Fear of Drug Interactions May Affect Adherence in Trans Women With HIV

Veronica Hackethal, MD

August 07, 2017

PARIS — Concerns over interactions between feminizing hormone therapy and antiretroviral therapy (ART) may hinder many transgender women with HIV infection from taking medications as prescribed, according to a new study presented as a poster here on July 24 at the International AIDS Society (IAS) 2017 Conference.

"Despite all indications that transgender women are a critical population in HIV care, very little is known about how to optimize coadministration of ART and hormonal therapies in this population," said lead author of the work, Jordan Lake, MD, currently continuing this research at the University of Texas Health Sciences Center at Houston but who was with University of California, Los Angeles David Geffen School of Medicine at the time this survey was conducted.

"This study suggests this void of information may mean some transgender women forgo life-sustaining HIV medications, identity-affirming hormone therapy, or some combination of the two," added Dr Lake in a press release issued by the US National Institute of Allergy and Infectious Diseases (NIAID).

Transgender women — people whose birth certificates indicate or once indicated male sex but who identify as women — are at high risk for HIV (Lancet Infect Dis. 2013;13:214-122). Between 2009 and 2014, 2351 transgender individuals were diagnosed with HIV in the United States, and 84% of these were transgender women.

ART, considered essential therapy for HIV, can decrease HIV transmission, prevent the development of AIDS, and lengthen life expectancy.

At the same time, hormone therapy plays an important role in gender-harmonizing care for transgender women. Some may consider hormone therapy so important that they seek it outside of supervised medical care.

However, both hormone therapy and ART have potential side effects and drug interactions. Little is known about the safety and effectiveness of combining ART and hormone therapy at doses used to treat transgender women, and no treatment consensus exists. 

"Making sure we are meeting the needs of transgender women living with HIV is key to addressing this pandemic. We need to provide an evidence-based response to these understandable concerns so that this key population and their sexual partners may reap the full benefits of effective HIV care," adds Judith Currier, MD, codirector of the Center for AIDS Research and Education Center at the University of California, Los Angeles and vice-chair of the NIAID-supported AIDS Clinical Trials Network.

Less Than Half of Transgender Women With HIV Had Discussed Interaction Fears

To investigate the issue, the researchers surveyed transgender women at a community AIDS center in Los Angeles. Of 87 transgender women surveyed, over half (n=47) were HIV positive and were currently prescribed ART.

Among transgender women with HIV, 66% (n=31) were currently using hormone therapy, 34% (n=11) of whom had obtained it outside the medical system.

Fifty-seven percent (n=24) of transgender women had concerns about interactions between ART and hormone therapy. But only 49% (n=21) had discussed these concerns with their provider.

In 40% of transgender women, concern over drug-drug interactions contributed to using hormone therapy and/or ART differently from that prescribed: 28% (n=12) used ART differently and 28% (n=12) used hormone therapy differently.

The authors note that the results support other evidence suggesting that transgender women have fears that ART will decrease the effectiveness of hormones.

Such fears may stem from interactions between ART and hormonal contraceptives, whose effectiveness can decrease when combined with some kinds of ART.

However, not taking ART as prescribed can increase the risk of HIV resistance and failure of ART to suppress HIV. Not taking hormone therapy as prescribed may cause suboptimal feminization or other side effects.

The good news is that the study also found increased adherence to hormone therapy and access to transgender-specific care were linked to higher ART adherence.

That points to an opportunity for comprehensive care programs for HIV-positive transgender women to improve care by integrating hormone therapy and ART services.

"The best thing a person living with HIV can do is to start and stay on safe, effective antiretroviral therapy both to maintain their own health and to prevent sexual transmission of the virus," states Anthony S Fauci, MD, NIAID director.

"We need to ensure we understand the perspectives of groups disproportionately affected by this pandemic to provide the best healthcare for them. Further study is needed to help determine how healthcare teams can optimally tailor care and treatment for those living with HIV."

More information on guidelines for avoiding drug interactions with ART can be found at the AIDSInfo website.

The study was supported by the Doris Duke charitable foundation, National Institutes of Health, and Gilead Sciences. The authors report no relevant financial relationships.

International AIDS Society (IAS) 2017 Conference. July 24, 2017, Paris, France. Abstract WEPEB0586

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