Laboratory-confirmed HIV prevalence estimates among transgender women (TW) in South Africa range from 45-63% versus 20% for the general population. This analysis sought to identify intervenable factors associated with self-reported HIV infection and treatment interruptions among TW.
From May to September 2018, we recruited 214 TW in Cape Town, East London, and Johannesburg through community outreach. Each TW completed an interviewer-administered survey. We collected data on structural and psychosocial factors; HIV risk behaviors; self-reported HIV status; and HIV treatment. Bivariate and multivariable logistic regression models tested associations between structural (homelessness, income, hunger, sex work), interpersonal (social support, physical and sexual violence), and individual (alcohol use, medical distrust) factors and 2 outcomes: HIV status among the entire sample and inability to access antiretroviral therapy (ART) at some point in the prior 12 months among the TW living with HIV (TWLHIV).
31% (67/214) of TW reported being HIV+, and 31% (20/64) of TWLHIV reported inability to access ART at some point in the prior 12 months. We found significant bivariate associations between HIV status and violence, sex work, alcohol use, and homelessness. Sex work was also significantly associated with history of violence. In multivariable models, a history of homelessness [aOR 7.7; 95%CI: 3.1, 19.2] and sex work [aOR 5.7; 95%CI: 2.5, 13.2] were most strongly associated with HIV+ status. Among TWLHIV, violence, homelessness, and medical distrust were positively associated with inability to access ART, while social support was negatively associated with inability to access ART. Homelessness was the only factor that remained significant in the multivariable model, and increased odds of inability to access ART by 6-fold [aOR 6.0; 95%CI: 1.6, 22.2].
Homelessness was strongly associated with reporting HIV infection and treatment interruptions, eclipsing individual and interpersonal factors. Ensuring access to stable housing for TW is an important structural intervention that may reduce HIV risk and improve outcomes among TWLHIV. Conversely, housing discrimination may lead to homelessness among TWLHIV. Additionally, associations between sex work, violence, and HIV highlight the need for safer working conditions, including violence prevention and access to high impact HIV prevention, for TW engaged in sex work.