Higher Risk of Loss to Follow-up Among Transgender People With HIV in Italy: Findings From the ICONA Cohort

Background: Official data on transgender people with human immunodeficiency virus (PWH) in Italy are lacking because gender identity is not recorded in national reports. We aimed to characterize transgender PWH in Italy and assess retention in care and clinical outcomes. Methods: We included PWH enrolled between 2010 and 2023 in 40 Italian Cohort Naive Antiretrovirals centers where gender identity could be reliably ascertained. Transgender PWH were compared with cisgender participants. Univariable and multivariable regression models assessed the association between gender identity and (1) loss to follow-up (LTFU; no visit or exam for ≥18 months) using Fine-Gray models and (2) a composite clinical endpoint including mortality, major adverse cardiovascular events, cancer, acquired immunodeficiency syndrome-defining events, and end-stage kidney and liver disease using Cox models. Sensitivity analyses were restricted to individuals who initiated antiretroviral therapy (ART) from 2016 onward. Results: Overall, 256 transgender and 9922 cisgender PWH were included. Transgender PWH were younger (median 32 vs 39 years, P < .0001), more often assigned male at birth (99.6% vs 82.4%, P < .0001). Transgender PWH had a higher unadjusted risk of LTFU (subdistribution hazard ratio [sHR] 1.88, 95% confidence interval [CI] 1.60-2.22), confirmed after adjustment (adjusted sHR [asHR] 1.41, 95% CI 1.18-1.68) and in the post-2016 subgroup (asHR 1.39, 95% CI 1.11-1.77). Composite endpoint analyses were inconclusive (transgender PWH vs cisgender PWH: overall adjusted hazard ratio [aHR] 1.30 [95% CI .79-2.14], P = .293; post-2016 aHR 1.69 [95% CI .91-3.16], P = .098). Conclusions: Transgender PWH had a substantially higher risk of LTFU than cisgender participants in this national Italian cohort. Tailored interventions are needed to improve retention and health outcomes.