HIV-Related Healthcare Access for Trans Women Living with HIV: A Systematic Review

Background and Purpose: Globally, trans women experience disproportionately high rates of HIV compared to cisgender (cis) adults, fuelled by transphobia and other intersecting oppressions (e.g., racism) which shape women’s access to the social determinants of health (e.g., healthcare). Most HIV research pertaining to trans women discusses HIV prevention, while there has been little focus on healthcare needs post-diagnosis. However, access to HIV-related healthcare is of pivotal importance to maximize the health and wellbeing of trans women living with HIV (WLWH). Social workers may be optimally positioned to address healthcare access disparities for this population. The aim of this study was to conduct a systemic literature review to identify studies describing HIV-related healthcare access among trans WLWH in the US and Canada, in order to inform population-specific and contextually-relevant social work interventions.

Methods: We used the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines to conduct our systematic literature review. A systematic search process was developed in consultation with a librarian. Proquest, EBSCO, OVID, Scopus, and Google Scholar were searched for empirical literature detailing trans women’s access to and experiences with HIV-related healthcare from 1990 to present. Search terms included: transgender women, HIV/AIDS, and healthcare. Included studies: (1) contained empirical data drawn from qualitative, quantitative, or mixed methods studies; (2) included data specific to trans WLWH; (3) discussed HIV-related healthcare access. Two reviewers independently abstracted key study characteristics (e.g., study designs, objectives, key findings).

Results: Fifteen studies were identified which focused on HIV-related healthcare access for trans WLWH, including quantitative (n=8; cross-sectional survey (n=6); retrospective cohort study (n=2); sample sizes 22 to 166) and qualitative (n=7; focus groups (n=3); semi-structured individual interviews (n=2); focus groups and interviews (n=2); sample sizes 10 to 38) studies. Quantitative studies suggested that trans WLWH experience differential access including lower retention in care, and lower ART use and adherence, compared to cisgender adults. Qualitative studies further suggested trans-specific factors may enable (e.g., access to gender-affirming healthcare) or constrain (e.g., transphobia) HIV-related healthcare access for trans WLWH and highlight intersecting oppressions (e.g., transphobia, HIV-related stigma, sexism/transmisogyny, gender non-conformity stigma) which constrain women’s access to HIV-related healthcare at structural (e.g., lack of availability of culturally-relevant services), interpersonal (e.g., discrimination by healthcare providers) and intrapersonal (e.g., depression) levels.

Conclusions and Implications: While there is a dearth of studies specific to trans women’s access to HIV-related healthcare, this systematic review suggests that access disparities exist and are shaped by stigma and discrimination. Social work researchers may utilized mixed methods may address the limitations inherent in mono-method approaches, such as those in current quantitative studies of trans WLWH and HIV-related healthcare (e.g., small sample size thus limited analytical power) and qualitative studies of trans WLWH and HIV-related healthcare (e.g., lack generalizability). Studies are urgently needed that move beyond documenting disparities to further explore barriers and facilitators to healthcare access for trans WLWH and test potential interventions to address disparities, such as increasing access to gender-affirming care, and reducing stigma which can be advocated for and implemented by social workers.