Apr 112016
 

Human immunodeficiency virus (HIV) is a major cause of illness. It particularly effects men who have sex with men (MSM) and trans women. Most studies of HIV and HIV pre-exposure prophylaxis (PrEP) lump MSM and trans women into one group. As if gay men, bisexual men, and trans women all have similar risk factors. In fact — they don’t. They are very, very different groups.

Truvada, the only FDA-approved PrEP preparation

Truvada is the only FDA-approved PrEP preparation right now

For most of the history of HIV, barrier methods and abstinence have been the only ways to prevent the spread of HIV. Today we have treatment-as-prevention and pre-exposure prophylaxis. Treatment-as-prevention involves treating people affected with HIV with HIV-suppressing medications. By reducing the number of viruses a person is carrying around with them, the chances that any one virus can infect another person go down.

Pre-exposure prophylaxis (PrEP) has been available since 2012. It involves taking an HIV-suppressing drug every day. That way, if an HIV virus actually comes into contact with that person the virus won’t be able to infect them. Only one medication is currently approved for use in the United States, and that is Truvada. PrEP prevents HIV infection when taken every day at the same time. All HIV infections that have happened to date while a person was on PrEP occurred because the person took PrEP inconsistently.

This week we look at a study exploring the use of PrEP and HIV risks among trans women specifically. To my knowledge no study until this one has separated out MSM and trans women.

This is important! Not only are trans women at high risk for being infected with HIV…but there have been few HIV prevention guidelines and interventions directly targeting trans women. Both the WHO and CDC HIV PrEP guidelines do not include trans women.

This paper examined data from the iPrEx study, which was a study of the use of PrEP among people assigned male at birth in the US, Brazil, Ecuador, Peru, South Africa, and Thailand. This paper in particular examined differences between trans women and MSM in the iPrEx trial.

What kinds of things did they find?

First — 15% of the participants in the trial were trans woman. They either identified explicitly as trans, or identified as a woman when asked. Compared with MSM participants, trans women were more likely to…

  • less education
  • have more sexual partners and have a history of sex work (64% vs 38% of MSM)
  • more likely to live alone (23% vs 14%)
  • less likely to use a condom for receptive anal sex (14% trans women used a condom vs 45% of MSM)
  • were more likely to use cocaine or methamphetamine (11% vs 7% of MSM)

Not the most heartening information, but also not brand new. It’s been known for a while that trans women do participate in sex work out of lack of options. Higher numbers of sexual partners, lower levels of condom usage, sex work, and substance use are all associated with HIV infection.

What about PrEP and HIV though? Trans women not on hormone therapy and MSM had similar levels of PrEP in their blood. That means they were taking the medications regularly and the medication was doing what it’s supposed to. And this wasn’t because of a hormone effect. The researchers did ask the participants how often they were taking their PrEP. Trans women on hormones were less likely to report always using PREP.

All the trans women who did become infected with HIV during this trial were taking PrEP at the time. In contrast, all the trans women who took PrEP regularly did not become infected with HIV.

It’s also good to note that there were no adverse drug effects noted in this trial. The PrEP medications did not cause significant harm. There were some changes to liver function tests and kidney tests. However those changes didn’t cause medically noticeable harm.

So what are the take-aways here?

  1. PrEP in trans women works when taken daily.
  2. There are significant differences between trans women and MSM. They should not be lumped together in one group.
  3. Further research on potential interactions between PrEP and hormone therapy should be done. This is just to be safe — we want to make sure that PrEP doesn’t effect hormone therapy and that hormone therapy doesn’t effect PrEP

Lastly — if you or your partner(s) are at risk for HIV infection, talk with your doctor about whether PrEP is right for you. It’s a great option in the fight to prevent HIV infection.

Want to read the study for yourself? The abstract is publicly available

Mar 072016
 

Double_mars_symbol.svgGay and bisexual cisgender men (men who have sex with men) have their own health needs…and unlike what the popular media would suggest, it’s not all about HIV.

All men who have sex with men should…

  • Talk with their physician about their physical and mental health
  • Talk with their physician about their risk for HIV infection and discuss pre-/post- exposure prophylaxis, in case prophylaxis is ever needed
  • Avoid the use of steroids
  • Practice safer sex where possible. Barrier methods such as condoms and dental dams are best.
  • Receive the Hepatitis A and Hepatitis B vaccines. If you are HIV+, you may also need additional immunizations depending on your T cell count. Those additional vaccines include measles/mumps/rubella, pneumococcus, and varicella (chicken pox).
  • If under the age of 26, get the HPV vaccine. This will reduce the chance for anal, oral, and penile cancer.
  • Talk with their physician about substance use, if relevant. If you choose to use substances (e.g., “poppers” during sex) and are unwilling to stop, consider using them in the safest ways possible. As always, it’s best to avoid tobacco, limit alcohol, and limit/avoid other drugs as much as possible
  • Take special care to maximize your mental health. Get a support network in place.
  • Get help if you’re experience domestic violence.
  • See your physician regularly to maintain your health

Your physician may wish to do other tests, including:Emoji_u1f46c.svg

  • Anal pap smear. This is a test to screen for anal cancer.
  • PSA blood test or digital rectal exam. These are screening tests for prostate cancer. The PSA, however, is not recommended routinely by the USPSTF because it is often positive even when there is no cancer. Talk with your physician about the pros/cons about the PSA before getting it.

If you have unprotected anal sex, especially with multiple partners, you should be checked for the following infections and health conditions:

  • Hepatitis B and Hepatitis C
  • HIV
  • Syphilis
  • Other sexually transmitted infections

Your physician may wish to screen you for these infections even if you do not have unprotected anal sex.

If you are HIV+ it is extremely important that you continue to receive medical care for HIV. This can be through specialized infectious disease physicians or your primary care. Keeping the HIV viral load low is the best way to live a long and healthy life and avoid spreading the virus to others.

Need more information? Check out the CDC, USPSTF, and GLMA webpages.

Sep 072015
 

In its August 27th issue, the New England Journal of Medicine (NEJM) published a paper reviewing primary health care needs of men who have sex with men. NEJM is one of the most prestigious American medical journals. It was home to the first paper detailing HIV infection in gay men. It’s one of the two major medical journals that my class has been urged to read weekly — part of our professional development as medical students.

What kinds of things does this review article recommend? And was it complete? Let’s take a look…

First is the recommendation to discuss a comprehensive and open sexual history. This should not stop at the classic “Are you sexually active?” question, but ask how the patient self identifies (gay, bisexual, etc), the kinds of sexual activity, the forms of protection used and the consistency with which they are used. Why? Because of HIV. Other sexually transmitted infections are a concern as well, but the big fear is HIV. Of all new infections in the United States each year, just under 2/3 are among men who have sex with men.

Other infections to be wary of include gonorrhea and chlamydia, Hepatitis A/B/C, and HPV. There has also been a rise in meningitis infections among gay men, caused by the bacterium Neisseria meningitidis. Of these infections, hepatitis A, hepatitis B, HPV, and meningitis all have vaccines. Where possible, men who have sex with men should be vaccinated against these diseases. HIV and hepatitis C have no vaccine. To prevent them, barriers such as condoms and gloves can be used in sexual encounters and screening tests should be performed. Pre-exposure prophylaxis and antiretroviral therapy for HIV+ individuals can also be helpful for preventing HIV spread, but cannot and should not replace barriers.

Thankfully, this article was not all about the sex lives of men who have sex with men. Too often the lives of gay and bisexual men are distilled down to just their sex lives, particularly because of HIV. The author points out that men who have sex with men should be screened for substance use, depression and anxiety. However, they stop there. While asking about tobacco, alcohol and illicit drugs is very important, there are other important aspects of the lives of gay and bisexual men that should be addressed. In particular, I would ask about…

  • Social support and living situation, particularly among young gay/bi men and older gay/bi men. Young men are at higher risk for being homeless because of family discrimination. Bullying also happens frequently among young gay/bi men. Older men may have lost their support group during the 1980s-1990s and may be facing the challenge of growing old alone. LGBT elders may face the prospect of going “back into the closet” to receive nursing home care.
  • Domestic violence. Same-sex domestic violence is under reported and specific resources are scarce.
  • History of assault or violence. Violence against men perceived to be gay/bi can have lifelong health consequences, including post traumatic stress disorder.
  • Attempts to self harm or suicide. These must never be ignored, no matter who one is talking to.
  • Diet and exercise. Eating disorders are known to occur in gay/bi men. Diet may be poor and exercise may be too low or too high, depending on the individual and his situation.

Yes, screening for HIV and other sexually transmitted diseases is important. And this article did bring some specific health issues to a large audience. However it’s important not to distill men who have sex with men down to a cluster of diseases. Let this article be a spark for discussion, and not the be-all and end-all of primary care for men who have sex with men.

What do you think? Did I miss anything important in the things I would add?

A preview of the paper is publicly available.

Jun 012011
 

For “older” adults, the IOM uses retirement age (around 60) as their starting age. For this group, there are no well-studied areas of health (beyond HIV/AIDS, which I don’t cover here). I’ve decided to leave the conclusion portion for another post – the last in this series.

  • Depression: Definitely more frequent in LGB elders than heterosexual elders. A very significant mental stress for this group is surviving the start of the HIV/AIDS epidemic. One study of elder gay/bisexual men found that 93% of them had known others who were HIV+ or had died of AIDS. There is no empirical data on rates of depression in elder transgender people, but it’s thought to be high.
  • Suicide/suicidal ideation: Empirical data suggest the rates of suicide are higher in LGB elders. No data on transgender elders.
  • Sexual/reproductive health: This is a rarely studied area. PCOS and its related risks may be an issue in some transgender elders. There is some indication that gay/bisexual men may be at the same risk as heterosexual men for prostate cancer. Early research implies that “lesbian bed death” may be a real phenomenon, but it’s a controversial topic. All cis-gendered women (bisexual, heterosexual, or lesbian) appear to have the same rate of hysterectomies. Sexual violence was reported on for transgender elders and it appears to be high. One study found about half of transgender elders had experienced “unwanted touch” in the past fifteen years.
  • Cancers: There are no data on cancers and transgender elders. Elder gay/bisexual men are at a higher risk of developing anal cancer (which is linked to receiving anal sex and HPV). Non-heterosexual women also appear to be at a higher risk for reproductive cancers (due to risk factors like smoking and obesity).
  • Cardiovascular health: Data appear to be conflicted. Transwomen using estrogen may be at a higher risk for venous thromboembolism (this may be because of the specific forms of estrogen used). There’s an association between transgender people getting their hormones from someone other than a doctor and poor health outcomes (e.g., osteoporosis, cardiovascular disease). The relevant transition hormones may cause long-term health problems at high doses, but no studies have really looked at this.

Risk factors include those for the younger age groups. Ageism within the LGBT communities may be an additional challenge for LGBT elders. Elders may also feel they need to hide their orientation if they move into a retirement home. Some retirement homes may also be discriminatory.  Transgender elders especially face very high threats of violence.

Some studies have found that elders felt more prepared for the aging process by being LGBT. Why? They’d already overcome huge difficulties. They’d already done a lot of personal growth. LGBT people are also more likely to have education beyond high school, and education is a well-known protective factor for the negative effects of aging. Conversely, some LGBT elders reported fewer relationship and social opportunities, being afraid of double discrimination, and problems with health care providers.

As for elder interactions with the health care system, again there’s a lot in common with younger age groups. One out of four transgender elders report being denied health care solely because they were transgender. Elders in general face problems if they need to enter assisted living homes, as some homes are discriminatory. It’s also worth noting that LGBT elder social structure is different from heterosexual social structure. LGBT elders rely much more on close friends than relatives (and/or adult children). Their chosen families are less likely to be recognized by the medical community, especially without legal paperwork.

So that’s it for what I’ll summarize from the report. Thanks for sticking around for it… this is hefty stuff.

May 262011
 

Welcome back! This part of the IOM report covers adults aged 20 to 60. There are more data available for adults than adolescents, so this part’s broken up a bit different from the last. As a reminder: GLBT (or LGBT – same meaning, different order) stands for gay, lesbian, bisexual, and transgender. I frequently do use GLB separate from T. That is intentional, not a typo. Also, the full report is available here – you can read it online for free.

The best studied aspects of health:

  • Mood/anxiety disorders: There are conflicting data here, but the consensus so far is that GLB people have higher rates of these problems. There’s almost no research on transgender people, but one preliminary study found that around half of transgender people have depression. Yikes!
  • Suicide/Suicidal ideation: LGBT people as a whole appear to be at higher risk. Bisexuals and transgender people appear to be at an even higher risk. Risk also seems to vary by age, sex, race/ethnicity, and how far out of the closet a person is.
  • Cancer: Gay and bisexual men are definitely at a higher risk for anal cancer than heterosexual men. This risk is linked to having anal HPV, which can be spread by anal sex.

Somewhat studied:

  • Eating disorders: May be more common for GLB people than heterosexuals, but we’re not sure. No data on transgender people.
  • Sexual: Gay/bisexual men don’t appear to be at an elevated risk for erectile dysfunction. Transgender people who have had sexual reassignment surgery may be at a higher risk for sexual difficulties…not entirely surprising given the potential for nerve damage from any surgery.
  • Cancer and obesity: Lesbian/bisexual women may be at a higher risk for breast cancer than heterosexual women.
  • Hormone replacement therapy -may- affect cardiovascular health, but it’s unknown.

Essentially not studied: Reproductive health (including the effects of hormone therapy on fertility for transpeople), cancer (especially in transgender patients), and cardiovascular health

Risk factors:

  • Stigma/Discrimination/Victimization: As we all know, LGBT people face these problems all the time.  Stigma is strongly associated with psychological distress. Bisexuals have reported facing discrimination from both the straight and gay communities. One study of transgender people found that 56% had faced verbal harassment, 37% had faced employment discrimination, 19% had faced physical violence.
  • Violence: LGBT people are at an elevated risk for suffering violence. LGBT people do experience intimate partner violence, but the statistics and relative risk are unknown.
  • Substance Use: LGBT people may be more likely to use substances, especially tobacco (read my previous post on this).
  • Childhood abuse: LGB may have higher rates of childhood abuse.

Potential protective factors (LGB): supportive environments, marriage, positive LGB identity, good surgical/hormonal outcomes (T)

As for access/quality of health care? Er…it’s complicated. GLB people get less regular screening (like pap smears and basic physical exams) than heterosexuals and use the emergency room more often. Two biggest obstacles to getting good health care?: problems with the health care providers. This could be perceived discrimination (thinking that someone is acting in a discriminatory way, whether that person is or not), or simply lack of knowledge on the part of the provider. One study found only 20% of physicians had received education about LGBT health issues. That’s only  one in five! I will note that this is improving – medical schools, depending on the school and its location, are starting to teach LGBT cultural competency more than they used to.

Lack of insurance is another barrier, and it especially affects transgender people. The services they need, like hormone therapy and sexual reassignment surgery aren’t covered by insurance. In addition, one study found that a third of transgender people had been treated ill by a physician.

Next time: Older Adults and conclusions…