Background
Despite a global HIV prevalence of nearly 20% among transgender women (TW), some studies have shown that this population often experiences longer time intervals within the continuum of care. This study aims to describe the evolution of these time intervals and analyze the impact of sociodemographic and clinical factors on the time to antiretroviral therapy (ART) initiation after entering care.
Methods
Treatment-naive TW living with HIV1 enrolled between 1997 and 2022 in France in the ANRS CO4 FHDH cohort were included in the analyses. Factors associated with the time to ART initiation after enrollment were analyzed for 1997-2004, 2005-2012, and 2013-2022 using a generalized linear model adjusted for age, geographic origin, time between diagnosis and enrollment, immuno-virological status, and year of enrollment.
Results
Of 104,348 PWH followed in the cohort between 1997-2022, 876 (0.8%) were TW. Most were from Latin America (67.6%), recruited in the Paris region (70.5%) at a median age of 31 (IQR: 27-37), and followed for a median of 9.1 years. (3.8-15.5). Between 1997-2004, 29.5% of TW accessed to care at an advanced stage (CD4 <200/mm³ or AIDS stage), compared to 21.5% in 2013-2022 (p=0.0023). From 1997-2004 to 2013-2022, the median time between HIV diagnosis and access to care decreased from 1.8 months (IQR: 0.3-24.7) to 0.4 months (0.03-4.6) (p<.0001), the time between access to care and ART initiation decreased from 4.4 months (IQR: 0.03-31) to 0.6 months (0.2-1.5) (p<.0001), and the time from ART initiation to achieving a viral load (VL) <200 cp/mL from 4.7 months (IQR: 2.4-15.5) to 1.7 months (1.1-4.4) (p<.0001). At the most recent follow-up, 98.3% were on treatment, and 89% achieved a VL <200 cp/mL. In multivariable analysis, during 1997-2004, advanced stage at access to care (vs early stage) and a VL ≥100,000 cp/mL at enrollment (vs <100,000) were associated with a shorter time to ART initiation (respectively -32.8 and -10.4 months). In 2013-2022, immuno-virological status was not significantly associated with time to ART initiation, but TW from Africa and Latin America had longer time to ART initiation compared to those born in France (+1.8 and +0.8 months, respectively).
Conclusions
Until 2013, time to ARV initiation of TW was mainly influenced by patient’s immuno-virological status at care entry. Since the “treat all” policy, delays have been significantly shortened, but disparities related to geographic origin have persisted beyond 2013, hindering rapid access to treatment.