30 years of HIV care continuum among transgender women

A key population in the HIV care pathway

Transgender women are a key population in the context of the global HIV epidemic. HIV prevalence in this population is particularly high, estimated at 20% worldwide and 7% in Europe. Most studies of their care pathways are cross-sectional and conducted in North America. A longitudinal approach, which involves following the same population over an extended period rather than at a single point in time, is essential for accurately assessing changes in HIV care.

A Study of the continuum of care with the ANRS CO4-FHDH Cohort

Only one longitudinal study had previously been conducted in Europe, but the time intervals and determinants associated with the initiation of antiretroviral therapy (ART) had not been investigated. Using longitudinal data from the ANRS CO4-FHDH cohort, researchers from Inserm, Sorbonne University and hospitals examined the care continuum of 801 transgender women in French hospitals over a period of 27 years (1997–2023), encompassing the pathway from diagnosis to entry into care, treatment initiation and achieving an undetectable viral load, synonymous with viral suppression.

Progress, but disparities linked to geographical origin

One of the main contributions of this study is its detailed analysis of the time intervals throughout the care pathway of transgender women living with HIV. The study showed improvements in care, with the delay in ART initiation falling from four months to 15 days between 1997–2004 and 2013–2023. This is likely explained by the “treat all” policy introduced in 2013, which recommends initiating treatment as soon as HIV is diagnosed, regardless of the stage of infection. The median time between treatment initiation and achieving viral suppression also decreased, from six months to around two months. At the same time, the proportion of transgender women living with HIV who were on ART and had viral suppression increased from 74.7% to 95.5%, reaching the viral suppression target set by UNAIDS.

The findings also revealed changes in the determinants associated with ART initiation. Until 2012, the time to treatment initiation depended mainly on the stage of infection. Following the introduction of the “treat all” policy in 2013, disparities linked to geographical origin were identified. Most participants (65%) were born in Latin America. However, transgender women born abroad are 32 to 35% less likely to initiate treatment promptly than those born in France.

Areas for improvement and future prospects

This delay could be explained in particular by administrative procedures and barriers to accessing state medical aid (AME), housing or a residence permit, which delay actual entry into care. The authors consider it essential to remove these administrative barriers, particularly those affecting access to AME, to ensure immediate and equitable access to treatment for migrants.

In the future, the widespread use of long-acting injectable antiretroviral therapy could mark a new turning point in the care of people living with HIV by facilitating adherence, particularly for key populations such as transgender women. However, its rollout will need to be accompanied by vigilance regarding the risks of loss to follow-up.

Reference

Juliette Hemery, ^a Pierre Tattevin, ^b Esaïe Marshall, ^a Margot Annequin, ^c Thibault Chiarabini, ^d Nathalie Dournon, ^e,f,g Anaenza Freire Maresca, ^h,i Jade Ghosn, ^j,k Valentina Isernia, ^j Florence Michard, ^j Segolene Perrineau, ^f,m Giovanna Rincon, ^l Elisabeth Rouveix, ^f,m Bruno Spire, ^c Pierre de Truchis, ^e,g,m and Sophie Grabar ^a,d. The HIV care continuum and determinants of antiretroviral therapy initiation among transgender women in France (1997–2023): a longitudinal cohort study. The Lancet Regional Health – Europe 2026;69: 101820.

^a Institut Pierre Louis d’Epidémiologie et de Santé Publique**, Inserm, Sorbonne Université, Paris, France ; ^b Service des Maladies Infectieuses et Emergentes, Hôpital Pontchaillou, Rennes, France ; ^c Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, Aix Marseille Univ, Marseille, France ;  ^d AP-HP, Hôpital Saint-Antoine, Paris, France ; ^e AP-HP, Hôpital Raymond Poincaré, Paris, France ; ^f AP-HP, Hôpital Ambroise Paré, Paris, France ; ^g UFR Santé Simone Veil, Université Paris Saclay, Garches, France ; ^h AP-HP, SMIT, Hôpital Avicenne, Bobigny, France ; ⁱ AP-HP, CSAPA, Hôpital Fernand Widal, Paris, France ; ^j AP-HP, SMIT, Hôpital Bichat, Paris, France ; ^k Université Paris Cité, Inserm, IAME, Paris, France ; ^l Association Acceptess-T, Paris, France ; ^m COREVIH Ile de France Ouest, France. 

** Since July 2026, the Institut Pierre Louis d’Epidémiologie et de Santé Publique has become the Sorbonne Public Health Institute.

Press contact

ANRS MIE: presse@anrs.fr