Sex Work and HIV Status Among Transgender Women: Systematic Review and Meta-Analysis

Operario, Don PhD*; Soma, Toho MPH†; Underhill, Kristen DPhil‡

JAIDS Journal of Acquired Immune Deficiency Syndromes: 1 May 2008 - Volume 48 - Issue 1 - pp 97-103
doi: 10.1097/QAI.0b013e31816e3971
Epidemiology and Social Science

Background: Transgender women are a key risk group for HIV, and epidemiologic studies have attributed high rates of HIV infection to behaviors associated with sex work in this population. This systematic review compared HIV prevalence among transgender female sex workers (TFSWs) with prevalence among transgender women who do not engage in sex work, male sex workers, and biologically female sex workers.

Methods: We conducted systematic searches of 6 electronic databases, and including studies that met pre-established criteria. We extracted data, appraised methodologic quality, assessed heterogeneity, and organized meta-analyses by comparison group.

Results: We identified 25 studies among 6405 participants recruited from 14 countries. Overall crude HIV prevalence was 27.3% in TFSWs, 14.7% in transgender women not engaging in sex work, 15.1% in male sex workers, and 4.5% in female sex workers. Meta-analysis indicated that TFSWs experienced significantly higher risk for HIV infection in comparison to all other groups (relative risk [RR] = 1.46, 95% confidence interval [CI]: 1.02 to 2.09), and particularly in comparison to female sex workers (RR = 4.02, 95% CI: 1.60 to 10.11). We observed significant heterogeneity among the included studies, along with methodologic limitations and imprecise definitions of sex work and gender.

Conclusions: TFSWs could benefit from targeted HIV prevention interventions, HIV testing, and interventions to help reduce the risk of contracting or transmitting HIV. Structural interventions to reduce reliance on sex work among transgender women may be warranted.

From the *Department of Social Policy and Social Work, University of Oxford, Oxford, United Kingdom; †School of Public Health, University of California at Berkeley, Berkeley, CA; and ‡Yale University Law School, New Haven, CT.

Received for publication July 19, 2007; accepted February 15, 2008.

Supported by the US National Institutes of Health/National Institute on Drug Abuse (grant R01-DA18621).

Correspondence to: Don Operario, PhD, Barnett House, 32 Wellington Square, Oxford OX1 2ER, United Kingdom (e-mail:

© 2008 Lippincott Williams & Wilkins, Inc.