HIV seropositivity and viral non-suppression in transgender, non-binary, and gender-diverse people in primary care receiving gender-affirming hormone therapy in the USA between 2013 and 2019 (LEGACY): an observational, longitudinal, cohort study.
Sari L Reisner, David R Pletta, Kenneth H Mayer, Madeline B Deutsch, Tonia Poteat, Jennifer Potter, Andrea L Wirtz, Alexander Harris, Juwan Campbell, Alex S Keuroghlian, Jaclyn M W Hughto, Alex Gonzalez, Asa E Radix
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引用次数: 0
Abstract
Background: Gender-affirming hormone therapy is medically necessary for many transgender, non-binary, and gender-diverse (trans) individuals and might improve HIV clinical outcomes for trans people. This study evaluated gender-affirming hormone therapy delivered in primary care as an intervention to improve HIV outcomes for trans adults in the USA.
Methods: LEGACY is a longitudinal cohort of trans adult participants receiving primary care at two US federally qualified health centres: Fenway Health (Boston, MA, USA) and Callen-Lorde Community Health Center (New York, NY, USA). Eligibility criteria were age at least 18 years, gender identity differing from assigned sex at birth, past 12-month medical visit, and signed consent with no research exclusion documented in electronic health record data. Eligible participants contributed electronic health data from 2013 to 2019. The exposure was gender-affirming hormone therapy prescription. Clinical outcomes were HIV seropositivity (all participants) and viral non-suppression (participants with HIV; ≥200 copies per mL) in the past 12 months. Log-Poisson generalised estimating equations assessed the longitudinal association of gender-affirming hormone therapy prescription (puberty blockers, anti-androgens, oestrogens, progesterone, and testosterone) with outcomes, adjusting for individual-level confounders.
Findings: Among the 8109 trans participants in 2019, median age was 29 years (IQR 24-37). 2960 (36·5%) were transgender women, 2541 (31·3%) were transgender men, 1507 (18·6%) were non-binary, and 1101 (13·6%) were another trans identity. 4446 (54·8%) were White, 1323 (16·3%) were Black or African American, 498 (6·1%) were multiracial, and 1663 (20·5%) were Hispanic or Latinx. 2736 (33·7%) of 8109 participants were publicly insured and 451 (5·6%) participants were uninsured. In 2013, 2549 (85·5%) of 2983 participants were prescribed gender-affirming hormone therapy, 272 (9·1%) of 2983 participants were HIV seropositive, and 61 (22·4%) of 272 participants were not virally suppressed. In 2019, 7252 (89·4%) of 8109 participants were prescribed gender-affirming hormone therapy, 560 (6·9%) of 8109 participants were HIV seropositive, and 88 (15·7%) of 560 participants were not virally suppressed. Gender-affirming hormone therapy prescription was associated with reduced rates of HIV seropositivity (adjusted risk ratio [RR] 0·63, 95% CI 0·56-0·70) and viral non-suppression (adjusted RR 0·56, 95% CI 0·45-0·69) across follow-up.
Interpretation: Gender-affirming care is important for optimising HIV outcomes among trans people. Our results underscore the vital role of gender-affirming models of care and access to gender-affirming hormone therapy for trans people.
Funding: Patient-Centered Research Outcomes Institute and the National Institutes of Health.
背景：性别确认激素治疗在医学上对许多跨性别、非二元性和性别多样化（跨性别）个体是必要的，并且可能改善跨性别者的艾滋病毒临床结果。本研究评估了在初级保健中提供的性别确认激素治疗作为一种干预措施来改善美国跨性别成年人的艾滋病毒预后。方法：LEGACY是一项纵向队列研究，研究对象是在两家美国联邦认证的卫生中心Fenway health （Boston， MA， USA）和Callen-Lorde Community health Center （New York， NY， USA）接受初级保健的跨性别成人参与者。资格标准为年满18岁，出生时性别认同与生理性别不同，过去12个月的医疗访问，并签署同意，电子健康记录数据中没有记录研究排除。符合条件的参与者提供了2013年至2019年的电子健康数据。暴露是性别肯定激素治疗处方。临床结果为HIV血清阳性（所有参与者）和病毒无抑制(HIV参与者；≥200拷贝/ mL)。Log-Poisson广义估计方程评估了性别肯定激素治疗处方（青春期阻滞剂、抗雄激素、雌激素、黄体酮和睾酮）与结果的纵向关联，调整了个体水平的混杂因素。研究结果：在2019年的8109名跨性别参与者中，年龄中位数为29岁（IQR 24-37）。其中女性变性2960人（36.5%），男性变性2541人（31.3%），非二元性1507人（18.6%），其他变性者1101人（13.6%）。白人4446人（54.8%），黑人或非裔美国人1323人（16.3%），多种族498人（6.1%），西班牙裔或拉丁裔1663人（20.5%）。8109名参与者中有2736人（33.7%）参加公共保险，451人（5.6%）没有参加保险。2013年，2983名参与者中有2549人（85.5%）接受了性别确认激素治疗，2983名参与者中有272人（9.1%）呈HIV血清阳性，272名参与者中有61人（22.4%）未受到病毒抑制。2019年，8109名参与者中有7252人（89.4%）接受了性别确认激素治疗，8109名参与者中有560人（6.9%）呈HIV血清阳性，560名参与者中有88人（15.7%）未受到病毒抑制。性别肯定激素治疗处方与HIV血清阳性率降低（校正风险比[RR] 0.63, 95% CI 0.56 - 0.70）和病毒无抑制（校正风险比[RR] 0.56, 95% CI 0.45 - 0.69）相关。解读：性别确认护理对于优化跨性别人群的艾滋病毒治疗效果非常重要。我们的研究结果强调了性别肯定的护理模式和获得性别肯定的激素治疗对跨性别者的重要作用。资助：以病人为中心的研究成果研究所和国立卫生研究院。
期刊介绍：
The Lancet HIV is an internationally trusted source of clinical, public health, and global health knowledge with an Impact Factor of 16.1. It is dedicated to publishing original research, evidence-based reviews, and insightful features that advocate for change in or illuminates HIV clinical practice. The journal aims to provide a holistic view of the pandemic, covering clinical, epidemiological, and operational disciplines. It publishes content on innovative treatments and the biological research behind them, novel methods of service delivery, and new approaches to confronting HIV/AIDS worldwide. The Lancet HIV publishes various types of content including articles, reviews, comments, correspondences, and viewpoints. It also publishes series that aim to shape and drive positive change in clinical practice and health policy in areas of need in HIV. The journal is indexed by several abstracting and indexing services, including Crossref, Embase, Essential Science Indicators, MEDLINE, PubMed, SCIE and Scopus.
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