HIV seropositivity and viral non-suppression in transgender, non-binary, and gender-diverse people in primary care receiving gender-affirming hormone therapy in the USA between 2013 and 2019 (LEGACY): an observational, longitudinal, cohort study.

BACKGROUND

Gender-affirming hormone therapy is medically necessary for many transgender, non-binary, and gender-diverse (trans) individuals and might improve HIV clinical outcomes for trans people. This study evaluated gender-affirming hormone therapy delivered in primary care as an intervention to improve HIV outcomes for trans adults in the USA.

METHODS

LEGACY is a longitudinal cohort of trans adult participants receiving primary care at two US federally qualified health centres: Fenway Health (Boston, MA, USA) and Callen-Lorde Community Health Center (New York, NY, USA). Eligibility criteria were age at least 18 years, gender identity differing from assigned sex at birth, past 12-month medical visit, and signed consent with no research exclusion documented in electronic health record data. Eligible participants contributed electronic health data from 2013 to 2019. The exposure was gender-affirming hormone therapy prescription. Clinical outcomes were HIV seropositivity (all participants) and viral non-suppression (participants with HIV; ≥200 copies per mL) in the past 12 months. Log-Poisson generalised estimating equations assessed the longitudinal association of gender-affirming hormone therapy prescription (puberty blockers, anti-androgens, oestrogens, progesterone, and testosterone) with outcomes, adjusting for individual-level confounders.

FINDINGS: Among the 8109 trans participants in 2019, median age was 29 years (IQR 24-37). 2960 (36·5%) were transgender women, 2541 (31·3%) were transgender men, 1507 (18·6%) were non-binary, and 1101 (13·6%) were another trans identity. 4446 (54·8%) were White, 1323 (16·3%) were Black or African American, 498 (6·1%) were multiracial, and 1663 (20·5%) were Hispanic or Latinx. 2736 (33·7%) of 8109 participants were publicly insured and 451 (5·6%) participants were uninsured. In 2013, 2549 (85·5%) of 2983 participants were prescribed gender-affirming hormone therapy, 272 (9·1%) of 2983 participants were HIV seropositive, and 61 (22·4%) of 272 participants were not virally suppressed. In 2019, 7252 (89·4%) of 8109 participants were prescribed gender-affirming hormone therapy, 560 (6·9%) of 8109 participants were HIV seropositive, and 88 (15·7%) of 560 participants were not virally suppressed. Gender-affirming hormone therapy prescription was associated with reduced rates of HIV seropositivity (adjusted risk ratio [RR] 0·63, 95% CI 0·56-0·70) and viral non-suppression (adjusted RR 0·56, 95% CI 0·45-0·69) across follow-up.

INTERPRETATION: Gender-affirming care is important for optimising HIV outcomes among trans people. Our results underscore the vital role of gender-affirming models of care and access to gender-affirming hormone therapy for trans people.

FUNDING: Patient-Centered Research Outcomes Institute and the National Institutes of Health.