Pre-Exposure Prophylaxis (PrEP) for Transgender Men

Reducing HIV Risk

Pill used for Pre-Exposure Prophylaxis (PrEP) to prevent
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Pre-exposure prophylaxis, or PrEP, involves taking medication to reduce your risk of acquiring HIV. It's called pre-exposure because people ideally are taking it before they are exposed to the virus. While not a perfect form of HIV prevention, PrEP can substantially reduce an individual's risk of becoming infected during sex with an infected partner, and also reduce the risk of becoming infected through shared needles. Unfortunately, to date, most of the research on PrEP has been in serodiscordant heterosexual couples, cisgender men who have sex with men, and transgender women who have sex with men. This has left out another risk group—transgender men and other transmasculine people.

Transmasculine individuals are those who were assigned female at birth but who have a more masculine gender identity. They may identify as men or transgender men, but they may also identify as transmasculine, gender queer, non-binary, etc. Binary- and non-binary transmasculine individuals have a diverse range of sexual orientations and behaviors. They may identify as straight, gay, pansexual, bisexual, or another sexual orientation. They may use their front hole (vagina) for sex, or they may not. They may have had a phalloplasty and/or metoidioplasty. All of these factors can affect HIV risk.

Transgender Men and HIV

There is remarkably little data about the HIV risk experienced by transgender men and other transmasculine individuals. The few studies that have looked at transmasculine HIV risk have mostly been small and/or included a small number of transgender men in a larger group of transgender women. To some extent, this reflects the demographics of HIV infection, both in the United States and around the world. Transgender men only account for around 11% of transgender adults receiving HIV care, and 0.16% of the total HIV infected population.

Despite that, the HIV-positive transmasculine individuals examined in the study experienced numerous difficulties in getting adequate HIV care. Almost half were living in poverty, a quarter were depressed, and 69% had at least one unmet healthcare need. In addition, only 60% were treated effectively enough for their viral load to remain suppressed over the entire 12 months before the survey.

So what are the sources of transmasculine HIV risk? They are as varied as the transgender men themselves. Studies have suggested that as many as 63% of transgender men may identify as gay, bisexual, and/or have sex with men. That means they may experience some of the same elevated HIV risk as cisgender gay and bisexual men.

One older (2008) small study of rapid HIV testing by community-based organizations found that 29% of transmasculine people recruited for testing reported unprotected receptive anal intercourse, and another 36% reported unprotected receptive vaginal intercourse. A significant number reported multiple sexual partners, and 17% reported injecting testosterone without medical supervision. In that study, none of the men tested positive for HIV, and almost half had been tested in the last year. A much larger study from 2019 found lower rates of risky behavior. Only 18% reported condomless, receptive anal or vaginal intercourse.

PrEP for Transgender Men

In order to be eligible for a prescription for PrEP, individuals must be engaging in sexual activity or other behavior that puts them at risk for HIV. For example, that could include unprotected receptive vaginal or anal intercourse. It could also include sex work, IV drug use, or large numbers of cisgender male or transgender female sexual partners. The Centers for Disease Control maintain guidelines for PrEP use, although they are not universally followed.

It was not until 2019 that several studies were published explicitly looking at PrEP access and use by transgender men. In a study of 1800 transmasculine individuals, around a quarter were eligible for PrEP based on their sexual activity of the past six months. Sexual minority individuals and individuals with the lowest incomes were the most likely to be eligible. However, of those PrEP-eligible transmasculine people, only a third had received information about PrEP from their doctor, and only a third of those got a prescription. That meant that only 10% of eligible transmasculine people received PrEP.

Another study looked at PrEP use among 857 transgender men who had had receptive anal or vaginal intercourse with a cisgender man within the last six months. More than half of them talked about behaviors that would make them eligible for PrEP, but only around a third had ever taken it. Importantly, that study pointed out some of the issues with using CDC guidelines to determine PrEP eligibility for trangender men. Depending on whether the researchers used the guidelines for men who have sex with men, heterosexual women, or injection drug users, the PrEP eligibility varied from 6% to 55%.

PrEP Efficacy for Transgender Men

How effective is PrEP for transgender men? We don't entirely know. There is no efficacy data specifically for the transmasculine population. However, in general, PrEP is expected to reduce HIV risk by 90% or more in individuals who take it reliably. Actual effectiveness is much lower. This is because few people are fully adherent to a PrEP regimen, and PrEP is more effective at reducing sexual transmission than transmission through IV drug use.

There is no evidence that PrEP interacts with gender-affirming hormone therapy. However, if you're concerned about this and want to start PrEP, talk to your doctor about checking your hormone levels more often. That way your dose can be changed as needed.

Should Transgender Men Consider PrEP?

Whether PrEP a good idea for transgender men and other transmasculine people depends on the person. Individuals who are at higher risk of HIV should definitely discuss PrEP with their doctor. Factors that constitute a higher risk include:

  • Having a sexual partner with HIV
  • Not consistently using a condom for vaginal (front hole) or anal sex
  • A recent sexually-transmitted disease (STD) diagnosis
  • Injecting drugs, if you have an injection partner with HIV or share needles

If you fall into one of those categories, talk to your doctor. That way you can weigh your options about whether PrEP is right for you. Just don't forget that PrEP only reduces your risk of HIV, not of other STDs. Therefore, safer sex is still a good idea.

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