HIV/AIDS and Transitioning

Seroprevalence in Trans Populations

The HIV seroprevalence rates within some trans communities, especially amongst trans women, are disproportionately high. Some research has been conducted in an effort to better understand some of the reasons behind the high seroprevalence rates, in order to create trans-specific HIV resources and prevention programs.

Some of the reasons behind the high HIV seroprevalence rates:

  • Many trans people share intravenous and intramuscular needles for both drug and hormone use. While in Québec clean needles can be accessed at pharmacies and needle exchanges, many of these locations do not distribute intramuscular needles for hormone injections. Easy access to clean intramuscular needles can be a challenge especially if people are using black market hormones. As a result, many people still share their gear. A list of locations where people can access clean needles can be found at http://www.msss.gouv.qc.ca/sujets/prob_sante/itss/index.php?aid=154. Call in advance to find out if the location distributes intramuscular needles.
  • Safer sex education and HIV-prevention materials and resources often fail to address the needs and realities of trans people by using language that alienates and excludes trans bodies and lives. There are very few safer sex resources that are created by and for trans people and that address their unique experiences.
  • Some trans people feel as if they are not vulnerable to HIV because of a lack of visibility and open dialogue.
  • Trans people often experience a lack of self-esteem and fear of rejection, especially surrounding sex and romantic relationships, which can lead people to take risks that they otherwise might not take.
  • Because of a fear of being mistreated and experiencing discrimination, many trans people are reluctant to access health care services.
  • Many HIV/AIDS service organizations do not actively seek to make their resources relevant to trans realities.
  • HIV/AIDS research often neglects to consider the experiences of trans people. Trans women, for example, are lumped into the men who have sex with men (MSM) category, despite the fact that they are women, and many of them do not necessarily sleep with men. This kind of research therefore obscures the realities of trans people. Some interesting information and practices on trans-inclusive research models, can be found at. Trans Pulse is a trans health–specific research project, and is a good example of community-based research project. The Trans Pulse website can be found at <www.transpulse.ca>.

Disclosure

Patients do not generally have to disclose their HIV status to their health care provider. Moreover, many medical ethics bodies have ruled that a person should not be denied services due to HIV status or refusal to take an HIV test.

Under the Québec Charter of Human Rights and Freedoms, HIV is considered a disability. Discrimination solely because of seropositivity is therefore a violation of the Charter. Furthermore, the WPATH Standards of Care state that, “It is unethical to deny availability or eligibility for sex reassignment surgeries or hormone therapy solely on the basis of blood seropositivity for blood-borne infections such as HIV, or hepatitis B or C, etc.” As well, the Québec code of ethics dictates that a “physician may not refuse to examine or treat a patient solely for reasons related to the nature of the patient’s deficiency or illness, or because of the race, colour, sex, pregnancy, civil status, age, religion, ethnic or national origin, or social condition of the patient, or for reasons of sexual orientation, morality, political convictions, or language; he may, however, refer the patient to another physician if he deems it to be in the patient’s medical interest.”

Finally, many practitioners follow the WPATH Standards of Care, which deal specifically with the medical care of transgendered and transsexual people, and so are ethically bound to offer services to HIV-positive clients.  From this we can also conclude that HIV in itself is not a valid cause for refusal of treatment.

There may be instances where a health care provider might discourage or deny hormones or surgery because of the health issues linked to advanced HIV. Unfortunately, since anti-HIV discrimination is often couched in these terms, sorting through medical truths versus medical discrimination remains an ongoing struggle for individuals and the people and organizations that advocate for them.

Occasionally, surgeons have refused to provide gender reassignment surgery based solely on the patient’s HIV status. This is entirely unethical and constitutes violation of Québec’s Charter of Human Rights and Freedoms. The only recourse one has in this case is to file a complaint with the human rights commission.

At the Centre Métropolitain de Chirurgie Plastique clinic in Montreal, HIV-positive trans people are deemed eligible for SRS on a case-by-case basis, depending on the overall health of the patient.

With all of that said, it is important to keep in mind that current Canadian law stipulates that HIV-positive individuals can face criminal charges for failing to disclose their HIV status when engaging in activities that pose a “significant risk” of transmission. Because of standard medical precautions, it is unlikely that this would be a cause for concern regarding disclosure with a health care provider. In most of these cases, people have faced charges related to nondisclosure with their sexual partners. As of yet, there have been no cases related to HIV-positive patients not disclosing their HIV status to their doctor.

For more information on the criminalization of HIV in Canada, visit the Canadian HIV/AIDS Legal Network website at www.aidslaw.ca.

Health Risks

HIV seropositivity is not a contraindication to Hormone Replacement Therapy. Risks do exist, however, and for this reason it is always best to be equipped with a wide variety of medical information and opinions. Some people have been able to do this by disclosing their serostatus to their doctor. Others do this research elsewhere, with the help of someone they trust.

There are particular risks if the person is planning on having any surgery, or if they are undergoing to planning to undergo feminizing or estrogen-based hormone therapy. There are no documented risks for masculinizing hormone therapy in HIV-positive individuals (though this could indicate a lack of research on the subject, rather than lack of risk).

Surgery and Serostatus

As previously mentioned, the WPATH Standards of Care highlight that it is unethical to refuse trans-specific health care based solely on an individual’s HIV status. However, HIV can have an impact on how quickly a person recovers from surgery, and on after-surgery risk level for opportunistic infections.

Some practitioners use the following criteria to help determine eligibility for surgery.

The patient

  • has no prior history of opportunistic infection
  • does not have fullblown AIDS
  • has a CD4 count above 200
  • has viral replicas less than 600

These guidelines are suggested by a doctor at the Detroit Medical Center Hospitals, where at least eleven successful SRS procedures have been performed on HIV-positive patients. Sheila Kirk is another doctor who has performed successful SRS on trans patients living with HIV, and has contributed to and co-edited an anthology on the topic called Transgender and HIV: Risks, Prevention, and Care.

Hormones and Serostatus

Some HIV medications result in lower hormonal levels for feminizing or estrogen-based hormone therapy. Sometimes, these levels result in the reversal of feminizing effects, including the return of body hair, more frequent erections, and weight loss.

The bottom line is that HIV itself does not make hormone therapy risky.  Negative results may occur with specific HIV and hormone drug combinations. For the practitioner and patient, it is advisable to consult with doctors experienced on these matters as specific questions arise.

From a harm-reduction perspective, a fully informed patient able to provide legal consent is ultimately the most important voice when considering treatment options. Hormone therapy in an individual desiring it can be expected to have a positive impact on emotional well-being, which needless to say is a factor in overall health.

Some clinical protocols of this nature have been developed by the Tom Waddell Health Centre clinic in San Francisco, which treats many HIV-positive transsexuals. Among these protocols is the strong recommendation that health care providers for trans people enhance their own knowledge of medical issues related to HIV.

The Tom Waddell Centre protocols can be found at http://www.sfdph.org/dph/comupg/oservices/medSvs/hlthCtrs/TransGendprotocols122006.pdf.

**This is a community resource that was created based on the knowledge and experiences of trans people. It does not contain medical or legal information from lawyers or doctors.