HIV prevention service disruption among transgender adults in the context of 2025 federal executive orders in the United States: a cross-sectional multi-state study.

BACKGROUND

In early 2025, the United States (U.S.) federal government issued several executive orders restricting healthcare access and non-discrimination protections for transgender and nonbinary (trans) populations. The current study investigated correlates of HIV prevention service disruptions among trans adults across five U.S. states.

METHODS

We analysed cross-sectional survey data of trans adults (Feb-April 2025) from the Priority Assessment in Trans Health Across States (PATHS2). This multi-state survey was conducted in five varying policy environments (Connecticut, Georgia, New York, Utah, and Washington). Analyses were restricted to participants currently using HIV prevention services, including PrEP (oral or long-acting) or HIV testing in the prior 12 months (N = 693). Main outcomes were (a) any HIV prevention service disruption (delayed or denied HIV prevention medications (PrEP: oral or long-acting), lost insurance or financial assistance coverage, reduced service availability, increased healthcare stigma) and (b) disruption breadth, modelled as ordinal (none/some [1-2 types]/significant [≥3 types]). Multivariable and ordinal logistic regressions assessed correlates across sociodemographic, psychosocial, and policy-related factors.

FINDINGS: Nearly two-thirds (64·5%, n = 447/693) of participants reported having experienced HIV prevention disruption; among this group. Among those reporting any disruption (n = 447), the most common disruption types included delayed/denied medications (53·2%, n = 238), reduced HIV service availability (50·3%, n = 225), lost coverage (40·9%, n = 183), and increased healthcare stigma (29·3%, n = 131). Compared with trans men, trans women had significantly higher odds of any disruption (aOR = 2·69, 95% CI 1·50-4·81) and greater disruption breadth (aOR = 1·85, 95% CI 1·16-2·93). Nonbinary individuals had elevated odds across all disruption types (aORs range = 2·99-6·58). Past-year discrimination was the strongest correlate of any disruption (aOR = 16·5, 95% CI 9·08-30·07) and breadth (aOR = 9·68, 95% CI 6·26-14·99). Black/African American participants had higher odds of any disruption compared with White participants (aOR = 2·17, 95% CI 1·06-4·46). State policy environment was not significantly associated with disruption in adjusted models.

INTERPRETATION: Past-year discrimination was the dominant correlate of disruption. State-level protective policies did not independently buffer against disruption in this short post-issuance window, suggesting that a federal policy shock of this magnitude may have exceeded the buffering capacity of state-level protections. Targeted, actionable responses, such as sustained funding for Black-trans-led community health organisations as trusted PrEP access points, anti-discrimination enforcement in healthcare, navigation services to maintain continuity of PrEP and prescription assistance during coverage instability, and insurance marketplace protections (e.g., Affordable Care Act) and programs (e.g., Medicaid, Ryan White) that explicitly prohibit gender-identity-based denials of HIV prevention coverage, are urgently needed.

FUNDING: The Royalty Research Fund at the University of Washington.