Adverse childhood experiences and risk of living with HIV among lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) people: a cross-sectional study.

Background: Adverse childhood experiences and HIV represent interconnected public health issues. However, studies characterizing the prevalence and associations remain limited among sexual and gender minorities (i.e., lesbian, gay, bisexual, transgender, and queer/questioning individuals, collectively referred to as LGBTQ+), especially in China. This study aimed to examine adverse childhood experiences patterns, association with risk of living with HIV, and potential mediating factors among LGBTQ+ individuals in China. Methods: An online survey was provided to LGBTQ+ people and the eligibility criteria were aged 16 or older and self-identified as LGBTQ+. Participants were enrolled in Chengdu, China, between August 2023 and March 2025. Adverse childhood experiences were assessed using a validated 10-item scale. Living with HIV was based on self-report. Cluster analysis based on the k-modes algorithm was used to identify distinct patterns of adverse childhood experiences. Unconditional logistic regression models were employed to explore the associations between adverse childhood experiences and living with HIV. Mediation analyses were conducted to quantify the mediating effects of modifiable psychosocial factors on the observed associations. Sex assigned at birth, age, ethnicity, number of siblings, and gender identity were adjusted in the above analyses. Findings: A total of 10,305 LGBTQ+ individuals were enrolled and 8384 met eligibility criteria. The median age of the participants was 26 years (interquartile range, 23-31 years). Overall, 63.5% (5325/8384) of participants reported at least one adverse childhood experience. Among specific adverse childhood experiences, physical abuse was most prevalent (34.4%, 2884/8384), closely followed by emotional abuse (34.1%, 2858/8384). Exposure to any adverse childhood experiences was significantly associated with higher risks of living with HIV (adjusted odds ratio [aOR] = 1.38, 95% CI: 1.14-1.66). Subgroup analyses revealed that exposure to any ACE was significantly associated with living with HIV risk among male (1.34, 1.11-1.61), cisgender gay man (1.38, 1.08-1.76) and queer/questioning + individuals (1.57, 1.06-2.33). Mediation analysis revealed that substance use and mental health problems were significant mediators of the association between specific ACEs and living with HIV. Interpretation: Adverse childhood experiences were associated with higher burden of living with HIV among LGBTQ+ people in China. These findings highlight the importance of integrating trauma-informed, identity-tailored sexual-health services into LGBTQ+ -competent care pathways. Funding: National Natural Science Foundation of China; Natural Science Foundation of Sichuan; West China Hospital, Sichuan University; Jiangsu Provincial Professorship Career Development Grant; Nanjing Medical University Career Development Grant.