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IDWeek 2013: HIV+ Transwomen Not Getting the Maximum Benefits of Care


More than three-quarters of HIV positive transgender women in San Franciscowere linked to care and 65% are taking antiretroviral therapy (ART), but only 44% achieve viral suppression, according to findings presented* at the recent Second IDWeek conference in San Francisco and in the American Journal of Public Health. A larger national survey, however, found that 68% of transgender people reached undetectable viral load.

The care cascade is a way of looking at how many people with HIV receive various levels of care. As described in the December 2, 2011, Morbidity and Mortality Weekly Report, Centers for Diseases Control and Prevention (CDC) researchers estimated that out of 1.2 million people living with HIV in the U.S., about 80% know their status. In 2010, about three-quarters of people who knew their status were linked to care and about half remained in care. While 77% of those on ART achieved viral suppression, this worked out to only 28% of the total HIV positive population after losing some people at every step along the way.

Milo Santos and Jenna Rapues from the San Francisco Department of Public Health (SFDPH) and colleagues assessed the cascade of care among transgender women in the city. Previous research indicates that transwomen are a disproportionately underserved population, but San Francisco has among the best networks of HIV/AIDS services and was the first city to recommend universal ART for everyone diagnosed with HIV.

Looking at the city as a whole, based on SFDPH's 2011 HIV/AIDS Epidemiology Annual Report, a total of 862 people were newly diagnosed with HIV during 2009-2010. Of these, 87% were linked to care within 6 months, 50% were retained in care for 6-12 months, and 50% achieved viral suppression within 1 year after diagnosis.

By population subgroup, the report estimated that while 83%-89% of people living with HIV overall were receiving ART at the end of 2011, this proportion fell to 79%-83% for all women and to 77%-82% for transgender women. Transwomen also had the lowest 5-year survival probability at 75%, compared with 76% for all women and 85% for men. A study by Moupali Das found that transgender people had the highest "community viral load" of all subgroups tested.

Santos' team aimed to estimate population-level treatment cascade indicators among transgender women using respondent-driven sampling (RDS) of participants in the Transfemales Empowered to Advance Community Health (TEACH) study. A secondary aim was to assess the suitability of the RDS method for this population.

The total sample included 314 transwomen contacted between August and December 2010. The RDS analysis statistically adjusted for probability of being recruited into the study -- acknowledging that individuals in a group tend to recruit others like themselves -- to minimize bias in the sample. Participants received HIV tests and were asked about linkage and access to care, most recent CD4 count and viral load, and use of ART.

According to the adjusted estimates, 38% of the transwomen were Latina, 22% were black, 18% were white, 5% were Asian, and 18% were "other." About 70% were born in the U.S. The researchers acknowledged that the low representation of Asian transwomen in this study (far lower than their proportion in the San Francisco population at large) limited their ability to draw conclusions about this group.

A majority of participants were in older age groups, with 22% being age 50 or older, 14% age 46-50, 19% age 41-45, 17% age 36-40, 9% each in the 31-35 and 26-30 age groups, 8% age 21-25, and only 2% age 18-20. Almost all lived full-time as women and 93% had taken female hormones, but only about 20% had undergone gender surgery. Nearly two-thirds were high school graduates, 30% had some high school education, and 7% had at least some college. Nearly 90% were low-income, making less than $21,000/year, but 85% had health insurance.

About two-thirds reported ever injecting substances not prescribed by a medical professional, but only 12% had injected in the past 12 months; non-injection drug use and alcohol use were common (42% and 66%, respectively). Nearly one-quarter reported ever having hepatitis C. Asked about number of sex partners during the past 6 months, 22% reported no partners, 24% reported 1 partner, 14% reported 2, 12% reported 3, 5% reported 4, and 24% reported 5 or more; 11% reported engaging in commercial sex work during the past 6 months.


  • The RDS-weighted population estimate of HIV prevalence was 40%, similar to a previous SFDPH 2011 consensus estimate of 36%.
  • HIV infection rates were 46% among black women, 32% among Latina woman, and 5% among both white and Asian women.
  • Among the transwomen who tested HIV positive in the study, 95% were already aware that they were infected.
  • 77% reported that they were linked to care within 3 months, and 87% accessed care within 6 months.
  • 65% reported currently being on ART.
  • 44% reported viral load suppression (<200 copies/mL).
  • 35% reported having a CD4 count below 350 cells/mm3.
  • Factors independently associated with HIV infection included being a transwoman of color, injection drug use, and low education level.
  • Participants who identified as transgender women were at significantly higher risk than those who identified simply as women or female.
  • Having a higher number of sex partners was not associated with HIV infection, and in fact transwomen who reported the most partners (>5) during the past 6 months had a significantly lower risk.

This analysis found "poorer HIV treatment outcomes for transwomen relative to San Francisco overall and other subgroups," the researchers concluded. There was "modest ART use" in the setting of universally offered treatment and "less than half of transwomen [were] getting the maximum benefits of care and treatment."

These data suggest that "additional efforts are needed to decrease gaps in service delivery" in an effort to reduce disparities in clinical outcomes among transwomen, elevate the health of transwomen living with HIV, and reduce risk of HIV transmission to partners, they recommended.

The more extensive report published in the August 2013 American Journal of Public Health noted that transwomen in San Francisco are"disproportionately affected by HIV compared with all other groups except men who have sex with men who also inject drugs."

"The relationship between lower HIV risk and identification as female may be an indicator of the protective effect of gender transition processes," the study authors suggested. "As such, this finding points to the potential importance of access to gender-related services for reducing HIV infections among this population." With regard to number of sexual partners, they speculated that transwomen reporting few partners may be exposed to HIV by a primary partner in a stable relationship, and not having a main partner may be protective (studies show that people are less likely to practice safer sex with their primary partner).

"It's really important to highlight how transgender women are disproportionately affected by HIV, with a high incidence and prevalence," said Santos. "We need to collect better data and aggregate the data we have collected so we know the treatment cascade indicators for transgender women, because they are an under-researched and underserved population."

A related study, described in a letter to the editor in the September 1, 2013, issue of Clinical Infectious Diseases, looked at a more geographically diverse U.S. cohort of transgender people (both transwoman and transmen).

This retrospective analysis included nearly 37,000 people with HIV who started care at 13 clinics in the HIV Research Network (HIVRN) between 2001 and 2011 (6 in the Northeast, 1 in the Midwest, 3 in the South, and 3 in the West), of whom 285 self-identified as transgender. Transgender patients were more likely to be young and Hispanic/Latino than other HIV positive people.

This study found that 80% of transgender people were retained in care, 76% received ART, and 68% achieved HIV suppression (based on proportions of patient-years). Non-transgender/cisgender men and women had similar rates of retention in care (81% and 81%), use of ART (77% and 73%), and viral suppression (69% and 63%, respectively).

"Compared to prior studies, which document low ART coverage and suboptimal adherence to HIV treatment in transgender [people living with HIV], these results reflect improvements in health equity for HIV-infected transgender individuals," the researchers concluded. "While our findings may not generalize to all transgender [people living with HIV], they suggest that when engaged in care transgender [people living with HIV] have similar outcomes as non-transgender men and women."

[*Editor's note: Due to a power outage at Moscone Center on October 5, the session at which these findings were to be presented was cancelled. obtained the presentation slides and spoke with scheduled presenter Milo Santos.]



GM Santos, EWilson, J Rapues, et al. HIV Treatment Cascade Among Transgender Women in a Respondent Driven Sampling Study in San Francisco. 2nd IDWeek Conference (IDWeek 2013). San Francisco. October 2-6, 2013.Abstract 1243.

J Rapues, EC Wilson, T Packer, et al.  Correlates of HIV Infection Among Transfemales, San Francisco, 2010: Results From a Respondent-Driven Sampling Study. American Journal of Public Health 103(8):1485-1492. August 2013.

BR Yehia, JA Fleishman, RD Moore and KA Gebo. Retention in Care and Health Outcomes of Transgender Persons Living With HIV. Clinical Infectious Diseases. 57(5):774-776. September 1, 2013.