We Need Research: PrEP and the Trans Community

In recent years, there has been a dramatic increase in public awareness and understanding of the transgender community. Comotions surrounding trans celebrities, bathroom bills, and military enrollment bans, all of which centering almost entirely around the physiological traits of these individuals, have sparked national conversations about this marginalized group, who make up about 0.6% of our adult population (1). Quite recently in fact, the transgender community has once again come under attack by the current presidential administration, which announced plans to repeal a rule in the Affordable Care Act that protected trans individuals from discrimination from healthcare and health insurance providers after “a federal judge in Texas had found that parts of it were unlawful.” Despite all the concern surrounding the trans community’s place in our understanding of human biology, rarely it seems is there ever talk about the actual medical needs of trans individuals, and even rarer still is there talk of the unique situation surrounding the trans community in regards to HIV/AIDS.

The AIDS crisis of the 80’s and 90’s caused a nationwide panic of both public safety concerns, and morality conflicts. In the early days of the epidemic, gay men were disproportionately affected by the deadly disease, and ever since then there has been a stigma around HIV/AIDS, and much of the research into the prevalence and treatment of the disease has been aimed specifically at gay, cisgender males, often categorized as “males who have sex with males,” or “MSM” for short (2). This leaves important questions to be answered about how AIDS and AIDS medications, both to treat and prevent the disease, affect other members of the LGBT+ community, namely transgender individuals.

Trans people are disproportionately placed at a higher risk to contract HIV/AIDS when compared to cisgender individuals. This is often due to a web of overlapping factors, including “stigma and transphobia, lack of protections against discrimination, trauma, violence, substance use and poor mental health, sex work, incarceration, homelessness, unemployment and limited access to trans-friendly health care” (6). Furthermore, the risk increases again when taking into account racial factors. While trans individuals are disproportionately affected by the virus, due to this long list of contributing factors, there is some concern with effectiveness of preventative medicines, mainly PrEP (pre-exposure prophylaxis), in members of the trans community.

Although there has been vast amounts of research into the effectiveness of PrEP in preventing the contraction of HIV/AIDS, there has been far less research that specifically concerns the trans community. In more recent years, however, there has been an increase in focus on the trans community, even if it is incredibly limited.

A study published in 2010, entitled “Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men,” centering on the preventative effectiveness of PrEP in individuals who were assigned male at birth (5), touched briefly upon trans individuals in the testing sample. Of the 2499 HIV-seronegative individuals in the study, 339 of them (14%) were trans women (5). The study found that PrEP was shown to be just as effective in preventing HIV/AIDS in these women, even those who reported themselves to be undergoing hormone therapy, although many were less likely to be taking the drug at the recommended amounts and times (5). This lack of proper use can most likely be attributed to the outside factors listed above.

While this study provided important data for HIV/AIDS prevention in the transgender community, it has come under scrutiny for a number of reasons. The main concern from critics of the study is that it was not designed to measure the effectiveness of PrEP on specifically transgender individuals, only the general category of MSM (4). In addition, there has been dissatisfaction with the term “MSM,” with some citing how it concentrates only on the implied sexual acts of cisgender males, while failing to take into account the myriad of other factors that influence the disease rates among trans women (3). Another important criticism of the “MSM” classification cites how the term also completely excludes trans men, since they are not born with what is often assigned as male genitalia (3). This is especially concerning, seeing that while compiling my research for this article, I could not manage to find a single study that directly addresses the effectiveness of PrEP on transgender men.

With the rise of public consciousness in relation to the trans community, there has been an increase in interest from scientists and medical professionals in regards to transgender health issues, and this is starting to look better for HIV/AIDS research specifically centered on trans individuals. As of 2016, the University of California began to fund “the first PrEP (pre-exposure prophylaxis) demonstration project in the United States to focus exclusively on transgender persons” (6). The currently-ongoing study is taking into account not only the outside factors, such as race and socioeconomic status, that affect AIDS prevalence in the trans community, but also the possible chemical interactions that may occur between the drug and hormone therapies, for which there is next to no existing data (6). The study is set to conclude by the end of 2019.

The University of California is doing important, vital work in the effort to combat the spread of AIDS and improve the wellbeing of the LGBT+ community, but we cannot let them be the only ones. Their new study is addressing the trans community’s unique place in the AIDS epidemic, and while I am very hopeful that this will spark further interest from other medical professionals and scientists, we will need to show that the public supports the much needed research. Considering all the intersecting barriers that the trans community is still facing when in need of medical help, it is vital that we come to a better understanding of their specific needs so that the few who actually receive care are given proper treatment.

References:

1. Andrew R. Flores et al. “How Many Adults Identify as Transgender in the United States?” The Williams Institute, June 2016, https://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf
2. Asa Radix. “PrEP and Transgender People.” positivelyaware.com, https://www.positivelyaware.com/articles/prep-and-transgender-people
3. Kenneth H. Mayer et al. “Transgender People and HIV Prevention: What We Know and What We Need to Know, a Call to Action.” Journal of Acquired Immune Deficiency Syndromes, 15 August, 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4969053/
4. Peter L. Anderson et al. “Pharmacologic Considerations for Preexposure Prophylaxis in Transgender Women.” Journal of Aquired Immune Deficiency Syndromes, 15 Aug, 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4955879/
5. Robert M. Grant et al. “Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men.” The New England Journal of Medicine, 30 December, 2010, https://www.nejm.org/doi/full/10.1056/NEJMoa1011205
6. Scott LaFee, Lisa Loeb Stanga. “An HIV Prevention Pill for Transgender Persons.” UC San Diego, 26 April, 2016, https://ucsdnews.ucsd.edu/pressrelease/an_hiv_prevention_pill_for_transgender_persons