Abstract
Summary
Previous studies have reported high HIV prevalence among transgender sex workers (TSWs). We performed a retrospective case-note review of known TSWs attending our unit. In all, 16/24 (66.7%) of patients were diagnosed with at least one sexually transmitted infection (STI) and 7/24 (29.2%) reported intentional unprotected anal or vaginal intercourse, which may explain the high prevalence of HIV in our cohort (37.5%). TSWs disclosed high rates of substance misuse, violence and sexual assault, which may also contribute to the increased prevalence of STI in this group.
Keywords
Introduction
Previous studies have reported a high prevalence of HIV among transgender communities in a variety of geographical locations.1-3 Although the increased risk of HIV acquisition among male-to-female transgender individuals is well recognized, one study estimated the prevalence of HIV among female-to-male transgender persons to be as high as 11.8%. 3 Furthermore, a recent meta-analysis demonstrated significantly higher frequency of HIV infection among transgender sex workers (TSWs) compared with transgender individuals not engaged in sex work, as well as the general male and female sex worker populations. 1
The aims of this study were to estimate the prevalence of HIV among TSWs attending our centre and to explore underlying factors influencing sexually transmitted infection (STI) and HIV transmission.
Methods
A retrospective case-note review was performed of known TSWs attending our service between 2000 and 2008; demographics, transgender status, number of attendances, condom use, STI diagnoses, recreational drug use and history of physical or sexual assault were entered into an Excel spreadsheet.
Results
Twenty-eight TSWs were identified, of whom 24 had medical notes available. In all, 23/24 (95.8%) were male-to-female transgender, and one was female-to-male; demographics are displayed in Table 1. The median number of attendances for sexual health screening was two (range 0-45). The median number of clients was seven per week (range 1-40). One patient (4.2%) was a dominatrix only. Eight of 24 (33.3%) also had a regular male partner. Seven of 24 (29.2%) had documented intentional unprotected anal or vaginal intercourse. Four of 24 (16.7%) had received HIV postexposure prophylaxis (PEP) at our centre following high-risk sexual exposures.
Cohort demographics, sexually transmitted infections (STIs) and drug use
Defined as chlamydia-negative urethritis or proctitis
More than one-third of patients (9/24, 37.5%) were HIV-positive; eight were diagnosed at their first visit or known to be HIV infected, and one seroconverted following ongoing high-risk sexual behaviour. One patient was found to have chronic hepatitis B infection, but the remaining TSWs were either core antibody positive (9/24, 37.5%) or successfully vaccinated against the infection (14/24, 58.3%).
Overall, 16/24 (66.7%) of patients were diagnosed with at least one STI and 10/24 (41.7%) admitted to recreational drug use, see Table 1.
Three of 24 (12.5%) had documented disclosure of a prior sexual assault, of whom two had reported it to the police. Six of 24 (25.0%) had experienced physical abuse at work or domestic violence.
Discussion
TSWs are a heterogeneous group and appear to be vulnerable not only to HIV and STIs but also substance misuse and physical and sexual abuse. High rates of ulcerative and bacterial STIs and intentional unprotected intercourse may be significant contributory factors to the high prevalence of HIV among this cohort. 4 Our findings are in keeping with published data demonstrating high rates of syphilis, unprotected intercourse and recreational drug use in TSWs.2,3,5,6 In behavioural studies, the latter has been shown to be associated with unprotected intercourse and/or increased risk of HIV acquisition.2,67
High-risk sexual behaviour and recreational drug use have a strong contextual basis, with transgender individuals reporting transphobia, need for gender validation, employment discrimination and urgent financial needs due to the high cost of gender re-assignment surgery as factors undermining safe-sex principles. 8 Likewise, drugs may be used to escape from these negative life experiences and the relationship difficulties often faced by those attempting gender transition. 8 Rates of depression and suicide in transgender individuals have been reported to be as high as 62% and 32%, respectively.2,3
All of the above indicate a need to develop HIV prevention strategies specifically targeted at the needs of the transgender community. These include promoting self-esteem, personal safety, access to affordable medical interventions for gender transition, psychological support and drug and alcohol services, in addition to traditional safe-sex messages and provision of condoms and HIV PEP.