Unmet basic needs may be related to poor rates of durable viral suppression among transgender women with HIV

Transgender women living with HIV are less likely to have excellent adherence to antiretroviral treatment (ART) and durable viral suppression compared to other groups, investigators report in the online edition of LGBT Health. The study also revealed that many transgender women living with HIV are struggling with the basic necessities of life, including food and housing.

The study involved people who received HIV care in the United States.

“Transgender women in care were socioeconomically more marginalized than non-transgender men and women; higher percentages of transgender women had lower income, were homeless and did not have health insurance,” comment the authors.

Transgender women have a high risk of acquiring HIV. In the US, HIV prevalence among transgender women is as high as 28% and globally approximately a fifth of transgender women are estimated to be living with HIV.

There are concerns that transgender women are less likely to engage with HIV care because of stigma and discrimination. Few studies have explored this question, but the research that has been conducted found that transgender women had similar rates of retention in care, uptake of ART and viral suppression compared to other groups.

Investigators from the US Centers for Disease Control and Prevention (CDC) wanted to further study the characteristics and needs of transgender women living with HIV, this time using population-based data.

They therefore examined information obtained via Medical Monitorial Project – a cross-sectional annual survey of individuals accessing HIV care – between 2009 and 2011. They compared the characteristics and needs of transgender women to non-transgender men and women.

Approximately 5700 people participated in the study and 1.3% identified as transgender.

Results showed that many transgender women were socially marginalised. Over 80% of the women identified as non-white and had an income below US$20,000 per year. A fifth reported homelessness and approximately a third did not have health insurance. Over 30% reported drug use.

However, transgender women had high levels of ART utilisation, with over 90% taking HIV treatment in the previous year. Approximately three-quarters reported 100% adherence in the previous three days and close to 70% had viral suppression (below 200 copies/ml) in their most recent test, but only 50% had durable suppression (undetectable viral load in all tests in the previous year).

Compared with non-transgender men and women, significantly higher proportions of transgender women had a low income, were homeless and did not have health insurance. Rates of drug use were higher among transgender women when compared to non-transgender women.

Rates of ART uptake were similar between transgender women and non-transgender men and women. However, transgender women were less likely to have perfect adherence to treatment (p = 0.01) and durable HIV suppression (p = 0.01).

“These findings suggest a need to investigate what happens to transgender women after they are prescribed ART to better understand what might interfere with medication adherence and long-term viral suppression,” comment the investigators. “One possibility is a residual need for supportive services given that transgender women are more likely to be socioeconomically marginalized.”

Transgender women did indeed have higher uptake of support services, including case management (71% vs 61%), adherence support (28% vs 20%), prevention counselling (50% vs 39%), mental health services (46% vs 32%), and domestic violence services (4% vs 2%).

Significantly higher proportions of transgender women had unmet needs for food (13% vs 7%) and housing (13% vs 7%).

“The noted disparities in durable viral suppression and unmet needs for basic services should be explored further,” conclude the investigators. “CDC will monitor progress towards the goal of reducing health disparities among transgender persons living with HIV.”