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HIV in Transgender Patients Anita Radix, MD MPH Callen Lorde Community Health Center 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: • 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 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 Case 27 y/o HIV-infected transgender (male-to-female) woman transferring care from California. • 6 months ago CD 4 420 cells/mm 3 HIV RNA level of 16, 000 copies/ml. • ARV naïve • PMH: HIV+ 2005, started CGHT at age 20 • Meds: spironolactone 100 mg tid, Premarin 2. 5 mg bid

The Basics • Basic terminology - what does transgender mean? • Gender vs. sexual 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 Background information Terminology What is gender? 6

Gender vs. Sex Traditional • Gender is binary (M/F) • Synonymous with sex (chromosomes, 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

Gender Return Gender Return

Trans-terminology • Transgender • umbrella term used to group the many gender different communities 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 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-terminology Common terms to describe transition: • MTF, male-to-female (trans women) • FTM, female-to-male (trans men)

Medical Terms • Gender Dysphoria (DSM III) or Gender Identity Disorder (DSM IV) • 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)

Sexual Orientation • Part of, but not the same as, gender identity • Trans-women Sexual Orientation • Part of, but not the same as, gender identity • Trans-women attracted to men and transmen 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

What is the Correct Pronoun? • How do I know which pronoun to use? 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

Transgender Epidemiology Transgender Epidemiology

Demographics No reliable data: Prevalence rates of MTF transsexualism • 1: 500 – 1: Demographics No reliable data: Prevalence rates of MTF transsexualism • 1: 500 – 1: 20001 • 1/11, 900, based on medical/surgical treatment 2 • 1: 2, 900 surgical treatment 3 • Transgender prevalence higher

HIV Prevalence • No national surveillance data • Transwomen designated as MSM • Meta-analysis 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 MTF 4 • 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 Francisco 7

HIV Incidence • High HIV incidence 3. 4 -7. 8% per 100 person-years 9, HIV Incidence • High HIV incidence 3. 4 -7. 8% per 100 person-years 9, 10 • African American transwomen 18. 1% per 100 person-years 10

Predictors of HIV infection among Transgender Women • • • African-American race 5, 7 Predictors of HIV infection among Transgender Women • • • African-American race 5, 7 Syphilis 5 High number of sex partners 7 Less than high school education 7 History of sex work 8 Unemployment 8

Sexual Assault Poverty Hate Crimes Harassment Discrimination Wrongful Incarceration Police Brutality Domestic Violence Homelessness Sexual Assault Poverty Hate Crimes Harassment Discrimination Wrongful Incarceration Police Brutality Domestic Violence Homelessness Return

Transphobia – an irrational fear of gender-different people leading to systematic discrimination Tyra Hunter Transphobia – an irrational fear of gender-different people leading to systematic discrimination Tyra Hunter (19701995) Died in Washington DC after paramedics withdrew treatment at scene of car accident. Robert Eads (19451999) Care for ovarian cancer delayed for one year because more than two dozen doctors refused to treat him. Brandon Teena (19721993) Raped and murdered by John Lotter and Marvin Nissen after they discovered he was anatomically female.

Initial Assessment Medical History Ask about: • Hormone use, dose, duration, obtained “on the 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 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 • 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” appearance 4 • Silicone • >25% of transgender women inject silicone to create “feminine” appearance 4 • 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: CD 4 count of 322 cells/mm 3 and an HIV Case cont. • Labs: CD 4 count of 322 cells/mm 3 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. 5 mg BID, spironolactone 100 mg TID)?

HIV Medications That Increase Estradiol and Ethinyl Estradiol Levels HIV Medications That Decrease Estradiol HIV Medications That Increase Estradiol and Ethinyl Estradiol Levels HIV Medications That Decrease Estradiol and Ethinyl 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 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

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

Gender Confirming Hormone Therapy Estrogens § Conjugated Estrogens : 1. 25 -10 mg po Gender Confirming Hormone Therapy Estrogens § Conjugated Estrogens : 1. 25 -10 mg po qd or divided as bid § Estradiol: 2 -8 mg po qd or divided as bid § Estradiol Patch : 0. 1 -0. 3 mg q 3 -7 days § Estradiol Valerate injection : 20 -60 mg IM q 2 wks • Ethinyl estradiol (OCP) 50 -100 g qd Anti-androgen § § Spironolactone 100 -400 mg daily, divided doses Finasteride 1 -5 mg po daily Cyproterone Acetate (Androcur) 5 - -reductase inhibitors: • Finasteride: 1 -5 mg daily; Dutasteride: 0. 5 mg daily • Flutamide (Eulexin) 50 -750 mg daily

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

Safety of Hormone Therapy • Very few published studies of long-term safety of MTF 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

Appropriate Follow-up • Routine screening on all organs as long as they are present: 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 - q 6 -12 mos: fasting Appropriate Follow-up • Periodic laboratory testing: • MTF - q 6 -12 mos: fasting glucose, lipid profile, liver function, prolactin; as needed: testosterone, potassium, hemoglobin • FTM - q 6 -12 mos: fasting lipids, liver function, hemoglobin [Evidence level C, expert opinion]

STI Screening • • • Assess the risk of STI’s for all transfemale patients 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 language that is sensitive to transgender identities • 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

Thank you! Thank you!

References 1. Olyslager F, Conway L. On the Calculation of the Prevalence of Transsexualism. References 1. Olyslager F, Conway L. On the Calculation of the Prevalence of Transsexualism. WPATH 20 th 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 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/resources/dge/gea 01011. pdf 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/Content. Files/Adultand. Adolescent. GL. 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