The quality of evidence (I-III) and strength of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
What's New – January 2012 Update
The World Professional Association of Transgender Health (WPATH), formerly known as the Harry Benjamin International Gender Dysphoria Association, has recently updated the WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Since its first release in 1979, the WPATH Standards of Care have been the most recognized standards of care for transgender patients. In addition to updated guidelines on diagnostic assessment, hormone therapy, and surgical therapy, the 7th Version of the Standards of Care includes updated information on addressing and promoting tolerance and equality for transgender patients.
Clinicians providing services to human immunodeficiency virus (HIV)-infected transgender patients should integrate transgender treatment recommendations and standards of care into their practice. (AII)
Gender identity is distinct from sexual orientation. Sexual orientation involves sexual attraction, whereas gender identity involves the individual's natal sex in relation to the gender that he/she experiences.
Baseline History and Psychosocial Assessment
As part of the routine management of HIV-infected patients, clinicians should perform a psychosocial assessment at baseline and at least annually in HIV-infected transgender patients. (AIII)
See Table 2 in the original guideline document and Mental Health Quick Reference Card for more information (see the "Availability of Companion Documents" field).
Routine Screening and Laboratory Assessments for HIV-Infected Transgender Patients
Routine medical screening of HIV-infected transgender patients should be performed according to standards of care, as determined by clinical judgment and according to the patient's level of comfort. (AIII)
For recommendations on cancer and cardiovascular screening for patients receiving hormone therapy, see "Hormone Therapy" section below.
|Table. Strategies to Help Alleviate Patient's Concerns about Physical Examination
- Address the patient's fears
- Explain each step of the examination prior to performing it
- Use the smallest clinically indicated speculum for Pap tests and pelvic examinations
- Use urine-based gonococcal/chlamydial testing for male-to-female patients
- For extreme cases of anxiety (particularly in patients with a history of physical or sexual abuse):
- Consider a referral for psychotherapy to decrease post-traumatic stress-type symptoms prior to physical examination
- Consider administration of a low-dose anxiolytic prior to physical examination
Clinicians should perform routine pelvic examinations in HIV-infected female-to-male (FtM) patients and male-to-female (MtF) patients who have undergone complete sex reassignment surgery according to HIV care guidelines for natal females. Before performing a pelvic examination in transgender patients, the clinician should explain the medical reasons for the examination. (AIII)
HIV-infected FtM patients remain at risk for gynecologic complications that can be detected by routine pelvic examinations (see the National Guideline Clearinghouse [NGC] summary of the New York State Department of Health [NYSDoH] guideline Primary Care Approach to the HIV-Infected Patient).
Clinicians should perform routine cervical Papanicolaou (Pap) tests in any HIV-infected FtM patient with cervical tissue; patients who are uncomfortable receiving a Pap test should be educated about the importance of obtaining cervical cytology. (AIII)
Clinicians should notify the pathologist when submitting a Pap test sample from an FtM patient who is receiving testosterone therapy because testosterone-related atrophy of the cervix may mimic cervical dysplasia (Grynberg et al., 2010). (AIII)
Anal Pap tests should be performed in HIV-infected transgender patients according to guidelines for natal males and natal females. (AIII)
Neovaginal Pap tests are not indicated for HIV-infected MtF patients. (AIII)
FtM patients receiving testosterone therapy may experience atrophy of the cervix, which can mimic cervical dysplasia (Grynberg et al., 2010). Notifying the pathologist of the patient's testosterone treatment status can increase accuracy of Pap test results.
Screening for Gonococcal and Chlamydial Infections
Clinicians should screen HIV-infected transgender patients at baseline for gonorrhea and chlamydia; screening should also be performed at least annually thereafter for sexually active HIV-infected transgender patients. (AIII)
Clinicians should obtain an accurate sexual history and test all possible sites of exposure when screening for gonorrhea and chlamydia, including the urethra, rectum, and pharynx. (AIII)
For additional information regarding gonococcal and chlamydial infections in HIV-infected patients.
Cross-Gender Therapy for HIV-Infected Transgender Patients
Clinicians should educate HIV-infected transgender patients about the possible health risks associated with hormone therapy. (AIII)
See Table 4 in the original guideline document for information on basic goals and effects of cross-gender hormone therapy.
Concomitant Hormone Therapy and Antiretroviral Therapy (ART)
Hormone therapy for HIV-infected transgender patients who are not initiating or receiving ART should be prescribed according to the same standards of care for all transgender patients. (AIII)
Before prescribing hormone therapy for HIV-infected transgender patients who are receiving ART, clinicians should (AIII):
- Consult with, or refer patients, to a provider who has experience in prescribing both hormone therapy and ART to select appropriate hormone treatment.
- Educate patients about the prescribing considerations, including hormone selection and dose, for optimizing the effects of hormone therapy when prescribed in conjunction with an ART regimen.
- Discuss the importance of adherence to ART with patients, including the risks associated with dangerously high circulating hormone levels due to ART interruption.
Clinicians should monitor hormone therapy in HIV-infected transgender patients according to established guidelines for all transgender patients. (AIII)
Educating patients about how hormone selection and dose can reduce interactions between hormones and ART may encourage acceptance of ART from those who would otherwise decline it.
Cross-gender hormone monitoring for HIV-infected transgender patients is the same as for all transgender patients. Established monitoring guidelines, such as those by the Endocrine Society (Hembree et al., 2009) should be used.
Cancer Screening and Hormone Therapy
Clinicians should perform breast cancer screening in the following HIV-infected transgender patients according to clinical judgment and consideration of current guidelines established for natal females of the same age (see Appendix A in the original guideline document):
- FtM patients with remaining breast tissue. (AIII)
- MtF transgender patients with breast tissue who have received hormone therapy for at least 5 years. (AIII)
Clinicians should perform digital rectal examinations as part of routine HIV care for HIV-MtF transgender patients (see the NGC summary of the NYSDoH guideline Primary Care Approach to the HIV-Infected Patient); clinical judgment and current guidelines for natal HIV-infected males should be used when considering prostate examinations in MtF transgender patients (see Appendix A in the original guideline document). (AIII)
Cardiovascular Disease and Hormone Therapy
When HIV-infected transgender patients choose to receive hormones, clinicians should educate them about the cardiovascular effects of hormone therapy and, when indicated, provide counseling to reduce the risk for cardiovascular disease; such discussions should take place at the time of initiation of hormone therapy and frequently thereafter. (AIII)
The standards of care for gender reassignment surgery, as well as less complicated gender confirming procedures, are the same for HIV-infected transgender patients as for transgender patients who are not infected with HIV. (AIII)
Surgery, including breast implantation and gender-reassignment surgery, is not contraindicated in HIV-infected patients. (AIII)
Mental Health and Substance Use Screening
Clinicians should perform a mental health and substance use assessment in HIV-infected transgender patients at baseline and at least annually thereafter. (AIII)
Clinicians should refer HIV-infected transgender patients requiring mental health services to a psychiatrist or psychologist with knowledge and experience in transgender treatment. (AIII)
If the HIV-infected transgender patient's substance use screening result is positive, or if the patient has a history of substance use, the clinician should re-evaluate the patient's substance use at least quarterly. (AIII)
Clinicians should offer patients with active substance use/abuse problems referral to appropriate substance use treatment programs or other substance use services. (AIII)
For information about mental health and substance use screening, refer to Mental Health Screening: A Quick Reference Guide for HIV Primary Care Clinicians and the NYSDoH guideline Screening and Ongoing Assessment for Substance Use .
Risk- and Harm-Reduction Approach for HIV-Infected Transgender Patients
Clinicians should assess for the following behaviors in HIV-infected transgender patients:
- Silicon use
- Hormones obtained without prescription, including specific hormones used
- Needle-sharing among those who inject hormones, silicone, and/or drugs
- Sexual risk behaviors
- Genital taping
Clinicians should provide risk-reduction counseling and, when appropriate, harm-reduction counseling for HIV-infected transgender patients who report potentially harmful behaviors. Patients at risk for intentionally harming their genitalia require referral for psychiatric evaluation. (AIII)
Case Management for HIV-Infected Transgender Patients
Case managers who provide services to HIV-infected transgender patients should:
- Develop expertise in transgender-related services, such as assisting patients with access to healthcare, assisting with adherence to medical treatment and medical appointments, and making appropriate referrals.
- Closely monitor changes in contact information, housing, and psychosocial support for patients with unstable living situations.
- Develop awareness of "trans-friendly" resources, including education, employment, legal aid resources, and harm-reduction programs.
- Be familiar with the resources available to assist patients with obtaining a change of name and gender status on their identification and health insurance cards. (AIII)
Transgender-Related Standards of Care and Referral Resources
Standards of Care
The most recognized transgender-related standards of care are the World Professional Association for Transgender Health (WPATH) Standards of Care, formerly known as the Harry Benjamin International Gender Dysphoria Association Standards of Care (www.wpath.org ).
The WPATH Standards of Care provides a comprehensive description of the "Five Elements of Treatment": 1) diagnostic assessment, 2) psychotherapy, 3) real-life experience, 4) hormone therapy, and 5) surgical therapy. The Standards of Care also serve as a resource for related treatment information, including hormonal treatment and surgical options.
Refer to the original guideline document for additional sources of information and referral resources.
Quality of Evidence for Recommendation
- One or more randomized trials with clinical outcomes and/or validated laboratory endpoints
- One or more well-designed, non-randomized trials or observational cohort studies with long-term clinical outcomes
- Expert opinion
Strength of Recommendation
- Strong recommendation for the statement
- Moderate recommendation for the statement
- Optional recommendation