Hepatitis C seroprevalence and engagement in related care and treatment among trans women

Hepatitis A, B and C prevalence among transgender women and travestis in five Brazilian capitals between 2019-2021

OBJECTIVE

To estimate the prevalence and factors associated with hepatitis A, B, and C in transgender women and travestis's networks, in 5 regions of Brazil.

METHODS

This cross-sectional study includedtransgender women and travestis in five Brazilian capitals (Campo Grande, Manaus, Porto Alegre, Salvador, and São Paulo), between December/2019 and July/2021. All samples were subjected to detection of serological markers of hepatitis virus A (HAV), B (HBV), and C (HCV) infections through rapid tests and chemiluminescent microparticle immunoassays. Positive samples in the screening tests were submitted to detect HBV DNA and HCV-RNA by real-time PCR and genotyped by Sanger sequencing.

RESULTS

Analysis of 1,317 samples showed network prevalence rates of 69.1%, 25.1%, and 1.5% for HAV, HBV, and HCV exposure, respectively. A high susceptibility rate to HBV infection (35.7%) and low prevalence of vaccine response markers (40%) were also observed. Age greater than 26 years, self-declared black/brown skin color, having only primary education, history of incarceration, and use of a condom in the last sexual intercourse with a casual partner were associated with total anti-HAV. Exposure to HBV was associated with age greater than 26 years, self-declared black/brown, history of being a sex worker, and incarceration. Age > 37 years, history of sexual abuse, and frequent alcohol consumption were associated with hepatitis C infection.

CONCLUSION

The highest prevalence of HAV in this population was found in the North and Northeast regions, and the prevalence found was higher than that in the general population, suggesting greater vulnerability. The prevalence of HCV infection in our study was similar to that observed in the general population.

High Hepatitis B Prevalence and Vaccination Needs Among Transgender Women and Men Sex Workers in Barcelona, Spain

Background

Transgender women sex workers (TWSWs) and men sex workers (MSWs) are especially vulnerable to acquiring hepatitis B virus (HBV) infection. We aimed to describe HBV prevalence (hepatitis B surface antigen [HBsAg] and core antibody [HBcAb]) and associated risk factors for HBV exposure (HBcAb), to assess vaccination status and risk factors for no prior vaccination, and to compare HBV prevalence and vaccination status between TWSWs and MSWs.

Methods

The SexCohort study was advertised to TWSWs and MSWs through several communication channels. At cohort entry through 2 community-based organizations in Barcelona, the study population was screened for HBV and other sexually transmitted infections, and an epidemiological questionnaire was administered (n = 271).

Results

Overall, 93.0% of participants were migrants, mostly from South and Central American countries. HBsAg prevalence was 1.9% (TWSWs, 2.4%; vs MSWs, 0.9%; P = .42), and previous exposure to HBV was 31.8% (TWSWs, 38.5%; vs MSWs, 20.8%; P = .002). Over 5 years of sex work (adjusted odds ratio [aOR], 9.35), prior exposure to Treponema pallidum (aOR, 3.49), and treatment with anxiolytic drugs (aOR, 3.23) were associated with HBV exposure. Overall, 33.7% of participants exhibited immunity from vaccination (TWSWs, 30.8%; vs MSWs, 38.61%; P < .001), while 34.4% were candidates to HBV vaccination (TWSWs, 30.8%; vs MSWs, 40.6%; P < .001). Never having been on pre-exposure prophylaxis for HIV (odds ratio [OR], 4.23) and non-Spanish origin (OR, 5.00) were associated with no prior HBV vaccination.

Conclusions

There is a need to reinforce screening and vaccination programs aimed at TWSWs and MSWs as integrated services offered at the community centers commonly accessed by these populations.

Hepatitis C Virus Testing and Care Cascade Among Transgender and Gender Diverse Individuals

INTRODUCTION

Hepatitis C virus (HCV) prevalence among transgender and gender-diverse individuals ranges from 1.8% to 15.7% versus 1% in the general population. Previous HCV studies inclusive of transgender and gender-diverse individuals primarily rely on convenience-based sampling methods or are geographically restricted. The purpose of this study is to compare the prevalence of HCV diagnoses, testing, and care engagement between transgender and gender-diverse and cisgender individuals.

METHODS

Using Optum's de-identified Clinformatics® Data Mart Database, in 2022, the unadjusted prevalence of HCV testing among all adults and people who inject drugs from January 2001 to December 2019 was measured. Multivariable logistic regression was used to compare the adjusted odds of HCV diagnoses and care engagement by gender subgroup.

RESULTS

The overall unadjusted frequency of HCV diagnoses among transgender and gender-diverse individuals was approximately 3 times that of cisgender individuals (1.06% vs 0.38%, p<0.001), including among people who inject drugs (6.36% vs 2.36%, p=0.007). Compared with cisgender women, transfeminine/nonbinary individuals had over 5 times the adjusted odds of a HCV diagnosis and approximately 3.5 times the odds of being tested for HCV. In addition, compared with cisgender women, transfeminine/nonbinary individuals had significantly increased odds of having a HCV‒related procedure (e.g., abdominal ultrasounds, liver biopsies, Fibroscans). Cisgender men had significantly increased odds of receiving HCV medication compared with cisgender women.

CONCLUSIONS

Although testing was higher among transgender and gender-diverse individuals, the higher overall frequency of HCV diagnoses among transgender and gender-diverse than among cisgender individuals signals persistent health disparities. Interventions are warranted to prevent HCV and increase ongoing testing and treatment uptake among transgender and gender-diverse populations.

High HIV/STI prevalence among cisgender men and transgender women sex workers attending community-based centres in Barcelona, Spain: The Sweetie Project

Background

The aim of this study was to describe the socio-demographics, and the sexual and health-seeking behaviours of cisgender men and transgender women sex workers (M & TWSW) attending community-based organisations (CBOs) in Barcelona, Spain, as well as to estimate the prevalence of HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), Chlamydia Trachomatis (CT) and Neisseria gonorrhoeae (NG) among them at different anatomical sites.

Methods

The Sweetie Project was a community-based cross-sectional study of 147 M & TWSW recruited in two CBOs in Barcelona between 2017 and 2018. A nurse collected biological samples from rectum, pharynx and urethra from the subjects at each CBO and the participants self-completed an epidemiological questionnaire.

Results

The highest prevalence observed was for HIV infection (25.3%) followed by bacterial STIs (NG 19.2% and CT 10.3%). The most prevalent anatomical site was pharyngeal (17.7%) followed by rectal (13.8%). More than half of participants who had a pharyngeal infection presented an isolated pharyngeal infection (57.7%) and half of those who had a rectal or urethral infection presented an isolated infection respectively. The seroprevalence of HCV and HBV was 2.4% and 34.2% respectively. There was a poor but statistically significant correlation between HIV and rectal CT infection ( r = 0.31), previous exposure to HCV ( r = 0.27) or self-reported STI ( r = 0.23), as well as between previous exposure to HCV and rectal CT ( r = 0.21) or self-reported STI ( r = 0.20).

Discussion

The Sweetie Project confirms the high burden of HIV and bacterial STIs among a sample of M&TWSW recruited in CBOs and reinforces the need to routinely screen them at all exposed anatomical sites.

A global cautionary tale: discrimination and violence against trans women worsen despite investments in public resources and improvements in health insurance access and utilization of health care

BACKGROUND

To determine if improvements in social determinants of health for trans women and decreases in transphobic discrimination and violence occurred over three study periods during which extensive local programs were implemented to specifically address longstanding inequities suffered by the transgender community.

METHODS

Interviewer-administered surveys from repeated cross-sectional Transwomen Empowered to Advance Community Health (TEACH) studies in 2010, 2013 and 2016-2017 in San Francisco collected experiences with transphobia violence and discrimination. Respondent-driven sampling was used to obtain a sample of participants who identified as a trans woman.

RESULTS

Violence due to gender identity was prevalent; in each study period, verbal abuse or harassment was reported by over 83% of participants, and physical abuse or harassment was reported by over 56%. Adverse social determinants of health including homelessness, living below the poverty limit, methamphetamine use, depression, PTSD, and anxiety all significantly increased from 2010 to 2016. When testing for trends, housing discrimination and physical violence were both more likely in 2016-2017 compared to the two earlier study periods. Housing discrimination (aOR 1.41, 95% CI 1.00-1.98) and physical violence due to gender identity/presentation (aOR 1.39, 95% CI 1.00-1.92) both significantly increased from 2010 to 2016.

CONCLUSION

Our findings are particularly alarming during a period when significant public health resources and community-based initiatives specifically for trans women were implemented and could have reasonably led us to expect improvements. Despite these efforts, physical violence and housing discrimination among trans women worsened during the study periods. To ensure future improvements, research and interventions need to shift the focus and burden from trans people to cisgender people who are the perpetuators of anti-trans sentiment, stigma, discrimination and victimization.

Reaching trans women in San Francisco for efforts to eliminate hepatitis C

Hepatitis C infections continue to rise among marginalized communities, including among transgender people. Efforts to eliminate hepatitis C from San Francisco require successful identification of active HCV infections among transgender women and subsequent treatment of infection. This secondary analysis of the National HIV Behavioral Surveillance Transgender Women (NHBS-Trans) Study aims to identify areas of improvement in the hepatitis C care cascade and associated barriers that preclude successful treatment. One hundred and eighty (89.6%) trans women reported being previously screened for HCV, 47 (26.1%) reported being diagnosed with HCV, twenty-eight of the 47 (59.6%) who reported HCV diagnosis also reported that they received HCV treatment, with and 24 of the 28 (85.7%) reported completing their treatment. Overall, we detected HCV antibodies among 23.9% of participants and detected HCV RNA among 6.0%. This suggests that despite improvements in screening for HCV, active cases may not be successfully treated. Efforts to reduce barriers to HCV care should be prioritized, with heightened consideration for trans-specific needs.

High hepatitis C virus seropositivity, viremia, and associated risk factors among trans women living in San Francisco, California

Trans women have been understudied in the Hepatitis C virus (HCV) epidemic, yet data suggest they may be at elevated risk of the disease. Using data collected from the Centers for Disease Control and Prevention's (CDC) National HIV Behavioral Surveillance (NHBS) survey, we measured HCV seropositivity, viremia, and associated risk factors for HCV infection among trans women in San Francisco from June 2019 to February 2020. Respondent-driven sampling (RDS) was used to obtain a diverse, community-based sample of 201 trans women, of whom 48 (23.9%, 95% CI 17.9% - 30.0%) were HCV seropositive. HCV seropositivity significantly increased with increasing age (adjusted prevalence ratio [APR] 1.04 per year, 95% CI 1.01-1.07) and history of injection drug use (APR 4.44, 95% CI 2.15-9.18). We also found that many had HCV viremia as twelve (6.0% of the total sample, 95% CI 2.7% - 9.3%) were RNA-positive for HCV. Trans women are highly impacted by HCV and could benefit from access to regular and frequent HCV screening and treatment access. HCV screening could be offered regularly in trans-specific health services, in the community, in jails and prisons, and integrated syringe exchange programs where treatment access or referral are also available.

Identifying and managing infectious disease syndemics in patients with HIV

PURPOSE OF REVIEW

We will present recent articles focusing on HIV synergistic interactions with other sexually transmitted infections, tuberculosis, and hepatitis, as well as recent advances in the study of social and behavioral determinants that facilitate this clustering of infectious disease. For each synergistic interaction, we highlight evidence-based interventions that clinicians and policymakers should consider to tackle HIV and infectious disease syndemics.

RECENT FINDINGS

Significant advances in understanding the behavioral and structural determinants of HIV and other infectious disease synergisms have been made in the past years. Intervention strategies based on these new models have also been developed. It is now well understood that treating infectious disease syndemics will require a multidisciplinary and multipronged approach.

SUMMARY

HIV is synergistic with multiple other infectious diseases because the risk behaviors that lead to HIV acquisition may be similar to the other infections. The influence of HIV on the other infection may be due to immunosuppression associated with disease progression resulting in increased susceptibility (e.g., HIV and tuberculosis), especially when patients are not virologically suppressed using antiretroviral therapy. In reverse, another infectious disease may, when not treated, influence HIV disease progression. Social/structural determinants like homelessness, mass incarceration, and structural discrimination precipitate psychiatric comorbidity, substance use, and risky sex behavior which lead to the spread and co-occurrence of infectious disease.

Drug Interactions with Gender-Affirming Hormone Therapy: Focus on Antiretrovirals and Direct Acting Antivirals

INTRODUCTION

Gender-affirming care may include hormonal therapy to attain desired health outcomes in transgender (trans) individuals. To provide safe, affirming medical care for trans patients, health care providers must identify and manage drug-drug interactions (DDIs) between gender affirming hormonal therapy (GAHT) and other medication therapies.

AREAS COVERED

This review summarizes available data on DDIs between GAHT and antiretrovirals (ARVs) or hepatitis C direct acting antivirals (DAAs). Potential pharmacokinetic and pharmacodynamic DDIs are predicted based on GAHT, ARV, and DAA pharmacology and adverse event profiles. Clinical management strategies are discussed.

EXPERT OPINION

GAHT may be involved in pharmacokinetic and/or pharmacodynamic DDIs. Certain ARV classes (non-nucleoside reverse transcriptase inhibitors, protease inhibitors) may alter GAHT disposition, whereas selected ARVs (unboosted integrase inhibitors, doravirine, or rilpivirine) may have less impact on GAHT. DAAs may interact with GAHT, but the clinical relevance is unclear. ARV- and/or DAA-associated side effects (including depression, cardiovascular disease, hyperlipidemia) are important to consider in the clinical management of trans patients. Clinicians must evaluate potential DDIs and overlapping side effects between ARVs, DAAs and GAHT when providing care for trans patients.