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 ART services."
Transgender 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.
The Positively 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 therapy.
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 health care.
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 non-nucleoside reverse transcriptase inhibitors (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 vs 33%).
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 per cent 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."
Braun HM et al. (Lake JE presenting) High levels of treatment non-adherence due to concerns for interactions between antiretroviral therapy and feminizing hormones among transgender women in Los Angeles, CA. 9th International AIDS Society Conference on HIV Science, Paris, abstract WEPEB0586, 2017.