3D illustration of VIH virus. © AdobeStock

HIV prevalence is very high among transgender women. Yet longitudinal studies focusing on this community remain rare in Europe. Most studies are cross-sectional and conducted in North America. A team of researchers from Inserm, Sorbonne University and hospitals assessed the HIV care continuum among transgender women over three decades using longitudinal data from the ANRS CO4-FHDH cohort*. This is the first study in Europe to comprehensively examine the time intervals between key stages of the care pathway, as well as the determinants associated with the initiation of antiretroviral therapy. Despite substantial progress in the care pathway, disparities linked to geographical origin have emerged. The findings of this study, funded by ANRS MIE and Inserm, were published in the October 2026 issue of The Lancet Regional Health – Europe.

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.

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.

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. 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.

“Transgender women face intersecting social and structural barriers, particularly those who are migrants, which hinder equitable access to HIV care. Our findings and those of other studies such as Trans&VIH highlight the need for structural, healthcare and community interventions to overcome these barriers.” (Juliette Hemery)

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.

*The ANRS CO4-FHDH cohort receives support from ANRS MIE, Inserm and the French Ministry of Health.