(see Poster Gallery) Systematic Review of HIV Prevention Interventions for Individuals of Transgender Experience

Background and Purpose: Untreated HIV leads to poorer health outcomes including premature mortality in individuals not treated. Individuals of transgender experience (ITE) are disproportionately affected by HIV. According to a 2021 CDC report, in a national sample of 1,600 transgender women, 42% were HIV positive. Despite the high rates of HIV among ITE, to date, no systematic reviews of HIV prevention studies have been conducted. To address this knowledge gap, this systematic review addressed the following questions: 1) What types of interventions have been conducted to reduce HIV risk among ITE? 2) What are the common outcomes assessed across studies? 3) What are the methodological strengths and weaknesses of the intervention studies? 4) What interventions are most effective when considering the rigor of the study’s methods?

Methods: A systematic search of 9 databases was conducted following the PRISMA guidelines to identify studies that evaluated interventions to reduce HIV risk among ITE. Inclusion criteria were the following: 1) published in peer-reviewed journals between 2012 and 2021, 2) study targeted ITE, 3). conducted in the United States, 4) empirically based quantitative methods. Studies were excluded if: 1) the intervention setting was a justice system (i.e., prisons, jails), 2) the study targeted female sex workers due to key population differences and unique population experiences. Methodological rigor was assessed using an adapted version of the 12-item Methodological Quality Rating Scale (MQRS). The mean of the total scale scores (possible range 0-14) was used to identify higher and lower rigor studies, and to assess methodological strengths and weaknesses. The primary outcome was HIV testing. Secondary outcomes were other preventive behaviors. Outcomes were compared by intervention type (peer-based vs. telehealth) and intervention approach (CBPR approach vs non-CBPR). The effectiveness of each intervention by outcome (significant or non-significant) was compared across intervention types, considering the study rigor (high versus low rigor).

Results: Nine studies met the inclusion criteria. Intervention types included peer-based (n=5), telehealth (n=3) and combination (n=1). Interventions also included CBPR- approach (n=5) and non-CBPR approach (n=4). The most common outcomes were HIV testing (n=5) and preventive behaviors (condom use and PrEP adherence) (n=7). Methodological rigor was high with a median of 11. (M=10.44, SD=2.35). Methodological strengths were theoretically based interventions and appropriate statistical analysis. Methodological weaknesses were lack of multiple site testing and blind follow up. Three of 5 interventions showed significant improvements on HIV testing. Three of 7 interventions showed significant improvements on preventive behaviors. Two studies showed significant improvements in both outcomes; one was a CBPR approach, and one was not. One was telehealth and one was peer-based. CBPR and non-CBPR interventions were equally effective.

Conclusions and Implications: Findings indicate that less than half of the 9 interventions demonstrated strong evidence for preventing HIV by improving testing, condom use, and/or PrEP adherence . Evidence does not suggest that CBPR is more effective than non-CBPR approaches, yet these findings should be considered with caution due to the small number of studies. Additional interventions need to be developed and evaluated for this vulnerable population.