The future of PrEP among transgender women: the critical role of gender affirmation in research and clinical practices

Abstract

IntroductionGlobally, transgender (“trans”) women are one of the key populations most disproportionately impacted by HIV. Pre-exposure prophylaxis (PrEP) is the newest and most promising biomedical HIV prevention intervention to date. This paper reviews relevant literature to describe the current state of the science and describes the potential role of PrEP among trans women, including a discussion of unique considerations for maximizing the impact of PrEP for this vulnerable population.MethodsAvailable information, including but not limited to existing scientific literature, about trans women and PrEP was reviewed and critiqued based on author expertise, including PrEP clinical trials and rollout.ResultsTo date, PrEP demonstration projects and clinical trials have largely excluded trans women, or have not included them in a meaningful way. Data collection strategies that fail to identify trans women in clinical trials and research further limit the ability to draw conclusions about trans women's unique needs and devise strategies to meet them. Gender-affirming providers and clinic environments are essential components of any sexual health programme that aims to serve trans women, as they will largely avoid settings that may result in stigmatizing encounters and threats to their identities. While there is currently no evidence to suggest drug-drug interactions between PrEP and commonly used feminizing hormone regimens, community concerns about potential interactions may limit interest in and uptake of PrEP among trans women.ConclusionsIn scaling up PrEP for trans women, it is essential to engage trans communities, utilize trans-inclusive research and marketing strategies and identify and/or train healthcare providers to provide gender-affirming healthcare to trans women, including transition-related care such as hormone provision. PrEP implementation guidelines must consider and address trans women's unique barriers and facilitators to uptake and adherence.

Transgender Women Living with HIV Frequently Take Antiretroviral Therapy and/or Feminizing Hormone Therapy Differently Than Prescribed Due to Drug–Drug Interaction Concerns

“…These findings also extend to ART for preexposure prophylaxis (PrEP) to prevent HIV acquisition, as TW may have concerns about possible DDIs between PrEP and feminizing HT. 20 In looking at the evidence for DDIs, published studies predominantly address HT-ART DDI between ART (typically NNRTI/PI-based regimens) and ethinyl estradiol, a synthetic estrogen used in contraception but not currently recommended for feminizing HT due to increased thrombotic risk. 21 A recent systematic review found that the most noteworthy interactions occurred for cisgender women using NNRTIs, and particularly efavirenz, although these outcomes were predominantly pharmacokinetic in nature and assessed interactions at doses used for contraception rather than feminizing HT.…”

Barriers and Facilitators to Oral PrEP Use Among Transgender Women in New York City

“…First, transgender women’s healthcare needs, HIV risk profile, and barriers to HIV prevention and treatment are distinct from gay and bisexual men (9–11). Therefore, transgender women are highly likely to have different challenges related to biomedical HIV prevention product use than these men, making extrapolation from gay and bisexual men-only studies inappropriate (7, 12–14). Second, to our knowledge, only one study that has examined gay and bisexual men and transgender women as one demographic has recruited a sufficient number of transgender women to power a separate, transgender-focused analysis (3, 4, 15, 16).…”

Gendered Social Institutions and Preventive Healthcare Seeking for Black Men Who Have Sex with Men: The Promise of Biomedical HIV Prevention

“…We examine the healthcare system and the labor market as two gendered institutions that influence BMSM’s preventive healthcare practices (Dovel et al, 2015; Fleming & Dworkin, 2016) and show how BMSM are negatively impacted by heteronormatively gendered institutional processes in health care and labor market settings. Assumptions about gender as a binary category mean that men often pay a penalty—in the form of social exclusion and stigma—for being gender non-conforming (Frye et al, 2015; Lerner & Robles, 2017; Messner, 1997; Sabo, 2005; Sevelius, Deutsch, & Grant, 2016). …”