HIV in Transgender

Transgender people are much more vulnerable to HIV acquisition than the general population. While the prevalence of HIV in the cisgender population is 1.1%1, transgender women face up to 49 times greater risk. The prevalence of HIV among transgender people in Thailand is 9.3%3, a similar rate to that seen in The United States of America (9.2%), with figures among transgender women being higher than that seen in transgender men (14.1% and 3.2% respectively). There are multiple factors that increase the risk of HIV acquisition among transgender people, such as having condomless anal sex, having less bargaining power with sex partners in using condoms, having sex under the influence of alcohol, frequent sex partner changes, having sex partners with high HIV acquisition risk, using injectable hormonal and/or recreational drugs, and engaging in sex work. HIV prevention and treatment in transgender people aims to reduce HIV-related illnesses, reduce onward transmission, and maximize quality of life. Such services should ideally be provided both within and beyond healthcare facilities.

Recommended services in healthcare facilities

• Condoms and lubricants
• Harm reduction services for substance addiction including education, needle exchange and opioid replacement therapy
• Risk reduction counseling
• HIV testing
• Care for people living with HIV
• Prevention and treatment of comorbidities, such as opportunistic infections, tuberculosis, other sexually transmitted infections (STIs), and psychiatric disorders.
• Sexual and reproductive health services

Key environmental success factors

• Laws, policies, and financial support, including decriminalization of activities of transgender people, such as sex work
• Policies promoting stigmatization and prohibiting discriminatory practices against transgender people in healthcare facilities
• Empowering transgender people
• Promotion of legislation and policies against the use of physical and mental abuse towards transgender people

HIV prevention

Transgender people can reduce their risk of HIV acquisition by use of condoms, avoidance of insertive sexual intercourse, regular screening and treatment for STIs, and male genital circumcision where applicable. Additionally, available HIV prevention methods are the use of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP).

Post-Exposure Prophylaxis (PEP)

Those with a history of exposure to HIV, whether from blood or secretions, within 72 hours should consider taking PEP. High-risk secretions include blood, semen, vaginal secretions, and pus. Exposures to mucus, saliva, tears, sweat, phlegm, vomit, feces, and urine without visible blood contamination are considered very low risk. High-risk activities include condomless anal or vaginal sex or in situations with condom breakage (for both insertive and receptive partners) and penetrating wounds with blood-contaminated hollow instruments, such as needles. Transgender women with neovaginas utilizing penile inversion or graft transplantation may be at higher risk of HIV acquisition if they engage in insertive sexual intercourse without the use of artificial lubrication due to the absence of naturally occurring lubricants predisposing such tissue to be vulnerable to tearing.

Pre-Exposure Prophylaxis (PrEP)

PrEP is another increasingly accessible modality available in the prevention of HIV infection. Its use is recommended in Thailand National Guidelines on HIV/AIDS Treatment and Prevention 2017 and the Thailand National Guidelines on Pre-Exposure Prophylaxis: HIV-PrEP 2018.

Daily oral PrEP is recommended for transgender people receiving gender-affirming hormone therapy. Event-driven PrEP is not recommended due to known drug-drug interactions between PrEP and hormonal drugs that may reduce the effectiveness of PrEP. Healthcare facilities providing PrEP should also offer other preventive measures, such as condoms and lubricants, and emphasize the importance of regular HIV testing. If clients are found to be HIV positive, ART should be initiated promptly. Service providers should be gender-sensitive and offer care through a holistic approach, which includes considerations towards mental health, gender-affirming care (both medical and surgical), encouragement of safe sex practices, and substance addiction, all in accordance with the UNAIDS 'reach-test-treat-retain' policies.

Transgender women are frequently concerned about side effects from using PrEP and gender-affirming hormonal therapy, particularly with regards to the impact on their physical appearance. Service providers should be conscious of this and provide information to address any concerns to support drug adherence. To address osteoporosis concerns for transgender women who have undergone orchiectomy, dietary advice, exercise, and smoking cessation are recommended, with further referral to endocrinologists as needed. Transgender people with any potential risk exposure to HIV anticipated in the next 3 months should be offered daily oral PrEP, which is now reimbursable under the National Health Security Office (NHSO) Universal Health Coverage Scheme. This package includes PrEP (300mg tenofovir diphosphate and 200 mg emtricitabine), HIV testing 4 times a year, creatinine testing twice a year, hepatitis B (HbsAg) testing once a year, STI testing twice a year, and condoms.

Transgender people may have access to a larger variety of HIV prevention options in the foreseeable future. Tenofovir alafenamide (TAF) may replace the currently used tenofovir disoproxil fumarate due to its superior bone and renal side effect profile. Its access is currently limited by cost. Injectable cabotegravir is currently under investigation in worldwide clinical trials. It has so far seen very promising results and given its route of administration could potentially help to address challenges related to daily drug adherence with existing PrEP regimens.

Reaching the transgender population

It is crucial that HIV at risk transgender populations are reached to provide HIV testing. This should be performed in conjunction with gender-affirming health services to build rapport, an important foundation for both short- and long-term retention in services. Access to high-risk transgender populations must begin with accurate population estimations followed by thorough risk and needs assessments. Those found to be HIV positive should be treated promptly at all CD4 levels.

Refer: Sexual Health in Transgender People: HIV and Hepatitis, The Thai Handbook of Transgender Healthcare Services, Center of Excellence in Transgender Health, Chulalongkorn University