“The biggest issue for my patients is still stigmatization,” says Christopher Nguyen, MD, of the San Francisco Department of Public Health (SFDPH). For more than a decade, Dr. Nguyen saw patients at the department’s Tom Waddell Transgender Clinic, where today he continues working as a volunteer doctor.
The clinic sees indigent patients, many homeless or dealing with addiction. The transgender patients, however, too often face even more difficulties and even greater discrimination. All of this makes it that much more difficult for those who are also living with HIV to take care of their health.
“There’s a huge amount of stigma that transgender people have to deal with in general—look at all the political aspects with bills floating around federally and statewide—then you add on top of that the stigma that comes with being HIV-positive. I think you can wreak havoc on people’s psyche and their ability to function, and with that there’s a lot more mental health issues, and issues around substance abuse,” Dr. Nguyen says. “So I see people who are really more desperate. When you throw both stigmatizations on there, I think it’s really hard for patients to cope. And I think that makes it harder for me to take care of them, because being HIV-positive and being stable and under control requires a lot of things to be in place that they just may not have access to.”
Across the Bay in the TransVision program, researcher Erin Wilson, DrPH, also of the SFDPH, conducts some of her work with transgender individuals to look at their needs.
“I think we often lump transgender folks together,” she says. “But the reality is that racial/ethnic minority transwomen, particularly black and Latina, are the ones really facing the breadth of the epidemic in the community. Having done work with lots of different groups of folks living with HIV, I’ve never seen the multiple disparities that transwomen of color face. As providers we need to think critically about developing models where we can adequately serve people, which is not going to be a 15-minute visit in a one-every-six-months check-in. It needs to be more intensive, and it needs to be trauma-informed.”
One of her colleagues recently published a paper looking at “multiple minority stress” that’s helping to lead the work on trans research. That paper found that in a cohort of transgender women followed in the study, those from racial or ethnic minority groups were less likely to live with their family of origin while growing up. “So there are some disadvantages at an early age, due to racial and ethnic identity with more residential segregation and poorer schools,” Wilson says, “and then that gets compounded with facing discrimination and transphobia over the course of their lives both from family and peers, and from society. I think human beings only have a capacity to deal with so much and I think transwomen of color take the breadth of everything that’s wrong in our society and adapt and cope with it.”
Oddly but appropriately, the East Bay clinic Wilson works with has added legal services to its care.
“I’m doing interviews with transgender women of color there who are getting legal services to help them engage in their HIV care, which is kind of a radical thought,” says Wilson. “We don’t think of HIV care as providing legal services. But this legal clinic we have for participants has been radically life-changing. We have these issues where people have a traffic ticket that turns into a warrant, that turns into a car being impounded, which turns into a three-hour commute to work and from work every day, which then becomes untenable and people can’t even make an appointment. Something like this gets addressed and all of a sudden there’s a light at the end of the tunnel. One of our participants said, ‘It’s wild. You never make a connection between a legal issue and my care, but until my housing is dealt with, until my legal issues are dealt with, until I have transportation, until I have food security, I can’t possibly come to a doctor appointment on some regular basis and be expected to stay on my meds and keep my prescriptions up to date.’”
Although those types of legal issues are related to poverty rather than being transgender, being transgender—especially for persons of color—leads to job discrimination and thus greater risk of poverty. Dr. Nguyen says many of his transgender patients trade sex for food, money, or a place to sleep. “So, survival sex, right?” he points out. He says it’s harder for these patients to ensure their safety from violence or from infection by insisting on the use of condoms, or that clean syringes be used when sharing drugs. Moreover, messages around HIV prevention with the use of PrEP tend to bypass transgender women, he says.
Health care for those who are living with HIV
“In terms of being HIV-positive, I don’t think there’s a huge difference between someone who’s transgender or not in terms of the effectiveness of the medications,” says Dr. Nguyen. “Obviously, there are some drug-drug interactions that you must always be on the lookout for, especially for patients who are on hormones and how the HIV medication might influence those. Once you account for that, the medications work very, very well for transgender patients … if they’re able to take them on a regular basis.
“Again, those issues around stigma, the issues around homelessness and everything that I’ve mentioned, really wreak havoc on the ability of patients, especially transgender patients, who are trying to stay adherent to their HIV medication,” he continues. “All this really affects mostly transgender women, much more so, because they’re way more affected than transgender men when it comes to HIV.”
Health care for transgender patients
“Be empathetic and just listen,” says Dr. Nguyen. “We teach this in medicine. You need to individualize care. Not everybody is the same, and everybody has different issues in their lives both medically and psychosocially. Be willing to hear the stories of the patients and just be there in a very non-judgmental way. After that you can explore options.
“It’s also really important to make sure you use the right pronoun. One of the first things I do when I have a new transgender patient, at the initial appointment, is I ask these two questions: ‘What was the sex you were assigned at birth? What gender do you identify with right now?’ Keep it very neutral because they can answer male, female, or none of the above. Gender non-conforming? It’s really up to them. Then I would also ask how they would like to be addressed. ‘For me I’m a he, him, his. How would you like me to address you?’ And if you make a mistake, just apologize and move on. Don’t make a big deal out of it. Because people make mistakes.
“The one thing that I have really learned in my work with transgender patients is to really treat them as they see themselves. Then allow the relationship to just mature to the point where they trust you, and make sure that you give them access to services as much as you can.”
NOTE: This is not a comprehensive list.
Hormones used for transgender therapy have not been tested in the lab for interactions with other drugs. Instead, the much lower dose of ethinyl estradiol (a form of estrogen) in birth control pills is used as a guide. Hormone therapy for transwomen, whether tablets, patches, or injections, requires a much higher dose of estrogen than that used in birth control pills. An increase in blood levels of a drug generally increases the risk of a side effect. A decrease in blood levels generally decreases the efficacy of a drug. Hormone dosage that is increased due to HIV medication needs to be reduced immediately upon discontinuation of the HIV drug (or drugs) due to dangerously high levels when off the HIV therapy.
Levels of ethinyl estradiol are INCREASED by:
Levels of ethinyl estradiol are DECREASED by:
Stribild (elvitegravir/cobicistat/tenofovir DF/emtricitabine)
Has NO EFFECT on levels:
Truvada (tenofovir DF/emtricitabine)
Viread (tenofovir DF)
NO DATA available:
Special thanks to Andrew Macdonald, PharmD, AAHIVP, of Community, a Walgreens Pharmacy, in Oakland, California, for reviewing and updating this drug chart.
See the “HIV Drug Interaction Checker” from the University of Liverpool, an invaluable resource for anyone living with HIV, at hiv-druginteractions.org. The checker quickly looks up known drug interactions between HIV medications and other drugs. It is updated every one to two weeks. Some dosing recommendations given. Free app available for Android and Apple smartphones.
See also a PDF of "A Transgender Therapy Primer" from the July/August 2008 issue of Positively Aware.
- Hormone therapy for HIV-positive transgender patients should be prescribed according to the same standards of care regardless if they are receiving antiviral therapy or not.
- In diabetic patients on testosterone, blood sugar decreases, requiring adjustments in dose of their diabetic medication.
- Testosterone may also potentiate the blood thinner warfarin (Coumadin).
- There are no published pharmacokinetic studies looking at drug-drug interactions with HIV medications and spironolactione (brand name Aldactone) or finasteride (brand name Proscar).
- It is important to monitor liver function.
- Clinicians should monitor hormone levels while patient is on ART in order to assess for elevated or subtherapeutic levels, as well as ongoing viral load monitoring.
- Clinicians should also be aware of possible increase in cardiovascular disease and osteoporosis among HIV-positive patients on hormones.
- More research is needed on interactions between oral, injectable, and transdermal hormones and ART medications.