Characterizing the Human Immunodeficiency Virus Care Continuum Among Transgender Women and Cisgender Women and Men in Clinical Care: A Retrospective Time-series Analysis

Abstract

Background: Prior studies suggest that transgender women (TW) with human immunodeficiency virus (HIV) are less likely to be virally suppressed than cisgender women (CW) and cisgender men (CM). However, prior data are limited by small sample sizes and cross-sectional designs. We sought to characterize the HIV care continuum comparing TW to CW and CM in the United States and Canada.

Methods: We analyzed annual HIV care continuum outcomes by gender status from January 2001 through December 2015 among adults (aged ≥18 years) in 15 clinical cohorts. Outcomes were retention in care and viral suppression.

Results: The study population included TW (n = 396), CW (n = 14 094), and CM (n = 101 667). TW had lower proportions retained in care than CW and CM (P < .01). Estimates of retention in care were consistently lower in TW, with little change over time within each group. TW and CW had similar proportions virally suppressed over time (TW, 36% in 2001 and 80% in 2015; CW, 35% in 2001 and 83% in 2015) and were lower than CM (41% in 2001 and 87% in 2015). These differences did not reach statistical significance after adjusting for age, race, HIV risk group, and cohort.

Conclusions: TW experience challenges with retention in HIV care. However, TW who are engaged in care achieve viral suppression that is comparable to that of CW and CM of similar age, race, and HIV risk group. Further research is needed to understand care engagement disparities.

Keywords: HIV continuum of care; HIV viral suppression; retention in care; transgender women.

Figure 1.

Proportion retained in care, by gender status, North American AIDS Cohort Collaboration on Research and Design, 2001–2015. Retention in care was defined according to the United States Health Services Resources Administration. The P values for trends in the outcomes over a calendar year were estimated using a log-binomial model with generalized estimating equations (GEE) and a continuous variable for calendar year, which tests the null hypothesis that there is no difference in the outcome over time and allows for repeated measurements from individuals. The P value for interaction of time and gender status was estimated using a nested model approach that allowed us to compare the fit statistics for models with and without the interaction terms using log-binomial regression models with GEE.

Figure 2.

Proportion with human immunodeficiency virus (HIV) RNA suppression (≤200 copies/mL), by gender status, North American AIDS Cohort Collaboration on Research and Design, 2001–2015. The last HIV RNA measurement was used if there were multiple measurements in a year for an individual. The P values for trends in the outcomes over a calendar year were estimated using a log-binomial model with generalized estimating equations (GEE) and a continuous variable for calendar year, which tests the null hypothesis that there is no difference in the outcome over time and allows for repeated measurements from individuals. The P value for interaction of time and gender status was estimated using a nested model approach that allowed us to compare the fit statistics for models with and without the interaction terms using log-binomial regression models with GEE.