OBJECTIVE:Evaluate the impact of initiating integrase strand transfer inhibitor (INSTI) - vs. nonnucleoside reverse transcriptase inhibitor (NNRTI) - or protease inhibitor-based regimens on weight and glycemia among people with HIV (PWH) and type 2 diabetes. DESIGN:Cohort study. METHODS:From multisite HIV cohorts in the United States and Canada (2007-2022), we identified PWH with diabetes who newly initiated INSTI-based, NNRTI-based, or protease inhibitor-based therapy. We used inverse probability of treatment-weighted (IPTW) generalized linear models to compare changes in weight and hemoglobin A1c (HbA1c) at approximately 12 months after antiretroviral therapy (ART) initiation. We assessed time to at least 5% weight gain and to glucose-lowering therapy augmentation or HbA1c increase at least 0.5 percentage points with IPTW Cox regression. RESULTS:Among 1279 PWH with diabetes, 548 initiated an INSTI-based regimen, 511 an NNRTI-based regimen, and 220 a protease inhibitor-based regimen. Compared with NNRTI users, INSTI users had greater adjusted mean weight gain [2.1 kg; 95% confidence interval (CI), 1.1-3.1], while the difference in HbA1c change was modest (0.2%; 95% CI, 0.0-0.5); both changes were similar between INSTI and protease inhibitor users. INSTI users had higher risk of at least 5% weight gain [adjusted hazard ratio (aHR), 1.35; 95% CI, 1.15-1.59] and glucose-lowering therapy augmentation or HbA1c increase at least 0.5% (aHR, 1.19; 95% CI, 1.02-1.41) compared with NNRTI users although similar risk vs. protease inhibitor users. CONCLUSION:Among PWH with diabetes, initiating INSTIs conferred modestly greater weight gain and worse glycemic outcomes vs. NNRTIs, but outcomes comparable to PIs, which is recognized for adverse metabolic effects. These findings inform the metabolic implications of INSTIs and support clinical monitoring after ART initiation.

Supplementary Table 2 supports figure 2 in the main text and includes the proportions of CIN2+ that were HPV16/18 positive that are used to make the graphs.

Background:CD4 T cells are critical for reducing disease severity and viral clearance of SARS-CoV-2, which is particularly important among populations that are immune compromised, including people with HIV (PWH). While vaccines are effective, risk and severity of COVID-19 breakthrough infections are higher in people with vs without HIV. Little is known about the effects of SARS-CoV-2 on CD4 counts among PWH after a breakthrough infection. Methods:We evaluated the impact of COVID-19 breakthrough infection on immediate (0-60 days) and short-term (61-180 days) CD4 count from 2020 to 2022 among PWH vaccinated for COVID-19 in the CIVETs-II study (Corona-Infectious-Virus Epidemiology Team). We utilized paired t tests to test for statistically significant changes in CD4 count before and after breakthrough infection and linear mixed effect models to quantify changes in CD4 count following SARS-CoV-2 breakthrough infection. Results:Among 152 PWH, 37% were White and 40% were ≥55 years of age. Median CD4 count prebreakthrough was 614 cells/mm3, while median postbreakthrough CD4 count was 612 cells/mm3. Most patients had an undetectable HIV viral load (62%). Paired t tests indicated no change in CD4 count prior to breakthrough infection as compared with CD4 count 0 to 60 days (-40 cells/mm3; 95% CI, -86 to 5), or ≥61 days (25 cells/mm3; 95% CI, -11 to 61). Longitudinal trajectories indicated CD4 count rebound ≥61 days following breakthrough infection (112-cell/mm3 increase per 60-day increase, P < .05). Conclusions:While changes in CD4 counts were observed after breakthrough infection, these results are likely not clinically significant, suggesting that among PWH vaccinated for COVD-19, CD4 count is not substantially affected by breakthrough infections.

BACKGROUND:Stagnating decreases in Kaposi sarcoma (KS) among men with HIV (MWH) following Treat-All policies necessitate evaluating changes in clinical drivers of KS. We examined clinical factors and their associations with KS rates among MWH in North America. METHODS:Among MWH in the North American AIDS Cohort Collaboration on Research and Design, we estimated annual KS rates (per 100 000 person-years [PY]) by viral suppression (<200 copies/mL), CD4 count (<500 vs ≥500 cells/mm3), and time since ART initiation (<1 year/naive vs ≥1 year) from 2009-2019. We quantified associations between clinical factors and KS rates using negative binomial regression, estimating incidence rate ratios (IRRs) with 95% CIs. Among MWH with KS, we estimated average annual percentage changes (AAPCs) in clinical factor distribution using joinpoint regression. RESULTS:There were 61 155 MWH (370 624 PY) contributing 262 KS diagnoses. KS decreased from 132 to 43 cases per 100 000 PY between 2009 and 2019. Viral suppression (IRR2009: .09 [95% CI: .04-.20]; IRR2019: .69 [.31-1.54]), recent/no ART initiation (IRR2009: .14 [.07-.30]; IRR2019: 1.16 [.53, 2.56]), and CD4 count ≥500 cells/mm3 (IRR2009: .13 [.05-.31]; IRR2019: .44 [.18-1.10]) were associated with reduced KS rates, attenuating over time. Unsuppressed viral load at KS diagnosis decreased by 10.6% (-15.8%, -4.8%) as did those on ART ≤1 year/naive (70%-40%; AAPC: -6.3% [-13.8%, 2.1%]). CONCLUSIONS:Our findings underscore the importance of early HIV diagnosis/treatment in reducing KS burden. Attenuating associations with HIV factors indicate that those successfully managing HIV increasingly represent KS patients. KS drivers are evolving, requiring patient/population-level monitoring.

BACKGROUND:Integrase strand transfer inhibitor (INSTI) initiation has been associated with diabetes in antiretroviral therapy (ART)-naive people with HIV. We aimed to examine the effect of switching to INSTIs on incident diabetes in ART-experienced people with HIV. METHODS:In this target trial emulation, we retrospectively used individual-level data from 27 longitudinal cohorts of people with HIV in the USA and Canada. We included participants aged at least 18 years without diabetes who had used non-nucleoside reverse transcriptase inhibitors (NNRTIs) or protease inhibitors for at least 180 days (in 2016-22) but had never used an INSTI. We used data from any clinical encounters in which participants continued an NNRTI or protease inhibitor versus switched to an INSTI, with a follow-up period of up to 5 years. The effect of switching to INSTIs on incident diabetes was estimated with weighted Cox regression with robust variance. We further assessed whether the effect varied by time since the switch and was explained by weight gain in the first year. FINDINGS:13 071 participants were followed up from 2702 encounters in which they switched to an INSTI from an NNRTI, 54 766 encounters in which they continued an NNRTI, 1714 encounters in which they switched to an INSTI from a protease inhibitor, and 26 599 encounters in which they continued a protease inhibitor. Switching from protease inhibitors to INSTIs conferred an adjusted hazard ratio (HR) of 1·38 (95% CI 1·06-1·80) for incident diabetes, whereas switching from NNRTIs to INSTIs conferred an adjusted HR of 1·10 (0·87-1·39). The diabetes risk was higher during the first 2 years after switching from protease inhibitors to INSTIs (HR 1·67, 95% CI 1·21-2·30), but not thereafter (1·08, 0·75-1·57; pinteraction=0·064). The effect of switching from protease inhibitors to INSTIs on diabetes did not appear to be explained by weight gain. In the sensitivity analysis in which weight gain did not exceed 5% in the first year after, the switch from NNRTIs to INSTIs had a HR of 1·03 (95% CI 0·79-1·36) and the switch from protease inhibitors to INSTIs had a HR of 1·37 (1·02-1·84). INTERPRETATION:The increased diabetes risk after switching from protease inhibitors to INSTIs highlights a metabolic implication of regimen change and could warrant close monitoring early after switch, regardless of weight gain. FUNDING:US National Institutes of Health.

BACKGROUND:Prior studies have found that women with HIV (WWH) have similar or lower breast cancer risk than women without HIV (WWoH). Detection of breast cancer relies on regular screening, but previous studies comparing mammogram rates between WWH and WWoH have had mixed results. SETTING:This study was conducted within Kaiser Permanente Northern California, a large, integrated health care system. METHODS:We conducted a cross-sectional study of WWH and 20:1 demographically matched WWoH aged 50-74 years in December 2019. Mammogram data were abstracted from the electronic health record for the prior 27 months, consistent with a 2-year recommendation for breast cancer screening with a 3-month grace period. We compared mammogram prevalence by HIV status using Poisson regression models, with adjustment for demographic and clinical factors. We then evaluated factors associated with receipt of mammograms in WWH and WWoH. RESULTS:Three hundred forty-five WWH and 6573 WWoH meeting study eligibility were included (demographically matched, mean age: 60.3 vs 60.4 years; White race: 38% for both groups). Mammogram prevalence was high in both groups (86% for WWH, 87% for WWoH), with an adjusted prevalence ratio of 0.95 (confidence interval: 0.91 to 0.99). Among WWH, factors associated with reduced mammogram use included smoking, fewer outpatient encounters, and no HIV RNA measurement within prior year. CONCLUSIONS:Mammogram prevalence was high in WWH and WWoH at Kaiser Permanente Northern California, exceeding national averages. Lower patient engagement with the health care system and smoking emerged as the most significant factors associated with reduced mammograms among WWH.

Plasma HIV-1 RNA viral loads (VLs) are measured via laboratory assays with changing lower limits of quantification over time. We described an approach to produce an analytic-ready dataset of VLs over time and across longitudinal cohorts of adults. A 3-step approach was used: (1) initial data cleaning, (2) data checking with visualization, and (3) final data cleaning. Assumptions, data-driven decisions, and information from cohort-specific data managers produce an analytic-ready dataset of VLs with minimal missing data for date of blood draw, HIV-1 RNA result (copies/mL), below the lower limit of quantification (BLLQ) indicator, and the lower limit of quantification (LLQ). Among 3 663 786 VLs from 186 990 participants (median number of VLs per participant = 12, interquartile range 4-27) measured from 1988 to 2021, 61% of VL records were harmonized via the 3-step approach. The proportion of VLs below the lower limit of quantification increased from 39% to 60% after application of this approach. Changes to LLQ, VL result, and BLLQ indicator variables were made to 45%, 36%, and 22% of VLs, respectively. Stated assumptions, visualized data distributions, and a documented approach to preparing an analytic-ready dataset of pooled individual-level longitudinal data revealed data idiosyncrasies, informed assumptions, and improved the data for research inference.

Supplementary Figure 1 shows the different assays used for HPV typing by collection date, HPV-IMPACT, 2008 to 2019.

BACKGROUND:Long-acting cabotegravir (CAB-LA) was approved as HIV preexposure prophylaxis (PrEP) in the United States in December 2021, but data are limited on uptake, adherence, and persistence in clinical practice. METHODS:We extracted electronic health records of adults receiving oral or injectable PrEP during December 2021 to June 2024 at Kaiser Permanente (KP) Northern California and Mid-Atlantic States, 2 large integrated healthcare systems. We used χ 2 tests to compare characteristics of CAB-LA users and oral-PrEP-only users. Among CAB-LA users, we assessed adherence to bimonthly injections after lead-in doses (weeks 0 and 4) and used Kaplan-Meier methods to estimate persistence. RESULTS:Among 23,311 individuals accessing oral or injectable PrEP, 180 (0.8%) received CAB-LA, with 23.9% having no documentation of previous PrEP use at KP. Compared with oral-PrEP-only users, a lower proportion of CAB-LA users were commercially insured (82.2% vs 89.2%; P = 0.014) and a higher proportion were Black (18.9% vs 10.2%) or Hispanic (34.4% vs 23.6%; P < 0.001 across race/ethnicity categories). Of 688 non-lead-in CAB-LA injections, 90.4% were administered within 8 weeks +7 days after the previous injection. Persistence on CAB-LA was 87.9% and 74.9% at 6 and 12 months, respectively. There were no incident HIV infections during CAB-LA use. CONCLUSIONS:CAB-LA is engaging new users, including populations traditionally underrepresented in PrEP uptake, and adherence and persistence are high in clinical practice. However, uptake of CAB-LA is extremely low, suggesting population affect will be limited without efforts to expand implementation and use.

INTRODUCTION:Little is known about anxiety, depression, and post-traumatic stress disorder (PTSD) diagnoses among midlife and older transgender adults (aged 45 years and older). METHODS:This analysis used electronic health record data from the Study of Transition, Outcomes, and Gender, and included transfeminine (TF;n = 3080) and transmasculine (TM;n = 1705) adults aged 45+, along with demographically matched cisgender men (CM) and cisgender women (CW). History of anxiety, depression, and PTSD diagnoses among TF and TM adults and their CM and CW referents was examined. Estimates were calculated overall and stratified by age groups (45-54, 55-64, 65-74, 75+). Analyses were repeated among subgroups (gender-affirming hormone therapy (GAHT) receipt, minoritized ethnoracial status). Adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) were estimated using Poisson regression. RESULTS:aPRs (95% CI) comparing TF to CM were 2.16 (2.08, 2.23) for anxiety, 2.77 (2.66, 2.89) for depression, and 7.11 (6.16, 8.20) for PTSD; corresponding TF versus CW estimates were 1.38 (1.34, 1.42), 1.65 (1.59, 1.71), and 3.27 (2.89, 3.71). Among TM adults, aPRs versus CM were 2.36 (2.26, 2.46) for anxiety, 3.18 (3.02, 3.34) for depression, and 11.12 (9.49, 13.04) for PTSD; corresponding estimates versus CW were 1.49 (1.44, 1.54), 1.80 (1.73, 1.88), and 4.76 (4.20, 5.39). Elevated prevalence was observed across age strata and among those with evidence of GAHT receipt and was more pronounced among individuals from minoritized ethnoracial groups. CONCLUSION:Anxiety, depression, and PTSD prevalence were substantially higher among TF and TM adults than among matched cisgender referents. Mental health disparities were evident across midlife and older adulthood, underscoring the need for interventions and policies that support equitable mental health among transgender adults.

Supplementary Table 1 shows characteristics by HPV typing data availability, HPV 16/18 results, and vaccination status.

Cancer remains a leading cause of morbidity and mortality in people with HIV, and the importance of cancer screening increases as this population ages. In 2017, 2020, and 2023, cross-sectional surveys were conducted at HIV care sites across 5 continents within the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. We described cancer screening availability in 2023 and over time for cervical and anal cancer screening using generalized estimating equations with a logit link function to account for site clustering, rurality, and country income. Of the 220 sites in the 2023 survey, 61% (134/220) reported cervical cancer screening by cytology or human papillomavirus (HPV) testing on-site, and 88% (194/220) reported cervical cancer screening by any method, including visual inspection. At sites serving predominantly rural populations, 62% (29/47) exclusively performed screening by visual inspection. Overall, 23% (50/220) of sites performed cytology-based anal cancer screening on-site, and 16% (35/220) had availability of high-resolution anoscopy, either on-site or by referral. Screening for cancer of the liver, colon, lung, prostate, or breast (by imaging) were each available at less than 43% of sites. The odds of cervical cancer screening availability increased by 16% annually from 2017 through 2023 (aOR = 1.16, 95% CI: 1.07-1.27, p = 0.001), while the relative odds of anal cancer screening availability decreased by 9% annually (aOR = 0.91, 95% CI: 0.84-0.99, p = 0.023). Lack of trained staff was the most frequently reported barrier, followed by lack of equipment. Understanding current practices and capacity is essential for the continued integration of cancer prevention in HIV care.

Background:Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are established antihypertensive treatments that reduce cardiovascular disease (CVD) risk. However, their comparative effectiveness in people with HIV (PWH) is not well examined. This study evaluated the comparative effectiveness of ACEIs and ARBs head-to-head and versus no antihypertensive treatment in preventing primary CVD. Methods:Using a target trial emulation framework and data from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), we estimated observational analogs of intention-to-treat (ITT) and per-protocol (PP) effects of antihypertensive treatments in preventing primary CVD (myocardial infarction, non-MI coronary artery disease, stroke, transient ischemic attack, peripheral vascular disease, cardiovascular death) among hypertensive PWH, with subgroup analyses for Black and White PWH. Results:Compared with no antihypertensive treatment, ACEIs and ARBs were both associated with lower CVD risk in PWH, with similar effect sizes in ITT and PP analyses (ACEI ITT adjusted hazard ratio (HR): 0.79, 95% CI [0.70-0.89]; ACEI PP: 0.71 [0.55-0.90]; ARB ITT: 0.87 [0.65-1.16]; ARB PP: 0.37 [0.18-0.76]). Race-stratified ITT and PP analyses suggested somewhat greater risk reductions in White than Black PWH, although differences were not statistically significant. In head-to-head comparisons, ACEIs and ARBs showed comparable effectiveness overall (ITT: 1.14 [0.84-1.55]; PP: 0.54 [0.25-1.18]), and within race strata. Conclusions:Our study found that both ACEIs and ARBs were effective in reducing CVD risk among PWH, with similar effectiveness observed for both medications. The analysis did not reveal statistically significant differences in effectiveness between Black and White PWH for either drug.

BACKGROUND:Weight gain is common following antiretroviral therapy (ART) initiation. Integrase strand transfer inhibitors (INSTIs) and tenofovir alafenamide (TAF) have been associated with greater weight gain, though prior analyses may have been confounded by the weight-suppressive effects of efavirenz (EFV) and tenofovir disoproxil fumarate (TDF). METHODS:Treatment-naïve adults in the North American AIDS Cohort Collaboration on Research and Design initiating ART between 2007-2020 were analyzed. Predicted weight change was modeled using linear mixed effects models adjusted for demographic and clinical factors, and nucleoside reverse transcriptase inhibitor (NRTI) backbone, with sub-analyses excluding EFV and stratifying by INSTI agent, NRTI, sex, and race. RESULTS:32,514 persons were included. At 2 years, INSTIs (4.9 kg, 95%CI 4.6-5.2) and protease inhibitors (PIs) (4.7 kg, 95%CI 4.4-5.1) were associated with greater mean predicted weight gain compared to non-nucleoside reverse transcriptase inhibitors (NNRTIs) (2.7 kg, 95%CI 2.4-2.9). Differences persisted when limiting analyses to TDF-containing regimens and excluding EFV. Among INSTIs, mean predicted weight gain was numerically highest with bictegravir (6.9 kg, 95%CI 5.8-7.9), followed by dolutegravir (5.3 kg, 95%CI 4.8-5.9), raltegravir (4.5 kg, 95%CI 3.8-5.3), and elvitegravir (4.0 kg, 95%CI 3.6-4.5). Participants receiving TAF with INSTIs gained more than those on TDF. Black females on bictegravir or dolutegravir with TAF had the highest gain at 2 years (10.0 kg, 95%CI 7.4-12.6). CONCLUSIONS:Weight gain with non-EFV NNRTIs was lower than with PIs and INSTIs, with the greatest increases observed among Black females starting TAF with contemporary INSTIs.

INTRODUCTION We investigated whether Alzheimer's disease and related dementias (ADRD) are more common among transfeminine (TF) adults than among demographically similar cisgender people enrolled in the same health system. METHODS We analyzed electronic health records of 856 TF adults aged 65+ and matched cisgender men (CM) and cisgender women (CW) and compared ADRD prevalence across groups by calculating enrollment-adjusted odds ratios (aOR) and 95% confidence intervals (CI). RESULTS The aOR of ADRD among TF adults were 1.39 (95% CI: 0.99-1.97) relative to CM and 1.29 (95% CI: 0.92-1.82) relative to CW referents. For TF adults with evidence of receiving gender-affirming hormone therapy (GAHT) receipt, the associations were slightly stronger: 1.75 (1.13-2.69) and 1.70 (1.11-2.60). Results restricted to minoritized ethnoracial groups appeared smaller, but imprecise. DISCUSSION These findings suggest that ADRD diagnosis and management may represent a priority in the healthcare of older TF people, particularly those with a history of GAHT.

Importance:Acne commonly affects transgender individuals prescribed gender-affirming hormone therapy, yet population-level incidence data remain limited. Objective:To compare the incidence of acne and moderate to severe acne in transgender individuals, including those initiating gender-affirming hormone therapy, with matched cisgender individuals. Design, Setting, and Participants:A retrospective matched cohort study of electronic health record data was carried out across 4 Kaiser Permanente health plan regions. Index dates were the earliest documentation of transgender status, ranging from January 2006 to February 2022, with up to 5 years of follow-up. Participants included individuals without baseline acne, transmasculine individuals, and transfeminine individuals matched with cisgender male and female individuals. Analyses were conducted from November 2024 to November 2025. Main Outcomes and Measures:The primary outcome was incident acne (first acne-coded visit after the index date). The secondary outcome was moderate to severe acne (incident acne followed by prescription fill for isotretinoin or 30 or more days of oral antibiotics). Exploratory analyses compared acne care utilization by transgender status. Results:Overall, 280 997 individuals without baseline acne, including 11 234 transmasculine and 9486 transfeminine individuals, were matched to 132 462 cisgender men and 127 815 cisgender women on age, self-reported race and ethnicity (25 340 Asian [9.0%]; 23 234 non-Hispanic Black [8.3%]; 56 876 Hispanic [20.2%]; 153 666 non-Hispanic White [54.7%]; 6989 other [2.5%]), enrollment year, and region. Of these, 12 156 transgender individuals initiated gender-affirming hormone therapy after the index date. The mean (SD) age at index date was 27.7 (10.0) years for transmasculine individuals and 33.2 (13.5) years for transfeminine individuals. Cumulative incidence of acne at 5 years was 15.8% in transmasculine individuals, 3.8% in matched cisgender male individuals, and 10.5% in matched cisgender female individuals and was 6.0% in transfeminine individuals, 2.9% in matched cisgender men, and 8.4% in matched cisgender women. Acne risk in transmasculine individuals was highest in the first year after testosterone initiation (vs matched cisgender male individuals: hazard ratio (HR), 8.29; 95% CI, 7.11-9.68; vs matched cisgender female individuals: HR, 2.63; 95% CI, 2.33-2.97) and remained higher in subsequent years than among cisgender men (HR, 5.29; 95% CI, 4.45-6.28) and cisgender women (HR, 1.69; 95% CI, 1.46-1.96). Acne risk was higher in transfeminine individuals after starting estradiol than cisgender men (HR, 1.56; 95% CI, 1.31-1.84) and lower than cisgender women (HR, 0.53; 95% CI, 0.46-0.62). Moderate to severe acne incidence followed similar patterns. Conclusions and Relevance:This study revealed distinct acne incidence patterns in transgender individuals compared with matched cis male and female cohorts. Clinicians should monitor and treat acne in transmasculine individuals prescribed testosterone per clinical guidelines, particularly during the first year. Clinicians should also recognize that acne may develop in transfeminine individuals after estradiol initiation.

Background:Delayed HIV diagnosis and treatment may increase the risk of developing dementia later in life. We evaluated whether low CD4 count (<200 cells/µL) prior to first known use of antiretroviral therapy (ART)-a proxy for delayed HIV diagnosis or treatment-was associated with risk of age-associated dementia. Methods:We conducted a retrospective cohort study (2000-2023) among U.S. adults with HIV aged ≥50 years, all on ART and dementia-free at baseline. The exposure of interest was low pre-ART CD4 count. Dementia diagnoses were identified via electronic health records. The association of low pre-ART CD4 with incident dementia was evaluated using Fine-Gray subdistribution hazard models, accounting for the competing risk of death and adjusting for sociodemographic and clinical confounders. Sub-analyses examined dementia risk among individuals who had low pre-ART CD4 but demonstrated CD4 recovery to ≥500 cells/µL after ART initiation. Results:Among 21 354 people with HIV on ART (mean age 54; 87% men; 46% White, 23% Black, 21% Hispanic, 4% Asian), 30% had pre-ART CD4 < 200 cells/µL. Over a mean follow-up of 7 years, 618 were diagnosed with dementia. Low pre-ART CD4 was associated with greater risk of dementia (adjusted hazard ratio [aHR]: 1.33, 95% CI: 1.13-1.57). CD4 recovery with ART attenuated but did not eliminate dementia risk (aHR: 1.17, 95% CI: 0.85-1.60). Conclusions:Low CD4 count prior to ART-reflecting delayed HIV diagnosis or treatment-was associated with higher dementia risk. Continuing assertive HIV screening and prompt ART initiation in the community will be important to support long-term cognitive health in people with HIV.

INTRODUCTION:Alcohol screenings and excessive alcohol use among transgender adults remain understudied. Prior research is limited by small samples, poor generalizability, and lack of validated gender identity data. This study examined alcohol screening rates and excessive use among transgender and cisgender adult members of a large, integrated health system. METHODS:Electronic health record data from Kaiser Permanente Northern California (2013-2021) were analyzed. Gender identity was previously verified. Primary outcomes included completion of a standardized alcohol screening over a 2-year follow-up and alcohol use exceeding national sex- and age-based limits. Concordance between screening parameters and sex assigned at birth versus gender identity was explored. RESULTS:Of the 7,933 transgender and 128,577 cisgender adults studied, 76% and 66% received alcohol screening, respectively. Transgender individuals had higher alcohol screening rates (adjusted hazard ratio=1.08; 95% CI=1.05, 1.11), and 68.3% were screened using drinking limits based on sex assigned at birth. Among those screened, excessive alcohol use was lower among transgender individuals (8.2% vs 10.6%; adjusted prevalence ratio=0.85; 95% CI=0.78, 0.93). Prevalence of excessive alcohol use was similar regardless of whether screening parameters aligned with sex assigned at birth or gender identity. CONCLUSIONS:Transgender individuals were more likely to receive alcohol screening, and those screened had lower prevalence of excessive alcohol use than cisgender comparators. This study adds to the limited literature on how transgender populations are screened in a real-world clinical setting and may inform future alcohol screening practices and guideline development.