HIV Risk Among Transgender People

from 'Bulletin of Experimental Treatments for AIDS' a U.S., based report

Transgender persons face myriad challenges that place them at increased risk for HIV infection. Precarious economic status, substance use, low self-esteem, social vulnerability, and lack of social support are common barriers to adopting and maintaining safer behaviours that can prevent the acquisition or transmission of HIV.

Economic Marginalization and Sex Work Economic marginalization as a result of institutional discrimination, stigma, and lower levels of education contributes to a severe lack of opportunity for many transgender persons. Studies have found that over one-third of MTF have experienced job discrimination, over one-fifth report income below the U.S., poverty level, and nearly two-thirds of 16-to-25-year-olds are unemployed. Such marginalization may lead MTF to engage in commercial sex work as a means of economic support. Forty-two percent of MTF in a recent meta-analysis reported participation in commercial sex work, as did 59% of transgender youth in another study.

Many MTF find that sex work offers a sense of social connection with other transgender persons, but sex work amplifies the risk of HIV transmission for MTF and their partners. Not only is HIV prevalence high among MTF engaged in sex work, it also appears that their infection rates are as much as four times higher than those of genetically female sex workers.

Sexual Practices and Partnerships HIV risk among MTF is not limited to exposure through sex work, however; sexual practices and partnership arrangements also play a role. The desire to affirm a feminine gender identity may lead MTF to have concurrent (multiple) sex partners and unprotected receptive anal intercourse (URAI) in high-risk sexual networks with higher HIV prevalence. Concurrent sex partners and URAI appear to be common among MTF:  Over one-third of MTF participants in one study reported multiple sex partners and nearly half reported URAI during casual sex.

Social Marginalization;

Transgender people may feel socially marginalized due to an absence of social support, rejection by their peers and families, and a lack of connection to the lesbian, gay, and bisexual community, intensifying the risk of HIV transmission and disease progression. Transgender persons report the lowest levels of family support compared with M2M and women who have sex with both men and women. Rejection from family and peers may lead to alienation and feelings of hopelessness, and may increase psychological and social vulnerability -- which may, in turn, increase HIV risk. For example, condoms may be perceived as undermining intimacy with primary partners, while sex with casual partners and willingness to engage in URAI may provide gender validation and a sense of attractiveness that MTF may not get from peers, family, and the larger society. HIV risk thus stems (in part) from willingness to engage with sexual partners who provide a sense of love and acceptance but who may also request unprotected sex.

Body Modification and HIV Risk;

Pump Parties unable or unwilling to acquire silicone injections or implants in a medical settiing, some transgender women gather at "pump parties," typically held at an acquaintance's home, to have a non-professional inject silicone into their breasts, cheeks, hips, and/or buttocks.

The dangers of pump parties are clear. Clean needles and a sterile environment may not always be available, putting participants at risk for HIV, hepatitis, and other infections. Silicone procured outside of a medical setting is often not medical grade but industrial -- in fact, it may have come straight from the plumbing department of a hardware store -- and is sometimes mixed with paraffin, motor oil, cooking oil, antifreeze, or other non-sterile materials to make it flow more easily through the syringe and into body tissues.

Most such silicone injections are ultimately disfiguring, as the silicone migrates, changes shape, or hardens over time. Despite a long history of fatalities, infections, severe local tissue damage, and disfigurement, injecting "street" silicone is still seen as a viable way to feminize the face and body and help a transgender woman "pass," and thus avoid discrimination, gain employment, and attract intimate partners.

Body modification, such as hormone therapy, may offer the benefits of affirming gender identity and both improving self-esteem and reducing discrimination by potential employers and others. However, unless monitored by a competent and knowledgeable health care provider, it may also create significant risk for HIV and other illnesses.

Hormones procured outside of a medical setting (on the street, for example) are typically injected rather than taken orally, and needle sharing may lead to increased risk for acquiring or transmitting HIV and or other bloodborne diseases, such as Hep C.

Unsanitary silicone injecting is also common despite the risk of transmitting or acquiring HIV, hepatitis B and C, and multidrug-resistant Staphylococcus aureus (MRSA), as well as the danger of foreign substance reactions, in which the body rejects the silicone. Nonetheless, many transgender persons who share syringes to inject hormones or silicone do not identify themselves as "drug users" and may not see the potential risk of what is, in fact, needle sharing.

Transgender Health and Hormone Therapy;

Patients request hormones -- synthetic versions of chemicals that naturally occur in the body and promote sexlinked characteristics, like breast growth -- to develop physical features that allow them to express their gender identity. Hormones are available as pills and injections and in transdermal preparations (delivered through the skin as creams, gels, or patches). FTM person may choose to take testosterone to increase body hair, deepen the voice, and develop more muscle mass, while MTF individuals may opt to take estrogen to enlarge the breasts, lose body and facial hair, transfer fat from the gut to the hips, and soften the skin. Hormone therapy can have the added benefit of connecting transgender people with medical care, including treatment for HIV and other chronic illnesses and education about HIV prevention.

Baseline Tests Follow-Up Tests Performed;

Complete blood count (CBC) Intermittently Liver panel (hepatic aminotransferase levels) At 3, 6, and 12 months, then annually if using oral estrogen Kidney panel At 3, 6, and 12 months, then annually if taking spironolactone (Aldactone) Lipid profile intermittently Prolactin and fasting glucose annually for three years. Hormone therapy for transgender persons is highly individualized and should include medical monitoring. A number of contraindications must be discussed with a knowledgeable health care provider before hormone use begins, including a history of breast cancer or thrombosis (blood clots) and active substance abuse, as well as use of antiretroviral drugs to manage HIV disease.

Health recommendations for those who wish to begin hormone treatment include smoking cessation, regular exercise, and reducing risk factors for cardiovascular disease. Transdermal or intramuscular hormones may be recommended for older individuals or those with other (non-age-related) risk factors for blood clots.

A large Dutch cohort showed that prescribed and monitored hormone therapy did not increase mortality; rather, the number-one cause of death in this cohort was suicide. As discussed previously, many transgender persons have attempted or committed suicide and often struggle with mental illness. Thirty-two percent of a San Francisco-based sample of transgender persons had attempted suicide; younger age, depression, substance abuse, and a history of forced sex, genderbased discrimination, or gender-based victimization were associated with attempted suicide. Thus, in addition to a full medical history, a complete psychosocial history should be taken and any necessary mental health treatment should be initiated before beginning hormone therapy, to ensure the best possible outcome.

When obtained on the black market, hormones come with no quality assurance, recommended dosages, or medical monitoring. Some transgender persons obtain hormones illegally to supplement prescribed hormones and speed up or intensify the desired effects, which puts these individuals at increased risk for unwanted side effects and drug interactions. Medical montoring is essential to safe and healthy hormone use.

Hormones and ART Estrogen-related risks an Amsterdam cohort study reported 36 incidents of blood clots in 816 subjects over 7734 patient-years. Most occurred in the first year of taking estrogens and most were in persons over age 40 who were taking oral ethinyl estradiol; of these, participants who switched to transdermal ethinyl estradiol saw their risk for blood clots decline.

While breast cancer may be a concern for transgender women, there have only been three reported cases in worldwide medical literature.

"We don't fully understand the impact of hormones by themselves on the transgender body, and we know even less about how hormones interact with HIV meds."

-- JoAnne Keatley, MSW, Director of the Center of Excellence for Transgender HIV Prevention, UCSF

Treatment with hormones may provide an opportunity for patients to address HIV disease. Tom Waddell Health Center (TWHC), a San Francisco-based center that offers a transgender health clinic, advises that transgender health care providers should have expertise in HIV care.

Cross-gender hormone therapy is not contraindicated in HIV-positive people on antiretroviral therapy (ART) at any stage of HIV-disease progression, although health care providers may still be wary, as there is so little medical literature on interactions between hormone therapy and antiretroviral drugs or the impact of hormones on CD4 counts for transgender persons. There is some evidence that certain HIV medications do impact hormone levels; for example, TWHC advises extreme care with the protease inhibitor indinavir (Crixivan) and the non-nucleoside reverse transcriptase inhibitor efavirenz (Sustiva), as they may increase levels of ethinyl estradiol, a form of the hormone estrogen. TWHC also advises transgender patients on hormone therapy to avoid the protease inhibitors fosamprenavir (Lexiva) and amprenavir (agenerase; no longer widely available) because hormone therapy may decrease blood levels of these drugs by 20%, putting the patient at risk for drug-resistant HIV.

HIV Medications That Increase Estradiol and Ethinyl Estradiol Levels

amprenavir (Agenerase)

atazanavir (Reyataz)

delavirdine (Rescriptor)

efavirenz (Sustiva)

etravirine (Intelence)

fosamprenavir (Lexiva)

indinavir (Crixivan)

saquinavir (Invirase)

HIV Medications That Decrease Estradiol and Ethinyl Estradiol Levels

darunavir (Prezista)

lopinavir/ritonavir (Kaletra)

nelfinavir (Viracept)

nevirapine (Viramune)

ritonavir (Norvir)

tipranivir (Aptivus)

Other Drugs Commonly Used by HIV Positive Persons That Increase Estradiol and Ethinyl Estradiol Levels

cimetidine (Tagamet)

clarithromycin (Biaxin)

diltiazem (Cardiazem)

erythromycin (E-mycin, Ery-Tab, Eryc)

fluconazole (Diflucan)

fluoxetine (Prozac, Sarafem)

isoniazid (Lanizid, Nydrazid)

itraconazole (Sprononox)

ketoconazole (Nizoral)

paroexetine (Paxil)

sertraline (Zoloft)

verapamil (Calan, Covera, Isoptin, Veralin)

Other Drugs Commonly Used by HIV Positive Persons That Decrease Estradiol and Ethinyl Estradiol Levels

dexamethasone (Decadron)

phenobarbital (Luminal)

phenylbutazone (Azolid, Butazolidin)

phenytoin (Dilantin)

progesterone (Crinone, Prochieve, Prometrium, Provera)

rifampin (Rifadin, Rimactane)

It is important to note that the quantities of hormones required for feminization and masculinization have not been thoroughly tested for interactions with other drugs. Drug interactions involving ethinyl estradiol -- a form of estrogen used in birth control pills -- offer some hints, but much higher doses of ethinyl estradiol are prescribed for hormone therapy for transgender persons compared with those taken for birth control. Decreased or increased levels of ethinyl estradiol in the body may lead to unwanted side effects, ranging from inadequate feminization of physical features to nausea and vomiting, headache, and drowsiness.

Sex Reassignment Surgery and HIV;

Sex reassignment surgery (SRS) -- also called "gender confirmation surgery" -- includes a number of surgical options which transgender persons may or may not choose to have, depending on their gender identity. SRS can be performed for HIV-positive transgender persons with a CD4 count of 220 cells/mm3 or above. The WPATH Standards of Care state that "it is unethical to deny availability or eligibility for sex reassignment surgeries or hormone therapy solely on the basis of blood seropositivity for blood-borne infections such as HIV, or hepatitis B or C, etc."

As with any surgery, the quality of the care the patient receives before, during, and after SRS is a major factor in how well and how quickly the individual recovers, and his or her satisfaction with this part of the transition experience. For both MTF and FTM persons, pre-procedure communication with surgeons and other members of the health care team is essential to a healthy recovery -- and to avoiding acquiring or transmitting HIV following surgery. Individuals should make sure they understand how long the healing time is for genital surgeries; sexual activity too soon may allow HIV to enter the body through unhealed surgical wounds or may put partners at risk for HIV transmitted through blood from surgical sites.

Once healing is complete, safer sex tools like male (non-insertive) or female (insertive) condoms, dental dams, and latex gloves cut to fit a new 'microphallus' can help protect the transgender individual and his or her sex partners from HIV and other sexually transmitted infections. Transgender women with neovaginas should be aware that most reconstructed vaginas cannot lubricate naturally; using a personal lubricant is recommended to decrease the likelihood that sex will cause abrasions and small tears through which HIV and other pathogens can pass. Care for a neovagina includes periodic dilation to prevent stenosis (narrowing). Microscopic tears caused by dilation or sex create ideal conditions for acquiring or transmitting HIV if barrier protection is not used during sexual intercourse.

In addition, the medical care team should be aware of any and all medications (including ART) the individual undergoing surgery is using to ensure continuity and avoid drug interactions during and after surgery. And regardless of their HIV status, transgender individuals who have had any sex reassignment surgery but retain pretransition organs or tissue remnants need regular screening for cancers commonly associated with their birth sex, including prostate, breast, cervical, and ovarian cancers.

Selected Sources American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (Text Revision). Arlington, VA: American Psychiatric Publishing, Inc. 2000.

Bockting, W. Transgender identity and HIV: Resilience in the face of stigma. Focus: A Guide to AIDS Research and Counselling form the AIDS Health Project. 23(2):1-4. Spring 2008.

Bockting, W. and others. Transgender HIV prevention: A qualitative needs assessment. AIDS Care 10(4):505-25. August 1998.

Bowman, C. and J. Goldberg. Care of the patient undergoing sex reassignment surgery. International Journal of Transgenderism 9(3/4):135-165. 2006.

Clements-Nolle, K and others. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health 91(6):915-21. June 2001.

De Cuypere, G. and others. Prevalence and demography of transsexualism in Belgium. European Psychiatry 22(3):137-41. April 2007.

Edney, R. To keep me safe from harm? Transgender prisoners and the experience of imprisonment. Deakin Law Review 9(2):327-38. 2004.

Feldman, J. and J. Goldberg. Transgender primary medical care. International Journal of Transgenderism 9(3/4):3-34. June 2007.

Herbst, J. and others. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS and Behavior 12:1-17. January 2008.

Keatley, J. and others. Transgender global HIV/AIDS epidemiology. Presentation at the 17th International AIDS Conference. Mexico City. August 3-8, 2008.

Kessler, S. and W. McKenna. Who put the "trans" in transgender? Gender theory and everyday life. International Journal of Transgenderism 4(3). July-September 2000.

Mayer, K and others. Sexual and gender minority health: What we know and what needs to be done. American Journal of Public Health 98(6):989-94. June 2008.

Nemoto, T. and others. Health and social services for male-to-female transgender persons of color in San Francisco. International Journal of Transgenderism 8(2.3):5-19. 2005.

Nemoto, T. and others. HIV risk behaviors among male-to-female transgender persons of color in San Francisco. American Journal of Public Health 94(7):1193-99. July 2004

Operario, D. Outside the Box: HIV prevention with hard to categorize people. Focus: A Guide to AIDS Research and Counseling from the AIDS Health Project 23(2):5-8. Spring 2008.

Tom Waddell Health Center. Protocols for hormonal reassignment of gender. December 2006.

van Kesteren, P and others. Mortality and morbidity in transsexual patients treated with cross-sex hormones. Clinical Endocrinology 47(3):337-42. September 1997.

This article was provided by San Francisco AIDS Foundation. It is a part of the publication Bulletin of Experimental Treatments for AIDS.