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Associate Professor of Medicine
Infectious Diseases and Global Public Health
University of California, San Diego
San Diego, California
Jill Blumenthal, MD, MAS: researcher: Gilead Sciences.
We know that multiple barriers exist to pre-exposaure prophylaxis (PrEP) uptake for transgender individuals. One is lack of access to healthcare. Even when healthcare is accessible, transgender individuals may be hesitant to use it because of prior experiences of discrimination and stigma. In addition, transgender individuals who are taking hormones may be concerned that taking additional medication, including PrEP, could interact or interfere with their hormone therapy.
Here we will discuss considerations for overcoming some of these challenges to provide effective and gender-affirming PrEP to transgender and nonbinary adults. (Throughout this piece, “transgender” is used to refer to the broader umbrella of transgender and nonbinary or gender-diverse individuals.)
One critical step to effectively get PrEP to transgender individuals is to make sure providers understand how to provide gender-affirming care.
What does that look like? The first step is for you and your staff to ask and use the patient’s chosen name and pronouns. Be aware that these may not always match the patient’s electronic medical records, and sometimes EMR updates are necessary to make sure that anyone accessing the EMR has a patient’s correct information.
The best care involves establishing a trusting patient-provider relationship, which may take time. You can help transgender individuals feel more comfortable by demonstrating that you’re an ally. You can have a a trans flag on your shirt or include your pronouns on your badge. Have brochures and posters in your clinics and waiting rooms that reflect different gender identities. Authentic expressions of gender-affirming support may help patients feel more comfortable and supported in their identity.
You can also use gender-neutral terms whenever possible. When I see a patient and start talking about sex, I will ask them how they’d like me to refer to their genitalia. For some patients, standard terms such as penis and vagina are not comfortable. Often, more neutral language may feel more comfortable. For example, transgender men or transmasculine nonbinary individuals may prefer to refer to their “chest” rather than “breasts.”
The bottom line of providing gender-affirming care is treating patients without judgement. For a lot of transgender individuals, the healthcare system has been unwelcoming or downright discriminating, at times even leading to refusal of care. We can help transgender and nonbinary individuals in our care feel as comfortable as possible by listening to them, making sure they know that we’re hearing them, and approaching their care without judgement.
Integrating PrEP and Gender Care
One way providers can facilitate gender-affirming care is to integrate PrEP whenever we are providing hormone therapy and referrals for surgeries or other procedures that affirm people’s gender. This may occur in a primary care setting, where someone is coming to establish general care and within that context asks about hormone therapy; that can be a good segue to take a sexual history to learn if they would be an appropriate candidate for PrEP. Alternatively, if a person who identifies as trans comes into a primary care setting and asks about PrEP, you can ask if they have thought about gender healthcare. I’ve had both experiences.
Encounters that occur outside of primary care are also important opportunities to introduce PrEP. For transgender individuals who visit an endocrinology office, for example, it would be important to take a basic sexual history and determine if they might be an appropriate candidate for PrEP. If this is not something that the provider can prescribe themselves or feels comfortable prescribing, they should know who to refer the patient to.
Providers should also be knowledgeable about wraparound services that transgender and nonbinary individuals may need. These may include housing resources, case management, mental healthcare, substance use treatment, and legal support for various arenas. Not all services may be available within a particular setting, but being aware of resources and facilitating warm handoffs is very helpful for patients.
Taking a sexual history is standard if a transgender person comes seeking PrEP, but it can be important and helpful even if they are coming to see you for another reason. Ideally, remember the 6 Ps of taking a sexual history. The main 5 Ps are asking about partners, people’s practices, past history of STIs, protection from STIs, and pregnancy plans. The sixth P is a plus, which is meant to include a a variety of additional things, such as past trauma or intimate partner violence, any sexual concerns or problems, and questions about sexual satisfaction.
In this context, it is also useful to ask about sexual orientation and gender identity, if you haven’t already. We should never assume gender, gender identity, pronouns, or sexual orientation of a patient or their partners, or the types of sexual activities they are engaging in. It is best to ask straightforward questions, such as what types of sex do you have, who are your partners, what are the gender identities of your partners, and what body parts are used during sex.
Consider, for example, an individual who is engaging in oral sex or other practices that typically do not cause acquisition of HIV but can transmit other STIs. This person may be a good candidate for PrEP even if they are not currently engaging in behaviors that would put them at risk for HIV. If they are new to their gender identity exploration or sexual expression or are undergoing gender affirmation, as they start to become more comfortable they may start to explore their bodies and new behaviors. PrEP is something that should be discussed with anyone who is sexually active in any form.
With transgender individuals, as with anyone, I think a sex-positive approach is a very good one. We don’t only want to focus on risk. Ask people about their sexual function and if sex is pleasurable for them. Being able to do that can open up patients to talking about their experiences more comfortably.
Hormone Therapy and PrEP Efficacy
Once a discussion about PrEP is initiated, it’s very important to make patients aware upfront that PrEP has not been found to diminish the effectiveness of hormone therapy—whether testosterone, estrogen, or androgen blockers—and that hormone therapy does not affect the clinical efficacy of PrEP. This has been shown by many studies and with all of the current PrEP regimens.
The most data that we have is for emtricitabine/tenofovir disoproxil fumarate (FTC/TDF), where multiple studies have shown no clinically relevant bidirectional effects. There was a very small study for emtricitabine/tenofovir alafenamide (FTC/TAF) that showed similar concentrations of tenofovir between trans women who were taking hormones and men who have sex with men who were not taking hormones. And there’s also data out about long-acting cabotegravir and hormone therapy which shows no interactions as well.
This is very reassuring for patients. I like to let them know upfront that regardless of which PrEP regimen is selected, they can feel assured that their hormone therapy will not be affected, based on current data.
What’s also really exciting is that we now have multiple PrEP options. Several years ago, FTC/TDF was the only PrEP medication. Today, I’ll often start with that when talking with transgender women, because that’s where we have the most data so far. But as transgender women have been included in more studies, it’s been shown that they can take daily FTC/TDF, daily FTC/TAF, and long-acting cabotegravir.
For transgender men, daily FTC/TDF and long-acting cabotegravir have been shown to be effective. Daily FTC/TAF has not been sufficiently studied in people who are engaging in vaginal sex acts and it’s not currently recommended, although I definitely know providers who will choose it if a patient isn’t tolerating FTC/TDF or long-acting cabotegravir. It is also a newer drug and I’ve found there are more barriers to accessing it at clinics or getting it approved by insurance companies.
The takeaway here is that HIV prevention and PrEP should be discussed with every sexually active transgender individual. This includes taking a nonjudgmental sexual history as part of the social history for every transgender and nonbinary individual. There are several different PrEP administration options available for transgender individuals, with essentially no concern for interactions with hormone therapy.
Ultimately, the best way we can ensure our patients feel comfortable and want to get their PrEP with us is being able to provide hormone therapy ourselves and creating a welcoming environment where transgender individuals feel supported and can receive all of their care.
Is your clinic currently providing both PrEP and gender-affirming care to transgender individuals? Join the discussion by posting a comment.