HEALTH: Presented by: Alsean R. Bryant, Pharm.D., AAHIVP AIDS Healthcare Foundation

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1 HEALTH: Presented by: Alsean R. Bryant, Pharm.D., AAHIVP AIDS Healthcare Foundation 1

2 The presenter has no actual or potential conflict of interest in relation to this presentation program. 2

3 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 3

4 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 4

5 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 5

6 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 6

7 7

8 84% were transgender women 15% were transgender men ,351 transgender people diagnosed with HIV Roughly half lived in the South Nearly one quarter of transgender women are living with HIV 8

9 9

10 10

11 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 11

12 MTF Effect 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 12

13 Drug Type Route of Admin Drug Name(s) Dosage Estrogen Oral Estradiol mg/day Transdermal patch Estradiol mg twice weekly IM Estradiol Valerate (Delestrogen) 5-20mg IM Q 2 weeks 2-10mg IM Q week Antiandrogrens Oral Spironolactone mg/day Oral Finasteride Oral Dutasteride Progestins IM Medroxyprogesterone 13

14 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 3 rd gen. progestins Risk decreased with use of transdermal estradiol Lipids Oral estrogen increase triglycerides, leading to pancreatitis and CV events Patients with pre existing lipid disorders may benefit from transdermal estrogens Liver/gallbladder Estrogen and cyproterone use may be assoc with elevated liver enzymes Estrogen use increase risk of cholelithiasis 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. Hypertension Estrogen may increase risk of HTN Spironolactone reduces blood pressure and is recommended for at-risk or hypertensive patients desiring feminization. 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. 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. 14

15 FTM Effect Onset (months) Maximum (years) Skin oiliness/acne Facial/body hair growth Scalp hair loss 6-12 Increased muscle mass/strength Fat redistribution Cessation of menses 2-6 Clitoral enlargement Vaginal atrophy Deepening of voice 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 15

16 Drug Type Route of Admin Drug Name(s) Dosage Transdermal Androgel 1% g/day Testosterone Transdermal Androderm mg/day IM Testosterone Cypionate mg Q 2wk 16

17 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 Weight gain/visceral fat Masculinizing hormone therapy can result in modest weight gain, with an increase in visceral fat. 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. 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. 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 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 Cardiovascular Masculinizing hormone therapy may increase the risk of cardiovascular disease in patients with underlying risks factors. 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 17

18 18

19 Concomitant drug PI Effect on PI and/or concomitant drug conc Dosing Rec and Clinical Comments Concomitant drug NNRTI Effect on NNRTI and/or concomitant drug conc Dosing Rec and Clinical Comments 19

20 Concomitant drug INSTI Effect on INSTI and/or concomitant drug conc Dosing Rec and Clinical Comments Concomitant drug CCR5 Effect on CCR5 and/or concomitant drug conc Dosing Rec and Clinical Comments 20

21 BARRIERS 21

22 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 22

23 84% trans women 12% trans men 80% 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

24 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 24

25 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? 25

26 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 26

27 Are there any questions??? 27

28 ALSEAN R. BRYANT, PHARM.D., AAHIVP AHF Pharmacy 2141 K St NW Ste 606 Washington, DC Alsean.Bryant@aidshealth.org 28

29 Insert here 29

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