Abstract
To the Editor:
H
Only one of five identified studies on transgender HPV prevalence in the United States focused on transgender women. 10 In that study, 97.7% of women tested positive for at least one type of HPV, 10 similar to international populations. Despite high HPV prevalence among transgender women, vaccine uptake is reportedly as low as 10%. 10
Although HPV vaccination recommendations are now gender inclusive, HPV-related cancer screening is only recommended for individuals with a cervix. 3 There are no formal recommendations or “gold standard” methods to screen for oral and anal cancers, and transgender HPV research has primarily focused on anal and cervical infection. As the HPV vaccine was recently approved for head and neck cancer prevention, this study fills a crucial gap by reporting prevalence of oral infection.
Given the limited research indicating the high priority of transgender HPV research, 11 this research seeks to expand the existing literature by describing data on HPV among transgender young adults in New York City.
Between October 2015 and January 2020, a total of 520 participants from the P18 Cohort Study enrolled in a substudy, known locally as P18 Viral, assessing HPV prevalence, incidence, and correlates. Concurrent with P18 Cohort Study visits, P18 Viral participants received multi-site HPV testing and responded to a brief computer-based survey. Detailed study methods have been previously published. 12 All participants provided informed consent and all study activities were approved by the New York University and Rutgers University institutional review boards. The present analysis is focused on the 43 (8.3%) transgender-identified participants at P18 Viral baseline.
Participants self-reported all sociodemographic data, including race/ethnicity, gender, nation of birth, total annual income, educational attainment, sexual identity, and self-rated health. HIV testing was conducted using the Alere Determine HIV-1/2 Ag/Ab Combo, with reflex confirmation. Participants provided blood samples for HSV-1/2 and were tested for oral and anal HPV using oral mouthwash samples and self-administered anal swabs, as detailed in previous publications. 12 All participants self-reported information on STI testing and diagnoses in the previous 6 months, including syphilis, chlamydia, gonorrhea, and hepatitis C. Participants reported history of HPV vaccination, including number of doses received; lifetime and past year anogenital STI symptoms; lifetime history of genital or anal warts; and behaviors associated with HPV transmission and clearance (e.g., cigarette use and condomless sex). All analyses were conducted in IBM SPSS version 26. Owing to the study's descriptive nature and sample size, only univariate analyses were performed.
Transgender participants (n = 43) were diverse in terms of race/ethnicity, gender identity, education, and income, with full details presented in Table 1. Based on laboratory-confirmed testing, 14.0% of participants were living with HIV. About half of participants (55.8%) tested positive for HSV. Of the 74.4% of participants who had been tested for chlamydia, gonorrhea, and/or syphilis in the 6 months before assessment, 46.9% had been diagnosed with chlamydia, gonorrhea, and/or syphilis.
Sample Characteristics and Human Papillomavirus Prevalence Among Transgender P18 Cohort Study Participants Enrolled in P18 Viral Substudy (n = 43)
Reported as mean (standard deviation).
Includes both oral and anal infections.
GED, general equivalency diploma; HPV, human papillomavirus; n/a, not applicable; STI, sexually transmitted infection.
Including all types and infection sites, 62.8% of participants tested positive for HPV. Nearly two-thirds of anal HPV tests (65.9%) were positive and few oral HPV tests (7.0%) were positive (Table 1). Among anal tests, 31.7% were positive for a high-risk strain and 43.9% were positive for a low-risk strain. Among oral tests, 2.3% were positive for a high-risk strain and 2.3% were positive for a low-risk strain. Including oral and anal sites, 39.5% tested positive for a vaccine-preventable strain. In addition, although 37.2% of participants tested negative for HPV, 34.9% tested positive for one genotype and 27.9% were coinfected with two to five genotypes.
A majority of participants (79.1%) reported any STI symptoms in their lifetime and just over half (55.8%) reported symptoms in the past 12 months (Table 1). Only 16.3% of participants reported experiencing anogenital warts at any time in their life. Less than half of participants were vaccinated (41.9%). Of those 18 individuals, 50.0% received one dose, 11.1% received only two doses, and only 38.9% received all three doses.
A majority of participants (83.7%) reported having oral or anal sex without a condom or other barrier in the past 30 days. The average number of sexual partners in that time was 3.56 (standard deviation = 4.80, range: 0–23). Most participants reported smoking at least one cigarette in the past 30 days (60.5%). About half of participants (53.5%) reported having a place where they usually receive medical care.
Prevalence of HPV infection in our sample of transgender young adults in New York City was high, similar to the few other studies available on HPV prevalence in transgender women. Study participants tested positive for a range of HPV genotypes; most were anal infections and many were vaccine preventable.
A majority of those who tested positive for HPV never had visible anogenital warts, indicating high prevalence of asymptomatic infection. This is crucial, as many transgender women are not tested for HPV, are not vaccinated, and are less likely to clear HPV infection due to factors such as cigarette smoking and HIV coinfection. 6,8 Many who tested positive for HPV had high-risk strains, aligning with previous findings that transgender New Yorkers are disproportionately burdened by HPV-associated cancers. 4
HPV vaccination was originally only recommended for cisgender women, with gender-inclusive guideline updates implemented in 2011. 3 Our participants were all vaccine eligible, but less than half had received at least one vaccine dose, drawing attention to previously identified inconsistencies in HPV vaccination for people assigned male at birth. Further research is necessary to better understand barriers and facilitators to vaccination among transgender women. 9 Given the known barriers to access, prevention efforts could be lifesaving.
These findings add to the scant literature, but must be considered alongside their limitations. Our sample was diverse and locally representative, but small—of 520 P18 Viral participants, only 8.3% were transgender—which prevented us from providing detailed information about within-population differences (e.g., racial/ethnic disparities). In addition, we did not collect data on gender-affirming surgeries and could not report on neovaginal infection, which have been previously identified in numerous case reports but have not been explored in larger research studies. Finally, the P18 Cohort Study took place in New York City, where transgender people have greater access to affirming health care and sociolegal protections, which may limit the generalizability of our findings to the larger US population.
Our findings, and the lack of data to which they can be compared, underscore a need for further research on HPV in transgender populations, particularly transgender women. Transgender women may be at greater risk for HPV and related illnesses due to factors such as increased HIV burden, barriers to vaccination, and absence of HPV screening recommendations. 7,9,10 Future research should explore these topics in diverse groups of transgender women, accounting for biopsychosocial HPV risk factors and the systemic inequalities that drive these disparities.
Footnotes
Authors' Contributions
All authors contributed to the conceptualization, writing, analysis, and revising of the article presented herein.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
The study was funded by grants from National Institute on Drug Abuse (NIDA; 2R01DA025537) and the National Institute of Allergy and Infectious Diseases (NIAID; R01AI132020, R56AI122000). C.L. and P.N.H. are supported by the National Center for Advancing Translational Sciences (NCATS), a component of the National Institute of Health (NIH) under award number UL1TR003017. C.L. is also supported by the New Jersey Commission on Cancer Research.