HEALTH:

Presented by:

Alsean R. Bryant, Pharm.D., AAHIVP

AIDS Healthcare Foundation

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The presenter has no actual or potential conflict of interest in relation to this presentation program.

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Pharmacists:

Define gender identity in the LGBTQ community

Review statistics regarding HIV amongst transgender people

List hormonal therapies used by transgender people

Recognize possible drug interactions between anti-retrovirals and hormonal therapies

Identify barriers to healthcare in the LGBTQ community

Identify the role of pharmacists in bridging relevant healthcare gaps in the LGBTQ community

Technicians:

Define gender identity in the LGBTQ community

Review statistics regarding HIV amongst transgender people

List hormonal therapies used by transgender people

List possible drug interactions between anti-retrovirals and hormonal therapies

Identify barriers to healthcare in the LGBTQ community

Identify the role of pharmacy technicians in bridging relevant healthcare gaps in the LGBTQ community

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LESBIAN A woman who self-identifies as

having an emotional, sexual, and/or relational attraction to other women

GAY A man who self-identifies as

having an emotional, sexual, and/or relational attraction to other men

May be used by women who prefer the term over lesbian

BISEXUAL A person who self-identifies as

having an emotional, sexual, and/or relational attraction to men and women

TRANSGENDER A person whose gender identity

and/or expression is different from that typically associated with their assigned sex at birth

MTF/FTM

Gender Identity – a person’s internal sense of being male, female, or something else. Since gender identity is internal, one’s gender identity is not necessarily visible to others

Gender Expression – the manner in which a person represents or expresses their gender identity to others (i.e. behavior, clothing, voice, etc.)

Sexual Orientation – a person’s emotional, sexual, and/or relational attraction to others. Usually classified as hetero-, bi-, or homosexual

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Several theories about how a person develops, accepts, and expresses their gender identity

Gender essentialism – the idea that men and women act differently and have different options in life because of intrinsic or essential differences between the sexes.

Gender schema theories - introduced by Sandra Bem in 1981 as a cognitive theory to explain how individuals become gendered in society, and how sex-linked characteristics are maintained and transmitted to other members of a culture. Bem argued that adhering to gender-related standards could promote negative rather than positive adjustment

During the mid-1960s to early 1980s, researchers such as Richard Green, Robert Stroller, and Harry Benjamin believed that incongruence between a person’s assigned sex at birth and their gender identity was of a biological, rather than psychological nature and went on the pioneer the establishment of gender identity clinics as well as gender-related medical and surgical treatments

Relationship to sexual orientation

Research shows that gender identity, in many cases, is independent of sexual orientation

i.e. transgender men may be attracted to men, women or both, and transgender women may be attracted to men, women or both

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• 84% were transgender

women

• 15% were transgender

men

• Roughly half lived in the

South

• Nearly one quarter of

transgender women are

living with HIV

2009-2014 2,351 transgender

people diagnosed

with HIV

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To provide a safe, effective hormone regimen that will:

Suppress endogenous hormone secretion determined by the person’s genetic/biologic sex

Maintain sex hormone levels within the normal range for the person’s desired gender

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MTFEffect Onset Maximum

Redistribution of body fat 3-6 months 2-3 years

Decrease in muscle mass and strength 3-6 months 1-2 years

Softening of skin/decreased oiliness 3-6 months Unknown

Decreased libido 1-3 months 3-6 months

Decreased spontaneous erections 1-3 months 3-6 months

Male sexual dysfunction Variable Variable

Breast growth 3-6 months 2-3 years

Decreased testicular volume 3-6 months 2-3 years

Decreased sperm production Unknown > 3 years

Decreased terminal hair growth 6-12 months > 3 years

Scalp hair No regrowth Familial scalp hair loss may occur if estrogens are

stopped

Voice changes None *Voice training by speech pathologist most effective

Monitoring: • Evaluate patient every 2-3 months in the first year and then 1-2 times/yr afterward to monitor for appropriate signs of feminization and for development of AE

• Measure serum testosterone and estradiol every 3 months

• For patients on spironolactone, serum electrolytes (ie K+) should be monitored every 2-3 months in the first year

• Consider BMD testing at baseline if risk factors for osteoporotic fractures are present

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Drug Type Route of Admin Drug Name(s) Dosage

Estrogen

Oral Estradiol 2.0 – 6.0 mg/day

Transdermal patch Estradiol 0.1 – 0.4 mg twice weekly

IM Estradiol Valerate

(Delestrogen)

5-20mg IM Q 2 weeks

2-10mg IM Q week

Antiandrogrens Oral Spironolactone 100-200 mg/day

Oral Finasteride

Oral Dutasteride

Progestins IM Medroxyprogesterone

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Likely Increased Risk Possible Increased Risk Inconclusive or No

Increased Risk

Venous Thromboembolic Disease • Estrogen use

• Particularly >40 yr old, smokers, highly

sedentary, obese, and underlying

thrombophilic disorders

• Risk increased with additional use of 3rd

gen. progestins

• Risk decreased with use of transdermal

estradiol

Diabetes Mellitus • Feminizing hormone therapy, particularly

estrogen, may increase the risk of type 2

diabetes, particularly among patients with

a family history of diabetes or other risk

factors for this disease.

Breast Cancer • Longer duration of feminizing hormone

exposure (i.e., number of years taking

estrogen preparations), family history of

breast cancer, obesity (BMI >35), and the

use of progestins likely influence the level

of risk.

Lipids • Oral estrogen increase triglycerides,

leading to pancreatitis and CV events

• Patients with pre existing lipid disorders

may benefit from transdermal estrogens

Hypertension • Estrogen may increase risk of HTN

• Spironolactone reduces blood pressure

and is recommended for at-risk or

hypertensive patients desiring

feminization.

Liver/gallbladder • Estrogen and cyproterone use may be

assoc with elevated liver enzymes

• Estrogen use increase risk of cholelithiasis

Prolactinoma • Estrogen use increases the risk of

hyperprolactinemia among MtF patients in

the first year of treatment, but this risk

unlikely thereafter.

• High-dose estrogen use may promote the

clinical appearance of preexisting but

clinically unapparent prolactinoma. 14

FTMEffect Onset (months) Maximum (years)

Skin oiliness/acne 1-6 1-2

Facial/body hair growth 6-12 4-5

Scalp hair loss 6-12

Increased muscle mass/strength 6-12 2-5

Fat redistribution 1-6 2-5

Cessation of menses 2-6

Clitoral enlargement 3-6 1-2

Vaginal atrophy 3-6 1-2

Deepening of voice 6-12 1-2

Monitoring: • Evaluate patient every 2-3 months in the first year and then 1-2 times/yr afterward to monitor for appropriate signs of virilization and for development of AE

• Measure serum testosterone every 2-3 months until levels are in the normal physiological male range

• Measure estradiol levels during the first 6 months of testosterone treatment or until there has been no uterine bleeding for 6 months

• Measure CBC and LFT at baseline and every 3 months for the first year and then 1-2 times/yr

• Consider BMD testing at baseline if risk factors for osteoporotic fractures are present

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Drug Type Route of Admin Drug Name(s) Dosage

Testosterone

Transdermal Androgel 1% 2.5-10g/day

Transdermal

Androderm 2.5-7.5mg/day

IM Testosterone

Cypionate

100-200mg Q 2wk

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Likely Increased Risk Possible Increased Risk Inconclusive or No Increased

Risk

Polycythemia • Masculinizing hormone therapy involving

testosterone or other androgenic steroids

increases the risk of polycythemia (hematocrit

> 50%), particularly in patients with other risk

factors.

• Transdermal administration and adaptation of

dosage may reduce this risk

Lipids • Testosterone therapy decreases HDL, but

variably affects LDL and triglycerides.

• Transdermal administration more lipid neutral

• Patients with underlying polycystic ovarian

syndrome or dyslipidemia may be at

increased risk of worsening dyslipidemia with

testosterone therapy.

Osteoporosis • Testosterone therapy maintains or increases

bone mineral density among FtM patients

prior to oophorectomy, at least in the first three

years of treatment. After which there is a

decrease in BMD

Weight gain/visceral fat • Masculinizing hormone therapy can result in

modest weight gain, with an increase in

visceral fat.

Liver • Transient elevations in liver enzymes may

occur with testosterone therapy.

• Hepatic dysfunction and malignancies have

been noted with oral methyltestosterone.

However, methyltestosterone is no longer

available in most countries and should no

longer be used.

Cardiovascular • Masculinizing hormone therapy may increase

the risk of cardiovascular disease in patients

with underlying risks factors.

Psychiatric • Masculinizing therapy involving testosterone

or other androgenic steroids may increase the

risk of hypomanic, manic, or psychotic

symptoms in patients with underlying

psychiatric disorders that include such

symptoms

Hypertension • Patients with risk factors for hypertension,

such as weight gain, family history, or

polycystic ovarian syndrome, may be at

increased risk when using masculinizing

hormones

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Concomitant

drug

PI Effect on PI and/or

concomitant drug conc

Dosing Rec and Clinical Comments

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Concomitant

drug

NNRTI Effect on NNRTI and/or

concomitant drug conc

Dosing Rec and Clinical Comments

Concomitant drug INSTI Effect on INSTI and/or concomitant drug

conc

Dosing Rec and Clinical Comments

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Concomitant drug CCR5 Effect on CCR5

and/or concomitant

drug conc

Dosing Rec and Clinical Comments

BARRIERS

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Summer 2015

Conducted by Transgender Law Center, in conjunction with a national advisory board of trans community leaders and the Elton John AIDS Foundation, to address structural inequities that drive the high rate of HIV/AIDS and poor health outcomes among trans people

Bilingual online needs assessment survey

157 transgender participants, representing 35 states and Puerto Rico were recruited through existing networks and clinics serving trans people with HIV

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84% trans women

12% trans men

80% 26-55 years

old

Identified as transgender for a median of 5 years longer than they had been living with HIV

42% lived in the South, 29% West, 14%

NE, 13% Midwest

70% lived in urban areas, 14%

suburban, 16% rural 23

Traditional obstacles to care are magnified in people who are also LGBT Race/ethnicity

Low income

Low education

Stigma Verbal abuse

Physical harassment/bullying

Discrimination

Social marginalization

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Family acceptance LGBT youth experience less depression, substance abuse, and suicide

Health insurance coverage Discrepancies with gender codes

Limits on quantity/day supply for transgender people

Increase in HIV risk behavior

Healthcare provider attitudes What are some of the challenges that we as healthcare providers face regarding the LGBT community?

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Create a welcoming environment Relevant health information and brochures including:

HIV/AIDS

Screenings

Cancer

PrEP

Magazines: POZ, Advocate, Out, Lesbian Connection, LN: Lesbian News, GayParent Eye contact Smile

Be involved. Be empathetic. Take interest in the patient Ex. I ask transgender patients about their trans process and the effects they notice when taking different medications

Establish preferred name/gender identity with patient (note that name changes can happen frequently)

Connect with benefits counselors if available to help patients navigate the insurance process

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Are there any questions???

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ALSEAN R. BRYANT, PHARM.D., AAHIVP

AHF Pharmacy

2141 K St NW Ste 606

Washington, DC 20037

202-293-8695

Alsean.Bryant@aidshealth.org

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