Transgender women are 49 times more likely to have HIV relative to the general population. That means millions of women across the globe are likely to require two lifesaving treatments at the same time: feminizing hormone treatment (FHT) and antiretroviral therapy (ART).
Now, a small study from the Philippines published in PLOS One underscores how misconceptions among health care providers can be detrimental to health outcomes for transgender women.
The Philippines has an urgent, fast-growing HIV crisis, with a 174% increase in HIV from 2010 and 2017.
"I decided to focus on this because transgender communities, particularly transgender women, are primarily impacted by the epidemic," said lead author Arjee Restar, M.P.H., a Ph.D. candidate, trans health researcher, epidemiologist, and social/behavioral scientist at Brown University.
"Additionally, transgender women and their gender goals are often dismissed by HIV providers and deprioritized over HIV treatment -- and this is also true in the Philippines, as this research showed," she said.
In the summer of 2017, Restar and her colleagues interviewed nine HIV-positive transgender women in the Philippines, discovering that they held mixed beliefs about taking FHT and ART at the same time. The transgender women interviewed were relatively young, with an average age of 25. Of the nine, five had some level of college education.
Each of these nine women had seen a clinician to discuss treatment options. Eight said they spoke with their provider about the idea of taking FHT with ART, and five said their providers did not use gender-affirming language.
Three were eventually prescribed ART without FHT, two were prescribed both at the same time, but without medical monitoring, and four of the women were prescribed FHT and ART at the same time, with close medical monitoring.
Meanwhile, the team also interviewed 15 clinicians, finding they were likely to use non-affirmative rhetoric -- meaning they did not prioritize their patient's gender identity and transition goals -- which in turn negatively influenced women's decision to take FHT and ART. Eight of the clinicians were based at a nonprofit HIV organization, two were based at a state-sponsored HIV organization, and the remainder were from other clinics and hospitals.
Using the information gleaned from these interviews, Restar and her colleagues created gender-affirming rhetoric for providers to use within the context of HIV care. The language providers use when speaking to their transgender patients should be gender-affirmative so that the treatment plan aligns with the patient's gender goals while also addressing HIV. This type of treatment approach is more likely to be successful for both health outcomes, Restar pointed out.
However, Restar recognizes that there are still lingering questions about the risks of taking FHT and ART at the same time.
"This is an area that needs further pharmacokinetics research," she said. "In the meantime, it is critical for providers to monitor how their patients' bodies react to both medicines when taken at the same time."
According to a literature review by Asa Radix, M.D., senior director of research and education at the Callen-Lorde Community Health Center, "There are insufficient data to address [drug-drug interactions] between ART and feminizing hormone regimens used by [transgender women]. There is an urgent need for further research in this area, specifically pharmacokinetic studies to study the direction and degree of interactions between oral, injectable and transdermal estradiol and ART. Clinicians need to be vigilant about possible interactions and monitor hormone levels if concerns arise."
Restar believes health care providers urgently need to learn how to provide FHT and ART safely at the same time, under careful monitoring, while adopting gender-affirming language and attitudes within their practices.
She noted that the problem is not confined to the Philippines. Across the globe, health facilities do not cater to transgender women's health needs. This is even true of HIV facilities, which may have expertise caring for men who have sex with men but whose staff are not trained to navigate the use of FHT alongside ART.
"Transgender communities, particularly in a highly religious environment like the Philippines, are often stigmatized and seen as 'not a priority' in society, particularly from providers' point of view -- which is primarily why HIV facilities do not cater to [and are not] sensitive to trans women's health needs and gender goals," she said.
"I hope that this new gender-affirmative HIV framework will help inform and align providers' and health care facilities' HIV treatment strategies specific to transgender women's gender goals."