Racial/ethnic differences in the association between transgender-related U.S. state policies and self-rated health of transgender women.

BACKGROUND: Policy protections for transgender adults in the United States are consistently associated with positive health outcomes. However, studies over-represent non-Latinx White transgender people and obscure variation in policies' intended goals. This study examined racial differences in the relationship between transgender-related policies and transgender women's self-rated health. Guided by Critical Race Theory, we hypothesized that policies conferring access to resources (e.g., healthcare) would be associated with better self-rated health among all participants while policies signifying equality (e.g., nondiscrimination laws) would be associated with better self-rated health only for White participants. METHODS: Using cross-sectional data collected between March 2018-December 2020 from 1566 transgender women, we analyzed 7 state-level 'access policies,' 5 'equality policies,' and sum indices of each. Participants represented 29 states, and 54.7% were categorized as people of color. We fit a series of multilevel ordinal regression models predicting self-rated health by each policy. Multivariate models were adjusted for relevant covariates at the individual- and state-level. We then tested moderation by race/ethnicity using interaction terms and generated stratified predicted probability plots. RESULTS: In bivariate models, 4 access policies, 2 equality policies, and both indices were associated with better self-rated health, but associations did not persist in adjusted models. Results from the multivariable models including interaction terms indicated that policies concerning private insurance coverage of gender-affirming care, private insurance nondiscrimination, credit nondiscrimination, and both indices were statistically significantly associated with better self-rated health for White participants and worse self-rated health for participants of color. CONCLUSIONS: The policies included in this analysis do not mitigate racism's effects on access to resources, indicating they may be less impactful for transgender women of color than White transgender women. Future research and policy advocacy efforts promoting transgender women's health must center racial equity as well as transgender people of color's priorities.

Stigma, social and structural vulnerability, and mental health among transgender women: A partial least square path modeling analysis.

INTRODUCTION: Existing literature suggests that transgender women (TW) may be at high risk for adverse mental health due to stress attributed to combined experiences of stigma and complex social and structural vulnerabilities. Little research has examined how these co-occurring experiences relate to mental health. We aimed to test a theoretically driven conceptual model of relationships between stigma, social and structural vulnerabilities, and mental health to inform future intervention tailoring. DESIGN/METHODS: Partial least square path modeling followed by response-based unit segmentation was used to identify homogenous clusters in a diverse community sample of United States (US)-based TW (N = 1418; 46.2% White non-Hispanic). This approach examined associations between latent constructs of stigma (polyvictimization and discrimination), social and structural vulnerabilities (housing and food insecurity, unemployment, sex work, social support, and substance use), and mental health (post-traumatic stress and psychological distress). RESULTS: The final conceptual model defined the structural relationship between the variables of interest within stigma, vulnerability, and mental health. Six clusters were identified within this structural framework which suggests that racism, ethnicism, and geography may be related to mental health inequities among TW. CONCLUSION: Our findings around the impact of racism, ethnicism, and geography reflect the existing literature, which unfortunately shows us that little change has occurred in the last decade for TW of color in the Southern US; however, the strength of our evidence (related to sampling structure and sample size) and type of analyses (accounting for co-occurring predictors of health, i.e., stigma and complex vulnerabilities, reflecting that of real-world patients) is a novel and necessary addition to the literature. Findings suggest that health interventions designed to offset the negative effects of stigma must include anti-racist approaches with components to reduce or eliminate barriers to resources that contribute to social and structural vulnerabilities among TW. Herein we provide detailed recommendations to guide primary, secondary, and tertiary prevention efforts. CLINICAL RELEVANCE: This study demonstrated the importance of considering stigma and complex social and structural vulnerabilities during clinical care and design of mental health interventions for transgender women who are experiencing post-traumatic stress disorder and psychological distress. Specifically, interventions should take an anti-racist approach and would benefit from incorporating social support-building activities.

Prevalence of sexually transmitted infections among transgender women living with and without HIV in the eastern and southern United States.

BACKGROUND: Data on the epidemiology of sexually transmitted infections (STIs) among transgender women (TGW) with and without HIV are limited. METHODS: We analyzed baseline data collected from a cohort of adult TGW across 6 eastern and southern US cities between March 2018-August 2020 (n = 1,018). Participants completed oral HIV screening, provided self-collected rectal and urogenital specimens for chlamydia and gonorrhea testing, and provided sera specimens for syphilis testing. We assessed associations with ≥1 prevalent bacterial STI using modified Poisson regression. RESULTS: Bacterial STI prevalence was high and differed by HIV status: 32% among TGW with HIV and 11% among those without HIV (demographic-adjusted prevalence ratio = 1.91 [95%CI = 1.39-2.62]). Among TGW without HIV, bacterial STI prevalence differed by geographic region, race and ethnicity, and gender identity, and was positively associated with reporting >1 sexual partner, hazardous alcohol use, homelessness, having safety concerns regarding transit to healthcare, and no prior receipt of gender-affirming health services. Among TGW with HIV, older age was inversely associated with bacterial STI. CONCLUSIONS: TGW had a high prevalence of bacterial STIs. The prevalence and correlates of bacterial STI differed by HIV status, highlighting the unique needs and risks of TGW with and without HIV. Tailored interventions may reduce sexual health-related inequities.

Caregiving During the COVID-19 Pandemic: A Cross-Sectional Study with Older Cisgender Sexual Minority Women in the United States.

Purpose: This study describes prevalence of caregiving before and after the onset of the COVID-19 pandemic among racially diverse older cisgender sexual minority women, examines factors associated with caregiving, and assesses relationships between caregiving and health. Methods: A convenience sample of participants aged ≥50 years completed self-administered online surveys assessing sociodemographic characteristics, caregiver status, self-rated health, and depressive symptoms. Bivariate statistics compared response variables by race, caregiver status, and timing of caregiving relative to the pandemic. Results: Of 365 participants, 82.7% identified as lesbian or gay and 41.1% as Black/African American; 40% were caregivers before (n = 32), during (n = 34), or both before and during (n = 80) the pandemic. A greater proportion of caregivers lived with a partner (45.9% vs. 35.6%, p = 0.06), were unemployed (37.7% vs. 29.7%, p = 0.07), and had high school or lower education (11.6% vs. 5%, p = 0.09). No differences were found in self-rated health by caregiver status; however, a higher proportion of Black (vs. White) caregivers reported good to excellent physical health (77.9% vs. 62.9%, p = 0.05). Caregivers more frequently reported depressive symptoms (28.1% vs. 17.8%, p = 0.03). Caregivers both before and during the pandemic had lower educational attainment than those who provided care only before or only during the pandemic (p = 0.04). Conclusion: Caregiving was common among older sexual minority women during the pandemic and experiences varied by race and other social factors. Consideration of these intersecting experiences is important for fully understanding caregiver experiences during COVID-19. Overall, caregiving was associated with depressive symptoms, underscoring the importance of psychosocial support for all caregivers.

PrEP initiation and discontinuation among transgender women in the United States: a longitudinal, mixed methods cohort study.

INTRODUCTION: Transgender women in the United States experience high HIV incidence and suboptimal Pre-exposure prophylaxis (PrEP) engagement. We sought to estimate PrEP initiation and discontinuation rates and characterize PrEP discontinuation experiences among a prospective cohort of transgender women. METHODS: Using a sequential, explanatory, mixed-methods design, 1312 transgender women at risk for HIV acquisition were enrolled from March 2018 to August 2020 and followed through July 2022 (median follow-up 24 months; interquartile range 15-36). Cox regression models assessed predictors of initiation and discontinuation. In-depth interviews were conducted among 18 participants, including life history calendars to explore key events and experiences surrounding discontinuations. Qualitative and quantitative data were integrated to generate typologies of discontinuation, inform meta-inferences and facilitate the interpretation of findings. RESULTS: 21.8% (n = 286) of participants reported taking PrEP at one or more study visits while under observation. We observed 139 PrEP initiations over 2127 person-years (6.5 initiations/100 person-years, 95% CI: 5.5-7.7). Predictors of initiation included identifying as Black and PrEP indication. The rate of initiation among those who were PrEP-indicated was 9.6 initiations/100 person-years (132/1372 person-years; 95% CI: 8.1-11.4). We observed 138 PrEP discontinuations over 368 person-years (37.5 discontinuations/100 person-years, 95% CI: 31.7-44.3). Predictors of discontinuation included high school education or less and initiating PrEP for the first time while under observation. Four discontinuation typologies emerged: (1) seroconversion following discontinuation; (2) ongoing HIV acquisition risk following discontinuation; (3) reassessment of HIV/STI prevention strategy following discontinuation; and (4) dynamic PrEP use coinciding with changes in HIV acquisition risk. CONCLUSIONS: PrEP initiation rates were low and discontinuation rates were high. Complex motivations to stop using PrEP did not consistently correspond with HIV acquisition risk reduction. Evidence-based interventions to increase PrEP persistence among transgender women with ongoing acquisition risk and provide HIV prevention support for those who discontinue PrEP are necessary to reduce HIV incidence in this population.

Cardiovascular Disease Risk Estimation for Transgender and Gender-Diverse Patients: Cross-Sectional Analysis of Baseline Data From the LITE Plus Cohort Study.

Introduction: Approximately 2% of the U.S. population identifies as transgender, and transgender people experience disproportionate rates of cardiovascular disease mortality. However, widely used cardiovascular disease risk estimators have not been validated in this population. This study sought to determine the impact on statin therapy recommendations using 3 different approaches to operationalizing sex in the American Health Association/American College of Cardiology Pooled Cohort Equation Risk Estimator. Methods: This is a cross-sectional analysis of baseline clinical data from LITE Plus, a prospective cohort study of Black and/or Latina transgender women with HIV. Data were collected from October 2020 to June 2022 and used to calculate Pooled Cohort Equation scores. Results: The 102 participants had a mean age of 43 years. A total of 88% were Black, and 18% were Latina. A total of 79% were taking gender-affirming hormones. The average Pooled Cohort Equation risk score was 6% when sex assigned at birth was used and statins would be recommended for the 31% with Pooled Cohort Equation >7.5%. The average risk score was 4%, and 18% met the criteria for statin initiation when current gender was used; the mean risk score was 5%, and 22% met the criteria for statin initiation when current hormone therapy was used. Conclusions: Average Pooled Cohort Equation risk scores vary substantially depending on the approach to operationalizing the sex variable, suggesting that widely used cardiovascular risk estimators may be unreliable predictors of cardiovascular disease risk in transgender populations. Collection of sex, gender, and hormone use in longitudinal studies of cardiovascular health is needed to address this important limitation of current risk estimators.

Interrogating Anti-Blackness in US Healthcare: Contextual Factors and Policy Implications.

Racial inequities exacerbated by the COVID-19 pandemic highlight how systemic anti-Black racism negatively impacts health. Anti-Black racism pervades the healthcare system, ranging from race-based corrections embedded in clinical algorithms to bias among healthcare providers. Systemic racism takes a physiological toll, causing illness and early mortality among Black people in the US and sending ripple effects across Black communities. The erasure of Black history is a common tool of racism that serves to impede progress toward racial justice. Structural changes, such as policies and laws that centre the lived experiences of Black people and directly address anti-Blackness racism, are essential for achieving health equity.

Brief Report: Interruptions in HIV Prevention and Treatment During the COVID-19 Pandemic: A Cross-Sectional Study of Transgender and Gender Nonbinary Adults in the United States.

BACKGROUND: Transgender and gender nonbinary (TNB) people have been disproportionately affected by HIV and the COVID-19 pandemic. This study explored the prevalence of HIV prevention and treatment (HPT) interruptions during the pandemic and identified factors associated with these interruptions. SETTING: Data were drawn from LITE Connect, a US-based, nationwide, online, self-administered survey designed to examine the experiences of TNB adults during the COVID-19 pandemic. A convenience sample of 2134 participants were recruited between June 14, 2021, and May 1, 2022. METHODS: The analytic sample was restricted to participants taking antiretroviral medications to prevent or treat HIV before the onset of the pandemic (n = 153). We calculated descriptive statistics as well as Pearson χ 2 bivariate tests and multivariable models to identify factors associated with HPT interruptions during the pandemic. RESULTS: Thirty-nine percent of participants experienced an HPT interruption. We found a lower odds of HPT interruptions among participants living with HIV [adjusted odds ratios (aOR) 0.45; 95% Confidence Intervals (CI): 0.22, 0.92; P = 0.02] and essential workers [aOR 0.49; 95% CI: 0.23, 1.0; P = 0.06] and higher odds among people with chronic mental health conditions [aOR 2.6; 95% CI: 1.1, 6.2; P = 0.03]. When sex and education were included, we found a lower odds of interruptions among people with higher education. CI widened, but the magnitude and direction of effects did not change for the other variables. CONCLUSIONS: Focused strategies to address longstanding psychosocial and structural inequities are needed to mitigate HPT treatment interruptions in TNB people and prevent similar challenges during future pandemics.

HIV incidence and mortality in transgender women in the eastern and southern USA: a multisite cohort study.

BACKGROUND: Epidemiological monitoring of HIV among transgender women is minimal despite prioritisation of this group in the US National HIV/AIDS Strategy (2022-2025). We aimed to estimate HIV incidence in a multisite cohort of transgender women in the eastern and southern USA. Participant deaths were identified during follow-up; thus, we felt it was an ethical imperative to report mortality alongside HIV incidence. METHODS: In this study, we established a multisite cohort across two modes: a site-based, technology-enhanced mode in six cities (Atlanta, Baltimore, Boston, Miami, New York City, and Washington, DC) and an exclusively digital mode that spanned 72 eastern and southern US cities that matched the six site-based cities based on population size and demographics. Trans feminine adults (≥18 years) who were not living with HIV were eligible and followed up for at least 24 months. Participants completed surveys and oral fluid HIV testing with clinical confirmation. We ascertained deaths through community and clinical sources. We estimated HIV incidence and mortality using the number of HIV seroconversions and deaths, respectively, divided by person-years accumulated from enrolment. Logistic regression models were used to identify predictors of HIV seroconversion (primary outcome) or death. FINDINGS: Between March 22, 2018, and Aug 31, 2020, we enrolled 1312 participants with 734 (56%) in site-based and 578 (44%) in digital modes. At the 24-month assessment, 633 (59%) of 1076 eligible participants consented to extending participation. 1084 (83%) of 1312 participants were retained at this analysis based on the study definition of loss to follow-up. As of May 25, 2022, the cohort participants had contributed 2730 accumulated person-years to the analytical dataset. Overall HIV incidence was 5·5 (95% CI 2·7-8·3) per 1000 person-years and incidence was higher among Black participants and those living in the south. Nine participants died during the study. The overall mortality rate was 3·3 (95% CI 1·5-6·3) per 1000 person-years, and the rate was higher among Latinx participants. Identical predictors of HIV seroconversion and death included residence in southern cities, sexual partnerships with cisgender men, and use of stimulants. Participation in the digital cohort and seeking care for gender transition were inversely associated with both outcomes. INTERPRETATION: As HIV research and interventions are increasingly delivered online, differences by mode highlight the need for continued community and location-based efforts to reach the most marginalised transgender women. Our findings underscore community calls for interventions that address social and structural contexts that affect survival and other health concerns alongside HIV prevention. FUNDING: National Institutes of Health. TRANSLATION: For the Spanish translation of the abstract see Supplementary Materials section.

SARS-CoV-2 Infection and Testing Experiences in a Nationwide Sample of Transgender and Gender-Diverse Adults, June-December 2021.

OBJECTIVES: COVID-19 surveillance data are rarely collected or disaggregated by gender identity in the United States. We quantified COVID-19 testing experiences and SARS-CoV-2 infection history among transgender and gender-diverse (TGD) people to inform testing strategies and public health responses. METHODS: From June 14 through December 16, 2021, TGD adults enrolled in a US nationwide online survey with optional SARS-CoV-2 antibody testing. We used multinomial regression analyses to identify correlates of suspected and confirmed SARS-CoV-2 infection (vs no known infection). We identified correlates of inability to access COVID-19 testing when needed using generalized linear models for binomial variables. RESULTS: Participants (N = 2092) reported trans masculine (30.5%), trans feminine (27.3%), and nonbinary (42.2%) gender identities. Ten percent of respondents had a confirmed history of SARS-CoV-2 infection, and 29.8% had a history of suspected SARS-CoV-2 infection. Nonbinary gender (adjusted prevalence ratio [aPR] = 1.68; 95% CI, 1.12-2.53), experiencing homelessness (aPR = 1.65; 95% CI, 1.05-2.60), and food insecurity (aPR = 1.45; 95% CI, 1.03-2.04) were associated with confirmed SARS-CoV-2 infection. Food insecurity (aPR = 1.38; 95% CI, 1.10-1.72), chronic physical health condition (aPR = 1.44; 95% CI, 1.15-1.80), chronic mental health condition (aPR = 3.65; 95% CI, 2.40-5.56), and increased anticipated discrimination scores (aPR = 1.03; 95% CI, 1.01-1.05) were associated with suspected SARS-CoV-2 infection. Thirty-four percent (n = 694 of 2024) of participants reported an inability to access COVID-19 testing when needed, which was associated with Latinx or Hispanic ethnicity, inconsistent telephone access, homelessness, disability, and transportation limitations. The majority (79.4%) reported a complete COVID-19 vaccine course at the time of participation. CONCLUSIONS: Inclusion of TGD people in public health surveillance and tailored public health strategies to address TGD communities' social and structural vulnerabilities may reduce barriers to COVID-19 testing.

Characterizing Arrest and Incarceration in a Prospective Cohort of Transgender Women.

This study characterized arrest, incarceration, and risk factors for incident incarceration among transgender women (TW) in the northeastern and southern United States. During semiannual study visits over 24 months in a multicenter cohort study, TW completed HIV testing and self-administered surveys. In total, 1571 TW completed baseline survey; 1,312 HIV-negative TW enrolled in the cohort and contributed 2134.3 person-years to the analysis. At baseline, 37% had been arrested and 21% had been incarcerated. Incident incarceration was 23.4 per 1,000 person-years (95% confidence interval [CI]: 16.9-29.9). Sex work was significantly associated with baseline and incident incarceration (p < .01). A history of incarceration at enrollment was the strongest predictor of incident incarceration (adjusted odds ratio [aOR] 6.99; 95% CI: 3.43-14.24). Living in the South (aOR 2.69, 95% CI: 1.22-5.93), income below the federal poverty level (aOR 2.65 95% CI: 3.43-14.24), and having a recent partner who had been incarcerated (aOR 2.62, 95% CI: 1.20-5.69) also increased the odds of incident incarceration in multivariable modeling. Structural interventions to reduce poverty and decriminalize sex work have the potential to reduce incarceration rates among TW.

Longitudinal HIV care outcomes by gender identity in the United States.

OBJECTIVE: Describe engagement in HIV care over time after initial engagement in HIV care, by gender identity. DESIGN: Observational, clinical cohort study of people with HIV engaged in routine HIV care across the United States. METHODS: We followed people with HIV who linked to and engaged in clinical care (attending ≥2 visits in 12 months) in cohorts in the North American Transgender Cohort Collaboration, 2000-2018. Within strata of gender identity, we estimated the 7-year (84-month) restricted mean time spent: lost-to-clinic (stratified by pre/postantiretroviral therapy (ART) initiation); in care prior to ART initiation; on ART but not virally suppressed; virally suppressed (≤200 copies/ml); or dead (pre/post-ART initiation). RESULTS: Transgender women ( N  = 482/101 841) spent an average of 35.5 out of 84 months virally suppressed (this was 30.5 months for cisgender women and 34.4 months for cisgender men). After adjustment for age, race, ethnicity, history of injection drug use, cohort, and calendar year, transgender women were significantly less likely to die than cisgender people. Cisgender women spent more time in care not yet on ART, and less time on ART and virally suppressed, but were less likely to die compared with cisgender men. Other differences were not clinically meaningful. CONCLUSIONS: In this sample, transgender women and cisgender people spent similar amounts of time in care and virally suppressed. Additional efforts to improve retention in care and viral suppression are needed for all people with HIV, regardless of gender identity.

Prevention-effective adherence trajectories among transgender women indicated for PrEP in the United States: a prospective cohort study.

PURPOSE: Adherence to pre-exposure prophylaxis (PrEP) during periods of PrEP-indication (i.e., prevention-effective adherence) is critical for preventing HIV. We sought to describe factors associated with prevention-effective adherence trajectories among transgender women (TW) to inform PrEP implementation strategies. METHODS: Using data from The LITE American Cohort (n = 728), we performed group-based multi-trajectory modeling (GBMTM) to identify clusters of TW with similar trajectories of PrEP adherence and indication, and sociodemographic, biobehavioral, and structural correlates of each trajectory. RESULTS: We identified five trajectories: (1) consistent indication/no PrEP (15.3%), (2) initial indication/no PrEP (47.1%), (3) declining indication/discontinued PrEP (9.5%), (4) consistent indication/PrEP adherent (18.5%), and (5) increasing indication/initiated PrEP (9.6%). TW diagnosed with an STI were more likely to follow a consistent indication/no PrEP trajectory compared to consistent indication/PrEP adherent trajectory (adjusted Relative Risk Ratio [aRRR], 2.54; 95% confidence interval [CI], 1.16-5.57). TW who experienced homelessness were more likely to follow PrEP discontinuation and initiation trajectories relative to PrEP adherence (aRRR, 2.71; 95% CI, 1.10-6.70 and 2.83; 95% CI, 1.13-7.05, respectively). CONCLUSIONS: Over a quarter of TW followed trajectories suggestive of prevention-effective adherence, while 15% did not initiate PrEP despite consistent indication. Findings highlight missed opportunities for PrEP engagement at STI diagnosis and suggest structural interventions addressing housing instability may improve prevention-effective adherence among TW.

Cardiovascular Disease in a Population-Based Sample of Transgender and Cisgender Adults.

INTRODUCTION: Existing data on cardiovascular disease among transgender people are inconsistent and are derived from nonrepresentative samples or population-based data sets that do not include transgender-specific risk factors such as gender-affirming hormone use and gender minority stressors. A nationally representative sample of cisgender and transgender adults aged ≥40 years was used to assess the prevalence and correlates of smoking, select cardiovascular disease conditions, and venous thromboembolism. METHODS: Participants were recruited from 2016 to 2018, with analysis conducted in December 2020 with 114 transgender and 964 cisgender individuals. Sample weights and multiple imputations were used for all estimates except for descriptive statistics. Logistic regression models estimated the ORs and 95% CIs expressing the relationship between each outcome variable and a set of independent variables. Each model controlled for race and age. RESULTS: No meaningful differences between cisgender and transgender participants were found in smoking or cardiovascular disease conditions. However, there was an increased odds of venous thromboembolism among transgender women compared with those among cisgender women. Transgender people had greater odds of discrimination, psychological distress, and adverse childhood experiences. These stressors were associated with increased odds of a cardiovascular condition, and everyday discrimination and adverse childhood experiences were associated with increased odds of smoking. Discrimination and psychological distress were associated with venous thromboembolism. CONCLUSIONS: Transgender people face disparities in cardiovascular disease risk. This study provides support for the gender minority stress model as a framework for understanding cardiovascular disease disparities. Future research with larger samples and adjudicated outcomes is needed to advance the field.

Delays in breast cancer care by race and sexual orientation: Results from a national survey with diverse women in the United States.

BACKGROUND: Despite known differences in breast cancer by both race and sexual orientation, data on the intersectional experiences of Black sexual minority women (BSMW) along the care continuum are scant. This study sought to understand delays in breast cancer care by examining the intersection of race and sexual orientation. METHODS: This online, cross-sectional survey enrolled racially and sexually diverse women aged ≥ 35 years who had been diagnosed with breast cancer within the prior 10 years or had an abnormal screening in the prior 24 months. The authors calculated summary statistics by race/sexual orientation categories, and they conducted univariate and multivariable modeling by using multiple imputation for missing data. RESULTS: BSMW (n = 101) had the highest prevalence of care delays with 5.17-fold increased odds of a care delay in comparison with White heterosexual women (n = 298) in multivariable models. BSMW reported higher intersectional stigma and lower social support than all other groups. In models adjusted for race, sexual orientation, and income, intersectional stigma was associated with a 2.43-fold increase in care delays, and social support was associated with a 32% decrease in the odds of a care delay. CONCLUSIONS: Intersectional stigma may be an important driver of breast cancer inequities for BSMW. Reducing stigma and ensuring access to appropriate social support that addresses known barriers can be an important approach to reducing inequities in the breast cancer care continuum.

Vulnerability to COVID-19-related Harms Among Transgender Women With and Without HIV Infection in the Eastern and Southern U.S.

BACKGROUND: COVID-19 is a new pandemic, and its impact by HIV status is unknown. National reporting does not include gender identity; therefore, data are absent on the impact of COVID-19 on transgender people, including those with HIV. Baseline data from the American Cohort to Study HIV Acquisition Among Transgender Women in High Risk Areas (LITE) Study provide an opportunity to examine pre-COVID factors that may increase vulnerability to COVID-19-related harms among transgender women. SETTING: Atlanta, Baltimore, Boston, Miami, New York City, Washington, DC. METHODS: Baseline data from LITE were analyzed for demographic, psychosocial, and material factors that may affect vulnerability to COVID-related harms. RESULTS: The 1020 participants had high rates of poverty, unemployment, food insecurity, homelessness, and sex work. Transgender women with HIV (n = 273) were older, more likely to be Black, had lower educational attainment, and were more likely to experience material hardship. Mental and behavioral health symptoms were common and did not differ by HIV status. Barriers to health care included being mistreated, provider discomfort serving transgender women, and past negative experiences; as well as material hardships, such as cost and transportation. However, most reported access to material and social support-demonstrating resilience. CONCLUSIONS: Transgender women with HIV may be particularly vulnerable to pandemic harms. Mitigating this harm would benefit everyone, given the highly infectious nature of this coronavirus. Collecting gender identity in COVID-19 data is crucial to inform an effective public health response. Transgender-led organizations' response to this crisis serve as an important model for effective community-led interventions.