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HIV in Transgender Patients

Anita Radix, MD MPH Callen Lorde Community Health Center. HIV in Transgender Patients. Learning Objectives. At the conclusion of this presentation, participants should be able to: •  Adapt and implement HIV prevention strategies for persons of transgender experience

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HIV in Transgender Patients

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  1. Anita Radix, MD MPH Callen Lorde Community Health Center HIV in Transgender Patients

  2. 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

  3. Off Label Disclosure This presentation will include discussion of the following non-FDA-approved or investigational uses of products/devices: • Cross gender hormone therapy

  4. 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

  5. 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

  6. Background information Terminology What is gender?

  7. Gender vs. Sex Traditional • Gender is binary (M/F) • Synonymous with sex (chromosomes, genitalia) New • Gender is a spectrum • Defined by several criteria • Separate from sex

  8. Gender Return

  9. 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

  10. 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

  11. Trans-terminology Common terms to describe transition: • MTF, male-to-female (trans women) • FTM, female-to-male (trans men)

  12. Medical Terms • Gender Dysphoria (DSM III) or Gender Identity Disorder (DSM IV) • Often perceived as pathologizing • DSM-V revising definition to Gender Incongruence (APA, 2010) • Sex Reassignment Surgery (SRS) or Gender Confirming Surgery (GCS)

  13. 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

  14. 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

  15. Transgender Epidemiology

  16. Demographics No reliable data: Prevalence rates of MTF transsexualism • 1:500 – 1:20001 • 1/11,900, based on medical/surgical treatment2 • 1:2,900 surgical treatment3 • Transgender prevalence higher

  17. 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

  18. HIV Incidence • High HIV incidence 3.4-7.8% per 100 person-years9,10 • African American transwomen 18.1% per 100 person-years10

  19. Predictors of HIV infectionamong Transgender Women • African-American race 5,7 • Syphilis5 • High number of sex partners7 • Less than high school education7 • History of sex work8 • Unemployment8

  20. Return

  21. Robert Eads (1945-1999) Care for ovarian cancer delayed for one year because more than two dozen doctors refused to treat him. Tyra Hunter (1970-1995) Died in Washington DC after paramedics withdrew treatment at scene of car accident. Brandon Teena(1972-1993) Raped and murdered by John Lotter and Marvin Nissen after they discovered he was anatomically female. Transphobia – an irrational fear of gender-different people leading to systematic discrimination

  22. Initial AssessmentMedical 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

  23. Initial AssessmentExam 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”

  24. Initial AssessmentCounseling • Counseling on minimizing modifiable risk factors • Smoking cessation • Alcohol and drug use harm reduction • STI prevention • Needle use and sharing • Silicone use

  25. 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

  26. 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)?

  27. Ethinyl estradiol may decrease levels of: amprenavir (Agenerase), fosamprenavir (Lexiva) Selzentry (Maraviroc) – no significant effect on ethinyl estradiol levels DHHS, 2009

  28. Adherence • Lower adherence rates noted among HIV+ MTF 12 • Negative provider 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

  29. Cross-Gender Hormone Therapy What hormones are used and what do they do?

  30. Gender Confirming Hormone Therapy Estrogens • Conjugated Estrogens : 1.25-10mg po qd or divided as bid • Estradiol: 2-8 mgpo qd or divided as bid • Estradiol Patch : 0.1-0.3mg q3-7 days • EstradiolValerate 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

  31. Adverse Effects of Hormone Therapy Risks (anecdotal): • Thromboembolism • Increased risk of breast cancer? • Hyperprolactinemia/pituitary adenoma • Hepatotoxicity • Cardiovascular risk? • Infertility • Anxiety/depression • Gallstones • Hypertension

  32. Safety of Hormone Therapy • Very few published studies of long-term safety of MTF or FTM regimens • Prospective study from The Netherlands13 • 30 years follow-up 2236 MTF, and 876 FTM. • MTF: ethinyl estradiol, 6–8% increase venous thrombosis

  33. 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]

  34. 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]

  35. 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

  36. Creating a Welcoming Space • Use language that is sensitive to transgender identities • Trans-sensitive intake forms – allow clients write in their gender • Become familiar with the gender pronoun your patient prefers • Cultural competency training for staff • Have trans-sensitive brochures, prevention information available • Be familiar with local resources available to assist with name/gender change

  37. Thank you!

  38. 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 ScandinavicaVolume 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 care use, and mental health status of transgender persons: implications for public health intervention. (2001 Jun). American Journal of Public Health.;91(6):915-21. 8. Xavier, J.M. (2000). The Washington, DC. Transgender Needs Assessment Survey Final Report for Phase Two. Washington, DC: Administration for HIV/AIDS of the District of Columbia. at: http://www.gender.org/ 9. Simon, P., et al. HIV prevalence and incidence among male-to-female transsexuals receiving HIV prevention services in Los Angeles County. (2000 Dec). AIDS, 14, 2953-2955. 10. Kellogg, 2001) Kellogg, T., Incidence of human immunodeficiency virus among male-to-female transgendered persons in San Francisco. (2001 Dec). Journal of Acquired Immune Deficiency Syndromes;28(4):380-4. 11. DHHS 2009 http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. 12. Sevelius, J et al. Antiretroviral Therapy Adherence among transgender women living with HIV.(2010) JANAC 21(3):256-264 13. Gooren, L. Long-Term Treatment of Transsexuals with Cross-Sex Hormones: Extensive Personal Experience. (2007) J. Clin. Endocrinol. Metab. 93:19-25

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