COMMENTARY

Care of the HIV-Infected Transgender Patient

Guideline and Commentary

Lois Jeannine Bookhardt-Murray, MD

Disclosures

April 10, 2012

In This Article

Cross-Gender Therapy for HIV-Infected Transgender Patients

Cross-gender therapy is used to physically transition transgender patients and may include hormone therapy alone or hormone therapy and physical enhancements, such as breast enlargement or complete gender reassignment surgery. Cross-gender therapy provides the opportunity to greatly increase quality of life for transgender patients by physically affirming their gender identity. For clinicians caring for HIV-infected transgender patients, cross-gender therapy may also facilitate retention in HIV care. However, both hormone therapy and gender reassignment surgery require careful consideration, as well as patient education, to optimize safety and reduce health risks associated with these forms of treatment, including infertility.

Hormone Therapy

Recommendation: Clinicians should educate HIV-infected transgender patients about the possible health risks associated with hormone therapy. (AIII)

Although several small retrospective cohort studies suggest hormone therapy is generally safe, particularly over the short- and midterm,[8] limited data exist on the long-term effects of cross-gender hormone therapy. Clinicians should inform patients that hormone therapy may increase the risk for:

  • Cardiovascular disease —particularly venous thromboembolism

  • Certain cancers —including breast, ovarian, and uterine cancers

  • Hepatic complications —due to disturbances in liver metabolism caused by elevated liver enzymes

  • Erectile dysfunction —due to increased circulating estrogen, which may also increase the risk for HIV transmission as a result of condom slippage or reduced condom use

Hormone treatment for transgender patients is most effective when clinicians provide therapy according to the fundamental principles listed in Table 4.

Table 4. Basic Goals and Effects of Cross-Gender Hormone Therapy

Considerations Before Initiating
  • Set realistic expectations

  • Emphasize the importance of medical supervision to optimize safety

  • Establish health literacy a regarding hormone therapy and possible interactions with other agents, including ART agents

Basic Goals of Hormone Therapy
  • Feminizing Therapy

    • Provide estrogen as a feminizing agent

    • Provide androgen-blocking agents to decrease the effect of circulating testosterone

    • Maximize feminization

    • Minimize health risks

  • Masculinizing Therapy

    • Provide testosterone as a masculinizing agent

    • Maximize masculinization

    • Minimize health risks

Basic Effects of Hormone Therapy

  • Feminizing Therapy

    • Integument:

      • Breast growth

      • Redistribution of body fat to a more gynecoid habitus (wider hips, narrowed waist)

      • Softening of skin

      • Decrease in body hair (facial hair generally diminishes to a lesser degree)

      • Slowing or stopping the androgenic hair loss

    • Genital:

      • Decreased sperm production and testicular size

      • Loss of fertility

      • Prostatic atrophy

      • Decreased libido

      • Less frequent, less firm erections b

    • Other:

      • Decreased upper body strength

      • Feminizing hormones generally do not affect the size of the larynx or pitch of the voice

    • Over time and depending on hormone dose, some of these changes may be permanent; breast enlargement will not completely reverse after discontinuation of treatment

  • Masculinizing Therapy

    • Integument:

      • Redistribution of body fat to a more android habitus (loss of fat on hips, larger waist)

      • Growth of body and beard hair in accordance with the patient’s genetic predisposition

      • Male-pattern hair loss in accordance with the patient’s genetic predisposition

      • Minimal breast atrophy

    • Genital:

      • Clitoral hypertrophy

      • Irregular menses at first, then cessation of menses

      • Atrophic vaginitis

      • Increased libido

      • Loss of fertility

    • Other:

      • Deepened pitch of the voice

      • Increased upper body muscle size and strength, particularly with exercise

    • Many of these changes are reversible

a As defined by the National Network of Libraries of Medicine,[9] health literacy includes the ability to understand prescribing instructions, appointment slips, medical education brochures, and doctor’s directions and consent forms and the ability to negotiate complex health care systems. Health literacy requires reading, listening, analytical, and decision-making skills, as well as the ability to apply these skills to health situations.
b Less firm erections can increase the risk for HIV and STI transmission due to condom slippage.

Concomitant Hormone Therapy and ART

Recommendations:

  • Hormone therapy for HIV-infected transgender patients who are not initiating or receiving ART should be prescribed according to the same standards of care for all transgender patients. (AIII)

  • Before prescribing hormone therapy for HIV-infected transgender patients who are receiving ART, clinicians should (AIII):

    • Consult with, or refer patients, to a provider who has experience in prescribing both hormone therapy and ART to select appropriate hormone treatment

    • Educate patients about the prescribing considerations, including hormone selection and dose, for optimizing the effects of hormone therapy when prescribed in conjunction with an ART regimen

    • Discuss the importance of adherence to ART with patients, including the risks associated with dangerously high circulating hormone levels due to ART interruption

  • Clinicians should monitor hormone therapy in HIV-infected transgender patients according to established guidelines for all transgender patients. (AIII)

The clinician’s selection of hormone and dose depends on whether or not the patient is also receiving ART. For ART-naïve patients who are not initiating ART, hormone therapy can be provided in the primary care setting according to standard guidelines for all transgender patients, such as the guidelines published by the Endocrine Society.[10] Hormone therapy can also be provided through referral to another provider or an endocrinologist with expertise in transgender treatment. See the section entitled Transgender-Related Standards of Care and Referral Resources for medical referral resources for transgender patients.

Hormone therapy for patients initiating or already receiving ART requires a careful approach. Some transgender patients may decline ART because of concerns about reduced hormone levels when prescribed with HIV-related medications.

Key Point
Educating patients about how hormone selection and dose can reduce interactions between hormones and ART may encourage acceptance of ART from those who would otherwise decline it.

When hormone adjustments are made because of concomitant ART, concentrations of circulating hormone can become dangerously high if a patient does not adhere to ART. Severe cardiovascular complications, including stroke, deep vein thrombosis, and pulmonary embolism, may occur. Therefore, clinicians should consult with, or refer patients to, a provider who has experience in prescribing both hormone therapy and ART to select appropriate hormone treatment. Clinicians should also emphasize the risks associated with increased hormone levels when discussing the importance of adherence to ART.

Key Point
Cross-gender hormone monitoring for HIV-infected transgender patients is the same as for all transgender patients. Established monitoring guidelines, such as those by the Endocrine Society,[10] should be used.

Cancer Screening and Hormone Therapy

Exogenous hormone therapy has been linked to breast, ovarian, and uterine cancers.[11] Estrogen therapy may reduce the risk for prostate cancer, although the extent of the reduction is unknown.[11]

Breast Cancer

Recommendation: Clinicians should perform breast cancer screening in the following HIV-infected transgender patients according to clinical judgment and consideration of current guidelines established for natal females of the same age (see Appendix):

  • FtM patients with remaining breast tissue (AIII)

  • MtF transgender patients with breast tissue who have received hormone therapy for at least 5 years (AIII)

MtF patients receiving feminizing hormones may be at increased risk for developing breast cancer in comparison with natal males. Although the risk is likely lower for MtF patients than it is for natal females,[11] clinicians should educate MtF patients receiving feminizing hormones about the increased risk for breast cancer and about breast cancer screening. Screening should be performed for MtF patients who have received hormone therapy for at least 5 years and should be based on clinical judgment and consideration of current guidelines for natal females of the same age (see Appendix).

The risk for breast cancer is reduced in FtM patients who have undergone chest reconstruction, including reduction or mastectomy. However, clinicians should inform patients that the risk is still present when breast tissue remains and should perform screening according to clinical judgment and consideration of current guidelines for natal females of the same age (see Appendix).

Prostate Cancer

Recommendation: Clinicians should perform digital rectal examinations as part of routine HIV care for HIV-MtF transgender patients (see Primary Care Approach To The HIV-Infected Patient ); clinical judgment and current guidelines for natal HIV-infected males should be used when considering prostate examinations in MtF transgender patients (see Appendix). (AIII)

Feminizing hormone therapy may reduce the risk for prostate cancer; however, the extent of the reduction is unknown.[11] Additional data are required before a transgender-specific recommendation can be established. See Appendix for HIV-related screening recommendations.

Cardiovascular Disease and Hormone Therapy

Recommendation: When HIV-infected transgender patients choose to receive hormones, clinicians should educate them about the cardiovascular effects of hormone therapy and, when indicated, provide counseling to reduce the risk for cardiovascular disease; such discussions should take place at the time of initiation of hormone therapy and frequently thereafter. (AIII)

Both feminizing and masculinizing hormone therapies increase the risk for cardiovascular disease, including increased arterial stiffness with androgen therapy[12] and venous thromboembolism and stroke with estrogen therapy.[8] These effects should be discussed at the time of initiation of hormone therapy and frequently thereafter. Transgender patients receiving hormone therapy who have comorbid cardiovascular risk factors require more frequent counseling and education to reduce their risk for cardiovascular disease, including smoking (see Smoking Cessation in HIV-Infected Patients ).

Gender-Confirming Surgery

Recommendations:

  • The standards of care for gender reassignment surgery, as well as less complicated gender confirming procedures, are the same for HIV-infected transgender patients as for transgender patients who are not infected with HIV. (AIII)

  • Surgery, including breast implantation and gender-reassignment surgery, is not contraindicated in HIV-infected patients. (AIII)

Some HIV-infected transgender patients may elect to receive surgery as part of the transitional process. Gender-confirming surgery may involve complete gender reassignment surgery, also known as gender realignment surgery or sex reassignment surgery; or less complicated procedures, such as rhinoplasty or breast and gluteal implantation in combination with feminizing hormone therapy. In either case, the standards of care for these gender-confirming surgical procedures are the same for HIV-infected transgender patients as for transgender patients without HIV infection. Decisions regarding gender-confirming surgery should be made in consultation with a specialist in transgender surgery. See the section entitled Transgender-Related Standards of Care and Referral Resources for referral resources for individuals seeking gender-confirming surgery.

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