ncrc-transgender-hiv.pptx

File 1 of 1 from DHHS Adult ART Guidelines: Transgender People with HIV

Treatment for Transgender People with HIV

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Treatment for Transgender People with HIV
Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents

January 2020

About This Presentation
These slides were developed using the Guidelines updated in December 2019.
The intended audience is clinicians involved in the care of patients with HIV.
Because the field of HIV care is rapidly changing, users are cautioned that the information in this presentation may become out of date quickly.
It is intended that these slides be used as prepared, without changes in either content or attribution. Users are asked to honor this intent.
May 2020

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents
Developed by the Department of Health and Human Services (DHHS) Panel on Antiretroviral Guidelines for Adults and Adolescents – A Working Group of the Office of AIDS Research Advisory Council (OARAC)

May 2020

Introduction
Disproportionate burden of HIV in transgender and nonbinary people: providers must be skilled in serving their care needs
ART is recommended for all transgender people with HIV (as for general population)

Gender affirmation:
Improves engagement in HIV care, viral suppression (VS)
Medical gender affirmation (e.g., hormonal or surgical treatment)
Improves mental health outcomes and well-being
Improves adherence to ART (Requiring ART adherence for access to hormones is associated with lower rates of VS
May 2020

Terminology (1)
Terminology is evolving, and is different in different regional and cultural contexts
Transgender (trans-): gender identity differs from sex assigned at birth
Examples of terms:
Women who were assigned male at birth: transgender women, trans women, transfeminine individuals, women of transgender experience
Men who were assigned female at birth: transgender men, trans men, transmasculine individuals, men of transgender experience
May 2020

Terminology (2)
Cisgender (cis-): identity is same as sex assigned at birth
Gender nonbinary, genderqueer, gender nonconforming: identity outside the gender binary
Gender fluid: no fixed sense of gender, or move among gender identities
Agender, null-gender, neutrois: identify with no gender

May 2020

Epidemiology
1.4 million (0.6%) U.S. adults identify as transgender
HIV prevalence in transgender people:
14% of transgender women
44% of black
26% of Latinx
2% of transgender men
Nonbinary people: few data
National HIV Surveillance system evaluation of trans people diagnosed with HIV 2009-2014 (n=2,351)
84% trans women,15% trans men, 0.7% other gender identities
>50% black/African American
44% lived in the South
18% had AIDS at time of diagnosis 

May 2020

HIV Care Continuum
Transgender women with HIV are less likely than cisgender men to
Receive ART
Be adherent to ART
Achieve viral suppression
Transgender men with HIV: few data, needs more study
May 2020

Barriers to Engaging in HIV Care
Higher rates of:
Unstable housing
Poverty
Violence, discrimination, other trauma
Stigma and past negative experiences in health care settings (e.g., use of wrong name/pronoun, invasive questions about being transgender, lack of provider knowledge about trans issues)
Prioritization of gender-affirming therapy over HIV care
Concerns about adverse interactions between ARVs and gender-affirming hormones

May 2020

Facilitating HIV Care Engagement
Gender affirmation
Affirmation (e.g., use of patients’ chosen names and pronouns) improves engagement and VS
Peer navigation
Visible transgender clinic staff

Integration of HIV care with gender care
Facilitates treatment, associated with higher VS rates
Minimizes number of provider visits (and potentially stressful clinic interactions)
Eases discussions of concerns about drug-drug interactions between ARVs and gender-affirming medications
If integrated care is not possible, ART prescriber should refer to and work closely with appropriate hormone therapy prescriber

May 2020

Gender-Affirming Clinical Settings
Registration forms and EMRs should include transgender and gender nonbinary identities
Chosen names and pronouns should be solicited, and used consistently
Resource lists, other materials for transgender people should be available
Integration of HIV services with hormone therapy is recommended
Providers must be knowledgeable about gender-affirming care
If not possible, refer for appropriate gender-affirming care

May 2020

Hormone Therapy (1)
Important aspect of gender-affirming care for many trans people
Consult Endocrine Society, WPATH, or other guidelines
Consider patient’s treatment goals, clinical outcomes, potential adverse effects (AEs), patient’s current hormone levels to determine appropriate medication doses
May increase risk of ART-related AEs, eg, on cardiovascular or bone health

May 2020

Hormone Therapy (2)
Feminizing therapies – usually estradiol (oral, IM, transdermal), with/without spironolactone (anti-androgen)
Other options available
Usual laboratory goals: increase estradiol to 100-200 pg/mL (usu. cisfemale range), suppress testosterone to <50 mg/dL
Masculinizing therapies – usually testosterone (IM, transdermal)
Usual laboratory goal: increase testosterone to 400-700 ng/dL (usu. cismale range)

May 2020

Hormones and ART: Potential Interactions
Most information on drug-drug interactions derived from studies of contraceptive use in cisgender women; few data on 17-beta estradiol (usually used in trans women)
No effect on hormone levels:
NRTIs (all)
Unboosted INSTIs (bictegravir, dolutegravir, raltegravir)
Doravirine, rilpivirine,
Entry inhibitors (ibalizumab, maraviroc, T-20)
Management: no dose adjustment needed

May 2020

Hormones and ART: Potential Interactions (1)
May decrease estradiol levels:
Efavirenz, etravirine, nevirapine
Ritonavir-boosted PIs
Management: increase estradiol as needed to achieve clinical effects and hormone concentrations
Unclear effect on estradiol levels:
Cobicistat-boosted PIs, elvitegravir/cobicistat
Management: may increase or decrease estradiol levels; adjust estradiol as needed to achieve clinical effects and hormone concentrations

May 2020

Hormones and ART: Potential Interactions (2)
May decrease testosterone, finasteride, or dutasteride levels:
Efavirenz, etravirine, nevirapine
Management: increase doses of gender affirming medication as needed to achieve clinical effects and hormone concentrations
May increase testosterone, finasteride, or dutasteride levels:
Boosted PIs, elvitegravir/cobicistat
Management: monitor for AEs, decrease doses of gender affirming medication as needed to achieve clinical effects and hormone concentrations

May 2020

Hormonal Therapy and Bone Health
Sex hormones affect bone metabolism
Few data in transgender people
Bone mineral density (BMD) changes in trans women: inconsistent data
BMD in trans men on testosterone: appears adequate
Osteoporosis risk increases after gonadectomy for both trans men and trans women, esp. if hormones are stopped
TDF: associated with decreased BMD, caution if risks for osteoporosis
Osteoporosis screening: not studied in trans people; screen by age 50, per current recs for people with HIV; consider early screening if gonadectomy
FRAX assessment: use birth sex

May 2020

Laboratory Test Interpretation
Normal values not established for trans people receiving hormonal or surgical treatments
Interpretation depends on patient’s physiology and the specific test
If not taking hormones and no gonadectomy: use sex assigned at birth
If s/p gonadectomy and on stable hormone therapy: use affirmed gender
If retain natal gonads and on hormone therapy for shorter time: some tests require male reference ranges, others require female ranges
Usually, apply range based on current hormonal sex
Use clinical judgment

May 2020

Hormonal Therapy and Renal Function
Gender-affirming hormones can change muscle mass, and thus change serum creatinine (sCr), and sCr-based estimated glomerular filtration rate (eGFR)
Trans men on testosterone: increase in serum sCr (approx 0.14 mg/dL); eGFR may underestimate GFR
Trans women on estrogen: decrease in sCr (approx 0.05 mg/dL); eGFR may overestimate GFR
Consider cystatin C-based eGFR calculation for persons with decreased renal function

May 2020

Cardiovascular Disease (CVD) Risk (1)
Risk of CVD may be higher in transgender persons: traditional risk factors and risks from hormone use
Tobacco use: higher rates in trans people (vs. general population)
Transgender women on estrogen:
Have higher risk of venous thromboembolism and stroke
Increased triglycerides and HDL, decreased LDL
Transgender men on testosterone:
Increased LDL, decreased HDL
Consider CVD risk when selecting ART and gender-affirming hormones

May 2020

CVD Risk (2)
CVD risk calculators do not accommodate transgender-specific factors such as hormone use or surgical changes
UCSF Transgender Care recs:
Depending on age of hormone initiation and total time on hormone therapy, use risk calculator for sex at birth, for affirmed gender, or for an average of the two
If CVD risks or history of CVD
Avoid ARVs associated with CVD, if possible
Trans women: transdermal estradiol -> lower risk of thromboembolism

May 2020

Pregnancy Potential
Transgender and nonbinary persons with childbearing potential (e.g., persons with a uterus and ovaries)
Ovulation may continue in presence of hormone therapy
Offer contraception counseling as appropriate
Pregnancy test before ART for all who engage in sex that could result in pregnancy
ART considerations: counsel on possible benefits/risks/AEs of ARVs at time of conception and during pregnancy (see Guidelines for considerations of INSTIs and other ARVs)

May 2020

Testosterone in Transgender Persons with Ovaries
Testosterone is not reliable in preventing pregnancy
Testosterone is a teratogen, and is contraindicated in pregnancy
Assess reproductive desires and fertility potential of transgender persons; provide accurate information on contraceptive and reproductive options
May 2020

Websites
AIDSInfo DHHS Treatment Guidelines https://aidsinfo.nih.gov
UCSF Transgender Care Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People https://transcare.ucsf.edu/guidelines
UCSF Center of Excellence for Transgender Health Education and training resources for clinicians and clinic staff https://prevention.ucsf.edu/transhealth/education

May 2020

About This Slide Set
This presentation was prepared by Susa Coffey, MD, for the AETC National Resource Center in January 2020.
See the AETC NCRC website for the most current version: http://www.aidsetc.org