In this guest blogpost, Aedan Wolton, Case Worker & Co-Lead on Service Development at cliniQ, explores why trans men need to think about PrEP – and why PrEP researchers, clinicians and activists need to think about trans men.
Awareness of PrEP is growing. Even outside of the queer communities, articles and blogposts are being shared on social media about a ‘new HIV wonder drug’ or ‘chemical condom’ on a daily basis. So, what is it? And why should trans men care?
PrEP
PrEP stands for pre-exposure prophylaxis, and it is a way of preventing HIV infection by taking medication on an ongoing basis. It works by stopping the virus from entering cells and replicating. Thus, preventing HIV infection. It is made up of the antiretroviral drugs, tenofovir and emtricitabine, which come in a single blue pill called Truvada.
PrEP has been available in the United States since 2012, but is not currently available on the NHS. Private clinics are able to prescribe PrEP, but not without significant cost, which has led to many people accessing the drug online from overseas. This lack of access to PrEP in the UK has resulted in a resurgence of community advocacy, with HIV activists and researchers demanding access to PrEP as soon as possible.
Why all the fuss about PrEP?
Because it works! The PROUD study, in the UK, demonstrated an 86% effectiveness in preventing HIV transmission. Of 275 participants taking daily Truvada, there were only 3 confirmed HIV infections and, even then, these were seen in participants who were not consistently taking their medication. This is compared to 20 HIV infections, in a group of 269 participants asked to wait a year before starting PrEP.
More recently, new analysis of a large, international study called iPrEX has looked more closely at the experiences of more than 300 trans women involved in the trial. "While this analysis did not include a large enough sample group to draw firm conclusions, we did find strong evidence pointing to efficacy," said principal investigator Robert Grant from the University of California at San Francisco. "Additional research designed specifically for transgender women is needed to confirm this finding."
Trans men – a gap in the research
The need for additional research doesn’t stop at trans women. Although sample sizes have been small, both iPrEX and the PROUD study have included transgender women, and have suggested effectiveness if the drug is taken consistently. However, no existing clinical trials for PrEP have trans men in their samples, meaning even if it were readily available, we cannot safely advise trans men on how to take it.
What we know so far is that for protective levels of the drug to be reached in both the blood and the rectum, PrEP needs to be taken daily for 4 to 7 days. For non-trans women, it takes up to three weeks for protective levels to be reached in the vagina and the cervix. None of the research evidence we have currently takes into account men who may be having receptive vaginal AND anal sex. It also doesn’t account for trans men’s experience of vaginal atrophy; a shrinking and thinning of the vaginal walls, which can occur during testosterone therapy.
Not only does vaginal atrophy decrease self-lubrication, it increases the chance of damage to the vaginal tissue, which could create additional routes of transmission. It can also mean that some guys experience a degree of irritation and discomfort when using condoms due the fragility of the tissue; all the more reason why trans men need to be able to access PrEP and reliable advice about dosing.
Supporting trans men
In London, as many as 1 in 8 MSM (men who have sex with men) are living with HIV. What is almost always discounted under the MSM umbrella is the number of trans men, who are adjusting to their changing roles in the world, as well as their evolving bodies, and sexualities; perhaps, trans men who are having unprotected sex, in part, to feel validated as men.
Research evidence is lacking, but trans MSM may have increased vulnerability to HIV. cliniQ recently submitted a series of recommendations on trans inclusion in PrEP guidelines to the World Health Organisation and UNAIDS. During a public consultation with a group of trans people using sexual health services, one participant stated, “I know I should be responsible, but I find it hard when people find me attractive, and I take risks. If I had to take a pill a day for even 10% more safety than I have now, I would do it as I don’t trust myself.”
I’m a health adviser at cliniQ – the UK’s first trans-led sexual health service – and this is the sort of narrative I hear over and over again from trans men. If trans inclusion isn’t addressed in clinical research, when the time comes and PrEP is available on the NHS, what am I going to tell my patients?
For more information
cliniQ is a free sexual health and wellbeing service for all trans* people, partners and friends. It offers a full range of sexual health services, counselling, support and advocacy. The service is open every Wednesday evening, 5.30-7.30pm, at 56 Dean Street, London, W1D 6AQ. For more details, visit the cliniQ website at http://cliniq.org.uk
56 Dean Street is a member of NAM’s Patient Information Scheme.
To find out more about PrEP, read or download our PrEP factsheet, or our PrEP briefing paper for people working in HIV prevention in the UK. For regular updates, sign up for our free email news bulletin, HIV prevention news: England.