At the Conference on Retroviruses and Opportunistic Infections (CROI 2026) held in Denver last week, Dr Sari Reisner from the University of Michigan presented data on how many transgender women in a national US cohort acquired HIV over a two-year period, and the factors associated with getting HIV.
“Our study found that HIV incidence remains high among trans women in the US and that disparities persist across race and ethnicity, with highest HIV incidence for Black, Latina and Asian trans women,” Reisner stated.
Globally, transgender women are one of the most vulnerable groups when it comes to acquiring HIV. However, gauging how many new trans women acquire HIV in any given population over a specific period can be challenging, as they have to be followed over time.
In the US, trans women were previously prioritised in the National HIV/AIDS Strategy for 2022 to 2025. However, decisions by the current administration have threatened the rights of trans people. Gender has been mistakenly reduced to biological sex, which is deemed to have two categories. This means that collecting data pertaining to gender identity has become challenging and will pose major obstacles for future research. Beyond data collection, there are numerous structural barriers to HIV prevention and care for trans people living in the US.
The study
The Enhanced Cohort Methods for HIV Research and Epidemiology (ENCORE) cohort collects data on adult trans women (and other people assigned male at birth who do not identify as men) from nine hubs in the US, including one in Puerto Rico, and online. While the digital cohort forms the backbone of the study, the hubs are strategically located in cities like Atlanta for increased engagement and in-person support. Participants were recruited in 2023 and 2024; they completed surveys and tested for HIV every six months for two years.
In total, 2504 trans women participated, mostly online (64%). All four US census regions were represented, with a third of participants from the South. The median age was 32, with most women aged 25 or older (81%). Most were White (78%), with fewer Black (12%) and Asian (5%) participants; 16% overall identified as Latina.
Just under half of participants had public or no health insurance (49%). In terms of other social determinants of health, 30% of the sample reported poverty, 10% engaged in sex work in the previous six months, and 9% were unhoused over that same period. Most participants (72%) had experienced violence in their lifetime, with just over a quarter reporting violence in the prior six months (26%). Nearly half the sample had four or more adverse childhood experiences such as neglect or abuse (48%).
In the previous six months, some participants reported psychological distress (40%), hazardous alcohol use (27%) and use of stimulants such as cocaine and crystal methamphetamine (11%).
The rate of self-reported STIs was low, at 4%, while just over a third of the sample had had sex with a cisgender man in the prior six months (34%).
In the previous six months, 16% of trans women were eligible for PrEP. This was based on both the US Centers for Disease Control and Prevention’s eligibility criteria and trans-specific risk factors, such as sharing needles for silicone injection. In the same time period, 18% took PrEP. Most took oral PrEP (94%), while around 4% took long-acting injectable PrEP and 2% used a combination of these methods.
High HIV incidence, particularly among Black trans women
There was a total of 39 new HIV diagnoses in the cohort: 25 at baseline and 14 during the follow-up period. This translated into an HIV incidence rate of 3.95 per 1000 person-years (95% Confidence Interval 2.2-6.6; all incidence rates below follow the same format).
While HIV incidence was similar by age group – younger vs older – there were many other stark disparities. Black trans women had a much higher incidence at 15.5 (95% CI 6.2-31.8) when compared to White trans women at 1.4 (95% CI 0.4-3.7). For Asian trans women, incidence was 5.7 (95% CI 0.1-31.6). In terms of ethnicity, Latina trans women had an incidence of 7.5 (95% CI 2-19.1) compared to 3.3 for non-Latina women (95% CI 1.6-6.1).
There were regional disparities too, with the Northeast having the highest incidence at 8.9 (95% CI 3.26-19.3). This was followed by the South at 4.1 (95% CI 1.3-9.6).
HIV incidence strongly linked to structural and healthcare access factors
Structural vulnerabilities and social determinants of health shaped HIV incidence for trans women. For instance, trans women who were unhoused in the six months prior were at a four times higher risk of acquiring HIV than those who were housed. This rose to a five times higher risk associated with sex work, and a six times higher risk for poverty. Those with public or no health insurance were at a nearly 14 times higher risk that those with private insurance. However, factors such as violence and childhood trauma were not associated with HIV incidence.
In terms of behaviour, trans women who used stimulants had over six times the risk of acquiring HIV than those who did not.
Trans women who were eligible for PrEP had nearly ten times the HIV incidence than those who did not. Trans women who reported an STI in the prior six months and those who had had sex with a cisgender man also had a higher risk. However, those who reported PrEP use were also found to have a higher risk of contracting HIV than those who did not. This likely reflects PrEP-related challenges, such consistent access to oral PrEP, leading to inadequate adherence.
“The association of PrEP uptake with HIV seroconversion – and low prevalence of long-acting injectable PrEP in the sample – suggests opportunities for scale-up of long-acting injectable PrEP in this study population,” Reisner noted.
“Trans women need tailored interventions that are gender-affirming, that are safe – particularly in the current moment in time,” Reisner concluded. “Continued gender inclusive research is vital, especially as we have erasure of the population from our federally funded datasets, to be able to see and monitor disparities and what’s working.”
References
Reisner S et al. HIV Incidence in a Nationwide Cohort of Transgender Women in the United States and Puerto Rico. Conference on Retroviruses and Opportunistic Infections, Denver, abstract 192, 2026.
