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 HIV Prevention programs 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. You can also get a free hiv test if it’s available in your area.

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

Apr 052016
 

Readers,

Open Minded Health is temporarily going to a biweekly post schedule. That is, posts will go from once a week to once every two weeks.

This is for a few reasons. My second year of medical school is coming to an end. I begin prepping for the first, and biggest, of the board exams next week. And I’ll be going into my clinical years in June. The clinical year is one of the busiest years in medical education, only surpassed by residency (the “internship” of medicine).

Going to a biweekly update schedule means updates can still come at regular intervals. I will do my best to make the posts more in depth so the wait is worth it.

I’m also working on a full update to Trans 101. I’ll let you all know when that’s done.

Thank you for continuing to read Open Minded Health!

~Rose

Apr 032011
 

Besides feeling good and being great fun, foreplay is important! Foreplay allows more time and stimulation for full arousal, which will likely make whatever activity you’re going to do easier and more pleasurable. Psychologically, foreplay helps lower inhibitions and increases emotional connectedness.

What physically goes on during arousal in foreplay?

For men, the most obvious change is the erection of the penis. Not all penises become erect when a man is aroused – this is especially true for older men. The glans (tip) of his penis may swell, and the foreskin, if he has one, may retract. He will also produce pre-ejaculatory fluid (pre-cum) which comes out through his urethra – this is produced by the bulbourethral glands (also known as Cowper’s glands), near the base of the penis. Why does this happen? Erection and foreskin retraction allow for easier penetration. Pre-ejaculatory fluid helps lubricate the urethra. It also contains chemicals that neutralize any remaining urine in the urethra (Urine is acidic and could be damaging to sperm).

For women, the most obvious changes are lubrication of her vagina (this is produced by the cervix of the uterus). Her vagina expands and the cervix lifts, creating more room in her vagina. Her labia change shape and color in response to increased blood flow, and her clitoris becomes swollen. Why does this happen? Largely to make vaginal penetration easier. Lubrication eases movement within the vagina, and the enlargement of the vagina allows larger items to penetrate. Also, for women, it may help with achievement of orgasm.

There are a bunch of ideas surrounding foreplay that may or may not be true. Here are a few:

  • “Men don’t really need foreplay, and women do.” I don’t think so. A fairly recent study found that both men and women need about ten minutes to reach (physical) peak arousal (Source). So physically, I’d say no. The study didn’t, however, look at mental arousal which could be a factor.
  • “Foreplay increases sexual satisfaction and chance of orgasm.” Maybe….maybe not. While the popular media and personal anecdotes definitely support this idea, a study of Czech women found that duration of sex was more important than the duration of foreplay. So the jury’s out on this one. My money, though, is on the statement being true.
  • “One technique is guaranteed to work on everybody.” Not true! Everyone is different. This is where communication is crucial.
  • “Aim for these erogenous zones.” Not as easy as it sounds. An erogenous zone is supposed to be one with heightened sensitivity…but it’s different for every person and for each situation. For a common example, look at feet. Some people find their feet to be very sensual and erotic. Others don’t feel much with their feet, and some can’t stand having their feet touched at all because they’re too sensitive. The best way to find out where they are? Explore!

What counts as foreplay? That depends very much on the people involved. I think I’ve managed to come up with a few categories of activities, though…

  • Sensual touch: including with  hands, fur, leather, metal, lips (kissing), body paint, temperature (ice/hot wax, etc) and breath. Massage (with or without oils). Includes pain and impact play (e.g., flogging).
  • Psychological play: including dirty talk, humiliation, and roleplaying.
  • Erotic dress and teasing: including strip teases, erotic clothing,
  • Preparatory: Getting ready for a “special night” – cooking, eating special foods (or feeding them to someone), getting dressed up all nice, bathing with extra care, etc.
  • Bondage: including rope, chains, leather, and handcuffs…and anything else you can think of.
  • Voyeurism: watching others having sex – whether with pornography or live.
  • Misc: talking, erotic games, tantra

All of this brings up what is probably the most important part of foreplay (or, heck, any relationship-based act): Communication. Your partner(s) are not psychic, so communicate, communicate, communicate! Even if it’s embarrassing.

There are a couple of things that may cause problems with foreplay or arousal that I feel I should mention. Physical problems or illnesses can make some foreplay activities difficult if not impossible. Nerve damage can affect otherwise sensitive areas. Erectile dysfunction and vaginal dryness are relatively common, especially as we get older. Psychology can also affect everyone’s foreplay (not just women!). Trauma especially can have debilitating effects on sexuality. Some medications or drugs can also affect sexuality. If you’re having troubles with anything like what I’ve mentioned, start by talking with your partner(s). Still need help? Try talking with your doctor or a qualified sex therapist – they ought to be able to help.

The take-away message? Foreplay is good for your sex, good for your relationship(s), and good for you. Go have fun!