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PrEP Works for Transgender Women, But Only If They Use It

Truvada as PrEP works for transgender women, but only if they take it.

After a closer look at outcomes among transgender women who took PrEP in the iPrEx trial, the results aren’t that surprising: PrEP works among this group, but only if the women take it.

And that proved to be a problem. Of 339 transgender women in the study, 11 who were on PrEP became infected with HIV. But none of those women had PrEP in their blood at the time of the seroconversion visit.

Conversely, none of the transgender women who had drug levels equal to four or more doses per week became infected. iPREx studied PrEP under the direction the drug be taken once daily, as opposed to before and after a sexual encounter.

“We think that one factor leading to lower rates of pill-taking may be due to either a fear of, or lack of information about drug-drug interactions between PrEP and gender-affirming hormone medications,” said lead study author Dr. Madeline B. Deutsch, assistant clinical professor of Family and Community Medicine at UCSF Center of Excellence for Transgender Health, in a UCSF news release. “And while there may be a negative behavioral interaction between the two therapies that is affecting pill-taking, we have no evidence to date for a biological interaction between the two, though further research is needed.”

The results of the subgroup analysis among transgender women in iPrEx was published Nov. 5 in the journal The Lancet HIV.

What was particularly concerning was that transgender women most at risk for HIV, such as sex workers, those reporting receptive anal intercourse without a condom and those who had more than five partners in the previous three months, were the least adherent. But among men who have sex with men enrolled in iPrEx, those most at risk tended to be more adherent.

Related HIV Equal News: How Trans Women of Color are fighting for their Lives

In an interview last year with Imstilljosh, Cecilia Chung of Transgender Law Center noted that transgender women experience so much stigma and discrimination, simply getting through each day is a battle. Issues related to health and taking medication is not front and center in their minds.

“Without hope, everything else is secondary,” Chung said. “If you don’t have your family and you don’t have a support system and you’re constantly being stigmatized and put down, what is the point in extending your life?”

In fact, simply finding food and water to take the medication with may be a challenge at times. “Transgender women face several structural barriers including lack of legal protection against discrimination and resulting difficulties in employment, access to income, food and housing,” Deutsch said. “They desperately need a tool that they control, one they can use without their partners’ consent or knowledge.”

Adherence to the pill form of PrEP is proving to be an issue among some groups at risk for HIV and is driving research to develop other forms of PrEP, such as a long-lasting injectable PrEP, a PrEP implant, even PrEP douches.

“When transgender women take PrEP as prescribed, it appears to work, but to retain and encourage PrEP use, research should be conducted and interventions should be delivered in gender-affirming environments,” said JoAnne Keatley, MSW and director of the UCSF Center of Excellence for Transgender Health. “One example would be to integrate PrEP delivery with gender-affirming services, including provision of gender-affirming hormone therapies. Social marketing campaigns and PrEP delivery programs should not lump transgender women in with MSM but should be explicitly designed to support transgender women.”

But transgender-specific health care services are scarce outside of progressive urban meccas such as New York, Los Angeles, San Francisco and Chicago. And no evidence-based HIV prevention interventions specifically designed for transgender women exist, according to the UCSF news release.

While the U.S. Centers for Disease Control and Prevention stresses that transgender women are at high risk for HIV, it does not mention them in its recommendations for PrEP as an HIV prevention tool