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HIV in Transgender Patients HIV in Transgender Patients Anita Radix, MD MPH Callen Lorde Community Health Center Learning Objectives At the conclusion of this presentation, participants should be able to: • Adapt and implement HIV prevention strategies for persons of transgender experience • Modify evaluation and treatment approaches to ensure culturally competent delivery of HIV-related health services for your patients Off Label Disclosure This presentation will include discussion of the following non-FDA-approved or investigational uses of products/devices: • Cross gender hormone therapy Case 27 y/o HIV-infected transgender (male-to-female) woman transferring care from California. • 6 months ago CD4 420 cells/mm3 HIV RNA level of 16,000 copies/ml. • ARV naïve • PMH: HIV+ 2005, started CGHT at age 20 • Meds: spironolactone 100mg tid, Premarin 2.5mg bid The Basics • Basic terminology - what does transgender mean? • Gender vs. sexual orientation • What pronoun to use • HIV & Primary care issues • Risks/benefits hormone therapy • Creating a welcoming space Background information Terminology What is gender? 6 Gender vs. Sex Traditional • Gender is binary (M/F) • Synonymous with sex (chromosomes, genitalia) New • Gender is a spectrum • Psychological sense of oneself as male or female • May not match anatomic sex Trans-terminology •Transgender • umbrella term used to group the many gender different communities • people who transcend typical gender paradigms •Transsexual • biological men and women whose gender identity most closely matches the other gender • Sometimes used to describe persons who have undergone genital surgery Trans-terminology Transition • The process from living and being perceived as the gender assigned at birth according to the anatomical sex (M or F) to living and being perceived as the individual sees and understands themselves Trans-terminology Common terms to describe transition: • MTF, male-to-female (trans women) • FTM, female-to-male (trans men) Sexual Orientation • Part of, but not the same as, gender identity • Trans-women attracted to men and trans- men attracted to women may identify as heterosexual • Trans-women attracted to women may identify as lesbian • Trans-men attracted to men may identify as gay Transgender Epidemiology Demographics No reliable data: Prevalence rates of MTF transsexualism • 1:20001 , surgery • 1/11,900, based on medical/surgical treatment2 (Netherlands) • 1:2,900 surgical treatment3 (Singapore) Transgender prevalence • 1:5001 HIV Prevalence • No national surveillance data • Transwomen designated as MSM • Meta-analysis - HIV prevalence estimated at 11.8 (self report) to 27.7% (confirmed) among MTF4 • Higher rates among transgender sex workers - 68%5 • African American MTFs 41-63%6,7 • HIV prevalence in transgender men was found to be 3% in Washington, DC 8 and 2% in San Francisco7 HIV Incidence • High HIV incidence 3.4-7.8 per 100 person-years9,10 • African American transwomen 18.1 per 100 person-years10 Predictors of HIV infection among Transgender Women • African-American race 5,7 • Syphilis5 • High number of sex partners7 • Less than high school education7 • History of sex work8 • Unemployment8 Discrimination Sexual Wrongful Assault Incarceration Poverty Police Brutality Hate Crimes Domestic Violence Harassment Homelessness Return Transphobia – an irrational fear of gender-different people leading to systematic discrimination Tyra Hunter (1970- 1995) Died in Washington DC Robert Eads (1945- after paramedics 1999) Brandon Teena (1972- withdrew treatment at Care for ovarian cancer 1993) scene of car accident. delayed for one year because more than two Raped and murdered by dozen doctors refused to John Lotter and Marvin treat him. Nissen after they discovered he was anatomically female. Initial Assessment What is the correct pronoun? How do I know which pronoun to use? • Ask politely • What’s the presenting gender? • Echo the language you hear; listen for new pronouns (hir, zie, s/he) • Make an effort to use the correct pronoun consistently Initial Assessment Medical History Ask about: • Hormone use, dose, duration, obtained “on the street” or prescription • Silicone injections, pump parties • Needles for injection (shared) • Psychosocial issues: depression, PTSD, support network, employment, sex work and substance use Initial Assessment Exam Keep in mind: •Transgender patients may have had previous negative healthcare experiences •Developing trust and rapport may take longer than you are used to •Avoid genital and rectal exams on first visit, if possible. •Be sensitive to disassociation from genitals •Discuss choice of language to describe anatomy Avoid using “pre-op” and “postop” Initial Assessment Counseling • Counseling on minimizing modifiable risk factors • Smoking cessation • Alcohol and drug use harm reduction • STI prevention • Needle use and sharing • Silicone use Silicone • >25% of transgender women inject silicone to create “feminine” appearance4 • May be industrial grade and mixed with paraffin or cooking oil • Pump Parties - venue for sharing and injecting silicone • Risks – pulmonary embolism, ARDS, local infections, disfigurement, Hepatitis C, HIV Case cont. • Labs: CD4 count of 322 cells/mm3 and an HIV RNA level of 82,000 copies/ml. • She is interested in antiretroviral therapy and there are no major concerns with adherence. Genotype is fully sensitive. • What about interactions with her CGHT (Premarin 2.5mg BID, spironolactone 100mg TID)? HIV Medications That Increase HIV Medications That Decrease Estradiol and Ethinyl Estradiol and Ethinyl Estradiol Levels Estradiol Levels amprenavir (Agenerase) atazanavir/ritonavir atazanavir (Reyataz) ↑ 48% darunavir/ritonavir (Prezista) ↓44% delavirdine (Rescriptor) fosamprenavir/ritonavir (Lexiva) ↓37% efavirenz (Sustiva) ↑ 37% lopinavir/ritonavir (Kaletra) ↓ 42% etravirine (Intelence) ↑22% nelfinavir (Viracept) fosamprenavir (Lexiva) nevirapine (Viramune) ↓20% indinavir (Crixivan) ritonavir (Norvir) saquinavir (Invirase) tipranivir (Aptivus) * Ethinyl estradiol may decrease levels of: amprenavir (Agenerase), fosamprenavir (Lexiva) Selzentry (Maraviroc) – no significant effect on ethinyl estradiol levels DHHS, 2009 Adherence • Lower adherence rates noted among HIV+ MTF 12 • Negative provider/pharmacy interactions • Perceived negative effects of ARVs on hormones • Selling ARVs to purchase hormones • Psychosocial 4,5,8,12 • ↑ Homelessness • ↑ Unemployment • ↑ Substance use • ↑ Incarceration • ↑ Social isolation What hormones are used and what do they do? Gender Confirming Hormone Therapy Estrogens . Conjugated Estrogens : 1.25-10mg po qd or divided as bid . Estradiol: 2-8 mg po qd or divided as bid . Estradiol Patch : 0.1-0.3mg q3-7 days . Estradiol Valerate injection : 20-60mg IM q2wks • Ethinyl estradiol (OCP) 50-100 g qd Anti-androgen . Spironolactone 100-400mg daily, divided doses . Finasteride 1-5mg po daily . Cyproterone Acetate (Androcur) . 5- -reductase inhibitors: • Finasteride: 1-5mg daily; Dutasteride: 0.5mg daily • Flutamide (Eulexin) 50-750mg daily Safety of Hormone Therapy • Very few published studies of long-term safety of MTF or FTM regimens • Prospective study from The Netherlands 13 • 30 years follow-up 2236 MTF, and 876 FTM. • MTF: ethinyl estradiol, 6–8% increase venous thrombosis Adverse Effects of Hormone Therapy Risks (anecdotal): • Thromboembolism • Increased risk of breast cancer? • Hyperprolactinemia/pituitary adenoma • Hepatotoxicity • Cardiovascular risk? • Infertility • Anxiety/depression • Gallstones • Hypertension Appropriate Follow-up • Routine screening on all organs as long as they are present: • Testicular and prostate exam • Pap smear • Breast exams and mammograms [Evidence level C, consensus opinion] Appropriate Follow-up • Periodic laboratory testing: • MTF - q6-12 mos: fasting glucose, lipid profile, liver function, prolactin; as needed: testosterone, potassium, hemoglobin • FTM - q6-12 mos: fasting lipids, liver function, hemoglobin [Evidence level C, expert opinion] STI Screening • Assess the risk of STI’s for all transfemale patients • Offer Hepatitis B immunization • Screen at least annually* (3-6 months for highest risk) for • Syphilis • Urethral & rectal N. gonorrheoeae and C. trachomatis testing [Evidence level C, expert opinion] *MTFs who have sex with men Creating a Welcoming Space • Use Trans-sensitive language and forms • Use the gender pronoun patient prefers • Cultural competency training for staff • Become knowledgeable about resources • Name/gender change • Medical referrals • Have trans-sensitive brochures, prevention information available • Provide or refer for CGHT Thank you! References 1. Olyslager F, Conway L. On the Calculation of the Prevalence of Transsexualism. WPATH 20th International Symposium. Chicago, Illinois, 2007. 2. Bakker, A, et al. (1993) The prevalence of transsexualism in the Netherlands Acta Psychiatrica Scandinavica Volume 87 Issue 4, Pages 237 - 238 3. Tsoi WF.The prevalence of transsexualism in Singapore. Acta Psychiatr Scand. 1988 Oct;78(4):501-4. 4. Herbst, J., et al. (2007). Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS and Behavior. 5. Elifson, K., et al. Male transvestite prostitutes and HIV risk. (1993 Feb). American Journal of Public Health;83(2):260-2. 6. Nemoto, T., et al. (2004) HIV risk behaviors among male-to-female transgender persons of color in San Francisco. American Journal of Public Health;94 (7):1193-1199. 7. Clements-Nolle, K et al (2001) HIV prevalence, risk behaviors, health
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