Undiagnosed HIV among transgender women in the United States: Implications for testing programs.

Introduction: Transgender women experience healthcare barriers which can impede HIV status awareness, increasing the risk of delayed diagnosis. We sought to characterize undiagnosed HIV among transgender women in the US.

Methods: We used data from a hybrid cohort utilizing digital and in-person strategies for transgender women in the US who are not living with HIV. Assessments include a sociobehavioral questionnaire and HIV testing. Using baseline screening data, we identified undiagnosed HIV among transgender women who self-reported no HIV testing history or a negative result at last test. Bivariate and multivariable Firth-penalized logistic regression models were fit to assess correlates of undiagnosed HIV.

Results: A total of 2549 participants completed HIV testing. Forty-three participants tested positive, 15 of whom disclosed during post-test counseling they had been previously diagnosed and were excluded from this sample. Of the 2534 with no previous HIV diagnosis, 28 (1.1%) were estimated to have undiagnosed HIV at baseline. Correlates of undiagnosed HIV included identifying as a person of color (aOR=4.8; 95%CI=2.1-11.1) and past 6-month stimulant use (aOR=2.8; 95%CI:1.2-6.4). Among transgender women of color, correlates of undiagnosed HIV were past 6-month stimulant use (OR=2.5; 95%CI=0.9-6.7), no lifetime HIV testing history (OR=3.1; 95%CI=1.2-8.0), and no insurance (OR=4.5; 95%CI=1.0-20.5) or public health insurance (OR=4.4; 95%CI=1.1-17.1) vs. private insurance.

Conclusions: Undiagnosed HIV among transgender women is concerning and disproportionately affects transgender women of color. Addressing stimulant use is important for HIV prevention. Findings underscore the urgent need for free, accessible HIV testing with linkage to HIV prevention and care to achieve HIV strategy goals.