Transgender women are less likely to start and stay connected to HIV care than cisgender (non-trans) women and men, but if they do, they are about equally likely to achieve viral suppression on antiretroviral therapy, according to a recent study.

Over the course of the epidemic, finding good data about HIV among transgender people has been difficult, in part because trans people have often either been excluded from research or classified according to their gender designation at birth (for example, trans women classified with “men who have sex with men”). Nonetheless, experts estimate that around one in five transgender people in the United States are living with HIV, with trans women accounting for most of these cases.

Numerous prior studies have shown that trans women have worse health outcomes than cisgender women and men, which is related to a host of factors ranging from poverty and stigma to lack of insurance and poor treatment by the health care system. Trans women have one of the highest rates of new HIV infections, and some research has found that trans women living with HIV are less likely to receive care and to achieve viral suppression. One study, for example, found that a majority of HIV-positive trans women were diagnosed with AIDS within three months of their HIV diagnosis, indicating delayed testing and engagement in care. But these studies have generally been small and observed participants only at a single point in time.

As described in a report in Clinical Infectious Diseases, Tonia Poteat, PhD, MPH, of the University of North Carolina at Chapel Hill, and colleagues therefore sought to characterize the HIV care continuum over time, comparing trans women, cisgender women and cisgender men between January 2001 and December 2015. The continuum of care refers to the successive steps from HIV testing and diagnosis to linkage to care to antiretroviral treatment initiation to achieving an undetectable viral load.

This retrospective analysis looked at medical records from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), the largest ongoing cohort study of people with HIV in the United States and Canada. Among the more than 20 cohorts that make up NA-ACCORD, 15 cohorts were able to contribute data on transgender participants; this group was dubbed the North American Transgender Cohort Collaboration, or NA-TRACC.

Altogether, the study population included 396 trans women, 14,094cisgender women and 101,667cisgender men.Transgender women included participants who were assigned male at birth and self-identified as women, had a reported diagnosis of genderdysphoria, were taking feminizing hormones or were identified as women by providers in medical records. The present analysis did not include the 38 trans men or two intersex people identified in the study population.

The trans women were younger, on average, than cisgender women and men (median ages 36, 40 and 44, respectively). By race/ethnicity, 40% of trans women were Black—the group with the highest HIV incidence—as were 56% of cisgender women and 36% of cisgender men. Trans women were more than twice as likely to be Latinx than cisgender women and men (21%, 7% and 9%, respectively). Just 8% of the trans women reported injection drug use, compared with about 20% of the cisgender women and men.

Poteat’s team found that a smaller proportion of trans women were retained in HIV care compared with either cisgender women or cisgender men. What’s more, trans women’s retention in care was consistently lower and did not change much over time.

However, among those who did stay in care, a similar proportion of trans women and cisgender women achieved viral suppression. All three groups showed substantial improvement in viral suppression over time. In 2015, 80% of trans women in care had undetectable virus, up from just 36% in 2001. Among cisgender women, the proportion rose from 35% in 2001 to 83% in 2015.

A higher proportion of cisgender men had viral suppression at both time points, though the magnitude of the increase was similar, rising from 41% to 87%. After adjusting for confounding factors, including age, race/ethnicity and HIV risk category, the differences between the groups were not statistically significant, meaning they could have been driven by chance.

“Transgender women experience challenges with retention in HIV care,” the study authors concluded. “However, transgender women who are engaged in care achieve viral suppression comparable to cisgender women and cisgender men of similar age, race and HIV risk group.”

These findings highlight the importance of better understanding the disparities in access to care between trans women and cisgender people and developing tailored programs to address these inequities.

“Transgender-specific barriers to engagement in care include fear of disclosure of transgender identity, poor treatment by staff, such as using the inappropriate name or pronoun, and provider lack of knowledge about transgender health,” the researchers wrote.

Some research suggests that trans women who receive both HIV care and gender-affirming care, such as hormones, from the same provider are more likely to be retained in care.

“Emerging data support that transgender women frequently prioritize gender-affirming care over other health issues, and meeting the gender-affirmation needs of transgender women living with HIV may be an effective way to improve care engagement,” Poteat’s team suggested.

Click here to read the study abstract.

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