Global mental health disparities among transgender women and transfeminine people living with HIV: a systematic review and meta-analysis of 63 studies

Document Type

Article

Publication Date

5-7-2026

Institution/Department

Psychiatry

Journal Title

The lancet. HIV

Abstract

BACKGROUND: Transgender women and transfeminine people face a disproportionate burden of mental health conditions driven by stigma, discrimination, and structural inequities, with additional psychosocial challenges related to HIV diagnosis and barriers to care among those living with HIV. We conducted a systematic review and meta-analysis to assess the global prevalence of mental health and substance use outcomes among transgender women and transfeminine people living with HIV. METHODS: We searched MEDLINE, Embase, Web of Science, PsycINFO, CINAHL, and Cochrane CENTRAL from database inception to Jan 22, 2025 for studies reporting mental health outcomes among transgender women and transfeminine people living with HIV. Outcomes included depression, suicidality, anxiety, post-traumatic stress disorder (PTSD), gender discrimination, and substance use. We assessed risk of bias using the Newcastle-Ottawa Scale and the Joanna Briggs Institute Checklist, and we pooled prevalence estimates for each outcome. We registered the protocol in PROSPERO (CRD42023465717). FINDINGS: Of 6293 records screened, 63 studies (n=8030) met inclusion criteria, with 49 classified as having low risk of bias. Most studies (89%) were conducted in North, Central, and South America, with a substantial proportion originating from the USA (57%). Pooled prevalence estimates were 40% (95% CI 33-48) for depressive symptoms, 29% (11-47) for suicidal ideation, 26% (12-40) for suicide attempt, 39% (32-46) for anxiety symptoms, 33% (20-46) for PTSD symptoms, and 50% (36-64) for gender discrimination. For substance use, results were 40% (33-47) for any substance use excluding tobacco and alcohol, 61% (52-69) for tobacco use, 40% (30-50) for any alcohol use, 31% (20-42) for hazardous alcohol use, 25% (15-34) for binge drinking, 35% (25-45) for marijuana use, 36% (25-47) for cocaine use, 29% (19-38) for crack cocaine use, 18% (7-29) for amphetamine use, 38% (32-44) for methamphetamine use, 13% (7-19) for opioid use, 25% (17-34) for injection drug use, and 32% (19-44) for chemsex. INTERPRETATION: This review highlights the disproportionate burden of mental health and substance use challenges among transgender women and transfeminine people living with HIV. Our findings emphasise the crucial need for integrated HIV care models that incorporate routine mental health screening with culturally affirming and trauma-informed interventions. Policies to address structural inequities and to scale up evidence-based strategies to improve mental health and HIV outcomes for this population are also needed. FUNDING: None.

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