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Trans women wary of antiretroviral drug and hormone interactions
Liz Highleyman, 2017-08-23 09:40:00
Transgender women living with
HIV may be hesitant to use antiretroviral therapy (ART) or not take it as
prescribed because of concerns about drug interactions with feminising
hormones, according to a presentation at the 9th International AIDS Society
Conference on HIV Science (IAS 2017) last month in Paris.
"Trans women expressed concerned about
potential ART and hormone therapy side-effects and drug-drug interactions, but
often did not discuss these concerns with their healthcare provider(s)," the researchers concluded. "As higher hormone therapy
adherence and access to transgender-specific healthcare are associated with
higher ART adherence, our data suggests a need for comprehensive care programs for
HIV-infected trans women, including clinical integration of hormone therapy and
women have among the highest rates of HIV infection. A 2013
meta-analysis estimated that 22% of trans women were living with HIV in five
high-income countries including the US, according to the Centers for Disease Control and Prevention. Trans women
who have sex with men have traditionally been classified together with "men
who have sex with men" in HIV prevention and treatment studies, and
researchers are only now starting to quantify their numbers and needs related
to HIV services.
Trans survey previously
found that many trans women prioritise hormone therapy for
gender confirmation/reassignment over HIV treatment, often expressing concern about
how their hormones might interact with
antiretroviral drugs. Such interactions could potentially reduce the
effectiveness or increase the side-effects of antiretrovirals, hormones or
both. Interactions between antiretrovirals and hormones for contraception have
been tested, but not the different doses used for gender-related hormone
Jordan Lake of the University of California at San Francisco and
colleagues set out to learn more about trans women's knowledge
about hormone therapy and antiretroviral side-effects and drug interactions,
and how this affected treatment adherence.
During 2016, the researchers recruited
self-identified trans women from APAIT (originally Asian Pacific AIDS
Intervention Team), a community-based AIDS service organisation
in Los Angeles.
Participants in this cross-sectional
(single point in time) study provided demographic information and were asked
about their medical history and knowledge of antiretroviral-hormone drug-drug
interactions. The researchers also assessed their access to and engagement in
The study included 87 trans women with a
mean age of 45 years. Just over 60% were Latina/Hispanic, 17% were African
American, 13% identified as multiracial, and 8% were white, Asian or other.
More than half of the participants (n = 47)
were HIV-positive. Within this group, the mean CD4 cell count was high at 555
cells/mm3, but 47% had a prior AIDS diagnosis. They were required to
be on ART with an undetectable viral load. Antiretroviral regimens included
integrase inhibitors (40%), protease inhibitors (32%) or NNRTIs (28%).
Nearly 40% reported substance use in the
past three months, and this was significantly more common among HIV-positive
compared with HIV-negative women (47 vs 25%). About a third had a history of
high blood pressure and 20% had a history of diabetes.
A majority of the women had a regular
healthcare provider and three-quarters had health coverage, mostly Medicaid
(for low-income people), Medicare (for seniors or disabled people) or both.
HIV-positive women were less likely than HIV-negative women to be uninsured (21
Overall, 64% of participants were
currently using feminising hormones, and the proportion was similar for
HIV-positive and HIV-negative women; 26% said they planned to do so in the
future. A quarter reported using hormones obtained outside of the medical
system, and unsupervised hormone use was more common among HIV-positive
compared with HIV-negative women (34 vs 13%).
In addition, 14% said they had received
medically unsupervised injections for body modification (such as fillers for
breast enlargement). Women with HIV were less likely than HIV-negative women to
have had feminising surgery (16 vs 26%, respectively).
Just over two-thirds of participants (69%)
said they had discussed potential hormone side-effects with their provider, but
HIV-positive women were less likely to have done so than HIV-negative women (61
vs 78%, respectively).
Although 57% of HIV-positive women reported
concerns about antiretroviral drug and hormone interactions, only 49% had discussed
this with a healthcare provider. Forty percent said this was a reason for not
taking ART, hormone therapy or both as directed.
"Despite all indications
that transgender women are a critical population in HIV care, very little is
known about how to optimize co-administration of ART and hormonal therapies in
this population,” Lake said in a press release issued by the US National Institutes of Health,
which co-sponsored the research. "This study suggests this void of
information may mean some transgender women forgo life-sustaining HIV
medications, identity-affirming hormone therapy, or some combination of the
two. By exploring the extent to which this is happening, we can find ways to better
serve this population."
"Making sure we are meeting the needs of transgender women living with
HIV is key to addressing this pandemic," added Judith Currier of the
University of California at Los Angeles and vice-chair of the AIDS Clinical
Trials Network. "We need to provide an evidence-based response to these
understandable concerns so that this key population and their sexual partners
may reap the full benefits of effective HIV care."