Infectious Disease

Consider PrEP, a hormone therapy used to eradicate health inequalities in LGBTQ patients

April 29, 2021

4 min read

Source / information

Source:

McNamara M. LGBTQ Health: A Practical Approach. Presented at: ACP Internal Medicine Meeting; April 29 – May 1, 2021 (virtual meeting).

Disclosure:
McNamara does not report any relevant financial information.

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Marginalization and stigma are directly related to poor physical and mental health outcomes, according to a spokesperson for the AKP internal medicine meeting held virtually.

LGBTQ patients are therefore among those affected Megan McNamara, MD, MS, A professor of medicine at Case Western Reserve University Medical School provided practical tips for doctors to consider when treating these patients, including screening recommendations on when to prescribe pre-exposure prophylaxis (PrEP), how to treat patients who have one Get Cross-Sex Hormone Therapy, and More.

A speaker at the ACP Internal Medicine Meeting provided practical tips for doctors to consider when treating LGBTQ patients.
Photo source: Adobe Stock.

Gay and bisexual men

Compared to heterosexual men, data shows that gay and bisexual men have higher rates of psychological distress, tobacco use, alcohol use, HIV, and other sexually transmitted infections (STIs). So it’s important to study these risk factors and conditions, McNamara said. Most new HIV diagnoses occur in younger men who have sex with men (MSM) ages 13 to 34, according to CDC data. However, elderly patients are still at risk.

“In my own practice, most of my patients are actually elderly, so I want to make sure I don’t think they are at risk,” McNamara said. “Having a thorough sexual history and assessing your risk for HIV is just as important in the elderly as it is in younger people.”

To prevent HIV in MSM, the CDC recommends offering PrEP to HIV-negative people who have had male sexual partners in the past 6 months, have not been in a monogamous relationship, and have had anal sex or a bacterial STI in the past 6 months. Two PrEP therapies are available in the US: Truvada (emtricitabine / tenofovir disoproxil fumarate; FTC / TDF) and Descovy (emtricitabine / tenofovir alafenamide) [F/TAF];; Gilead Sciences).

McNamara said both therapies are “equally effective” against HIV infection and have similar safety profiles. The “main difference,” she said, is that Descovy is safe for patients with an estimated creatinine clearance greater than 30 ml / min.

“The same is not true of Truvada,” said McNamara. “Truvada must have an estimated creatinine clearance greater than 60 ml / min to use it.”

Lesbian and bisexual women

Similar to MSM, according to McNamara, lesbian and bisexual women are disproportionately affected by psychological stress, tobacco consumption and heavy alcohol consumption. They are also more likely to be overweight or obese. McNamara cited data in the American Journal of Public Health that showed that lesbian women were more than twice as likely to be overweight (OR = 2.69) or obese (OR = 2.47) compared to heterosexual women. Bisexual women were also slightly more likely to become overweight compared to heterosexual women (OR = 1.38).

In light of the data, McNamara said doctors should screen lesbian and bisexual women for cardiovascular risk factors “because we know that increased tobacco use, obesity, and overweight can increase the patient’s risk for CVD.”

Other data show that lesbian and bisexual women are less likely to have cervical cancer screening, and lesbian women are less likely to have a series of HPV vaccinations. Therefore, clinicians should offer cervical cancer screening in accordance with current guidelines and discuss the benefits and risks of HPV vaccination in unvaccinated patients between the ages of 26 and 45, according to McNamara.

Transgender patients

When treating transgender people, it’s important to check for mental health, which is five times higher in transgender people compared to the general population, and suicidality, which is nine times higher in transgender people than the general population, McNamara said .

“I can tell you that these data are true in my own practice,” she said. “Many, many of my patients have attempted suicide, so it’s really something you want to think about right now.”

Doctors should also screen transgender patients for HIV, as their rate of new diagnoses in 2017 was more than three times higher than the national average in 2017, according to McNamara. CDC data shows that an estimated 44% of black or African American transgender women and 26 % of Hispanic and Latin American transgender women have HIV, compared to 7% of white transgender women.

Cross-gender hormone therapy is another important aspect of care – even “medically necessary” – for many transgender patients, said McNamara. The therapy has clear benefits, including improving quality of life, she added. Still, clinicians should screen patients for contraindications including pregnancy, unstable CVD, and polycythemia for transmasculine cross-sex hormone therapy, as well as for estrogen-sensitive cancer, end-stage liver disease, and a history of venous thromboembolism (VTE) for transfeminin cross-sex hormone therapy said McNamara.

She warned that transmasculine cross-sex hormone therapy is linked to an increased risk of erythrocytosis, but there are ways doctors can help reduce that risk.

“Basically, you just want to keep the hematocrit level below the upper limit of normal,” she said. “In my facility, I try to keep the hematocrit below 51%. Sometimes I need to lower the testosterone dose to make sure the patient does not develop significant erythrocytosis. ”

McNamara also recommended counseling patients interested in transfeminin therapy with cross-sex hormones about the risk of VTE. In addition, there has been recent concern that transfeminin therapy with cross-sex hormones could increase the risk of a cerebrovascular accident, she added.

However, there are “significant consequences” for suddenly discontinuing cross-sex hormone therapy, including “significant emotional and psychological distress,” she said. Although patients should be made aware of these risks, it does not mean they should stop treatment unless, according to McNamara, they develop an “acute life-threatening illness” or hormone-dependent malignancy.

“The vast majority of patients treated with hormone therapy consider it a life support treatment, just like metformin or one [angiotensin-converting enzyme] Inhibitor, ”she said. “It is important to view cross-gender hormone therapy as a factor in your daily life as well as treating diabetes or high blood pressure.”

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Meeting of the American College of Physicians for Internal Medicine

Meeting of the American College of Physicians for Internal Medicine

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