Pharmacology and drug interactions with HIV PrEP in transgender persons receiving gender affirming hormone therapy

Drug-drug interactions between gender-affirming hormone therapy and antiretrovirals for treatment/prevention of HIV

Transgender persons face a greater burden of HIV compared to cisgender counterparts. Concerns around drug-drug interactions (DDIs) have been cited as reasons for lower engagement in HIV care and lower pre-exposure prophylaxis (PrEP) uptake among transgender populations. It is therefore imperative for hormone therapy, PrEP and antiretroviral therapy providers to understand the DDI potential between these therapies. Studies of tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) PrEP with feminizing hormone therapies (FHTs) show reduced plasma tenofovir concentrations, but intracellular concentrations of tenofovir-diphosphate are not reduced. Efficacy of PrEP is expected to be maintained despite this interaction. Masculinizing hormone therapies have no effect on tenofovir concentrations but may increase FTC to a nonclinically relevant extent. No interactions between FHT and cabotegravir or tenofovir alafenamide have been demonstrated. Administration of TDF/FTC PrEP has no effect on hormone levels in transmen or transwomen. PrEP is expected to be effective and safe in transpersons and should be provided to high-risk individuals regardless of gender affirming hormone use. Enzyme inducing/inhibiting antiretroviral therapy may decrease or increase, respectively, the concentrations of FHT and masculinizing hormone therapy. Unboosted integrase inhibitors or enzyme neutral non-nucleoside reverse transcriptase inhibitors are not expected to affect and are not affected by gender affirming hormones and can be considered in transmen and transwomen. Overlapping toxicities including weight gain, dyslipidaemia, cardiovascular disease and bone density effects should be considered, and antiretroviral modifications can be made to minimize toxicities. Interactions between supportive care medications should be assessed to avoid chelation interactions and hyperkalaemia.

Bidirectional pharmacokinetics of doravirine, tenofovir, and feminizing hormones in transgender women (IDentify): A randomized crossover trial

Transgender women may have concerns of drug interactions between feminizing hormone therapy (FHT) and antiretrovirals, leading to nonadherence. This randomized, three-period crossover, open-label, phase I trial assessed the effects of doravirine (DOR) and tenofovir disoproxil fumarate (TDF) on the pharmacokinetics (PKs) of estradiol, spironolactone, and total testosterone and vice versa in healthy transgender women. Volunteers were randomized 1:1 into two sequences containing three treatment groups (DOR, lamivudine [3TC], and TDF alone; estradiol, spironolactone, and placebo; and DOR/3TC/TDF, estradiol, and spironolactone). Eight subjects enrolled in the study and six had completed all study periods. The geometric mean ratios for DOR area under the concentration-time curve from zero to last measured concentration (AUC0-last ), maximum concentration (Cmax ), and concentration at 24 h (C24 ) were similar. However, tenofovir (TFV) AUC0-last , Cmax , and C24 moderately increased by 14%-38%. Last, estradiol AUC0-last , Cmax , and C24 were increased by 10%-13%. Whereas most 90% confidence intervals did not meet the bioequivalence bounds of 80%-125%, the point estimates fell within the intervals. Log-transformed DOR, TFV, and estradiol PK parameters computed with and without co-administration were not statistically different (p > 0.05). There were no serious adverse events. There is not a clinically significant impact of FHT on DOR/TFV PKs. Similarly, there is no observed impact on estradiol PKs and total testosterone following use of DOR/3TC/TDF.

Determinants of HIV Pre-Exposure Prophylaxis (PrEP) Retention among Transgender Women: A Sequential, Explanatory Mixed Methods Study

Transgender women (TW) face inequities in HIV and unique barriers to PrEP, an effective biomedical intervention to prevent HIV acquisition. To improve PrEP retention among TW, we examined factors related to retention using a two-phase, sequential explanatory mixed methods approach. In Phase I, we used data from a trial of 170 TW who were provided oral PrEP to examine predictors of 24-week retention. In Phase II, we conducted 15 in-depth interviews with PrEP-experienced TW and used thematic analysis to explain Phase I findings. In Phase I, more participants who were not retained at 24 weeks reported sex work engagement (18% versus 7%) and substantial/severe drug use (18% versus 8%). In Phase II, participants reported drug use as a barrier to PrEP, often in the context of sex work, and we identified two subcategories of sex work. TW engaged in "non-survival sex work" had little difficulty staying on PrEP, while those engaged in "survival sex work" struggled to stay on PrEP. In Phase I, fewer participants not retained at 24 weeks reported gender-affirming hormone therapy (GAHT) use (56% versus 71%). In Phase II, participants prioritized medical gender affirmation services over PrEP but also described the bidirectional benefits of accessing GAHT and PrEP. TW who engaged in "survival sex work" experience barriers to PrEP retention (e.g., unstable housing, drug use) and may require additional support to stay in PrEP care.

Assessing Knowledge of, Experience with, and Willingness to Prescribe Hormone Therapy to Transgender Individuals with HIV: A National Survey of HIV Practitioners

Purpose

The purpose of this study was to determine if human immunodeficiency virus (HIV) practitioners offer gender-affirming hormone therapy (GAHT) to their transgender patients living with HIV, as previous studies have shown that these patients are more likely to be virally suppressed and retained in care.

Methods

We conducted an online survey sent to 2570 HIV practitioners who attended an International Antiviral Society-USA event between 2017 and 2019. We also assessed demographics, transgender care training, comfort, prescribing practices, and knowledge.

Results

Respondents (N=385) were mainly primary care (49%) and infectious disease (ID)/HIV (42%) practitioners. Fifty-seven percent prescribed GAHT to transgender people living with HIV, but only 7% received formal training. Thirty-five percent were ID/HIV, 60% were primary care, and 5% were other specialty practitioners. Most felt that it would be beneficial to have formal education in GAHT practices during training (83%). There were statistically significant differences in GAHT education, experiences, knowledge, and interest in future training and prescribing by health care specialty. Commonly cited barriers to providing therapy included lack of training (33%), lack of transgender people living with HIV in practice (18%), and lack of qualified mental health professionals (15%).

Conclusion

This survey is the first to assess GAHT practices among HIV practitioners from across the United States. The majority of those surveyed prescribe GAHT to their transgender patients living with HIV. Although most felt comfortable doing so, few had formal training and knowledge scores were low. We advocate for the integration of GAHT education into formal training programs and offer resources for those who wish to pursue education.

Clinical Relevance of Drug Interactions in People Living with Human Immunodeficiency Virus on Antiretroviral Therapy-Update 2022: Systematic Review

BACKGROUND

The clinical outcomes of antiretroviral drugs may be modified through drug interactions; thus, it is important to update the drug interactions in people living with HIV (PLHIV).

AIM

To update clinically relevant drug interactions in PLHIV on antiretroviral therapy with novel drug interactions published from 2017 to 2022.

METHODS

A systematic review in Medline/PubMed database from July 2017 to December 2022 using the Mesh terms antiretroviral agents and drug interactions or herb-drug interactions or food-drug interactions. Publications with drug interactions in humans, in English or Spanish, and with full-text access were retrieved. The clinical relevance of drug interactions was grouped into five levels according to the gravity and probability of occurrence.

RESULTS

A total of 366 articles were identified, with 219 (including 87 citation lists) were included, which allowed for the identification of 471 drug interaction pairs; among them, 291 were systematically reported for the first time. In total 42 (14.4%) and 137 (47.1%) were level one and two, respectively, and 233 (80.1%) pairs were explained with the pharmacokinetic mechanism. Among these 291 pairs, protease inhibitors (PIs) and ritonavir/cobicistat-boosted PIs, as well as integrase strand transfer inhibitors (InSTIs), with 70 (24.1%) and 65 (22.3%) drug interaction pairs of levels one and two, respectively, were more frequent.

CONCLUSIONS

In PLHIV on antiretroviral therapy, we identify 291 drug interaction pairs systematically reported for the first time, with 179 (61.5%) being assessed as clinically relevant (levels one and two). The pharmacokinetic mechanism was the most frequently identified. PIs, ritonavir/cobicistat-boosted PIs, and InSTIs were the antiretroviral groups with the highest number of clinically relevant drug interaction pairs (levels one and two).

Estradiol and Spironolactone Plasma Pharmacokinetics Among Brazilian Transgender Women Using HIV Pre-Exposure Prophylaxis: Analysis of Potential Interactions

BACKGROUND AND OBJECTIVE

An important barrier to HIV prevention among transgender women (TGW) is the concern that oral pre-exposure prophylaxis (PrEP) negatively affects the efficacy of feminizing hormone therapy (FHT). We aimed to assess the impact of PrEP on FHT pharmacokinetics (PK) among TGW from Brazil.

METHODS

We performed a drug-drug interaction sub-study among TGW enrolled in a daily oral PrEP demonstration study (PrEParadas, NCT03220152). Participants had a first PK assessment (PK1) 15 days after FHT (estradiol valerate 2-6 mg plus spironolactone 100-200 mg) initiation and then started PrEP (tenofovir disoproxil fumarate 300 mg/emtricitabine 200 mg). A second PK evaluation was performed 12 weeks later (PK2). Blood samples were collected prior and after the directly observed dosing (0, 0.5, 1, 2, 4, 6, 8, and 24 hours). Pharmacokinetic parameters of estradiol, spironolactone, and metabolites were estimated by non-compartmental analysis (Monolix 2021R2, Lixoft®) and compared as geometric mean ratios (GMRs, 90% confidence interval [CI]).

RESULTS

Among 19 TGW who completed the substudy, median age was 26 years (interquartile range: 23-27.5). Estradiol area under the plasma concentration-time curve (AUCτ) and trough concentrations did not differ between PK1 and PK2 evaluations (GMR [90% CI]: 0.89 [0.76-1.04] and 1.06 [0.94-1.20], respectively). Spironolactone and canrenone AUCτ were statistically lower at PK2 than PK1 (0.76 [0.65-0.89] and 0.85 [0.78-0.94], respectively). Canrenone maximum concentration was also lower at PK2 than PK1 (0.82 [0.74-0.91]).

CONCLUSION

Estradiol PK was not influenced by PrEP concomitant use. The small differences observed in some spironolactone and canrenone PK parameters should not prevent the concomitant use of estradiol-based FHT and PrEP.

TRIAL REGISTRATION

This trial (NCT03220152) was registered on July 18, 2017.

Mapping Community-Engaged Implementation Strategies with Transgender Scientists, Stakeholders, and Trans-Led Community Organizations

PURPOSE OF REVIEW

Pre-exposure prophylaxis (PrEP) represents one of the most effective methods of prevention for HIV, but remains inequitable, leaving many transgender and nonbinary (trans) individuals unable to benefit from this resource. Deploying community-engaged PrEP implementation strategies for trans populations will be crucial for ending the HIV epidemic.

RECENT FINDINGS

While most PrEP studies have progressed in addressing pertinent research questions about gender-affirming care and PrEP at the biomedical and clinical levels, research on how to best implement gender-affirming PrEP systems at the social, community, and structural levels remains outstanding. The science of community-engaged implementation to build gender-affirming PrEP systems must be more fully developed. Most published PrEP studies with trans people report on outcomes rather than processes, leaving out important lessons learned about how to design, integrate, and implement PrEP in tandem with gender-affirming care. The expertise of trans scientists, stakeholders, and trans-led community organizations is essential to building gender-affirming PrEP systems.

Inclusion of Transgender and Gender Diverse People in Phase III Trials: Examples from HIV Pharmacologic Prevention Studies

Although at least 25 million adults are transgender worldwide, few phase III clinical trials have enrolled transgender and gender diverse (TGD) people. HIV is the only therapeutic area to include TGD people intentionally in phase III randomized clinical trials during the development of certain newer HIV pharmacologic prevention interventions. Pharmacologic assessments for HIV prevention efficacy in TGD populations are important, as there may be specific considerations for product use and potential interactions with hormone therapies. Herein, we summarize ongoing and completed phase III HIV trials that included TGD people as part of the study population, we examine investigators' strategies for recruiting and engaging TGD priority populations in these phase III trials, and we comment on the implications of these studies for prioritizing TGD populations in clinical pharmacology research within the phase III clinical trial landscape.

PrEP Use and Adherence among Transgender Persons in Chicago, IL (SHIPP Study, 2014-2018, USA)

Few studies investigating daily oral preexposure prophylaxis (PrEP) focus on transgender persons. The Sustainable Health Center Implementation PrEP Pilot (SHIPP) Study included a large observational cohort of transgender persons with implications for PrEP in the United States. We examined data from SHIPP's observational cohort and its Medication Adherence Substudy (MAS) to understand adherence among transgender participants in Chicago, IL. We assessed adherence by the proportion of days covered (PDC) for PrEP medication prescriptions, self-reported interview data, and concentrations of intracellular tenofovir diphosphate (TFV-DP) in dried blood spot (DBS) samples. Between 2014 and 2018, there were 510 transgender participants, 349 (68.4%) transgender women and 152 (29.8%) transgender men. Forty-five of these participants were enrolled in the MAS, 31 (68.9%) transgender women and 9 (20.0%) transgender men. By the 3-month follow up, 100% of MAS participants who completed an interview reported taking 4 or more doses of PrEP in the previous week. At 6, 9, and 12 months, taking 4 or more doses in the past week was reported by 81.0%, 94.1%, and 83.3% of participants, respectively. Results from TFV-DP DBS indicated that fewer participants reached the same level of adherence (4 or more doses/week) at clinical visits compared to self-report and even fewer participants reached this level of adherence based on the calculated PDC. Among participants who remained on PrEP throughout the study, DBS adherence levels declined after the first three months. There remains a critical need to develop strategies to address barriers and interventions that support PrEP adherence among transgender people.

Parental Concerns of Their Sexual and Gender Minority Adolescents Using HIV Pre-Exposure Prophylaxis

Although parents of sexual and gender minority (SGM) adolescents are key stakeholders in SGM adolescents using HIV pre-exposure prophylaxis (PrEP), there is limited understanding of parental concerns and attitudes about their SGM adolescents taking PrEP. Fifty-four parents in the West South Central region of the U.S. completed an online, mixed-method, cross-sectional questionnaire to explore their concerns and questions about PrEP. Quantitative and qualitative results show that participants were more concerned about side effects, drug interactions, (non)adherence, and eligibility and duration of PrEP. Parents are less worried about picking PrEP from a pharmacy or returning to follow-up lab testing every three months. Most parents reported receiving medication information their adolescent takes from a medical provider and the media. Findings from this study can inform the development of parent-based PrEP interventions. Without further parent-based research and programming, SGM adolescents may continue to be disproportionately affected by HIV.

Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2022 Recommendations of the International Antiviral Society-USA Panel

Importance

Recent advances in treatment and prevention of HIV warrant updated recommendations to guide optimal practice.

Objective

Based on a critical evaluation of new data, to provide clinicians with recommendations on use of antiretroviral drugs for the treatment and prevention of HIV, laboratory monitoring, care of people aging with HIV, substance use disorder and HIV, and new challenges in people with HIV, including COVID-19 and monkeypox virus infection.

Evidence Review

A panel of volunteer expert physician scientists were appointed to update the 2020 consensus recommendations. Relevant evidence in the literature (PubMed and Embase searches, which initially yielded 7891 unique citations, of which 834 were considered relevant) and studies presented at peer-reviewed scientific conferences between January 2020 and October 2022 were considered.

Findings

Initiation of antiretroviral therapy (ART) is recommended as soon as possible after diagnosis of HIV. Barriers to care should be addressed, including ensuring access to ART and adherence support. Integrase strand transfer inhibitor-containing regimens remain the mainstay of initial therapy. For people who have achieved viral suppression with a daily oral regimen, long-acting injectable therapy with cabotegravir plus rilpivirine given as infrequently as every 2 months is now an option. Weight gain and metabolic complications have been linked to certain antiretroviral medications; novel strategies to ameliorate these complications are needed. Management of comorbidities throughout the life span is increasingly important, because people with HIV are living longer and confronting the health challenges of aging. In addition, management of substance use disorder in people with HIV requires an evidence-based, integrated approach. Options for preexposure prophylaxis include oral medications (tenofovir disoproxil fumarate or tenofovir alafenamide plus emtricitabine) and, for the first time, a long-acting injectable agent, cabotegravir. Recent global health emergencies, like the SARS-CoV-2 pandemic and monkeypox virus outbreak, continue to have a major effect on people with HIV and the delivery of services. To address these and other challenges, an equity-based approach is essential.

Conclusions and Relevance

Advances in treatment and prevention of HIV continue to improve outcomes, but challenges and opportunities remain.

Clinical Pharmacological Considerations in Transgender Medicine

Transgender medicine is a growing clinical field. Hormone therapy (testosterone or estrogen treatment) is part of the standard of gender-affirming medical care, yet clinical pharmacological knowledge in transgender medicine is lacking. Herein, we summarize available clinical and pharmacologic data for hormone therapy among transgender and gender diverse people.

Impact of feminizing hormone therapy on tenofovir and emtricitabine plasma pharmacokinetics: a nested drug-drug interaction study in a cohort of Brazilian transgender women using HIV pre-exposure prophylaxis

OBJECTIVES

Potential interactions between feminizing hormone therapy (FHT) and pre-exposure prophylaxis (PrEP) may be a barrier to PrEP use among transgender women (TGW). We aimed to assess the impact of FHT on PrEP plasma pharmacokinetics (PK) among TGW.

METHODS

This was a PK substudy of the effects of FHT on tenofovir disoproxil fumarate/emtricitabine nested to a trans-specific PrEP demonstration study (NCT03220152). Participants were assigned to receive PrEP only (noFHT) or standardized FHT (sFHT; oestradiol valerate 2-6 mg plus spironolactone 100-300 mg) plus PrEP for 12 weeks, after which they could start any FHT (aFHT). Short- and long-term PK assessment occurred at Weeks 12 and 30-48, respectively (plasma samples prior and 0.5, 1, 2, 4, 6, 8 and 24 h after dose). Non-compartmental PK parameters of tenofovir and emtricitabine were compared as geometric mean ratios (GMRs) between noFHT and PrEP and FHT (sFHT at short-term PK; aFHT at long-term PK) participants.

RESULTS

No differences in tenofovir and emtricitabine plasma PK parameters were observed between the short-term PK of noFHT (n = 12) and sFHT participants (n = 18), except for emtricitabine Cmax [GMR: 1.15 (95% CI: 1.01-1.32)], or between noFHT short-term PK and aFHT long-term PK (n = 13). Most participants were on oestradiol valerate 2 mg at the short-term PK (56%) and 4 mg at the long-term PK (54%). Median (IQR) oestradiol levels were 56.8 (43.2-65.4) pg/mL at short-term PK (sFHT) and 44.8 (24.70-57.30) pg/mL at long-term PK (aFHT). No participants in this analysis seroconverted during the study.

CONCLUSIONS

Our results indicate no interaction of FHT on tenofovir levels, further supporting PrEP use among TGW using FHT.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

PrEP Use and Adherence Among Transgender Patients

This cross-sectional study used 2012 to 2019 Oregon Medicaid claims to estimate the prevalence of PrEP use and identify determinants of high adherence across transgender and cisgender men and women. Gender identity (cisgender woman/man; transgender, assigned female sex at birth [AFAB]; transgender, assigned male sex at birth [AMAB]) was based on medical history and enrollment records. Proportion of days covered ≥ 0.80 was considered high adherence to PrEP. The association between gender identity and PrEP uptake or high adherence was estimated using multivariable logistic regression. 1555 PrEP users, including 171 (11.0%) cis women, 1171 (75.3%) cis men, 67 (4.3%) AFAB, and 146 (9.4%) AMAB individuals, were included. The probability of PrEP use per 10,000 people was highest in transgender groups (AMAB 546.8, 95% CI 462.4-631.3; AFAB 226.5, 95% CI 173.4-279.6), followed by cisgender men (20.6, 95% CI 19.4, 21.8) and women (2.6, 95% CI 2.2, 3.0). High adherence was significantly lower in AMAB recipients (72.6%) than cisgender women (86.0%) and cisgender men (82.2%). Among the 279 PrEP users with female on their enrollment record, 76 (27.2%) were AMAB, while among the 1276 PrEP users with male on their enrollment record, 35 (2.7%) were AFAB. This demonstrates the importance of surveillance methods that take gender identity into account in addition to sex assigned at birth. There were significant differences in PrEP use and adherence by gender identity. PrEP surveillance, outreach, and prescribing practices must consider gender identity-unique risk factors.

Low PrEP adherence despite high retention among transgender women in Brazil: the PrEParadas study

Introduction

We aimed to evaluate daily oral pre‐exposure prophylaxis (PrEP) uptake, retention, and adherence and predictors of study non‐attendance and low PrEP adherence in a Brazilian trans‐specific 48‐week study (PrEParadas).

Methods

We enrolled transgender women (TGW) engaging in high‐risk sexual behaviours between August 2017 and December 2018. PrEP adherence was based on tenofovir diphosphate concentrations in dried blood spots (DBS). We used random effects logistic regression models and ordinal models to estimate the odds of having a missed visit and of low PrEP adherence, respectively. Multivariable models were adjusted for variables with p‐value<0.10 in the univariate analysis.

Results

From the 271 eligible, 130 participants were enrolled in the study (PrEP uptake: 48%), out of which 111 (85.4%) were retained at 48 weeks. Multivariable model for study non‐attendance included study visit, age, main sexual partner and stimulant use. The odds of missing a visit increased after the week 24. Participants aged 18–24 (adjusted odds ratio [aOR] = 8.76, 95% CI: 2.09–36.7) and 25–34 years (aOR = 6.79, 95% CI: 1.72–26.8) compared to TGW aged 35+ years had significantly higher odds of having a missed visit. The odds of a missed visit were higher among participants reporting stimulant use (aOR = 4.99, 95% CI: 1.37–18.1) compared to no stimulant use. DBS levels at week 48 showed that 42 (38.5%), 14 (12.8%) and 53 (48.6%) of 109 participants had low, moderate and high PrEP adherence. Multivariable model for low PrEP adherence included study visit, age, schooling, race/colour, housing, binge drinking, stimulant use, feminizing hormone therapy (FHT) use and received text message. Low PrEP adherence was significantly higher among participants with less years of schooling (aOR = 6.71, 95% CI: 1.30–34.5) and had a borderline association with Black colour/race (aOR = 6.72, 95% CI: 0.94–47.8). Participants using the FHT available at the site had decreased odds of low PrEP adherence (aOR = 0.38, 95% CI: 0.16–0.88). No participant seroconverted over the course of the study.

Conclusions

Although high PrEP retention can be achieved in a gender‐affirming setting, PrEP adherence may be an important challenge faced among TGW due to social disparities. The scale‐up of prevention tools like PrEP will have to address systemic social determinants as these stand as important barriers for TGW's access to health services.

A qualitative assessment in acceptability and barriers to use pre-exposure prophylaxis (PrEP) among men who have sex with men: implications for service delivery in Vietnam

Background

HIV Pre-exposure prophylaxis (PrEP) is being considered for implementation among MSM nationwide in Vietnam. However, there may be concerns about potential obstacles for PrEP adherence among Vietnamese MSM. This study aims to assess the acceptability to use PrEP, potential barriers and facilitators, and the preferences for PrEP service accessibility and delivery among Vietnamese MSM.

Methods

Four focus group discussions (FGDs) were conducted with 30 HIV-negative MSM in January 2018 in Hanoi, Vietnam. FGDs explored MSM’s awareness regarding PrEP, perceived benefits and barriers of PrEP use, and willingness to use PrEP. FGDs were audio-recorded and transcribed verbatim. Content analysis was used.

Results

The mean age of participants was 23.9 years old. Most participants realized the advantages of PrEP given its efficacy in HIV risk reduction and expressed high motivation and interest to use PrEP in the future. PrEP was considered as a supplement alongside condoms. Common concerns about PrEP included side-effects, forgetting to take the pill daily, stigmatization due to using PrEP, negative attitudes toward PrEP from other MSM and accessibility of PrEP. Participants would prefer an injectable PrEP regime if available as it was seen as easier to adhere to. Concerns were also raised that PrEP usage could be interpreted as an indication of engaging in sexual risk behavior for HIV, potentially causing suspicion in love relationships or by family and friends. Participants preferred to receive PrEP in civil business organizations and MSM-friendly clinics, and recommended that pharmacy stores would not be suitable for PrEP implementation due to lack of trust and fear of fake drugs.

Conclusion

This study indicated a high level of willingness to use PrEP among MSM in Vietnam in combination with condom. Strategies to raise awareness of PrEP, reduce stigma towards PrEP, and improve the accessibility among MSM in Vietnam is needed. Existing MSM-friendly clinics were recommended to implement PrEP programs in Vietnam.

A Review of Recent HIV Prevention Interventions and Future Considerations for Nursing Science

ABSTRACT

As our knowledge of HIV evolved over the decades, so have the approaches taken to prevent its transmission. Public health scholars and practitioners have engaged in four key strategies for HIV prevention: behavioral-, technological-, biomedical-, and structural/community-level interventions. We reviewed recent literature in these areas to provide an overview of current advances in HIV prevention science in the United States. Building on classical approaches, current HIV prevention models leverage intimate partners, families, social media, emerging technologies, medication therapy, and policy modifications to effect change. Although much progress has been made, additional work is needed to achieve the national goal of ending the HIV epidemic by 2030. Nurses are in a prime position to advance HIV prevention science in partnership with transdisciplinary experts from other fields (e.g., psychology, informatics, and social work). Future considerations for nursing science include leveraging transdisciplinary collaborations and consider social and structural challenges for individual-level interventions.

Endocrine Management of Transgender Adults: A Clinical Approach

The attention to transgender medicine has changed over the last decade and the interest is most likely going to increase in the future due to the fact that gender-affirming treatments are now being requested by an increasing number of transgender people. Even if gender-affirming hormone therapy (GAHT) is based on a multidisciplinary approach, this review is going to focus on the procedures adopted by the endocrinologist in an out-clinic setting once an adult patient is referred by another specialist for ‘gender affirming’ therapy. Before commencing this latter treatment, several background information on unmet needs regarding medical and surgical outcomes should be investigated. We summarized our endocrinological clinical and therapeutic approaches to adult transgender individuals before and during GAHT based on a non-systematic review. Moreover, the possible relationships between GAHT, gender-related pharmacology, and COVID-19 are also reported.

Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2020 Recommendations of the International Antiviral Society-USA Panel

Importance

Data on the use of antiretroviral drugs, including new drugs and formulations, for the treatment and prevention of HIV infection continue to guide optimal practices.

Objective

To evaluate new data and incorporate them into current recommendations for initiating HIV therapy, monitoring individuals starting on therapy, changing regimens, preventing HIV infection for those at risk, and special considerations for older people with HIV.

Evidence Review

New evidence was collected since the previous International Antiviral (formerly AIDS) Society-USA recommendations in 2018, including data published or presented at peer-reviewed scientific conferences through August 22, 2020. A volunteer panel of 15 experts in HIV research and patient care considered these data and updated previous recommendations.

Findings

From 5316 citations about antiretroviral drugs identified, 549 were included to form the evidence basis for these recommendations. Antiretroviral therapy is recommended as soon as possible for all individuals with HIV who have detectable viremia. Most patients can start with a 3-drug regimen or now a 2-drug regimen, which includes an integrase strand transfer inhibitor. Effective options are available for patients who may be pregnant, those who have specific clinical conditions, such as kidney, liver, or cardiovascular disease, those who have opportunistic diseases, or those who have health care access issues. Recommended for the first time, a long-acting antiretroviral regimen injected once every 4 weeks for treatment or every 8 weeks pending approval by regulatory bodies and availability. For individuals at risk for HIV, preexposure prophylaxis with an oral regimen is recommended or, pending approval by regulatory bodies and availability, with a long-acting injection given every 8 weeks. Monitoring before and during therapy for effectiveness and safety is recommended. Switching therapy for virological failure is relatively rare at this time, and the recommendations for switching therapies for convenience and for other reasons are included. With the survival benefits provided by therapy, recommendations are made for older individuals with HIV. The current coronavirus disease 2019 pandemic poses particular challenges for HIV research, care, and efforts to end the HIV epidemic.

Conclusion and Relevance

Advances in HIV prevention and management with antiretroviral drugs continue to improve clinical care and outcomes among individuals at risk for and with HIV.

Drug Interactions with Gender-Affirming Hormone Therapy: Focus on Antiretrovirals and Direct Acting Antivirals

INTRODUCTION

Gender-affirming care may include hormonal therapy to attain desired health outcomes in transgender (trans) individuals. To provide safe, affirming medical care for trans patients, health care providers must identify and manage drug-drug interactions (DDIs) between gender affirming hormonal therapy (GAHT) and other medication therapies.

AREAS COVERED

This review summarizes available data on DDIs between GAHT and antiretrovirals (ARVs) or hepatitis C direct acting antivirals (DAAs). Potential pharmacokinetic and pharmacodynamic DDIs are predicted based on GAHT, ARV, and DAA pharmacology and adverse event profiles. Clinical management strategies are discussed.

EXPERT OPINION

GAHT may be involved in pharmacokinetic and/or pharmacodynamic DDIs. Certain ARV classes (non-nucleoside reverse transcriptase inhibitors, protease inhibitors) may alter GAHT disposition, whereas selected ARVs (unboosted integrase inhibitors, doravirine, or rilpivirine) may have less impact on GAHT. DAAs may interact with GAHT, but the clinical relevance is unclear. ARV- and/or DAA-associated side effects (including depression, cardiovascular disease, hyperlipidemia) are important to consider in the clinical management of trans patients. Clinicians must evaluate potential DDIs and overlapping side effects between ARVs, DAAs and GAHT when providing care for trans patients.