Gender affirmative HIV care framework: Decisions on feminizing hormone therapy (FHT) and antiretroviral therapy (ART) among transgender women

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.

Highs, Lows, and Hormones: A Qualitative Metasynthesis of Transgender Individuals' Experiences Undergoing Gender-Affirming Hormone Therapy

Gender Affirming Hormone Therapy (GAHT) is a key therapeutic approach which aims to help trans and gender diverse (or simply "trans") individuals' transition from their sex-presumed-at-birth to their experienced gender identity. Previous reviews have focused on synthesizing quantitative experiences; however, a qualitative lens is important to understand the personal journey of GAHT. This review provides a qualitative meta-synthesis of the experiences of trans people around the world who have undergone GAHT to elicit contextualized understanding of the changes experienced. Systematic searches of eight databases identified an initial 2670 papers, refined to a final 28 papers. Overall, findings suggested that the GAHT journey is unique and elicited a myriad of changes which, whilst challenging at times, were life-changing and brought about positive psychological, physical, and social changes. Other themes explored GAHT not being treated as a fix-all for associated mental health issues, the rules that govern appraisal of physical changes, how privilege and social identity evolve, and the power of affirmation. This work offers important recommendations to improve the care offered to trans people undergoing GAHT. Namely, person-centered support is essential, and peer-navigation may be a useful future direction to explore.

Twelve tips for LGBT+-inclusive undergraduate and postgraduate medical education

Sexual and gender minority (LGBT+) populations continue to experience worse health outcomes and reduced healthcare access compared to their cisgender, heterosexual counterparts, perpetuated by a lack of sufficient LGBT+-specific healthcare education within medical schools. Developing educational material that encourages self-reflective, proactive, and affirmative practice has been identified as a mechanism for increasing the quality of doctor-patient relationships and breaking down barriers in healthcare access for LGBT + communities. In this article, we provide twelve tips for those designing and delivering undergraduate and postgraduate medical curricula. We summarise evidence-based approaches to inclusive care, key overarching concepts that curricula should include and common issues to be avoided. We hope these tips provide a standard against which existing curricula and teaching practices can be appraised and form the basis of future educational material.

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.

Prevalence of and factors associated with the use of gender-affirming hormonal therapy outside the reference regimen among transgender people in a community-led clinic in Metro Manila, Philippines: a retrospective cross-sectional study

OBJECTIVES

We aimed to describe the gender-affirming hormonal therapy (GAHT) intake behaviour and regimen and the factors associated with the use of hormones inconsistent with reference GAHT regimen among transgender people in the Philippines.

DESIGN

Cross-sectional study.

SETTING

Transgender community clinic in Metro Manila, Philippines from March 2017 to December 2019.

PARTICIPANTS

Gender-affirming care-seeking individuals of at least 18 years old, who self-identified as transgender or non-binary, and who self-reported current or previous use of GAHT at baseline consult.

PRIMARY OUTCOME MEASURES

Reported drugs and/or administration routes not congruent with the World Professional Association for Transgender Health Standard of Care eighth edition were classified as hormone use outside the reference regimen.

RESULTS

253 transgender people reported current or previous intake of GAHT. Many trans women and transfeminine people (TWTFP; 58.9%, 86/146) reported using oral contraceptive pills (OCPs), whereas most trans men (TM; 73.8%, 79/107) reported injecting testosterone esters. Furthermore, 59.7% (151/253) used hormones outside the reference regimen, widely using OCP and anabolic steroids among TWTFP and TM, respectively. TWTFP (crude prevalence ratio, PR, 3.52; 95% CI 2.35 to 5.49) and those who take unprescribed GAHT (crude PR 2.37; 95% CI 1.08 to 6.68) were more likely to use hormones outside the reference regimen than TM and taking healthcare provider-prescribed GAHT, respectively. On adjusting for covariates, the prevalence of using hormones outside the reference regimen was approximately three times higher (adjusted PR 3.22; 95% CI 2.09 to 5.12) among TWTFP than TM.

CONCLUSION

Trans people act on their high unmet gender-affirming care needs by taking unprescribed GAHT, many outside the reference regimen. Structural changes in the health system are warranted, including strengthened community-based self-administration practices.

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.

Patient and Physician Preferences Regarding Long-Acting Pre-Exposure Prophylaxis and Antiretroviral Therapy: A Mixed-Methods Study in Southern California, USA

Antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) are key strategies in ending the HIV epidemic. However, poor adherence to daily ART and PrEP increases the risk of HIV transmission and acquisition. Long-acting ART and PrEP formulations attempt to improve adherence through providing long-lasting forms of the medication delivered through different routes of administration: oral (potentially monthly), injection (1-6 months), and subdermal implant (up to annually). This study explored patient and physician preferences for long-acting ART and PrEP as well as adherence support strategies. Adult patients (n = 42) with experience taking ART or PrEP participated in individual interviews or focus groups. Physicians (n = 13) currently prescribing ART and/or PrEP completed an online questionnaire. Rapid qualitative analysis systematically synthesized qualitative data, and descriptive statistics examined survey responses. Patients supported improved adherence as a top potential advantage of long-acting ART and PrEP, and reduced internal stigma as a strong benefit specific to long-acting ART. Annual coverage offered through subdermal implants had strong appeal; however, oral was the preferred modality for long-acting ART and PrEP. Patients preferred injectable ART and PrEP if concurrently receiving hormone therapy injections. Side effects, medication cost, and treatment accessibility were potential barriers. Patients preferred calendar tracking and text messages/phone reminders for adherence supports. Physicians reported that they would reduce clinic visits and HIV testing for all patients on long-acting PrEP, except men who have sex with men who would continue to complete HIV testing every 3 months. Physicians were mixed on whether they believed long-acting ART and PrEP would improve patient adherence. Overall, findings demonstrate the potential benefits of long-acting ART and PrEP, while highlighting the need to obtain additional information to address treatment concerns.

Responsive Medical Providers and Recent HIV Medical Services Engagement Among Transgender Women and Cisgender Men Who Have Sex With Men in the Philippines

Transgender women and cisgender men who have sex with men (trans-WSM and cis-MSM) comprise the majority of new HIV infections in the Philippines. There is limited research in the Philippines on the relationship between having a provider responsive to the needs of these populations and recent engagement in HIV medical services such as HIV testing and treatment. We used multivariate logistic regression to examine the relationship between having a responsive medical provider and engagement in HIV medical services in the past 12 months among an online sample of 318 trans-WSM and cis-MSM in the Philippines. Participants without a responsive medical provider had lower adjusted odds of recent HIV medical service engagement than those who did (aOR = 0.32, 95% CI [0.16, 0.62], p = .00). In stratified analyses, this relationship was significant for trans-WSM but not cis-MSM. Increasing access to responsive providers in the Philippines could bolster recent engagement with HIV medical services.

'I'm not interested in research; i'm interested in services': How to better health and social services for transgender women living with and affected by HIV

This paper presents results of a research priority setting process focused on trans women living with and affected by HIV across Canada. It features data from semi-structured interviews and focus groups conducted with a diverse group of 76 trans women in five urban centers across the country on how they have navigated health and social service programming within their geographic context. The results focus on the structure and types of services. Respondents offered simple, yet creative ways to address barriers to vital services based on their individual and collective experiences. Notably, participants stressed the need for 1) trans-friendly and trans-specific services, 2) integrated health services, and aid in navigating complex, overlapping systems, and 3) comprehensive community-based services. They also suggest employing trans women as care coordinators or case managers in order to foster more trans-friendly environments and empower community members. We identify concrete ways to improve health and social services at the level of service delivery and program design, as well as recommendations for future participatory research. We close with an interrogation of trans people, and trans women living with and affected by HIV in particular, as 'hard to reach' populations.