Transgender women (TW) are disproportionately affected by HIV infection and related comorbidities [1–4]. Globally, 19% of TW are living with HIV and TW have 49 times greater odds of HIV-infection compared to cisgender adults of reproductive age in their respective countries [5]. In the United States, the most recent HIV prevalence estimate among TW is 14% [1] compared with 0.3% in the general population [6]. People living with HIV have a higher prevalence of cardiovascular disease (CVD) than persons without HIV, related to both higher prevalence of traditional risk behaviors for CVD such as smoking [7, 8], and the effects of HIV itself [9, 10]. HIV infection is associated with chronic inflammation and elevated burden of CVD risk factors such as diabetes [11].
Specific antiretroviral therapy (ART) regimens have also been associated with higher risk of CVD [12, 13]. In the general population, TW experience disparities in prevalence of CVD risk factors, rates of events (e.g., myocardial infarction, stroke, venous thromboembolism) [7, 8, 11], and potentially risk of CVD-related mortality [14, 15] compared to their cisgender counterparts. This elevated CVD burden is a function of multilevel factors, including biological (e.g., exogenous sex-hormone use), interpersonal (e.g., gender-based stigma) and socio-structural (e.g., discrimination) [3, 14–16].
TW living with HIV are uniquely vulnerable to CVD morbidity as a result of potentially mutually-reinforcing HIV-related and gender-identity-related risks. For example, gender related stigma contributes to sub-optimal: retention in care [15], ART adherence, and viral suppression for TW living with HIV [17], all factors that may impact CVD risk. Gender affirming hormone therapy (GAHT), including exogenous sex-hormone use, is an important part of healthcare for many TW [18–20]. GAHT can increase ART adherence and viral suppression for TW living with HIV [18–20] which may improve outcomes [21]. However, exogenous estrogen use affects inflammation and immune function, potentially conferring increased CVD risk among TW using GAHT [2, 9, 12, 14, 16, 19, 22]. In short, both HIV and GAHT play a role in CVD [23, 24]. Despite the unique vulnerability to CVD-related morbidity and mortality faced by TW living with HIV, data on CVD risk among TW living with HIV are lacking [14]. The objectives of this study were to quantify elevated CVD risk prevalence for TW compared to cisgender women (CW) and cisgender men (CM) engaged in HIV.
