HIV disproportionately affects transgender people.
A 2013 study estimated 22% of transgender women in the US are HIV positive.
Despite this, according to findings released this year by the Center for Disease Control (CDC), trans people are half as likely to get a HIV test than cisgender gay and bisexual men.
Two-thirds of trans men and women in the US say they’ve never had a HIV test.
Similarly, where it is available, trans people are less likely to be seeking out PrEP (Pre-Exposure Prophylaxis) medication. PrEP is the daily dose of Truvada that greatly reduces your chances of contracting HIV.
A new study being conducted at the LA LGBT Center is seeking to discover why more trans and non-binary people are not taking the medication.
‘PrEP takes a back seat’
It’s running two concurrent studies over the course of a year. It wants to recruit hundreds of trans and non-binary participants in the San Diego and Los Angeles areas.
The participants will be surveyed on their attitudes towards PrEP and the reasons why they might not be inclined to use the medication.
Others will be given free PrEP. They will have to return six times a year to discuss whether they are adhering to the treatment regime.
Risa Flynn, the Center’s Health Services Senior Manager of Research, says varied factors are behind the trans community’s slow uptake of PrEP.
‘[There are] economic, social, psychological, emotional, medical factors in the lives of trans and gender non-conforming people. Things like employment struggles, legal issues, housing, substance use, partner violence, to name just some.
‘These issues can demand immediate attention … [meaning] PrEP takes a back seat.’
‘How’s it going to affect my hormones?’
However, besides the daily challenges of life in a cisgender world, other issues unique to transgender people emerge.
‘When you start talking to trans and gender non-conforming individuals, one of their first questions is, “How’s it going to affect my hormones?”’ says Flynn.
To this end, the LA LGBT Center study will include a sub-study. With consent, some of those studied will have their hormone levels monitored to see if PrEP has any impact.
A similar pharmacokinetic study is also being carried out by the Center of Excellence for Transgender Health (CETH) at the University of San Francisco. Again, some transgender people have expressed concerns about potential interactions.
Luis Gutierrez-Mock, TRIUMPH Project Director at CETH says, ‘We don’t think there are any biological indicators that would lead us to think PrEP would negatively interact with hormones. However, we cannot definitively state that.
‘Very often, trans people will prioritize their gender-related health goals over almost anything else in their lives. So if people feel that Truvada is negatively impacting their gender-related goals, it leaves them not wanting to take Truvada.’
A similar concern was found in a 2016 Los Angeles-based study. This concluded trans women ‘frequently have concerns about potential anti-retroviral treatment (ART) and hormone therapy (HT) side effects and (DDIs) drug-drug interactions that, coupled with sub-optimal provider engagement, contribute to both ART and HT non-adherence.’
The marketing of PrEP to gay men
What does it mean by ‘sub-optimal provider engagement’?
The media emphasizes the fact HIV disproportionately affects gay and bisexual men. PrEP has been aggressively marketed to cisgender gay men. As a result, many trans people simply don’t know about it, or don’t perceive themselves as being at risk of HIV.
‘Some believe they might not even need Truvada,’ says Flynn’s colleague and fellow researcher, Chloé Opalo.
‘They believe they’re not at risk. They say, “I don’t want more chemicals in my body,” which is understandable, but at the same time, if they understood how high at risk they are, I feel like they’d be more willing to take PrEP.’
Trans people left out
‘The PrEP roll-out has been fantastic,’ says Gutierrez-Mock, but ‘with the focus it initially had on gay and bisexual men, unfortunately, it left out trans people. And in particular trans women, who as a group are at the highest risk of HIV among any other population, certainly within the US but possibly globally.’
‘All of the early PrEP studies were done in men who have sex with men,’ says Flynn. ‘In one of the important first studies, called iPrEx, there was a small percentage of trans individuals, but early studies were definitely focused on men who have sex with men.
‘As PrEP has gained media attention, and public health departments are starting to supply and promote PrEP, it still is mainly in that population.’
Gutierrez-Mock also points out that relationship dynamics play a role.
‘I’m thinking in particular of trans women right now, with their male partners. We see very similar experiences that non-trans women have with their male partners.
‘If somebody is taking PrEP and their male partner doesn’t agree with that, there’s then this gender dynamic within that relationship where the female partner is trying to take control of her own sexuality and her own sexual health.
‘If the male partner disagrees with that then that creates a struggle in the relationship. That could be a reason why someone isn’t taking PrEP.’
The LA LGBT Center study is open to transgender men and women and non-gender specific individuals. Many welcome the studies.
Sarah McBride is National Press Secretary for HRC (Human Rights Campaign). She is also the writer of the forthcoming book, Tomorrow Will Be Different. She made history last year as the first transgender person to address the Democratic Party Convention.
‘Trans women, particularly trans women of color, continue to be at heightened risk for HIV infection,’ she told GSN.
‘The LA LGBT Center’s efforts to gain a better understanding of the barriers that trans women encounter when accessing and adhering to HIV prevention and treatment medicine is a critical next step as we all work to end the epidemic once and for all.’
Anyone interested in participating in the LA LGBT Center study can call +1-323-993-8919 or email [email protected]