Social determinants of HIV status and viral load suppression among transgender women in South Africa: a cross-sectional analysis

Transgender women in South Africa face a heavy HIV burden, but data on key psychosocial and structural factors remain limited. This cross-sectional study examined associations between HIV outcomes and psychosocial (substance use, alcohol use, medical distrust, community connectedness) and structural (education, homelessness, income, sex work, violence) factors. We conducted interviewer-administered surveys with 213 transgender women in Cape Town, Johannesburg, and East London between June and November 2018. Of the 213 participants, 196 knew their HIV status and 67 reported living with HIV. Multivariable logistic regression found homelessness (aOR 4.50 [95%CI: 1.67, 12.23]), sex work (aOR 5.90 [95%CI: 2.14, 16.29]), and earning above the poverty level (aOR 3.08 [95%CI: 1.37, 6.94]) were significantly associated with living with HIV. Among participants with HIV, sex work (aOR 13.39 [95%CI: 1.17, 153.67]) was the only significant predictor of viral suppression. South Africa's provision of financial support specifically for PHIV may account for associations between income and HIV; while South Africa's sex-worker specific clinics, tailored to this population's needs, may account for their higher viral suppression. Study findings highlight the importance of context-specific HIV research with key populations to identify locally relevant strategies to improve HIV outcomes.