Transgender (trans) people have a gender identity/expression that is different from the sex they were assigned at birth. Trans women, specifically, identify as women or have a feminine gender expression.
Globally, trans women are disproportionately affected by HIV, while also facing disparities in mental, physical and sexual health.1–3 In Canada, HIV prevalence data among trans women are not routinely collected.4 This contributes to gaps in our understanding of HIV among trans women. Research about HIV prevalence and related factors in trans women is needed to inform HIV prevention and support services that are gender equitable and culturally tailored for this population.
About the study
A retrospective study looked at HIV prevalence and factors associated with having HIV among trans women in two large Canadian cities.4 The study reviewed medical charts of 1,059 trans women 16 years of age or older, who were engaged in clinical care at one of six clinics in Toronto and Montreal between 2018 and 2019. The participating sites are family medicine and/or HIV clinics that provide clinical care to the majority of trans women in Toronto and Montreal.
The research team, which included trans community members in addition to clinicians and researchers, developed a data collection tool for the chart review. HIV status was recorded as either HIV positive, HIV negative or missing (not documented). The researchers examined associations between HIV positive status and a variety of sociodemographic and clinical variables.
Results
The prevalence of HIV in the sample of trans women engaged in clinical care in two urban Canadian cities was 7.5%. Over a third of the sample (38.1%) was missing HIV status data and 54.4% of the sample had their HIV status documented as HIV negative.
The multivariate analysis found that several factors were associated with being HIV positive in this sample. Trans women in the sample were more likely to be HIV positive if they were over the age of 50, were of Black race/ethnicity compared with white, were an immigrant or refugee compared with a Canadian citizen, received social assistance compared with not receiving such assistance, or had a history of recreational drug use.
What does this study tell us?
The study authors conclude that trans-specific HIV prevention and support is important given the prevalence of HIV in this population. They note an overall need for culturally appropriate prevention and support programs that address the social determinants of health, especially for Black trans women and those who are immigrants or refugees to Canada.
A high proportion of trans women in this study were missing HIV status data. Missing HIV status suggests a lack of HIV testing. However, the researchers acknowledge that participants may have had an HIV test elsewhere and that some may not have sexual or other risk factors that would trigger an HIV test. However, they call for more research to better understand this potential gap in HIV testing.
The researchers also note that a fifth of the sample (19.8%) was over 50 years old and that trans women over 50 were almost three times more likely to be living with HIV than those under 30 years old. Future research should focus on improving our understanding of the needs and experiences of aging trans women living with HIV.
Limitations
The HIV prevalence estimate found in this study may not be representative of the prevalence of HIV in the general population of trans women in Canada. The estimate (7.5%) was higher than that in another recent study from Ontario2 and lower than global estimates.5 The authors note that the clinics included in this study are known for their gender-affirming care, which may have led to the higher number of trans women in care at these clinics. Along with the fact that some sites were HIV clinics, the study sampling may have contributed to an overrepresentation of trans women living with HIV.
The cross-sectional nature of this study means that we can’t draw conclusions about causality between HIV positive status and various factors. The factors related to being HIV positive in this study may have occurred before the participants were diagnosed with HIV or afterward, possibly as a result of living with HIV. Additionally, the large amount of missing data may lower confidence in the strength of the results. However, the authors note that research on trans women and HIV in Canada is lacking and this study sheds light on possible trends and areas to consider for support, prevention and future research.
References
- Baral SD, Poteat T, Stromdahl S et al. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infectious Diseases. 2013;13:214–22.
- Abramovich A, de Oliveira C, Kiran T et al. Assessment of health conditions and health service use among transgender patients in Canada. JAMA Network Open. 2020;3:e2015036.
- Downing JM and Przedworski JM. Health of transgender adults in the U.S., 2014–2016. American Journal of Preventive Medicine. 2018;55:336-44.
- Lacombe-Duncan A, Persad Y, Shokoohi M et al. HIV prevalence among a retrospective clinical cohort of transgender women in Canada: results of the Montreal–Toronto Trans study, collected 2018–2019. International Journal of STD & AIDS. 2023;0(0):1-10.
- Becasen JS, Denard CL, Mullings MM et al. Estimating the prevalence of HIV and sexual behaviors among the US transgender population: a systematic review and meta-analysis, 2006–2017. American Journal of Public Health. 2019;109:e1-8.
About the author(s)
Camille Arkell is CATIE’s manager, harm reduction, HIV prevention and testing. She has a master of public health degree in health promotion from the University of Toronto and has been working in HIV education and research since 2010.