The HIV care continuum and determinants of antiretroviral therapy initiation among transgender women in France (1997–2023): a longitudinal cohort study

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Background Studies on transgender women living with HIV (TWH) are scarce in Europe. We aimed to describe TWH and their care continuum during years 1997–2023 in France, focusing on determinants of time to antiretroviral therapy (ART) initiation. Methods In this longitudinal cohort study, we included treatment-naïve TWH with immuno-virological data from the ANRS CO4 French Hospital Database on HIV (FHDH). HIV care continuum outcomes, ART and viral suppression rates, and time intervals between HIV diagnosis, ART initiation, and viral suppression, were analyzed across three calendar periods (1997–2004, 2005–2012, and 2013–2023). Factors associated with time to ART initiation were assessed for each period using Cox models adjusted for age, geographic origin, year and region of enrollment, time between diagnosis and enrollment, and baseline immuno-virological status. Findings 801 TWH entered care between January 1, 1997 and December 31, 2023, mostly originating from Latin America (65%, 522/801), with a median age of 31 years [IQR, 27–36]. Between 1997–2004 and 2013–2023, time to ART initiation after entering care decreased from 3.9 [0–31] to 0.5 [0.2–1.2] months. More advanced HIV disease was associated with faster ART initiation until 2012 (hazard ratio [HR]: 3.17, 95% CI 2.14–4.68 for CD4 <200/mm 3 or AIDS in 2005–2012). In 2013–2023, baseline viral load ≥100,000 was associated with faster ART initiation (HR: 1.45, 95% CI 1.14–1.86), whereas originating from Latin America (HR: 0.68, 95% CI 0.50–0.91) or other countries outside France (HR: 0.65, 95% CI 0.45–0.95) was associated with delayed ART initiation. Time to viral suppression after ART initiation decreased from 6.2 [3.0–27.9] in 1997–2004 to 2.3 [1.1–5.7] months in 2013–2023. Over the same periods, TWH on ART with viral suppression increased from 74.7% (109/146) to 95.5% (315/330). Interpretation Despite major improvements in the HIV care continuum for TWH in France, including faster ART initiation and viral suppression reaching UNAIDS 95% targets in 2013–2023, disparities by geographic origin have emerged, showing a delay in ART initiation among foreign-born TWH. Given that most TWH are foreign-born, targeted strategies and policies are needed to ensure equitable and timely access to HIV care. Funding ANRS-MIE and INSERM.