Addressing Needs of Transgender Patients: The Role of Family Physicians

Asa E. Radix, MD, PhD, MPH

Disclosures

J Am Board Fam Med. 2020;33(2):314-321. 

In This Article

HIV

Transgender patients experience many health disparities but possibly the most concerning is the high rate of HIV infection. Transgender women in the United States have an estimated HIV prevalence of 14%, one of the highest prevalence rates of any group, except for men who have sex with men (MSM).[44,45] African-American transgender women face an even greater disparity in HIV prevalence, with up to 44.2% living with HIV compared with 25.8% of Hispanic/Latina transgender women and 6.7% of white transgender women.[45] Although transgender men have a lower HIV prevalence rate (3.2%), those who identify as gay and have sex with cis-gender MSM may be at higher risk for HIV infection.[45,46] Once diagnosed with HIV, transgender women continue to face further disparities lower rates of viral suppression compared with cisgender people.[47,48] This may be due to having increased risk factors associated with nonadherence to antiretroviral therapy, such as poverty, housing instability, physical and emotional trauma,[49,50] prioritization of other health issues,[51] or concern about the potential for drug interactions between their hormone therapy and antiretroviral agents.[52,53]

Medical providers can also help to diminish some of the HIV-related health disparities that transgender people face. This starts with assessing risk for HIV and sexually transmitted diseases. When obtaining a sexual health history from transgender patients, providers can continue to follow the strategies of showing respect and avoiding assumptions, especially regarding sexual behaviors and the gender of sexual partners. Providers need to be sensitive to the fact that transgender people may prefer other words to describe their bodies. For example, a transgender man may use "chest" rather than "breast," regardless of whether he has had "top surgery" (ie, a mastectomy or breast reduction surgery). Providers can ask patients about their preferred terms for body parts or use less gendered language (e.g., use "genitals" instead of "penis" or "vagina").[54] Using gender neutral terms is preferred by some clinicians as it can be challenging to remember the terms used by every patient. If patients engage in receptive anal or oral sex, these sites are screened with a rectal swab for gonorrhea and chlamydia and an oral swab for gonorrhea, per CDC guidelines.[55] The preferred method uses nucleic acid amplification testing. Currently there is no guideline regarding routine screening of the surgically constructed neovagina; however, testing is recommended if the patient is symptomatic.

Both the CDC and the US Preventive Services Task Force recommend that adolescents and adults receive at least a 1-time screening for HIV screening.[56,57] This is especially important for people of transgender experience given their elevated HIV risk.[58]

Counseling about risk reduction includes discussions about HIV pre-exposure prophylaxis (PrEP) and postexposure prophylaxis. Studies indicate that knowledge about PrEP is low among transgender women.[30] Additional barriers to PrEP for transgender women include medical mistrust, concerns about drug-drug interactions with hormone therapy, financial or insurance barriers and lack of representation in educational materials.[31] Data on the efficacy of PrEP—specifically tenofovir disoproxil fumarate-emtricitabine—among transgender women are limited. A recent subanalysis of the Pre-Exposure Prophylaxis Initiative (iPrEx) trial revealed that PrEP adherence was lower among transgender women than MSM. In addition, PrEP efficacy among transgender women was not demonstrated; however, no transgender woman who seroconverted was taking PrEP as prescribed.[32] This underscores the importance of facilitating PrEP adherence among transgender women. Clinicians can improve awareness about PrEP among transgender patients, reassure their patients about the lack of significant interactions between hormone therapy and tenofovir disoproxil fumarate-emtricitabine used for PrEP, and direct patients to assistance programs to reduce out-of-pocket costs (https://preplocator.org/). Medical providers can find educational materials that feature transgender people at the CDC's Act Against AIDS Web site.[18]

As with all people living with HIV, transgender individuals will have better health outcomes if they are engaged in care and are able to achieve viral suppression through optimal adherence to antiretroviral therapy. Transgender-friendly support services and other services important to transgender people, including case management, legal assistance, and housing referrals can be offered if needed. Lastly, patients need to be reassured about the safety of using both hormones and antiretroviral therapy. Many antiretroviral regimens have no interactions with estrogens.[35] Although interactions may occur with boosted protease inhibitors, resulting in lower estrogen levels, careful monitoring and dose adjustments allow providers to both successfully treat HIV and enable optimal use of hormonal therapy.[59]

The AAFP's comprehensive curriculum on LGBT health outlines attitudes, knowledge and skills that are critical for delivery of appropriate care to sexual and gender minority people. Family physicians who implement these recommendations into clinical practice will help to drive improved health outcomes for transgender patients. Clinicians need to be aware of the barriers to effective HIV prevention and treatment in transgender communities and use existing resources to improve HIV screening, provision of PrEP and postexposure prophylaxis and linkage to HIV treatment services. Ensuring a gender-affirming clinical environment and gaining clinical expertise in transgender medicine are the cornerstones to achieving these goals.

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