A few weeks ago, I had a teenaged patient who I’ll call Alex, that came to my health center to get tested for sexually transmitted infections (STI). She had previously been going to local urgent care for regular STI testing, but decided to visit my health center because it was closer to her new home. The patient identified as a woman, was of Jamaican descent, and said she was sexually active with men.
A quick and simple medical and sexual history revealed that Alex was assigned male at birth and now presents and identifies as a woman. She has a boyfriend with whom she uses condoms but is also sexually active with multiple male partners and reports intermittent condom use with them. She has receptive anal intercourse as well as oral sex. We talked about her risk for HIV and pre-exposure prophylaxis (PrEP), as well as testing for syphilis and hepatitis. We also discussed screening for gonorrhea and chlamydia from the body parts she is using for sex—both the throat and anus.
She said she had never been offered PrEP, a daily preventative pill against HIV from sex and IV drugs, and she only vaguely knew about it from an advertisement she had recently seen. She had never received screening for gonorrhea or chlamydia in her throat or anus.
Alex was troubled that she had never been offered the care that she now realized she needed. She felt tired of explaining her identity, body parts, and sexual behaviors to healthcare providers. She often met with uncomfortable or irrelevant questions about her health history. She felt like she was always correcting medical providers and educating them about gender identity. She was exhausted.
Unfortunately, what Alex experienced with her other healthcare providers isn’t particularly unusual. Many medical providers are uncomfortable asking for a thorough sexual history, leaving patients uncomfortable, and not wanting to come back. It makes it incredibly hard for them to access care and leads to a lack of information about many things, including HIV. I wish every patient walked away from their healthcare provider feeling understood and equipped with knowledge about how best to protect themselves.
PrEP can be a valuable tool for women of all experiences who either can’t or don’t want to negotiate condom use with their partners. In July of 2012, the Food and Drug Administration approved Truvada, a daily pill, for PrEP, or pre-exposure prophylaxis, for HIV prevention among adults who are at high risk of getting the infection. Earlier this year, the FDA approved Truvada for PrEP for adolescents. People aged 13 to 24 accounted for 21 percent of new infections in 2016 and the majority of those infections were among black and Hispanic youth.
While condom use, both internal and external, is an effective way to prevent HIV, STIs, and unplanned pregnancy, in the past several years, biomedical interventions (or medications) for HIV prevention have been of growing interest. Currently, Truvada is the only method of PrEP that has been approved, but other medications are being studied. Truvada is active against the HIV virus and when it reaches high enough levels in the blood, it prevents the virus from replicating in the body. If taken daily as directed, it can reduce the risk of HIV over 92 percent.
When PrEP was approved, it was meant to be taken at times of highest risk. Patients should periodically evaluate their risk for HIV because it can increase, decrease or stay the same. If a patient’s risk for HIV continues to be high, the benefit of staying on Truvada outweighs the potential long-term side effects.
HIV is under-discussed, especially within the context of women’s health, even though women of all experiences are at risk for the infection. About a quarter of all people living with HIV in the United States are cis women. And about a quarter of all transgender women are living with HIV. Trans women and trans women of color are at particularly high risk of HIV infection.
Rates of HIV among all groups have gone down or stabilized, but have risen among others, particularly black and Hispanic people. Sixty-one percent of women living with HIV in the United States are black and one in 48 black women will contract HIV in her lifetime.
These communities have higher rates of HIV infection for multiple reasons. Medical providers aren’t always prepared to talk about sexual behaviors and appropriate risk-reducing interventions. They may impose an unconscious bias against certain communities like people of color and/or members of the LGBTQ community who may not trust the medical system or feel stigmatized in a healthcare setting.
“High risk for HIV infection” may be defined in several ways. It is important to note that sexual behaviors (anal, oral, vaginal sex) determine an individual’s risk, not sexual orientation. For example, a patient who identifies as a woman may also identify her as gay because she is sexually active with a trans woman. But if she engages in vaginal and anal sex, she should be counseled on her personal risk for HIV as well as other STIs.
Anal sex carries the highest risk of HIV infection because of the micro-tears that can occur in the anal tissue during penetration. Those micro-tears can then serve as an entry point into the body for the virus. It takes seven days for Truvada to become effective in the tissue in the anus and 20 days to become effective in the tissue in the vagina and blood (for people who use IV drugs). While anal sex carries a higher risk of HIV transmission than vaginal sex, transmission through the vaginal tissue is possible. And age-related thinning and dryness of the vagina may also increase the risk of HIV infection in older women. Mouth-to-penis sex is the riskiest form of oral sex, but the risk of HIV transmission is still very low and much lower than with either anal or vaginal sex. Risk of HIV infection through neovaginal sex is not known.
But risk evaluation goes beyond the actual act of sex; it means taking into consideration the context in which the woman is having sex. A woman may say that she is sexually active with her husband but she may not disclose that they have an open relationship if she’s not explicitly asked. This may mean that a woman is sexually active with multiple partners and she is not aware of their status. Clinicians should be specific in the way they take a sexual history and standardize this for all of their patients. A woman may be exchanging sex for money; she may be using intravenous drugs and not always using clean needles. Her sexual partners may be using intravenous drugs and sharing needles.
She may be a trans woman who is using condoms every single time she has receptive anal sex with her cis male partner who is not living with HIV and with whom she is in a mutually monogamous relationship. But she may still have anxiety about getting HIV which interferes with her ability to feel pleasure during sex, so she asks for PrEP. This scenario is very common and should be taken seriously by healthcare providers. In addition to prevention, PrEP can also facilitate increased pleasure for some.
High risk can also mean a cis woman who is having vaginal sex or anal sex consistently with one partner who is living with HIV and she wants to protect herself from infection. That same cis woman may be using condoms with her partner who is living with HIV but they want to become pregnant. In both instances, she should be offered PrEP and her partner should be encouraged to continue taking his antiretroviral medications. We know that treatment as prevention has encouraged people diagnosed with HIV to start and maintain treatment, not only improve their health outcomes, but also to prevent transmission to others. The Centers for Disease Control reports that individuals with an undetectable viral load have “effectively no risk of sexually transmitting the virus to an HIV-negative partner.” But she should be offered PrEP and encouraged to come in regularly for HIV testing.
For those who choose not to take PrEP for HIV prevention or use internal and external condoms, regular testing and post-exposure prophylaxis (PEP) are available methods of prevention.
If a condom breaks or isn’t used during intercourse and is potential for HIV exposure, patients can see their healthcare provider to receive a prescription for PEP and emergency contraception (EC), as needed. PEP is a regimen of anti-retroviral medications that are taken for 28 days. It is best if PEP is started within two hours of exposure, but can be initiated up to 72 hours. Testing for all STIs is done at the initial visit and again at the completion of the course of PEP. It’s a good idea to discuss switching to PrEP once PEP has been completed if there is an ongoing risk for HIV. EC can be taken up to three to five days after sex, depending on the method that’s chosen (Plan B, Ella, or Paragard IUD). EC prevents a pregnancy from occurring but won’t end an already established pregnancy.
Regular testing for HIV and sexually transmitted infections is recommended for all sexually active people. The CDC recommends that everyone between the ages of 13 and 64 gets tested for HIV at least once in their lifetime and more frequently depending on their risk. Testing for HIV has become is quick and easy; the newest tests take less than just a few minutes and provides results right away.
Women of all experiences may be at risk for HIV infection. Gender identity or sexual orientation alone do not increase or decrease the risk of HIV. Trans women, trans women of color and cis women of color, both adults and youth, are at particularly high risk of HIV acquisition. A lot of this has to do with stigma, homelessness, poverty, and immigration status, as well as poor access to healthcare. And unfortunately, healthcare providers may impose their own biases or might not be equipped to counsel patients on certain sexual behaviors. The reasons are intersectional and complex, but simple changes in the healthcare space can help facilitate better access to HIV prevention services. Medical providers need to have the tools to talk to all patients about their sexual behaviors and drug use in a non-judgmental and inclusive way. Patients should be made to feel welcome and safe in healthcare spaces and comfortable enough to talk about their intimate needs.
Dr. Meera Shah, MD, MPH, MS is the Associate Medical Director of Planned Parenthood Hudson Peconic in New York and a fellow with the Physicians for Reproductive Health.