Gender-Affirming Hormone Therapy Linked to Improved HIV Outcomes in Transgender Populations
A large, longitudinal study1 published in Lancet HIV, found that gender-affirming hormone therapy (GAHT), when delivered as part of primary care, is associated with significantly better HIV-related health outcomes among transgender, non-binary, and gender-diverse adults in the United States.
The researchers, led by Sari L. Reisner, ScD, associate professor at the University of Michigan School of Public Health, analyzed electronic health records from more than 8000 transgender individuals who received care between 2013 and 2019 at two federally qualified health centers: Fenway Health in Boston and Callen-Lorde Community Health Center in New York City.
The observational study, known as the LEGACY cohort, included adults aged 18 or older whose gender identity differed from their sex assigned at birth. All participants had received at least one medical visit in the prior year and provided consent to share their health data. Researchers assessed two primary outcomes: HIV seropositivity among all participants and viral non-suppression—defined as ≥ 200 copies/mL—among participants living with HIV. The primary exposure of interest was the prescription of gender-affirming hormone therapy, which included puberty blockers, anti-androgens, estrogens, progesterone, and testosterone. Using log-Poisson generalized estimating equations, the study adjusted for individual-level confounders including age, race and ethnicity, insurance status, and duration of care engagement.
During the 6-year study period, the proportion of participants receiving hormone therapy increased from 85.5% in 2013 to 89.4% in 2019. During the same time, HIV seropositivity among the cohort declined from 9.1% to 6.9%, and the proportion of individuals with HIV who were not virally suppressed dropped from 22.4% to 15.7%. Importantly, receipt of GAHT was independently associated with a 37% lower likelihood of HIV seropositivity (adjusted risk ratio [RR] 0.63; 95% CI, 0.56–0.70) and a 44% lower risk of viral non-suppression (adjusted RR 0.56; 95% CI, 0.45–0.69).
The median age of participants in 2019 was 29 years, with 36.5% identifying as transgender women, 31.3% as transgender men, and 18.6% as non-binary. The cohort was racially and ethnically diverse, with 16.3% identifying as Black or African American, 20.5% as Hispanic or Latinx, and 6.1% as multiracial. Over one-third were publicly insured, and 5.6% were uninsured. The study also revealed substantial racial disparities in HIV prevalence, with higher rates among Black, Hispanic/Latino, and multiracial trans participants compared to their white counterparts.
Despite the high HIV risk in this population—transgender people are estimated to be 13 times more likely to be HIV-positive than other adults of reproductive age—the study found that uptake of pre-exposure prophylaxis (PrEP) was remarkably low. Only about 3% of HIV-negative participants were on PrEP, highlighting a missed opportunity for prevention in a high-risk group.
The study also confirmed that patients with longer durations of consistent care had better health outcomes, especially regarding viral suppression.
“Preventing HIV and optimizing HIV care are not ‘one size fits all’ in public health,” Dr Reisner said in a University of Michigan press release.2 “We need tailored approaches that address the lived experiences and priorities of trans people, such as integrated models of care that incorporate gender care with HIV prevention and care services.”
Resources:
- Reisner SL, Pletta DR, Mayer KH, et al. 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. Lancet HIV. 2025;10(4):e200-e210. doi:10.1016/S2352-3018(25)00004-9.
- University of Michigan News. HIV risk decreases in transgender individuals receiving hormone therapy, U-M study shows. Published March 27, 2025. Accessed March 31, 2025. https://news.umich.edu/hiv-risk-decreases-in-transgender-individuals-receiving-hormone-therapy-u-m-study-shows/