HIV incidence and mortality in transgender women in the eastern and southern USA: a multisite cohort study

Andrea L Wirtz; Elizabeth Humes; Keri N Althoff; Tonia C Poteat; Asa Radix; Kenneth H Mayer; Jason S Schneider; J Sonya Haw; Andrew J Wawrzyniak; Christopher M Cannon; Meg Stevenson; Erin E Cooney; Dee Adams; James Case; Chris Beyrer; Oliver Laeyendecker; Allan E Rodriguez; Sari L Reisner; American Cohort to Study HIV Acquisition Among Transgender Women (LITE) Study Group

doi:10.1016/S2352-3018(23)00008-5

HIV incidence and mortality in transgender women in the eastern and southern USA: a multisite cohort study

Lancet HIV. 2023 May;10(5):e308-e319. doi: 10.1016/S2352-3018(23)00008-5. Epub 2023 Feb 28.

Authors

Andrea L Wirtz¹, Elizabeth Humes², Keri N Althoff², Tonia C Poteat³, Asa Radix⁴, Kenneth H Mayer⁵, Jason S Schneider⁶, J Sonya Haw⁶, Andrew J Wawrzyniak⁷, Christopher M Cannon⁸, Meg Stevenson⁹, Erin E Cooney¹⁰, Dee Adams⁹, James Case¹¹, Chris Beyrer¹², Oliver Laeyendecker¹³, Allan E Rodriguez¹⁴, Sari L Reisner¹⁵; American Cohort to Study HIV Acquisition Among Transgender Women (LITE) Study Group

Affiliations

¹ Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Center for Public Health and Human Rights, Johns Hopkins University, Baltimore, MD, USA; Department of International Health, Johns Hopkins University, Baltimore, MD, USA. Electronic address: awirtz1@jhu.edu.
² Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA.
³ Center for Health Equity Research, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
⁴ Callen-Lorde Community Health Center, New York, NY, USA.
⁵ Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA; The Fenway Institute, Fenway Health, Boston, MA, USA.
⁶ Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
⁷ Department of Psychiatry and Behavioral Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA.
⁸ Whitman-Walker Institute, Washington, DC, USA.
⁹ Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Center for Public Health and Human Rights, Johns Hopkins University, Baltimore, MD, USA.
¹⁰ Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Center for Public Health and Human Rights, Johns Hopkins University, Baltimore, MD, USA; Department of International Health, Johns Hopkins University, Baltimore, MD, USA.
¹¹ Johns Hopkins Bloomberg School of Public Health, School of Nursing, Johns Hopkins University, Baltimore, MD, USA.
¹² Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Center for Public Health and Human Rights, Johns Hopkins University, Baltimore, MD, USA; Duke Global Health Institute, Duke University, Durham, NC, USA.
¹³ Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA; Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA; Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.
¹⁴ Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA.
¹⁵ Department of Medicine, Harvard University, Boston, MA, USA; Harvard Medical School and Department of Epidemiology, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA; The Fenway Institute, Fenway Health, Boston, MA, USA; Division of Endocrinology, Diabetes, and Hypertension, Brigham Women's Hospital, Boston, MA, USA.

Abstract

Background: Epidemiological monitoring of HIV among transgender women is minimal despite prioritisation of this group in the US National HIV/AIDS Strategy (2022-2025). We aimed to estimate HIV incidence in a multisite cohort of transgender women in the eastern and southern USA. Participant deaths were identified during follow-up; thus, we felt it was an ethical imperative to report mortality alongside HIV incidence.

Methods: In this study, we established a multisite cohort across two modes: a site-based, technology-enhanced mode in six cities (Atlanta, Baltimore, Boston, Miami, New York City, and Washington, DC) and an exclusively digital mode that spanned 72 eastern and southern US cities that matched the six site-based cities based on population size and demographics. Trans feminine adults (≥18 years) who were not living with HIV were eligible and followed up for at least 24 months. Participants completed surveys and oral fluid HIV testing with clinical confirmation. We ascertained deaths through community and clinical sources. We estimated HIV incidence and mortality using the number of HIV seroconversions and deaths, respectively, divided by person-years accumulated from enrolment. Logistic regression models were used to identify predictors of HIV seroconversion (primary outcome) or death.

Findings: Between March 22, 2018, and Aug 31, 2020, we enrolled 1312 participants with 734 (56%) in site-based and 578 (44%) in digital modes. At the 24-month assessment, 633 (59%) of 1076 eligible participants consented to extending participation. 1084 (83%) of 1312 participants were retained at this analysis based on the study definition of loss to follow-up. As of May 25, 2022, the cohort participants had contributed 2730 accumulated person-years to the analytical dataset. Overall HIV incidence was 5·5 (95% CI 2·7-8·3) per 1000 person-years and incidence was higher among Black participants and those living in the south. Nine participants died during the study. The overall mortality rate was 3·3 (95% CI 1·5-6·3) per 1000 person-years, and the rate was higher among Latinx participants. Identical predictors of HIV seroconversion and death included residence in southern cities, sexual partnerships with cisgender men, and use of stimulants. Participation in the digital cohort and seeking care for gender transition were inversely associated with both outcomes.

Interpretation: As HIV research and interventions are increasingly delivered online, differences by mode highlight the need for continued community and location-based efforts to reach the most marginalised transgender women. Our findings underscore community calls for interventions that address social and structural contexts that affect survival and other health concerns alongside HIV prevention.

Funding: National Institutes of Health.

Translation: For the Spanish translation of the abstract see Supplementary Materials section.

Publication types

Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

MeSH terms

Acquired Immunodeficiency Syndrome*
Adult
Cohort Studies
Female
HIV Infections* / epidemiology
HIV Infections* / prevention & control
HIV Seropositivity*
Humans
Incidence
Male
Transgender Persons*

Abstract

Publication types

MeSH terms

Grants and funding