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Background Transgender migrants (TM) often present with distinct social and clinical profiles. The extent to which HIV care trajectories are driven by gender identity per se or by underlying structural vulnerabilities may vary across healthcare settings. We aimed to describe the profile of TM living with HIV and to investigate determinants of linkage to care and loss to follow-up (LTFU) compared with cisgender migrants (CM) in a real-world care setting with established third-sector organizations providing general support to migrant populations, including outreach, health system navigation, and linkage to HIV care.Methods This retrospective study included all migrants living with HIV taken into care at the Infectious and Tropical Diseases Unit of a tertiary teaching hospital in Florence, Italy, between 1 January 2014 and 1 March 2025, with data censored on 28 February 2026. Time to linkage to care was defined as the interval from arrival in Italy to linkage for ART-experienced individuals, and from first HIV-positive test to linkage for ART-naïve individuals. Early linkage was defined as linkage within 3 months, while LTFU was defined as absence from care for ≥12 months without documented transfer.Determinants of linkage to care and LTFU were assessed using Cox regression models.Results Among 308 migrants (217 CM, 91 TM), TM were almost exclusively Latin American transgender women (98.9%), with higher out-of-status rates than CM (82.4% vs 23.9%, p<0.001) and sex work prevalence increasing from pre- to post-migration (47.2% to 75.8%, p<0.001) ( table 1) TM consistently accounted for nearly one third of new linkages to care over the study period.In multivariable analysis with an interaction between ART experience and administrative status, out-of-status condition was associated with earlier linkage to care among ART-naïve migrants (HR 1.65, 95% CI 1.01–2.69; p=0.048), while ART-experienced migrants with regular status were less likely to link early (HR 0.26, 95% CI 0.14–0.47; p<0.001). This effect was attenuated among ART-experienced out-of-status individuals (HR 0.60, 95% CI 0.35–1.02; p=0.057).Transgender identity and age were not associated with linkage timing (table 2).During 2101.7 person-years of follow-up, the incidence rate of LTFU was 4.1 per 100 person-years (95% CI 3.3–5.1), with no differences between TM and CM (figure 1). In multivariable analysis, administrative vulnerability was the only factor independently associated with LTFU (HR 2.25, 95% CI 1.28–3.94) (table 3).Conclusions In our setting HIV care trajectories among migrants appear to be shaped primarily by structural and legal vulnerability rather than gender identity. Administrative vulnerability facilitates early linkage mainly at diagnosis and represents the main driver of loss to follow-up regardless of prior ART experience, highlighting the potential role of integrated community–healthcare models in mitigating HIV care disparities.Abstract OC19 Table 1–3Abstract OC19 Figure 1Kaplan-Meier estimotes of time to loss to follow-up among migrant peopte Nwing with HIV, strotifled by gender identity