Cardiovascular Risk Profile of Transgender Women With HIV: A US Health Care Database Study

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.

Cardiovascular Risk Factors in Transgender People after Gender-Affirming Hormone Therapy

INTRODUCTION

In the last decade, healthcare for the transgender population has increased considerably in many countries thanks to depathologization movements and the easier accessibility of medical assistance. The age at which they request to start gender-affirming hormones (GAHs) is increasingly younger. The cardiovascular risk associated with hormonal treatment is a novel research field, and the published studies are heterogeneous and inconclusive. Our objective is to determine the metabolic impact of GAHs in the transgender people treated in our Gender Identity Treatment Unit.

METHODS

We designed a pre-post study to analyze changes in anthropometric parameters (weight and body mass index), analytical determinations (fasting blood glucose, glycated hemoglobin, and lipoproteins), and blood pressure control in the transgender population treated with GAHs in Puerta del Mar University Hospital. These variables were collected before and one year after hormonal therapy.

RESULTS

A total of 227 transgender people were recruited between 2017 and 2020, 97 (40.09%) transwomen and 136 (59.91%) transmen. The average age at which GAHs began was 18 years. Weight, body mass index, and blood pressure increased significantly in both genders. Transmen showed a more atherogenic lipid profile, with a decrease in cholesterol LDL (p < 0.001) and an increase in triglycerides (p < 0.001). The risk of developing prediabetes or diabetes did not increase one year after treatment, although non-specific alterations in carbohydrate metabolism were detected, such as an increase in glycated hemoglobin in transmen (p = 0.040) and fasting blood glucose in transwomen (p = 0.008). No thromboembolic processes or cardiovascular events were reported during the first year of treatment.

CONCLUSION

In our setting, transgender people developed changes in their metabolic profiles in the first year after hormonal treatment. Both transmen and transwomen showed early alterations in lipid and carbohydrate metabolism, slight elevations in blood pressure, and a tendency to gain weight. This makes lifestyle interventions necessary from the beginning of GAHs.

Clinical and Behavioral Outcomes for Transgender Women Engaged in HIV Care: Comparisons to Cisgender Men and Women in the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) Cohort

Describe health of transgender women (TW) with HIV vs. cisgender men and women (CM, CW) in a U.S. HIV care cohort. Data were from Centers for AIDS Research Network of Integrated Clinical Systems (CNICS), 2005-2022. TW were identified using clinical data/identity measures. PWH (n = 1285) were included in analyses (275 TW, 547 CM, 463 CW). Cross-sectional multivariable analyses compared HIV outcomes/co-morbidities between TW/CM and TW/CW, and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were estimated. TW had poorer adherence (> 90% adherent; aOR 0.57; 95%CI 0.38, 0.87) and were more likely to miss ≥ 3 visits in the past year than CM (aOR 1.50, 95%CI 1.06, 2.10); indicated more anxiety compared to both CM and CW (p ≤ 0.001, p = 0.02); hepatitis C infection (p = 0.03) and past-year/lifetime substance treatment (p = 0.004/p = 0.001) compared to CM; and substance use relative to CW. TW with HIV differed in HIV clinical outcomes and co-morbidities from CM and CW.

What Cardiothoracic Radiologists Should Know About Imaging in Transgender Patients

Transgender and gender diverse (TGD) individuals may undergo a wide range of care during gender transition including mental health counseling, gender-affirming hormonal therapy, and various surgeries. Hormone therapy effectively converts the hormonal milieu into that of the affirmed gender and produces measurable alterations in serum markers for coronary artery disease and other hematologic conditions (eg, erythrocytosis, venous thrombosis). Although illegal in the United States, some transgender women may receive silicone injections for breast and soft tissue augmentation, which can lead to devastating local complications, as well as silicone migration, pulmonary embolism, systemic reactions, and death. Smoking rates are higher among transgender and sexual minority populations, placing them at elevated risk of smoking-related diseases, including lung cancer. Some opportunistic infections may be more common in the TGD populations, attributable to higher rates of coexisting infection with human immunodeficiency virus. Radiologists should be aware that these patients may develop cancer of their natal organs (eg, breast, prostate), especially as some of these tissues are not completely removed during gender-affirming surgery, which may manifest with thoracic involvement by secondary neoplasia. As more TGD patients seek medical care, thoracic radiologists can reasonably expect to interpret imaging performed in this population and should be aware of possible disease processes and potential complications of hormonal and surgical therapies.

Cardiovascular Disease Risk Among Transgender People with HIV

PURPOSE OF REVIEW

Transgender individuals are at disproportionate risk for HIV infection, with prevalence rates highest among transgender women of color. Antiretroviral therapy (ART)-treated people with HIV (PWH) are at increased risk for cardiovascular disease (CVD), in relation to persistent systemic immune activation and metabolic dysregulation. The purpose of this review is to examine parameters which may affect CVD risk among transgender PWH.

RECENT FINDINGS

Among transgender women and men, prospective longitudinal studies have shown that gender-affirming hormonal therapy (GAHT) is associated with select deleterious cardiometabolic effects such as increases in visceral adipose tissue. Retrospective studies among transgender women and men suggest an increase in CVD risk, such as venous thromboembolism, cerebrovascular accidents, and myocardial infarction. Studies among transgender PWH adhering to GAHT and ART suggest heightened systemic immune activation/inflammation. Prospective longitudinal studies assessing factors associated with increased CVD events among transgender PWH are needed to guide the development of CVD prevention strategies in this at-risk population.

Cardiovascular disease risk among transgender women living with HIV in the United States

BACKGROUND

Transgender women (TW) are disproportionately affected by both HIV and cardiovascular disease (CVD).

OBJECTIVES

We aim to quantify prevalence of elevated predicted CVD risk for TW compared to cisgender women (CW) and cisgender men (CM) in HIV care and describe the impact of multiple operationalizations of CVD risk score calculations for TW.

DESIGN

We conducted a cross-sectional analysis of patients engaged in HIV care between October 2014 and February 2018.

SETTING

The Centers for AIDS Research Network of Integrated Clinical Systems, a collaboration of 8 HIV clinical sites in the United States contributed data for this analysis.

PATIENTS

221 TW, 2983 CW, and 13467 CM.

MEASUREMENTS

The measure of interest is prevalence of elevated 10-year cardiovascular disease risk based on ACC/AHA Pooled Cohort Risk Assessment equations (PCE) and the Framingham Risk Score (FRS), calculated for TW by: birth-assigned sex (male); history of exogenous sex hormone use (female/male); and current gender (female).

RESULTS

Using birth-assigned sex, the adjusted prevalence ratio (aPR) was 2.52 (95% CI: 1.08,5.86) and 2.58 (95% CI: 1.71,3.89) comparing TW to CW, by PCE and FRS, respectively. It was 1.25 (95% CI: 0.54,2.87) and 1.25 (95% CI: 0.84,1.86) comparing TW to CM, by PCE and FRS, respectively. If TW were classified according to current gender versus birth-assigned sex, their predicted CVD risk scores were lower.

LIMITATIONS

PCE and FRS have not been validated in TW with HIV. Few adjudicated CVD events in the data set precluded analyses based on clinical outcomes.

CONCLUSIONS

After adjustment for demographics and history of HIV care, prevalence of elevated CVD risk in TW was similar to CM and equal to or higher than in CW, depending operationalization of the sex variable. Future studies with CVD outcomes are needed to help clinicians accurately estimate CVD risk among TW with HIV.

Characteristics of REPRIEVE Trial Participants Identifying Across the Transgender Spectrum

Because persons who identify across the transgender spectrum (PATS) are a key population in human immunodeficiency virus (HIV) yet are underreported in HIV and cardiovascular research, we aimed to characterize this population within the REPRIEVE global clinical trial (n = 7770). Acceptance of gathering gender identity was high (96%). Participation by PATS was 1.7% overall, 2.4% among natal males, 0.3% among natal females, and varied across geographic regions (from 0% in sub-Saharan Africa to 2.3% in High Income Region). Thirty percent of natal male PATS identified other than transgender. Some characteristics differed by gender. Most notably, 38% of natal male PATS receiving gender-affirming treatment had waist circumference >102 cm (compared with ≤25% in other groups). Given that PATS is a key population, HIV research should routinely report trial participation and outcomes by gender in addition to natal sex, to provide the results needed to optimize medical care to PATS.

Assessing gender identity differences in cardiovascular disease in US adults: an analysis of data from the 2014-2017 BRFSS

The purpose of this study was to assess gender identity differences in CVD risk and CVD conditions among adults in the U.S. Using data from the 2014-2017 BRFSS we compared CVD risk and CVD conditions in gender minorities (transgender men, transgender women and gender nonconforming persons) to both cisgender men and women. The sample consisted of 662,903 participants. Transgender women (AOR 1.34, 95% CI 1.05-1.72) and transgender men (AOR 1.54, 95% CI 1.07-2.24) were more likely to be overweight than cisgender women. Compared to cisgender women, transgender women reported higher rates of diabetes (AOR 1.45, 95% CI 1.05-1.99), angina/coronary heart disease (AOR 1.90, 95% CI 1.34-2.68), stroke (AOR 1.88, 95% CI 1.16-3.03), and myocardial infarction (AOR 2.98, 95% CI 2.14-4.17). Gender nonconforming participants (AOR 2.68, 95% CI 1.14-6.30) reported higher odds of myocardial infarction than cisgender women. Transgender women also had higher rates of reporting any CVD than cisgender men (AOR 1.38, 95% CI 1.01-1.88). There is a need to elucidate the cardiovascular effects of minority stressors and gender affirming therapy in this population. More research focused on CVD prevention and management in gender minorities is recommended.

Cardiovascular disease in transgendered people: A review of the literature and discussion of risk

This review examines the impact of gender affirming hormone therapy used in the transgendered and non-binary populations on cardiovascular outcomes and surrogate markers of cardiovascular health. Current evidence suggests that hormonal therapy for transgendered women decreases or is neutral regarding myocardial infarction risk. There is an increased incidence of venous thromboembolism (VTE), but newer studies suggest that the risk is significantly lower than previously described. For transgendered men, there appears to be an adverse effect on lipid parameters but this does not translate into an increased risk of cardiovascular disease above that of general male population. In all transgendered people, risk factor interventions such as smoking cessation, weight management and treatment of co-morbid conditions are important in optimising cardiovascular health. The effect of gender affirming hormonal therapy in transgendered people is difficult to interpret due to the variety of hormone regimens used, the relative brevity of the periods of observation and the influence of confounding factors such as the historical use of less physiological, oestrogens such as conjugated equine oestrogen and ethinylestradiol which are more pro-thrombotic than the 17β oestradiol that is used in modern practice.