. Women who sought care for transitioning were less likely to seroconvert, while women who had sex with cisgender men or used stimulants were more likely to do so.
Seroconversions also differed by study mode–56% of the women who seroconverted visited physical sites, while 44% contributed data only virtually. At 8.7/1,000 PYs, site-based participants acquired HIV at higher rates than digital-only participants (1.6/1,000 PY). In-person assessments included quarterly HIV self-testing at the site, while remote participants were asked to submit oral samples twice a year for laboratory testing.
Discussion Highlights and Implications for Practice
While the lack of PrEP among the women who seroconverted is concerning, violent and preventable deaths should be given a greater focus in HIV research, the study authors noted. They recommend specific structural-level interventions focusing on access to services, as well as individual interventions including substance abuse and sexual health interventions. They also pointed out that a thoughtful approach to PrEP use in this population is needed.
The commentary authors agreed, arguing that “the high mortality regularly found in longitudinal studies in transgender women should raise concerns, because death is competing with the aim of preventing HIV infection among transgender women for them to enjoy healthy lives.”