Asa Radix

Integrated and Gender-Affirming Transgender Clinical Care and Research.

Abstract:Transgender (trans) communities worldwide, particularly those on the trans feminine spectrum, are disproportionately burdened by HIV infection and at risk for HIV acquisition/transmission. Trans individuals represent an underserved, highly stigmatized, and under-resourced population not only in HIV prevention efforts but also in delivery of general primary medical and clinical care that is gender affirming. We offer a model of gender-affirmative integrated clinical care and community research to address and intervene on disparities in HIV infection for transgender people. We define trans terminology, briefly review the social epidemiology of HIV infection among trans individuals, highlight gender affirmation as a key social determinant of health, describe exemplar models of gender-affirmative clinical care in Boston MA, New York, NY, and San Francisco, CA, and offer suggested “best practices” for how to integrate clinical care and research for the field of HIV prevention. Holistic and culturally responsive HIV prevention interventions must be grounded in the lived realities the trans community faces to reduce disparities in HIV infection. HIV prevention interventions will be most effective if they use a structural approach and integrate primary concerns of transgender people (eg, gender-affirmative care and management of gender transition) alongside delivery of HIV-related services (eg, biobehavioral prevention, HIV testing, linkage to care, and treatment).

Screening Yield of HIV Antigen/Antibody Combination and Pooled HIV RNA Testing for Acute HIV Infection in a High-Prevalence Population

IMPORTANCE Although acute HIV infection contributes disproportionately to onward HIV transmission, HIV testing has not routinely included screening for acute HIV infection. OBJECTIVE To evaluate the performance of an HIV antigen/antibody (Ag/Ab) combination assay to detect acute HIV infection compared with pooled HIV RNA testing. DESIGN, SETTING, AND PARTICIPANTS Multisite, prospective, within-individual comparison study conducted between September 2011 and October 2013 in 7 sexually transmitted infection clinics and 5 community-based programs in New York, California, and North Carolina. Participants were 12 years or older and seeking HIV testing, without known HIV infection. EXPOSURES All participants with a negative rapid HIV test result were screened for acute HIV infection with an HIV Ag/Ab combination assay (index test) and pooled human immunodeficiency virus 1 (HIV-1) RNA testing. HIV RNA testing was the reference standard, with positive reference standard result defined as detectable HIV-1 RNA on an individual RNA test. MAIN OUTCOMES AND MEASURES Number and proportion with acute HIV infections detected. RESULTS Among 86,836 participants with complete test results (median age, 29 years; 75.0% men; 51.8% men who have sex with men), established HIV infection was diagnosed in 1158 participants (1.33%) and acute HIV infection was diagnosed in 168 participants (0.19%). Acute HIV infection was detected in 134 participants with HIV Ag/Ab combination testing (0.15% [95% CI, 0.13%-0.18%]; sensitivity, 79.8% [95% CI, 72.9%-85.6%]; specificity, 99.9% [95% CI, 99.9%-99.9%]; positive predictive value, 59.0% [95% CI, 52.3%-65.5%]) and in 164 participants with pooled HIV RNA testing (0.19% [95% CI, 0.16%-0.22%]; sensitivity, 97.6% [95% CI, 94.0%-99.4%]; specificity, 100% [95% CI, 100%-100%]; positive predictive value, 96.5% [95% CI, 92.5%-98.7%]; sensitivity comparison, P < .001). Overall HIV Ag/Ab combination testing detected 82% of acute HIV infections detectable by pooled HIV RNA testing. Compared with rapid HIV testing alone, HIV Ag/Ab combination testing increased the relative HIV diagnostic yield (both established and acute HIV infections) by 10.4% (95% CI, 8.8%-12.2%) and pooled HIV RNA testing increased the relative HIV diagnostic yield by 12.4% (95% CI, 10.7%-14.3%). CONCLUSIONS AND RELEVANCE In a high-prevalence population, HIV screening using an HIV Ag/Ab combination assay following a negative rapid test detected 82% of acute HIV infections detectable by pooled HIV RNA testing, with a positive predictive value of 59%. Further research is needed to evaluate this strategy in lower-prevalence populations and in persons using preexposure prophylaxis for HIV prevention.

Transgender women, hormonal therapy and HIV treatment: a comprehensive review of the literature and recommendations for best practices

Studies have shown that transgender women (TGW) are disproportionately affected by HIV, with an estimated HIV prevalence of 19.1% among TGW worldwide. After receiving a diagnosis, HIV‐positive TGW have challenges accessing effective HIV treatment, as demonstrated by lower rates of virologic suppression and higher HIV‐related mortality. These adverse HIV outcomes have been attributed to the multiple sociocultural and structural barriers that negatively affect their engagement within the HIV care continuum. Guidelines for feminizing hormonal therapy among TGW recommend combinations of oestrogens and androgen blockers. Pharmacokinetic studies have shown that certain antiretroviral therapy (ART) agents, such as protease inhibitors (PIs), non‐nucleoside reverse transcriptase inhibitors (NNRTIs) and cobicistat, interact with ethinyl estradiol, the key oestrogen component of oral contraceptives (OCPs). The goal of this article is to provide an overview of hormonal regimens used by TGW, to summarize the known drug‐drug interactions (DDIs) between feminizing hormonal regimens and ART, and to provide clinical care recommendations.

What's in a Guideline? Developing Collaborative and Sound Research Designs that Substantiate Best Practice Recommendations for Transgender Health Care.

Transgender medicine presents a particular challenge for the development of evidence-based guidelines, due to limitations in the available body of evidence as well as the exclusion of gender identity data from most public health surveillance activities. The guidelines that have been published are often based on expert opinion, small studies, and data gathered outside the US. The existence of guidelines, however, helps legitimate the need for gender-affirming medical and surgical interventions. Research conducted on transgender populations should be grounded in gender-affirming methodologies and focus on key areas such as health outcomes after gender-affirming interventions.

Breast Cancer Screening, Management, and a Review of Case Study Literature in Transgender Populations

&NA; Because of a lack of uniform collection of gender identity data, population‐level breast cancer statistics in the transgender community are unknown. With recent estimates that at least 0.6% (1 in every 167 people) of the U.S. population is transgender, guidance on breast cancer risk, screening, and management in this population is needed. Such guidance should examine modifications, if any, to recommendations in cisgender populations, taking into consideration any history of hormone therapy exposure or breast surgery. This article describes existing evidence on breast cancer incidence in transgender women and men, and attempts to make rational recommendations regarding the screening for and approach to managing breast cancer in transgender populations. Current data are mostly limited to case reports which are reviewed here. More prospective, population‐level research is needed to better understand the risks and predictors of breast cancer in this population, as well as to better inform the most appropriate screening modality, age of starting screening, and interval. Ultimately, a risk score calculator similar to existing risk models such as the Gail score, as well as an approach to shared decision making that involves patient‐centered perspectives, is needed to best guide practices in this area.

Medical Transition for Transgender Individuals

Transition refers to the process of affirming a gender identity that is different from the birth-assigned gender role. For some individuals this may be a social transition, involving changes in gender roles and expression without the need to medically feminize or masculinize their bodies. For others however transition includes the use of cross-gender hormone therapy and/or surgical procedures that fall under the umbrella of gender confirming surgeries. The purpose of this chapter is to discuss the development of medical protocols that guide provision of hormones for medical transition, with particular attention to the philosophy of the informed consent model of care. The chapter summarizes the usual doses of hormones and other agents used for masculinizing and feminizing regimens as well as discussing the beneficial and potential adverse effects of treatment. The chapter reviews the short and long-term management of clients on hormones and addresses primary care concerns specific to transgender clients. Key references and resources are provided to assist clinicians who wish to optimize their knowledge and skills caring for transgender clients.

Transgender health care: improving medical students' and residents' training and awareness

Background A growing body of research continues to elucidate health inequities experienced by transgender individuals and further underscores the need for medical providers to be appropriately trained to deliver care to this population. Medical education in transgender health can empower physicians to identify and change the systemic barriers to care that cause transgender health inequities as well as improve knowledge about transgender-specific care. Methods We conducted structured searches of five databases to identify literature related to medical education and transgender health. Of the 1272 papers reviewed, 119 papers were deemed relevant to predefined criteria, medical education, and transgender health topics. Citation tracking was conducted on the 119 papers using Scopus to identify an additional 12 relevant citations (a total of 131 papers). Searches were completed on October 15, 2017 and updated on December 11, 2017. Results Transgender health has yet to gain widespread curricular exposure, but efforts toward incorporating transgender health into both undergraduate and graduate medical educations are nascent. There is no consensus on the exact educational interventions that should be used to address transgender health. Barriers to increased transgender health exposure include limited curricular time, lack of topic-specific competency among faculty, and underwhelming institutional support. All published interventions proved effective in improving attitudes, knowledge, and/or skills necessary to achieve clinical competency with transgender patients. Conclusion Transgender populations experience health inequities in part due to the exclusion of transgender-specific health needs from medical school and residency curricula. Currently, transgender medical education is largely composed of one-time attitude and awareness-based interventions that show significant short-term improvements but suffer methodologically. Consensus in the existing literature supports educational efforts to shift toward pedagogical interventions that are longitudinally integrated and clinical skills based, and we include a series of recommendations to affirm and guide such an undertaking.

Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons

of the Clinical Issue Transgender individuals have a gender identity that does not align with their sex assignment at birth (gender incongruence). They account for about approximately 0.4% of the US population (1 million people).1 Some transgender people experience gender dysphoria, distress caused by the discrepancy between gender identity and birth-assigned sex, linked to lifetime suicide attempt rates of 40%.2 Some may start to live or transition into their affirmed gender. This may include social or legal transition, such as changes to attire, name, and pronouns. Some may request hormones, surgery, or both to diminish the secondary sex characteristics associated with their birth sex. Children diagnosed as having GD/GI may start GnRH agonists after beginning puberty to prevent permanent changes, including facial hair, deepening of the voice, and breast growth. Thereafter, they may initiate hormones to acquire the secondary sex characteristics of their affirmed gender. Prospective studies suggest these interventions are associated with improved psychological functioning and reduction in anxiety and depression.3

Cancer care in lesbian, gay, bisexual, transgender and queer populations

Lesbian, gay, bisexual, transgender and queer (LGBTQ) populations experience health and healthcare disparities that may place them at higher risk for developing cancer. In addition, LGBTQ communities have psychosocial factors, such as fear of discrimination, that have substantial impacts on their medical care. As a result, these populations have specific needs with regard to cancer screening, treatment and support that must be addressed by cancer care providers. Although much has been done to address cancer care in the general population, more improvement is needed in the care of LGBTQ patients. We aim to present an overview of the current state of LGBTQ cancer care, opportunities for improvement and how cancer centers and providers can create a better future for the care of LGBTQ cancer patients.

Pharmacists’ role in provision of transgender healthcare

Over the past decade, transgender and gender-nonconforming (TGNC) individuals (i.e., people whose gender identity does not conform to their sex assigned at birth) have gained greater visibility and acceptance in society. TGNC people may decide to undergo medical transition, including hormone therapy