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.

Oct 052015
 

480px-RGB_LED_Rainbow_from_7th_symmetry_cylindrical_gratingI’ve been saying for years now that the phrase “LGBT community” is insufficient when it comes to health. It’s not one community — it is multiple communities. The social issues and health issues that a gay transgender man faces every day are different from the issues a bisexual cisgender woman faces every day. There are some similarities and grouping the communities together has been politically useful. But it should never be forgotten that L, G, B, and T all face different types of health concerns and have different civil rights battles to face.

A study came out in August that has to be one of my favorites this year. Researchers in Georgia surveyed over three thousand lesbian, gay, bisexual, pansexual, transgender, gender non-conforming, and queer people. They asked about health behaviors of all kinds. And then they did statistical analysis, comparing the various genders (cis male, cis female, trans male, trans female, genderqueer) and sexual orientations (lesbian, gay, bisexual, pansexual, queer, straight). Let’s look at what they found!

  • Diet and exercise: The researchers asked about fatty foods, eating while not hungry, quantity of vegetables and fruits eaten, and about hours and types of exercise. Transgender women had the least healthy diet of all genders. As a group, they were less likely to eat many fruits and vegetables, and more likely to drink sugared drinks and eat when they weren’t hungry. Both cisgender and transgender men were also less likely to eat many vegetables compared with other groups. Genderqueer people and gay cisgender men were most likely to exercise.
  • Substance use: The researchers asked about smoking tobacco and alcohol consumption. Cisgender men were the most likely to drink alcohol, binge drink, and to drink even when they didn’t want to. Participants who identified as queer were also more likely to drink. When it came to tobacco, transgender men and straight participants were the most likely to smoke.
  • Motor vehicle risk: The researchers asked about seatbelt use, speeding, and texting while driving. No clear differences for speeding were noted. Transgender men and straight participants were most likely to drive without a seatbelt. Texting while driving varied considerably; gay and lesbian drivers were most likely to text while driving.
  • Sexual behaviors: The researchers asked about frequency of unprotected sex and sex while intoxicated. Gay men were least likely to have unprotected sex while lesbian women were most likely to have unprotected sex. When it came to sex while intoxicated, only the bisexual participants stood out as being most likely among the groups to have sex while intoxicated.
  • Violence: The researchers asked about self harm and expressing anger at others. Overall rates of interpersonal anger were very low. Transgender men and pansexual people were most likely to self harm.
  • Medical risk taking: The researchers asked about delaying medical care and not following physician advice. Transgender women were least likely to seek care; 1/3 reported that they regularly delayed seeking medical care. Both transgender women and transgender men were more likely to not follow medical advice when it was given. Bisexual people were also more likely to delay seeking medical care compared to lesbian and gay participants.

That’s a mouthful, right? There are a lot of details I left out of this summary and it still threatens to be overwhelming with detail. So how we can break this down even more simply? By talking about the conclusions.

The researchers go into some possible causes for all these different results. Maybe gay men are safer about sex because of HIV risk. Maybe transgender men eat few vegetables because of cultural expectations that “men eat lots of meat and not many vegetables.” Maybe gay and lesbian people text more while driving because of the lack of community-specific messages.

Maybe. And they’re all good thoughts.

I tend to look forward more to what we can do with these data. I’m pretty happy with this study — it’s one of the broadest I’ve seen for inclusion. Few health-oriented pieces of research include pansexual and genderqueer individuals.

It’s important to remember that these results are at the group level. Any individual person who is a gender/sexual minority will have their own health behaviors and risks. They should be evaluated and treated as individuals. From a public health perspective though, this research brings valuable data. Only by knowing what each group faces can prevention, screening, and treatment campaigns be created. Only by knowing, for example, that transgender and bisexual people avoid seeking medical care can we then examine “why?” and act to remove the barriers so that appropriate, respectful medical care is available.

So — can we change the conversation? Instead of talking about “the LGBT community”, let’s talk about “the LGBT communities”. Or, even better, “gender and sexual minority communities” — removing the alphabet soup and expanding the definitions at the same time. This research is only the tip of the iceberg. We have so much more to explore.

The paper is published online ahead of print. The abstract is publicly available.

Jun 032014
 

6763959_10420a4b6a_mThe biggest news for May of 2014 is really that Medicare lifted the blanket ban on covering genital surgeries for trans people. The National Center for Transgender Equality has a good summary (PDF) of what the decision actually means. If you’re trans and interested in surgery and are a Medicare recipient, I recommend calling the physician who’s prescribing your hormones and consulting with them about next steps. The news was covered in multiple outlets including the NY Times and CNN.

The other piece of news I spotted that is not getting as much traction as I’d like is this: Urine is NOT sterile! For a long time it’s been believed that urine produced by healthy people is sterile – at least until it passes through the urethra. Turns out not to be the case. Something to keep in mind if you have contact with urine. Source

Interested in the other news? Read on!

  • Work continues on the possibility of three-parent babies. While much of the research and reporting talks about preventing mitochondrial diseases, I still think it opens a wonderful door for three-parent poly households. The latest news is fairly political, but supportive.
  • Another study out of Europe indicates that transgender hormone therapy is safe. This was a 1-year study of both men and women, just over 100 people total No deaths or serious adverse reactions were reported. Highly recommend you skim the abstract for yourself! For US readers, please do note though that the hormones used in the study were different formulations than those used in the US. Source.
  • A published case study reminds us that not all “odd” physical things during medical transition are related to transition. This was a case of a trans man who had undiagnosed acromegaly from a benign brain tumor. Eek! He was correctly diagnosed and treated, thankfully. Source.
  • A Swedish review of transgender-related records found a transition regret rate of 2.2%. Other prevalence data, including the usual male:female ratios, are included. Source.
  • A study of gay men found that they have worse outcomes from prostate cancer treatments than straight men. Source.
Apr 162014
 

One of the premier medical journals, the New England Journal of Medicine, regularly has perspective/opinion pieces. For a pre-med like me, they can be some of the most valuable pages in the journal — they can be windows into medical practice, public policy and the study and practice of medicine. I read them regularly, since my wife got me a subscription to NEJM. Most aren’t related to gender and sexual minority health, so I haven’t addressed them here much. But in the April 10th edition of NEJM, a treasure! Gilbert Gonzales did a good summary of the intersection between same-sex marriage and health.

Many health journals, including NEJM, tend to live behind a pay wall. This particular article, thankfully, is not. But in the interests of public knowledge and discourse, I wanted to summarize some of the interesting points in this article. A heads up: this is a distinctly United States-focused article.

  • Despite recent advances, roughly 60% of the US population lives in a state that prohibits same-sex marriage
  • There are significant health disparities between LGBT and heterosexual/cisgender people, as shown by the 2011 Institute of Medicine report on LGBT health (which I summarized in 3 parts at the time).
  • Discriminatory environments lead to poorer health outcomes. Example: LGBT people in states that ban same-sex marriage have higher rates of depression, anxiety, and alcohol use than straight/cis people in the same states. By the same token, states where same-sex marriage (e.g., MA and CA) was legalized show a drop in mental health care visits for some GLBT people (e.g., gay men).
  • Legalizing same-sex marriage improves access to health insurance for both same-sex spouses and children of same-sex parents.
  • The Affordable Care Act prohibits insurance companies from denying health insurance coverage because of sexual orientation, transgender identity, or pre-existing conditions like HIV.
  • The recent decision on DOMA (United States v Windsor) means couples in a same-sex marriage get taxed like other married couples. This lowers the tax burden of health care costs and health insurance.
  • Health benefits of same-sex marriage should be included in discussion of marriage equality.

All good things to point out, and good to see in such a mainstream medical journal.

We’re lucky enough that the NEJM has decided to have this article be open access. So if you can, read it to form your own opinions!

And as always…  Stay healthy, stay safe, and have fun!