Transgender women have the highest HIV rate in the United States, and new data show which ones are most likely to have favorable outcomes.

Researchers with the Centers for Disease Control and Prevention (CDC) looked at data provided by 1,608 trans women in seven cities during 2019 and 2020. Overall, the women were struggling financially: 39% had been homeless, 40% reported going hungry and 44% earned less than $10,000 a year. While 83% reported that they currently had health insurance, one in five had gone without medical care in the past year.

Over one third (38%) of the women had received a positive HIV test result, with the rest either knowing they were negative or not knowing their status. Most trans women living with HIV (90%) were currently taking antiretroviral medications, and around 75% had an undetectable viral load. But this varied depending on life circumstances: Only 55% of women who had been homeless for a full year had viral suppression compared with 82% of those with stable housing. Among HIV-negative women, less than one third had used pre-exposure prophylaxis (PrEP) during the past year.

A majority of the women said they had a health care provider with whom they felt comfortable discussing their gender identity. Those with a gender-affirming provider were 12% more likely to receive HIV care, 17% more likely to have an undetectable viral load and 79% more likely to use PrEP.

“Although access to health insurance and gender-affirming health care is critical to connecting transgender women to HIV prevention and care services, access to food, housing and income are also essential,” Kathryn Lee, MPH, and colleagues wrote.