Underscoring what various trans male activists have argued, a study in the American Journal of Public Health (AJPH) reveals that HIV-positive trans men (FTM) have significant unmet social and healthcare.
According to authors Ansley Lemons MPH, Linda Beer PhD, Teresa Finlayson PhD, MPH, Donna Hubbard McCree PhD, MPH, RPh, Daniel Lentine MPH, and R. Luke Shouse MD, MPH, for the Medical Monitoring Project:
"Approximately half were living in poverty and only 60 percent had sustained viral suppression.
Many transgender men receiving HIV medical care in the United States face socioeconomic challenges and suboptimal health outcomes,” write the authors. “Although these transgender men had access to HIV medical care, many experienced poor health outcomes and unmet needs.”
Over two-thirds (69 percent) had an unmet support needs and a quarter were currently living with depression.
Most were sexually active."
The study goes on to say, that transgender men need their own studies to address their unique needs. “To decrease disparities and achieve health equity among HIV-positive men, HIV care models could incorporate transgender-sensitive health care and mental health services and health insurance inclusive of sex reassignment procedures and physical sex-related care.”
Dr. Jessica Rongitsch, a primary care doctor at Capitol Hill Medical, an LGBTQ clinic in Seattle, Washington has been providing gender affirming care for the trans community for over 15 years. Rongitsch agrees there needs to be more studies that include trans individuals around HIV, especially in regards to PrEP.
"Many of my trans masculine patients have condomless penetrative sex with penises so are at risk of HIV infection. Testosterone causes thinning and dryness or vaginal mucosa which increases risk of bleeding and tearing during sex. While there aren't studies specifically looking at this, I believe trans men may be at higher risk of contracting HIV if exposed to the virus, compared to cisgender women. Studies looking at PrEP efficacy in cis women might not apply to trans men as they might be at higher risk.”
The good news according to Rongitsch is that in the over 15 years she’s been caring for trans patients, “I do feel like tides in healthcare are turning thanks to years of tireless activism from trans leaders. Care is becoming more accessible in many parts of the country, awareness among medical providers is increasing, and we are starting to see more focus on trans health research — all positive steps to remedy decades of terrible disparities in healthcare for trans individuals."
Dr. Asa Radix of Callen-Lorde and a medical expert on trans issues says that while there’s been no formal research on the efficacy of PrEP in trans men who have or are in the process of hormone replacement therapy (HRT), “There is unlikely to be a change in efficacy. All cis women have some testosterone and there is a wide variation in testosterone levels in cis and trans men. There really isn’t a reason why PrEP would not work in a trans man on T. There are obvious differences between cis and trans guys who have sex with men — for those men who have front sex we need to screen for pregnancy and STI testing needs to include trichomoniasis.”
The concern says Radix “is that trans men are often not informed about PrEP and providers may not take comprehensive sexual health and substance use histories, so providers may not even be aware of risk factors and the need for PrEP. This is one of the main reasons why the uptake is low, for all people of trans experience.”
Radix says we know PrEP works, and we need to "look at why people aren’t using PrEP and best ways to get those who need it on it, whether issues of HIV or PrEP stigma play a role, and investigate the best ways to get information into the community and to implement PrEP in trans communities — but this study is already happening."
Dr. Perry Halkitis, head of the Rutgers School of Public Health, adds, "The problem I see in the literature, reminds me very much of the early days of AIDS when all of the trials on medication were being done on men and then what ended up happening is the women started taking meds and having really awful side effects. Somebody should have thought, 'You know, we should have women in these trials too.' I think there is a parallel there."
Halkitis notes that from the perspective of a researcher, "I’ve had this cohort study that's been going on now for eight years called the P18 Cohort Study. The folks in the study were 18 when they started, a sub set of them are transitioning. We've been funded for two cycles and we're going back next year. We're going to ask for more money to study the trans and non-conforming folks separately because we can't keep studying them the same."
At Rutgers, Halkitis is convening a group that's called the Gender and Sexuality Work Group. "What is interesting and challenging is that I do experience some tension that exists on issues of gender and sexuality. The challenge is trying to manage these conversations in a way that recognize that one doesn't have to be at the expense of the other. That's my job as a leader to do that. It's not just about the hormones and biology, there is psychology and social conditions. When you treat the health of a trans person you have to think about all of those things."