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AIDS/HIV and HRT

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This topic will explore both the positive and negative aspects of hormone replacement therapy while having HIV (Human Immunodeficiency Virus). Be aware that many "antiviral" meds are extremely hard on the kidneys &\or liver. Cross-sex hormones are too, so informing a doctor or doctors of both a person's HIV status and gender transition is important to all our good health. The provider should still be able to provide an antiviral regimen that compliments an HRT regimen and that will not effect the kidneys &\or liver as much due to the stress they already have under HRT.

HIV and AIDS

HIV (Human Immunodeficiency Virus) is the virus that directly causes AIDS (Acquired Immunodeficiency Syndrome). A diagnosis of HIV does not mean a person has AIDS. A diagnosis of AIDS is determined by a physician using specific clinical or laboratory standards like Viral load & T cell count to name a few.

HIV in the Transgender community

Accurate data is hard to find but these are some general statistics from a variety of sources and encompassing many different social classes in the transgender community. A study in Atlanta collected data among transgender “sexworkers” and found that 68% of them were infected with the HIV virus. Another study surveyed transgender individuals seeking hormones in a public health setting. Of those, 15% were HIV infected. In a more recent study, 35% of transgender individuals seeking HRT were found to be HIV positive. And in Los Angeles one study showed 22% of transgender people were infected with the HIV virus.

  • Figures from "Supporting People who are Transgender"; PJ Two Ravens MSW; 2003.

HIV diagnosis and what that means to a transsexual

When an individual first finds out that they have HIV, they will need to adjust to this major change in their life. We are fortunate that HIV/AIDS is no longer the death sentence it was when it was first discovered but it still makes a huge impact on the lives of its victims. Family members, friends or a support group (or groups) might be able to help. Talking with a counselor or social worker can also help a great deal. A person should take the time and adjust to this change. Then they should start taking these next steps:

  • Learn more about HIV disease
  • Keep track of their immune system's health status
  • Decide how they want to deal with HIV
  • Inform the Endocrinologist, other doctors and anyone else who might prescribe medications that HIV is present
  • Keep an accurate record of ALL medications they are taking, what the dosages are and how often or how many a day are taken.

These are things that can help a person stay healthier with HIV disease. They must also remember to take time and learn about the options. Remember, the individual is in charge of their own health care. They must decide which doctor(s) to work with, and with whom else they want to consult about their treatments. They will decide, with the expert assitance of their medical advisors, which treatments they want to use and when they want to use them.

HIV Medications and classifications

Antiretroviral (ARV) medications are grouped within 4 basic classes.

The following list contains the names (with brand names in parenthesis) of the current medications that are used to treat HIV infection and AIDS

Nucleoside AND Nucleotide Analog Reverse Transcriptase Inhibitors (NUKES)

Abacavir (Ziagen), Combivir, Didanosine (DDI, Videx, Videx EC), Emtricitabine (FTC, Emtriva), Epzicom, Lamivudine (3TC, Epivir), Stavudine (d4T, Zerit, Zerit XR), Tenofovir (Viread), Trizivir, Truvada, Zalcitabine (ddC, Hivid), Zidovudine (AZT, Retrovir)

Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)

Delavirdine (Rescriptor), Efavirenz (Sustiva), Nevirapine (Viramune)

Protease Inhibitors

Amprenavir (Angenerase), Atazanavir (Reyataz), Fosamprenavir (Lexiva), Indinavir (crixivan), Lopinavir/Ritonavir (Kaletra), Nelfinavir (Viracept), Ritonavir (Norvir), Saquinavir (Invirase), Tipranavir (Aptivus)

Fusion Inhibitors

Enfuvirtide (Fuzeon)

Antiretroviral (ARV) and drug reactions with HRT (Hormonal Replacement Therapy)

Negative Interactions

NNRTI's & Protease Inhibitors, as well as most other drugs, are metabolized by the liver. Drug interactions can cause large increases or decreases in the blood levels of drugs an individual takes, leading to effects that can range from under-doses that can be ineffective to overdoses that can be fatal. Oral progestin and equine estrogen pills can increase a number of risks, including the risk of worsening existing liver or gallbladder problems in a individual on ARV. Therapy with equine estrogen, unopposed by progesterone, may also have more of an affect on blood triglyceride levels in individuals on ARV. It is known that NNRTI's & Protease Inhibitors often have significant interactions with oral contraceptive pills like Estrofem & Estrostep. Efavirenz increases estrogen AUC (Area Under the Curve, a measurement of how much drug gets past the liver into the bloodstream on the first pass through). Nevirapine, lopinavir and ritonavir decrease estrogen AUC. An individual and their doctor should carefully review the information "package insert" that comes with each medication in order to learn and understand the terminology used and the risks involved. They should ask the pharmacist for this information on each drug they are taking too. Also, the patient must make sure that the doctor reviews ALL medications, drugs and herbs they are taking or plan on taking in order to be certain that none of them will interact negatively.

Positive Interactions - HRT & ARV on a cellular level

HRT in Transsexuals have a variety of different effects on the body, some at a cellular level. One of the main goals of HRT is to modify a person body to produce secondary sex characteristics of the other sex. First, there are documented sex differences between men and women in the development of adverse effects associated with the NRTIs, in particular, lactic acidosis. Observational studies have shown that women experience greater toxic effects (side effects) with all classes of antiretroviral drugs. Although sex differences in the effects of these drugs may be due in part to physiologic and hormonal differences between men and women, variations in the activities of drug transporters and metabolizing enzymes involved in phase 1 and 2 reactions may also be involved suggesting, that antiretroviral agents (or their metabolites) that undergo biotransformation by these pathways may reach higher concentrations in the cells and tissues of female HIV patients than in male patients. Women in general appear to have higher concentrations or decreased clearance rates of several antiretrovirals. Gender-associated differences in hepatic enzyme expression (cytochrome P450 3A is involved predominantly in anti-retroviral metabolism) may account for these pharmacokinetic differences. In a recent study, female subjects had a 25% higher mean EFV AUC (Area Under the Curve, a measurement of how much drug gets past the liver into the bloodstream on the first pass through) than their male counterparts. This association remained statistically significant after adjusting for weight, racial group and co-administered medications (amprenavir [APV]; ritonavir [RTV]; and any NNRTIs). This could be related to MDR "Multi drug resistant" pumps and Pgp or P-glycoprotein and their differences in men vs. women. Pgp is encoded by the human multidrug resistance (MDR1) gene and is constitutively expressed in epithelial cells, especially in tissues important for drug disposition. Pgp activity among women was only one third to one half that of men in a study provided by Schuetz and colleagues. These observed lower expressions of Pgp in women suggest that women might be more likely than men to achieve higher cellular and tissue concentrations of antiretroviral drugs that are Pgp substrates. This may partially explain the increased frequency and severity of adverse reactions and perhaps the enhanced efficacy of some of these drugs in women compared with men. So in regards to a MtF transsexual on HRT one might come to the conclusion that with the administration of HRT they are creating lower expression of Pgp and therefore able to maintain a higher level of cellular and tissue concentrations of antiretroviral drugs that are Pgp substrates. In regards to FtM transsexuals one might come to the conclusion that with HRT they are creating higher expression of Pgp and therefore lowering level of cellular and tissue concentrations of antiretroviral drugs that are Pgp substrates. Unfortunately, there is no current study that supports this theory. There is a study currently underway in California to test this very theory, however, the study is only in phase 1 (recruiting subjects, HIV+ MtF and FtM transsexuals, to participate in the study).

Alternatives methods for HRT & ARV

BHRT

(HRT formulated to contain the naturally occurring human estrogens, estradiol and estriol, as well as bioidentical human progesterone and sometimes testosterone.)

Often delivered via topical administration of a cream or gel solution of the hormones to the skin, this method can be considered as an alternative to transitioning individuals who are HIV+. Absorbing hormones through the skin reduces concerns about liver effects potentially caused by combined HRT and ARV therapies since they do not have to pass through the liver first, before passing into the bloodstream. Also, because the hormones bypass the liver on their first pass, smaller initial doses can be prescribed which also lessens the risks.

Alternatives to ARV:

Using complementary and alternative therapies people with HIV have many different kinds of treatments for their disease. Some believe they have stayed healthier because they use traditional healing practices, massage, acupuncture, herbs, or other therapies.

Support groups & resources for individuals diagnosed with HIV

The CDC National AIDS Hotline can provide practical information on maintaining health and general information about treatment options, including antiretrovirals and prophylaxis for opportunistic infections.

The hotline numbers are (800) 342-2437 (English), (800) 344-7432, (Spanish), or (888) 480-3739 (TTY). The CDC Hotline can also provide referrals to treatment hotlines, local AIDS Service Organizations and HIV/AIDS-knowledgeable physicians.

Detailed information on specific treatment options is available from the HIV/AIDS Treatment Information Service (ATIS) at (800) 448-0440.

If you require financial assistance for obtaining HIV medications the following website provides lists of phone numbers for drug assistance programs (AIDS Drug Assistance Program, or ADAP) administered by the states. You may call these numbers for information on basic eligibility requirements (e.g., CD4 cell count, income limits) http://www.sfaf.org/treatment/beta/b37/b37stateadap.html

See also

HRT Risks of anti-retroviral drugs

References

External links

NATIONAL RESOURCES

The Centers for Disease Control maintains a database of over 19,000 service organizations in the United States dealing with HIV/AIDS, tuberculosis, and sexually transmitted diseases. You can search this database on the Internet at http://www.cdcnpin.org/scripts/locates/LocateOrg.asp

NEW MEXICO RESOURCES

  • Health Management Alliances,
    • District I: New Mexico AIDS Services, Albuquerque, (888) 882-2437, (505)938-7100; http://www.nmas.org, UNM Infectious Disease Clinic, Albuquerque: (505) 272-1312
    • District II: Southwest Care Center, Santa Fe: (888) 320-8200, (505) 989-8200; http://www.southwestcare.org/
    • District III: Camino de Vida Center for HIV Services, Las Cruces: (800) 687-0850, (505) 532-0202
    • District IV: Alianza of New Mexico, Roswell: (800) 957-1995

Individuals who contributed to writing this article

Dr. Robert Bettiker MD (Temple Hospital, Philadelphia, PA)
Milagros Acevedo (Temple Hospital, Philadelphia, PA)
Siniaya Kantrell (Mazzoni Center, Philadelphia, PA)

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*Some information provided in whole or in part by http://en.wikipedia.org/

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