Dec 052016
 

Too often gender and sexual minority health is distilled down to just the Human Immunodeficiency Virus (HIV)…as if that’s the only disease that could possibly be relevant. Some small amount of time might then be dedicated to STD’s like gonorrhea. But really it’s all about HIV. But ignoring all the other aspects of GSM health ignores the diversity of our communities. When I started Open Minded Health I wanted to avoid that topic. I saw so much time and so many resources being dedicated to HIV…I wanted to do something different.

Halfway through my third year of medical school now, I’m beginning to change my mind. We still need to avoid focusing only on HIV. But this one single disease has caused so much devastation, so much individual and cultural harm… I can’t just ignore it here on Open Minded Health. The focus here will still be on non-HIV aspects of GSM health care, but I’ll be sneaking in some articles on HIV too when I think it’s appropriate. Don’t worry, OMH won’t become “All AIDS all the time.”

Which all brings me to today’s article!

Literature Review

Radix, Sevelius, and Deutsch did a literature review looking at HIV in transgender women. Trans women, as a group, have the highest risk for HIV infection of all groups. Although we don’t have great data yet, the best estimate is that 19% of trans women are living with HIV.

Worse, preliminary data show that trans women are less likely to know their HIV status. As a group they’re likely to have higher viral loads. That means their HIV is not suppressed. One study in particular found that among trans women who were diagnosed, only 77% were referred to primary care, 65% were taking anti-retrovirals, and only 55% had suppressed their viral load.

HIV treatment 101
HIV

Diagram of an HIV particle

HIV cannot be cured. It causes harm by destroying part of the immune system. The goal of treatment is to reduce the number of copies of the virus, the “viral load”. The lower the viral load, the better your immune system can work (measured as a “CD4 count”). This has two benefits. First, you live longer. You’re less likely to get an infection or cancer. Second, you’re less likely to spread HIV to others. HAART is the modern gold standard of treatment. HAART stands for “highly active antiretroviral therapy”. Think of it as the new improved ART, or antiretroviral therapy. HAART is a mix of 3+ drugs that work to keep the viral from copying itself.

Trans women and HIV

Why are trans women at such high risk for HIV? Previous studies suggest it comes down to social issues. Trans women are often more visibly “trans” than trans men, and are a easier target for discrimination. They may be more likely to work in the sex industry. In that industry, anal sex is what they likely end up performing, and anal sex is the most likely to spread HIV. In addition, substance use is higher in trans populations. Sharing needles and items used for snorting can also spread HIV.

For whatever reason though trans women are at high risk. Why such a lower rate of treatment? Why are only 65% taking antiretrovirals? First there’s always cost. HAART can cost $10,000 per year and more. Second, some studies suggest that trans women may prioritize hormone therapy over HIV treatment.

HAART and hormones

Lastly, there are some very real concerns about interactions between HAART medications and hormone therapy. Both estrogen and HAART medications are processed by the liver and often by the same enzymes. Estrogen may change the amount of HAART medications that stay in the body, or vice versa.

According to this paper, the only research that’s been done so far on estrogen and HIV therapy has been done with cisgender women on birth control. As long time readers of OMH know, birth control is not hormone therapy. Birth control has both estrogen and progesterone. And the type of estrogen is different between birth control and transgender hormone therapy. Still, it’s what we have to use. These studies showed that some antiretroviral medications do change the blood level of estrogen, and that the levels of some antiretrovirals are changed by estrogen.  However we don’t know if that effect is true with the type of estrogen in transgender hormone therapy…and we don’t know if the differences in the blood levels has a real clinical effect.

I won’t go into detail of which HAART medications did what. Antiretroviral medication names are notoriously difficult to read, pronounce, and remember. Instead, here’s the important part: It is very important for your health care provider to know what you are taking. If you’re taking estrogen, tell your provider. That way they can check for drug-drug interactions and adjust medications appropriately.

What about anti-androgens, like spironolactone, finasteride, and GnRH agonists? Do they interact with antiretrovirals? There are no studies specifically about them and antiretrovirals. No interactions are known. We just don’t know.

The potential effects of transgender hormone therapy on antiretroviral medication blood levels may not even matter in HIV treatment in the end. Why? Well, we don’t just put someone on HAART and never see them again. Physicians check the viral load to see if HAART is working. So they know if doses or medications need to be changed. If there’s an interaction between drugs, they’ll see that the viral load isn’t low and they’ll change the drugs anyway.

Conclusion

In other words: There is no clear reason to avoid HAART while on hormone therapy.

Get tested, know your status, and get treatment if needed. Doing so will allow you to live for many, many years to come.

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

Citation: Radix A et al. Journal of the International AIDS Society 2016, 19(Suppl 2):20810

Aug 152016
 

Welcome back to Open Minded Health Promotion! This week we’re looking at health promotion for transgender women and individuals assigned male at birth. Depending on your history some of these tips will apply more or less to you.

TransgenderPlease remember that these are specific aspects of health in addition to the standard recommendations for everyone (e.g., colonoscopy at age 50). Based on your health and your history, your doctor may have different recommendations for you. Listen to them.

All transgender women should consider…
  • Talk with their doctor about their physical and mental health
  • Practice safer sex where possible. Sexually transmitted infections can be prevented with condoms, dental dams, and other barriers. If you share sexual toys consider using condoms/barriers or cleaning them between uses.
  • Consider using birth control methods if applicable. Hormone therapy is not birth control. Orchiectomy and vasectomy are permanent birth control options. You can still have vaginoplasty after those procedures if you desire. Alternatively, you can use condoms and asking your partner to use hormonal birth control.
  • Store sperm before starting hormone therapy if you want genetic children. Estrogen and anti-androgens definitely affect fertility. You may never be able to have genetic children after hormone therapy.
  • If you’re under the age of 26, get the HPV vaccine. This will reduce the chance for anal, oral, and penile cancers. Theoretically it may also reduce your risk for (neo) vaginal cancers.
  • Protect yourself from HIV. Consider using pre-exposure prophylaxis in addition to condoms in sexual encounters that are higher risk. Avoid selling sex if you can.
  • Avoid tobacco, limit alcohol, and limit/avoid other drugs. If you choose to use substances and are unwilling to stop, consider strategies to limit your risk. For example, consider participating in a clean needle program. Vaporize instead of smoke. And use as little of the drug as you can.
  • Maintain a healthy weight. While being heavy sometimes helps to hide unwanted physical features, it’s also associated with heart disease and a lower quality of life.
  • Limit high-potassium foods while on spironolactone if possible.
  • Exercise regularly. Anything that gets your heart rate up and gets you moving is good for your body and mind! Weight bearing exercise, like walking and running, is best for bone health. If you’re looking to avoid “bulking” up your muscles, cardio exercises are probably your best bet. Staying physically active is especially important if you have a family or personal history of cardiovascular disease.
  • Avoid buying hormones from online stores or on the street. There is no guarantee that you’re getting what you think you’re getting. Even if you do there is no guarantee that the drug was created in a safe lab or was stored properly. Drugs made in the US are guaranteed to contain what they said they do. They are also made in clean facilities and stored correctly so they don’t degrade. Additionally buying hormones online is far more expensive than getting a prescription and going to a pharmacy (especially with discount plans many pharmacies provide). Thus if you can get a prescription, doing so is less risky and far cheaper. For more information, see the FDA.
  • Do not inject silicone. It not only disfigures, it kills. Additionally unsafe needle practices risk spreading HIV and Hepatitis C.
  • If you’ve had genital surgery and you’re all healed from surgery, remember to continue to dilate and take care of your vagina. Keep in touch with your doctor as you need to. Call your surgeon if something specific to the surgery is concerning. Continue to practice safe sex. And enjoy!
Your doctor may wish to do other tests, including…
  • Prostate cancer screening. Vaginoplasty does not remove the prostate. Testosterone is one of the major drivers of prostate cancer. Therefore trans women are at a lower risk for prostate cancer. However, that risk may still exist. Your doctor may recommend a blood test or a digital rectal exam. They should discuss with you the benefits and potential harms of screening.
  • Breast examination for potential detection of breast cancer. We really don’t know yet how much risk trans women are at for breast cancer. Current data suggest that trans women are at low risk. However your doctor may wish to perform a breast examination as part of a physical exam. The goal of the exam is to detect lumps and/or bumps that may need further investigation. They may also teach you how to do a self-exam.
  • Mammography. Again, this is for potential detection of breast cancer. Some doctors recommend following the typical recommendations for cis women. However even those recommendations vary depending on the organization recommending them. Most recommendations include a mammography every 1-2 years starting around age 50. Thus once you turn 50, consider talking with your doctor about the need for mammography.
  • Vaginal examination. For post-op trans women, the vagina is either (penile) skin or intestine. Either way, it can still develop cancer. Some doctors recommend a visual inspection of the vagina to detect such cancers. Others do not.
  • Testicular/penile examination. As long as you have a penis and testes, your doctor may recommend examination. They look for potential cancer as well as hernias (the “turn your head and cough” test).

And most importantly: Take care of your mental health. We lose far too many people every year to suicide. Perhaps worse, far more struggle with depression and anxiety. Do what you need to do to take care of you. If your normal strategies aren’t working then reach out. There is help.

Want more information? You can read more from UCSF’s Primary Care Protocols and the Gay and Lesbian Medical Association.

Apr 252016
 

For many reasons, transgender women as a group are at high risk for sexually transmitted infections (STIs). The types of STIs a trans woman is at risk for changes after vaginoplasty but doesn’t go away. Reports of (neo) vaginal infection by gonorrhea and chlamydia are rare, for example. Trans women with (neo) vaginas may be at higher risk for HIV because of the greater possibility of a vaginal tear. Relatively little is known about the risk for other STIs, such as the human papilloma virus (HPV). Today I take a look at a new paper on HPV infection in post-vaginoplasty trans women.

HPV, the Human Papilloma Virus

HPV, the Human Papilloma Virus

HPV is a virus spread by skin-to-skin contact. There are different types of the virus. Some types cause warts (NSFW link). All warts are caused by a version of HPV. Warts that are on the genitals or anus are caused by specific types of HPV that are considered sexually-transmitted infections (types 6 and 11). The warts can be uncomfortable or painful. They can be very small or grow to become large masses. Warts themselves are fairly harmless otherwise.

The types of HPV that don’t cause warts are more dangerous. Those include types 16, 18, 31, and 33. These types don’t cause warts, but they cause changes that can lead to cancer. Cancers that have been associated with infection include cervical cancer, vaginal cancer, anal cancer, penile cancer, and some throat/oropharyngeal cancers. As you can tell from where these cancers happen, these types of HPV are often sexually transmitted. Screening tests for associated cancers include cervical pap smear, anal pap smear, and testing for the virus.

HPV can be prevented by vaccine and by barriers such as condoms and dental dams. Most vaccines prevent both the cancer-causing and genital wart-causing types. There is no cure for infection. Treatment is limited to removal of warts and treatment for cancers.

What about HPV infection in post-vaginoplasty trans women? Since HPV is a skin-to-skin contact infection, the (neo) vagina can still be infected by HPV. What has been reported in the medical literature about HPV infection? This paper presented 4 cases of vaginal HPV in their clinic and summarized 9 reports that had previously been reported in the medical literature. So they discussed 13 reports of HPV total.

They only reported symptomatic HPV cases. So only women who were having pain, discomfort, or other symptoms from an infection were discussed.

Most of the women had had a penile inversion vaginoplasty. One woman had a sigmoid vaginoplasty, one had a “split skin graft” (NSFW) vaginoplasty, and one was unknown. Split skin graft is a technique that uses skin from elsewhere on the body, and is sometimes used for cis women who were born without a vagina.

Of the four new cases discussed in the article, all came to the clinic with pain, either vaginal or vulvar. Three of the four women had genital warts, which were removed. The fourth had a white discoloration (“leukoplakia”), also caused by human papilloma virus. The pain and symptoms of all four were resolved with treatment and the lesions did not come back. All four were HIV negative and had previously had penis-in-vagina sex with at least one cis man.

There was less reported about the 9 cases that had previously been reported in the medical literature. 7 out of the 9 had genital warts. 6 of those 7 had the warts successfully removed. The 7th had to have a vaginectomy to remove the warts. Of the two who did not have warts, one had vaginal cancer and had to have a vaginectomy and chemo. The last had a pre-cancerous lesion, and we don’t know what happened to her.

The types of treatment for warts varied. Some were removed successfully with medication. Others were removed surgically. Still others were removed with laser or electricity.

Ultimately — all these results sound like what happens with cis women. Warts happen, cause pain or distress, and are treated. Less commonly, HPV causes cancer or pre-cancerous lesions and that is treated.

What this article brings to attention is that trans women need HPV prevention as much as everyone else. HPV vaccination for people up to age 26 is recommended. For those older than 26, barriers during sex with partners is a useful tool.

UCSF recommends “periodic” visual examination of the (neo) vagina to look for changes that may be pre-cancerous lesions. But they don’t define what “periodic” means. Cis women get pap smears every 3-5 years; 3-5 years may be a reasonable range for trans women too, but we just don’t know for sure. So if you’re concerned, talk with your physician about screening.

Want to know more about HPV? The CDC has good information.

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

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 282016
 

In the United States, spironolactone is the oral anti-androgen of choice for trans women. It’s the cheapest and is well tolerated by most people. Outside of the United States cyproterone acetate, also known as Androcur, is the preferred drug. This week I take a look at this drug, how it works, and why it hasn’t been approved for use in the United States.

The chemical structure of cyproterone

The chemical structure of cyproterone

Cyproterone is an anti-androgen. It blocks androgen receptors, preventing testosterone and other androgens from having their effects. By blocking those receptors, it reduces the amount of testosterone in the body through a mechanism called negative feedback. Cyproterone is chemically similar to progesterone and has some progesterone-like effects as well. Outside of transgender care it’s also used for prostate cancer, as combination antiandrogen and hormonal birth control for cis women (e.g., Dianette), and for chemical castration of sex offenders.

It’s available both as a pill and intramuscular injection. The pill form should be taken every day at the same time after a meal. The dose often used for transition in the literature is 100mg/day. Anecdotally I’ve been told that lower doses, such as 25-50mg/day, have been used. The injection is given once every 1-2 weeks.

Cyproterone acetate is not risk-free and is definitely not for everyone. Most seriously, cyproterone is associated with liver damage. That damage can be severe. It can lead to liver failure even after the drug is stopped. Damage has been reported with doses over 100mg/day. Because of this, people on cyproterone should have their livers regularly monitored with blood tests. The drug should not be combined with other drugs that can cause liver damage. That includes alcohol and many prescription drugs. Individuals with known liver damage/disease should not take cyproterone.

There is also some question of whether the drug is associated with some cancers. In particular, liver cancer and some brain cancers. Specifically, hepatocellular carcinoma and meningioma are the cancers of concern. Researchers are still exploring this connection. Other negative side effects of cyproterone include allergic reactions and worsening of depression.

Many trans women are concerned about fertility. The effects of cyproterone alone, without estrogen, on fertility are somewhat known. Sperm count goes down with oral doses as low as 50mg. Infertility can happen in as little as 2 months. The infertility is reversible once cyproterone is stopped. Fertility returns anywhere from 3-20 months. But remember — no anti-androgen is a birth control method. Please use birth control if you or your partner are at risk of pregnancy.

In the literature, 100mg/day is the dose that seems to be preferred for transition. No cases of liver cancer in trans women have been reported. However some women do have higher levels of liver enzymes. That’s a sign that the drug is causing some damage to liver cells. Transdermal, instead of oral, estrogen is recommended to reduce potential liver damage and blood clots.

Cyproterone is a potential alternative for trans women. So why hasn’t the FDA approved it? That’s a little murky. I wasn’t able to find public document describing the reasoning. But the biggest reason cited by other sources is the concern of liver damage. The FDA is likely trying to do its job and protect the population from drugs that cause more harm than good. In its efforts it may well overstretch. Cyproterone only rarely causes liver problems, and those problems can be screened for with regular blood tests. However it’s important to remember that there are safer alternatives still available. Spironolactone and the GnRH agonists (puberty blockers) are generally safer and mostly well tolerated. Other androgen receptor blockers (e.g., bicalutamide), while not in common use for trans care, are also available and have lower rates of liver damage. So there’s little pressure on the FDA to approve a riskier drug.

So in summary — cyproterone is an androgen receptor blocker in use outside the United States for trans care, prostate cancer, and birth control. It’s biggest side effect is potential liver damage. It’s not FDA-approved for use in the US probably because of that liver damage. People currently using the drug should be under a physician’s supervision.

Want to learn more? The wikipedia article on this drug is super excellent!

Note on references — I pulled most of my information from LexiComp, which I have access to through my university and can’t easily reference. However, prescribing information is publicly available and has much of the same information.