EPIDEMIOLOGY AND SOCIAL SCIENCE
Sex Work and HIV Status Among Transgender Women
Systematic Review and Meta-Analysis
Don Operario, PhD,* Toho Soma, MPH,† and Kristen Underhill, DPhil‡
Background: Transgender women are a keyrisk group for HIV, and
epidemiologic studies have attributed high rates of HIV infection to
behaviors associated with sex work in this population. This system-
atic 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
Methods: We conducted systematic searches of 6 electronic data-
bases, and including studies that met pre-established criteria. We ex-
tracted 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 HIVinfection 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 defi-
nitions 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.
Key Words: HIV, sex work, systematic review, transgender/
(J Acquir Immune Defic Syndr 2008;48:97–103)
ologic studies have shown that transgender women are at
elevated risk of HIV infection compared with the general
population.1–7Factors associated with HIV status in trans-
gender women include unprotected sex with primary male
partners, injection drug use, social stigma, and being an ethnic
minority.8,9Sex work might further contribute to HIV prev-
alence in transgender women.10Studies suggest that a large
proportion of transgender women engage in sex work attrib-
utable, in part, to social stigma and employment discrimina-
tion, which limit opportunities for income generation and
challenge basic survival needs.10–12
In general, sex workers have been shown to experience
risk for various adverse health conditions, including HIV
and other sexually transmitted infections (STIs).13–17Few evi-
dence-based HIV prevention interventions for sex workers
exist, and many health policy approaches to reduce HIV risk
for sex workers are challenged by legal frameworks that
criminalize prostitution.18In previous research, cofactors for
HIV risk among sex workers have included soliciting cus-
tomers from streets (as opposed toworking in brothels or other
sites), frequent sex with partners of unknown serostatus, in-
consistent condom use, low socioeconomic status, homeless-
ness, and dependency on drugs and alcohol.19These sex work
risks can add to other factors that predispose transgender
women to HIV infection, leading to a state of heightened risk
among transgender sex workers.20–24
We conducted a systematic review to (1) examine the
association between sex work and HIV status among trans-
gender women and (2) assess whether transgender female sex
workers (TFSWs) experience higher rates of HIV compared
with male and biologically (nontransgender) female sex
workers. The goal of this review was to identify all studies
that have assessed HIV status in transgender sex work samples
compared with non–sex-working transgender women, male
sex workers, or biologically female sex workers. We aimed to
describe characteristics of these studies, assess their methodo-
logic quality, and conduct meta-analyses of HIV prevalence in
TFSWs versus these 3 comparison groups.
ransgender women are individuals classified as male at
birth but who identify as female. International epidemi-
We included any study measuring the prevalence of HIV
described earlier. Study designs included cross-sectional
Received for publication July 19, 2007; accepted February 15, 2008.
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.
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: don.operario@
Copyright ? 2008 by Lippincott Williams & Wilkins
J Acquir Immune Defic Syndr?Volume 48, Number 1, May 1, 2008
Copyright © 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Copyright © 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.