HIV prevalence in transgender populations and cisgender men who have sex with men in sub-Saharan Africa 2010–2022: a meta-analysis

INTRODUCTION: The Global AIDS Strategy 2021–2026 calls for equitable and equal access to HIV prevention and treatment programmes for all populations to reduce HIV incidence and end HIV/AIDS as a public health threat by 2030. Transgender populations (TGP), including transmen (TGM) and transwomen (TGW) are populations that have been marginalised and are at high risk of HIV infection in sub-Saharan Africa (SSA). Limited surveillance data on HIV among TGP are available in the region to guide programmatic responses and policymaking. Surveillance data on cisgender men who have sex with men (cis-MSM) are comparatively abundant and may be used to infer TGP HIV prevalence. METHODS: Data from key population surveys conducted in SSA between 2010–2022 were identified from existing databases and survey reports. Studies that collected HIV prevalence on both TGP and cis-MSM populations were analysed in a random effect meta-analysis to estimate the ratio of cis-MSM:TGW HIV prevalence. RESULTS: Eighteen studies were identified encompassing 8,052 TGW and 19,492 cis-MSM. TGW HIV prevalence ranged from 0–71.6% and cis-MSM HIV prevalence from 0.14–55.7%. HIV prevalence in TGW was 50% higher than in cis-MSM (prevalence ratio (PR) 1.50 95% CI 1.26–1.79). TGW HIV prevalence was highly correlated with year/province-matched cis-MSM HIV prevalence (R(2) = 0.62), but poorly correlated with year/province-matched total population HIV prevalence (R(2) = 0.1). Five TGM HIV prevalence estimates were identified ranging from 1–24%. Insufficient TGM data were available to estimate cis-MSM:TGM HIV prevalence ratios. CONCLUSION: Transgender women experience a significantly greater HIV burden than cis-MSM in SSA. Bio-behavioural surveys designed and powered to measure determinants of HIV infection, treatment coverage, and risk behaviours among transgender populations, distinct from cis-MSM, will improve understanding of HIV risk and vulnerabilities among TGP and support improved programmes.