J Islamabad Med Dental Coll 2022 241
Open Access
Sexually Transmitted Diseases and Associated Risk Factors
Among Transgenders in Peshawar
Muhammad Asif Zeb1, Arsalan Waqas2, Fawad Inayat3, Aman Ullah4, Amir Afzal Khan5, Awal Mir6
1,4,6Lecturer, Institute of Paramedical Sciences, Khyber Medical University, Peshawar.
2MPhil Biochemistry Student, Abdul Wali Khan University, Mardan.
3Lecturer, Allied Health Sciences, Iqra National University, Peshawar.
5Lecturer, Department of Allied Health Sciences, Iqra National University, Peshawar.
A B S T R A C T
Background: Transgenders, male to female, are exceptionally predominant in India-Pakistan, dreaded to be alarming
for sexually transmitted diseases. The objective of this study was to determine the frequency of sexually transmitted
diseases and their associated risk factors among transgenders.
Methodology: This cross-sectional study was conducted amongst transgenders at Institute of Paramedical Sciences
(IPMS), Khyber Medical University Peshawar from January to July,2021. About two ml of venous blood was collected in
a gel tube under aseptic conditions among 100 individuals to check for HBsAg, anti-HCV, HIV and syphilis by ICT rapid
strip method. Positive samples of HBsAg and anti-HCV were confirmed by Polymerase Chain Reaction (PCR), while
positive cases of syphilis were confirmed by Treponema Pallidum Hemagglutination (TPHA). Chi-square test was
applied to determine the association between sexually transmitted disease and associated risk factors.
Results: Out of 100, seven (7%) samples were positive for HBsAg, five (5%) for anti-HCV and nine (9%) were positive
for syphilis while there were no positive cases of HIV. HBV infection was significantly associated with blood
transfusion, a drug injection history and some surgical procedure (p<0.05). For syphilis, the data were significantly
associated with a history of blood transfusion and drug injection (p<0.05).
Conclusion: Frequency of HBV, HCV and syphilis infections are high in transgenders with common associated risk
factors to be sexual activities, drug injection, unsafe blood transfusion and surgical procedures.
Keywords: Chromatography, Hepatitis B surface antigen, Hepatitis C Antibodies, HIV, Syphilis, Transgenders
Authors’ Contribution:
1,2Conception; Literature research;
manuscript design and drafting;3,4Critical
analysis and manuscript review; 5,6Data
analysis; Manuscript Editing.
Correspondence:
Muhammad Asif Zeb
Email: muhammadasif.ipms@kmu.edu.pk
Article info:
Received: October 1, 2021
Accepted: November 9, 2022
Cite this article.Zeb A M, Waqas A, Inayat F, Ullah A, Khan A A, Mir A. Sexually Transmitted
Diseases and Associated Risk Factors Among Transgenders in Peshawar.J Islamabad Med Dental
Coll. 2022;11(4): 241-246.
Funding Source: Nil
Conflict of Interest: Ni
DOI: https://doi.org/10.35787/jimdc.v11i4.794
I n t r o d u c t i o n
Individuals whose gender presentation differs from
their assigned sex at birth are referred to as
transgender. Various identities that fall under the
umbrella of transgender are trans men, trans
women, gender queer, non-binary, sister girl,
brother boy, gender nonconforming, gender fluid
or two-spirited. (1)
Viral hepatitis is a global health issue in which viral
types A, B, C, D, and E are the main pathogenic
agents. In 2013, 1.45 million people died as a result
of hepatotropic viruses, with chronic hepatitis B
O R I G I N A L A R T I C L E
J Islamabad Med Dental Coll 2022 242
and C virus infections accounting for 91 percent of
the deaths. (2) Almost two billion individuals are
infected by HBV worldwide and the number of
chronic carriers is 350 million. Every year, the HBV
virus kills one million people. In Latin America,
400,000 new cases are recorded each year, with 10
to 70% of them progressing to hepatocellular
carcinoma. (3) On the basis of HBV infection
epidemiology, the environment was categorised
into high, middle, and low endemicity zones.
Infection rates of more than 8% are considered
high, 2–8% are considered intermediate, and less
than 2% are considered low endemicity zones.
Pakistan is one of the countries with the highest
rates of chronic viral hepatitis infection in the
world. (4)
Hepatitis C virus (HCV)-related liver disease is a
serious public health concern that affects millions
of individuals around the world. (5) HCV infection is
spread mostly by contact with contaminated
devices and tools, haemodialysis, infected blood or
blood products, IV medication misuse and organ
donation. (6) The prevalence of HCV infection in
transgender men was 8.0% and 3.7% in transgender
women. (7)
The World Health Organization (WHO) Predicted in
2015 that by 2030, viral hepatitis incidence and
mortality would be reduced by 90% and 65%,
respectively. However, in order to offer current
prevalence/incidence figures, this global goal will
necessitate regional Studies (8)
Despite on-going attempts to manage HIV
outbreaks, in 2019 a total of 1.7 million new HIV
infections occurred, with Sub-Saharan Africa having
the highest disease burden. With almost 35 million
deaths and counting, HIV continues to be a serious
hazard to public health, and in 2016, there were
still over 2 million infected individuals. (9)
The frequency of HIV for transgender women was
17.7% according to a meta-analysis of ten middle
and low-income countries. (10) In Indonesia, among
1,150 transgender women who were frequently
involved in sexual activities, 26.8% had syphilis,
24.4% HIV and 47% rectal sexually transmitted
infections. (11)
In Indo-Pak regions, transgender individuals are
intensely demoralized as they are considered a
major social taboo in society, therefore, they live in
isolated communities. Transgenders usually
undergo unsafe sexual activities due to lack of
education. This study was conducted to determine
the frequency of sexually transmitted diseases and
their associated risk factors among transgenders in
Peshawar that may help in devising strategies to
create health awareness among this group.
M e t h o d o l o g y
This cross-sectional study was conducted in
Peshawar among transgenders from Jan 2021 to
July 2021 at Institute of Paramedical Sciences
(IPMS), Khyber Medical University. The study was
approved by the undergraduate ethical committee
of IPMS. A self-designed questionnaire was used for
the risk assessment, based on previous literature.
One hundred participants were included in this
study, selected through convenience sampling
technique. According to the census 2017, the total
transgender population in K.P.K is 913 and the total
population of transgenders in Peshawar is 292.
Using the Raosoft sample size calculator, the
estimated sample size was 167 with confidence
interval of 95% and margin error 5% but many
refused to participate in the study with only 100
willing participants. Transgenders between 18 to 50
years of age were included while those who had
chronic liver disease were excluded from the study.
Informed consent was taken from all individuals.
About two ml of venous blood was collected in a
gel tube under aseptic conditions and centrifuged
at 2500 rpm for 10 minutes to procure the serum.
For screening of HBV, HCV, HIV and syphilis,
Immune chromatography technique (ICT) was used.
All positive samples were confirmed by Polymerase
Chain Reaction (PCR) and Treponema Pallidum
Hemagglutination (TPHA) techniques. The data
J Islamabad Med Dental Coll 2022 243
were analysed using SPSS v22.0. For descriptive
statistics, the frequencies were calculated and
presented in tabulated form. For categorical
variables, Fisher’s exact test was applied to
determine the association with risk factors.
R e s u l t s
Out of 100, seven (7%) were positive for HBV, five
(5%) for HCV infection, and no positive case for HIV
was reported. Nine (9%) individuals had syphilis
infection. The frequency of HBV, HCV, HIV and
Syphilis within their associated risk factors was also
determined such as the previous history of blood
transfusion, drug injection history, sexual behavior,
surgical procedures, family history and organ
piercing for jewelry. HBV and syphilis infections
were frequent among transgenders having a blood
transfusion, drug injecting history, sexual
behaviors, having surgical procedures and organ
piercing for jewelry purposes, while HCV infection
was common in transgenders involved in sexual
activities and organ piercing for jewelry purposes
(Table 1)
Table I: Frequency of HBV, HCV, HIV and Syphilis with Associated Risk Factors Among Transgenders
R
isk
F
a
cto
rs
P
a
ra
m
e
te
r
F
re
q
u
e
n
cy
(%
)
Hepatitis B
Status
Hepatitis C
Status
Syphilis Status
H
IV
S
ta
tu
s
P
o
sitiv
e
(%
)
N
e
g
a
tiv
e
(%
)
P
v
a
lu
e
P
o
sitiv
e
(%
)
N
e
g
a
tiv
e
(%
)
P
v
a
lu
e
P
o
sitiv
e
(%
)
N
e
g
a
tiv
e
(%
)
P
value
Blood
transfusion
Yes 33
(33)
5(5) 28(28) 0.0377 2(2) 31(31) 0.99 6(6) 27(27)
0
.0
5
5
N
o
n
e
o
f
th
e
P
a
rt
ic
ip
a
n
ts
w
a
s
d
ia
g
n
o
se
d
w
it
h
t
h
e
H
IV
I
n
fe
ct
io
n
No 67(67) 2(2) 65(65) 3(3) 64(64) 3(3) 64(64)
Drug
injection
Yes 41(41) 6(6) 35(35) 0.018 2(2) 39(39) 0.99 7(7) 34(34
%)
0.055
No 59(59) 1(1)
58(58)
3(3) 56(56) 2(2) 57(57)
Sex
Behaviour
Yes 79(79) 4(4) 75(75) 0.15 4(4 ) 75(75) 0.99 7(7) 72(72) 0.17
No 21(21) 3(3) 18(18) 1(1 ) 20(20) 2(2) 19(19)
Surgical
Procedure
Yes 17(17) 5(5) 12(12) 0.0014 1(1 ) 16(16) 0.99 3(3) 14(14) 0.99
No 83(83) 2(2) 81(81) 4(4 ) 79(79) 6(6) 77(77)
Family
History
Yes 12(12) 2(2) 10(10) 0.197 2(2 ) 10(10) 0.108
0
2(2) 10(10) 0.151
No 88(88) 5(5) 83(8) 3(3 ) 85(85) 4(4) 84(84)
Organ
piercing (for
jewellery
purpose)
Yes 48(48) 4(4) 44(44) 0.7075 3(3 ) 45(45) 0.66 6(6) 4(42) 0.30
NO 52(52) 3(3) 49(49) 2(2 ) 50(50) 3(3) 49(49)
An association was established between HBV
infection and risk factors. There was statistically
significant association between HBV and associated
risk factors such as blood transfusion (p=0.03), drug
injected history (p=0.01) and surgical procedure
(p=0.00), while insignificant association with family
history, sexual behaviors and organ piercing with p-
value > 0.05. In case of HCV, there was no
significant association with any parameter (p>0.05).
(Table 1)
J Islamabad Med Dental Coll 2022 244
Two individuals had both HBV and HCV infection,
while three individuals had both HBV and syphilis
infection. Three individuals had HCV and syphilis,
while one individual had HBV, HCV and syphilis.
D i s c u s s i o n
In this study, we determined the frequency of HBV,
HCV, HIV and syphilis and their associated risk
factors among transgenders. According to this
study, 7% of transgenders were found to have
hepatitis B infection, 5% HCV, while positive cases
of HIV were not reported. The frequency of syphilis
was 9%, which was highest among others.
The current study revealed that 33% of
transgenders were having previous history of blood
transfusion, out of which 5% were positive for HBV,
2% for HCV and 6% had syphilis, while 67% had no
history of blood transfusion. Blood transfusion is a
common transmission route for HBV, HCV, syphilis
and blood parasites because of inappropriate blood
screening facilities in Pakistan. (12) In Pakistan,
3.27% of donors were found to be infected with
transmissible transfusion infection leading to
infection in patients during transfusion. (13) In the
present study, 79% of the transgenders had a
sexual history with one or multiple sex partners.
Among them, 4% were diagnosed with hepatitis B
and C, while 75% were negative for both hepatitis B
and C. Transgenders involved in sexual activities
have the highest frequency of syphilis that is 7%.
Because of social discrimination and stigma,
transgender individuals are deprived of higher
education or initial compulsory education, leading
to poor literacy and hence live in isolated societies.
It is hard for them to get jobs in societies that
indulge them to be involved in sexual activities for
accomplishing their daily necessities. (14) In addition
unprotected sexual relationship with partners may
increase the risk of transmission of hepatitis B and
C. (15)
In a study conducted in Rawalpindi, it was reported
that the prevalence of HBV and HCV among
transgender people was 2.94% and 25.5%
respectively. In this study, majority of the
transgenders were involved in sexual activities with
one or multiple partners. (16) Our results differed
from this study because of the small sample size
and geographical difference. In another study, it
was reported that most transgender people were
aware that using a condom during sex with their
partners (17) could be another reason of reducing
the prevalence of HBV, HCV and syphilis in
Peshawar.
The current study reported that needle exchange
for drug injection is another risk factor among
transgenders. Among drug addicts, the frequency
of HBV, HCV, and syphilis were 6%, 2%, and 7%,
respectively. According to Awan et al, it was
reported that exchanging needles for drug injection
is a risk factor for transmitting viral hepatitis,
syphilis and HIV infections. (13) A study conducted in
Sindh reported that using unsterilized syringe is a
risk factor for transmitting HBV and HCV infections.
(18) Another study from Pakistan reported that
majority of the transgenders were involved in
sharing drug injection needle with one another. (19)
Needle sharing is most common cause of
transmitting infection among transgenders. (20)
Hence needle sharing for drug use is a risk factor
among transgenders for transmitting HBV, HCV,
syphilis and HIV infections.
In this study, another significant risk factor among
transgender was organ piercing (ear, nose, and
J Islamabad Med Dental Coll 2022 245
tattoos) for jewelry purposes. Transgender people
with a history of organ piercing were 48%, while
52% had no history. Among 48% individuals, 4%
were HBV positive, 2% HCV positive and 6%
syphilis. Transgenders live in a community where
they love to dress in female clothing and wear
pieces of jewelry. For this purpose, they are
piercing the ear, nose and make tattoos on various
parts of the body using shared instruments/needles
leading to a rise in HBV, HCV and other
transmissible diseases. (21)
The strength of this study is that it is the first study
conducted in Peshawar to determine the frequency
of sexually transmitted diseases (HBV, HCV, HIV,
syphilis) and their associated risk factors among
transgender individuals. Positive cases were
confirmed using a gold standard method. However,
this study has a few limitations. First, this study has
a small sample size as most of the transgenders
were reluctant to participate in this study. Second,
the ICT method was used for screening the
transgender population due to limited resources.
C o n c l u s i o n
Frequency of syphilis is highest, followed by
Hepatitis B and C in the transgender community in
Peshawar. The common associated risk factors are
unsafe blood transfusion, exchange of needles for
drugs, sexual behavior and organ piercing. An
appropriate screening program is essential for
transgender individuals to prevent sexually
transmitted infections.
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