Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States

Special Populations

Perinatal HIV Prevention for Transgender and Gender-Diverse People Assigned Female at Birth

It is important for health care providers to be aware that not all people who become pregnant identify as women or female. Because many transgender and gender-diverse people assigned female at birth retain their reproductive organs, pregnancy can occur, and many desire and/or experience pregnancy in their lifetime.^1-7 This section provides an overview of recommendations from the Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission (the Panel) regarding perinatal HIV prevention and treatment of HIV in pregnancy for transgender and gender-diverse people assigned female at birth. The Panel uses the terms transgender and gender-diverse people assigned female at birth to include people who do not identify as cisgender women while acknowledging individual preferences and ongoing changes in the terminology used to describe this population. The Panel aims to make the guidelines inclusive of transgender and gender-diverse people by incorporating inclusive language, considering the appropriateness of existing Panel recommendations for the care of transgender and gender-diverse individuals assigned female at birth, and adding relevant recommendations and content. Additional information is available in the Adult and Adolescent Antiretroviral Guidelines (see Transgender People with HIV), guidance from the American College of Obstetricians and Gynecologists about health care for transgender and gender-diverse individuals,⁸ standards of care developed by the World Professional Association for Transgender Health,⁶ and guidelines for primary and gender-affirming care developed by the Center of Excellence for Transgender Health at the University of California, San Francisco.⁹

Perinatal HIV Prevention and Care of Transgender and Gender-Diverse People During Prepregnancy, Antepartum, and Postpartum Periods

Research into the fertility, pregnancy-related, and perinatal HIV prevention needs of transgender and gender-diverse people is in early stages, and descriptions of pregnancy-related care are limited. After careful consideration, the Panel has decided it is often appropriate to extrapolate existing recommendations to transgender and gender-diverse people assigned female at birth and to provide additional content and recommendations, when data are available, to address the unique and varied needs of this population if indicated. This approach is consistent with other guidelines for primary care, family planning,¹⁰ and HIV care¹¹ for transgender and gender-diverse people.

Health care providers should periodically assess the reproductive and parenting desires and intentions of transgender and gender-diverse patients and support access to fertility preservation and reproductive health care services.¹² Transgender and gender-diverse people experience multiple barriers to accessing health care, particularly sexual and reproductive health care, which is often delivered in gender-segregated spaces.^13,14

Some transgender and gender-diverse people assigned female at birth take testosterone to achieve gender-affirming bodily changes. While testosterone may lead to amenorrhea, it does not reliably suppress ovulation. Individuals having condomless sex that can lead to pregnancy and who want to avoid pregnancy should be counseled on the need for contraception. Testosterone is not recommended during pregnancy due to possible irreversible fetal androgenic effects.^14-17 Experts recommend that patients who are pregnant or are trying to conceive should stop taking testosterone.^6,18-20 Persons taking testosterone who desire pregnancy but have concerns about stopping testosterone should consult with their gender-affirming hormone prescriber or another transgender care expert about risks and benefits.²¹ The optimal time period for stopping testosterone prior to conception is unknown.^2,21 For people wanting to conceive, prepregnancy planning and care provide an opportunity to address HIV prevention—including HIV testing and pre-exposure prophylaxis—for those who are HIV negative. For people with HIV, it provides an opportunity to optimize antiretroviral therapy (ART) and viral suppression before pregnancy. It also enables providers to identify and address transgender and gender-diverse people’s concerns about the relationships between pregnancy or parenthood and their gender identity and gender-affirming medical interventions, such as hormones or surgeries. For additional information, see Pre-Exposure Prophylaxis (PrEP) to Prevent HIV During Periconception, Antepartum, and Postpartum Periods; Prepregnancy Counseling and Care for Persons of Childbearing Age with HIV; and Reproductive Options When One or Both Partners Have HIV.

Selection and management of ART for transgender and gender-diverse people with HIV should follow Recommendations for Use of Antiretroviral Drugs During Pregnancy: Overview, Table 6: What to Start: Initial Antiretroviral Regimens During Pregnancy for People Who Antiretroviral-Naive, and Table 7: Situation-Specific Recommendations for Use of Antiretroviral Drugs in Pregnant People and Nonpregnant People Who Are Trying to Conceive. The potential for drug interactions should be considered and discussed with patients who plan to start or resume hormonal therapy postpartum (see Table 17. Potential Interactions Between the Drugs Used in Gender-Affirming Hormone Therapy and Antiretroviral Drugs in Transgender People with HIV).

Gender-Affirming Care

Health care providers should work to develop patient-centered approaches that assess and address the gender affirmation needs of transgender and gender-diverse individuals in all health care settings.^12,19,21,22 Gender affirmation encompasses processes and interventions that recognize and support a person’s gender identity and expression.²³ Gender-affirming care may include psychosocial support, hormone therapy, surgery, and other interventions.¹⁹ Gender affirmation—including such medical interventions as hormonal therapy—has been shown to improve mental health outcomes and quality of life in transgender individuals.⁶ Rates of viral suppression have been shown to be higher among transgender people with HIV who are receiving gender-affirming hormone therapy.^24,25 A national needs assessment found that transgender and gender-diverse people with HIV were more likely to be virally suppressed when they worked with HIV care providers who affirmed their gender (e.g., providers who use their chosen name and pronoun[s]).^11,26 Language is important for inclusivity and for providing respectful, affirming health care.^12,27 Many transgender and gender-diverse people use terms unique to them and their anatomy; therefore, providers should never assume that a patient prefers a certain term and should respect the patient’s expressed preferences.^27,28 All patients should be asked about their gender identity, including the pronouns they use and how they (and their partners) want to be referred to as parents (i.e., birth parent, father, mother, or another name). Clinicians should also ask patients about desired terminology for sexual and reproductive anatomy and be aware that terminology is rapidly changing.²⁸

Health care providers should be aware that although transgender and gender-diverse patients may adjust well to pregnancy, some patients may experience and require support for the onset or worsening of gender dysphoria and associated symptoms during prepregnancy, antepartum, and postpartum periods. Gender dysphoria and associated symptoms may be precipitated or exacerbated by the body changes that occur in pregnancy and the harmful practices of misgendering pregnant transgender and gender-diverse people in prenatal, labor and delivery, and postpartum care settings.^18,19,21,29 Gender dysphoria refers to the distress that results from incongruence between a person’s sex assigned at birth and their gender identity³⁰ and is manifested by a range of symptoms, such as depression, anxiety, and a sense of unease.³¹ Gender dysphoria can be reduced when a person receives affirmation for their gender identity through various interventions that include interpersonal approaches, such as adaptations made in gender-specific clinic environments and procedures, and medical interventions, such as hormones.^19,31 Health care providers should have individualized discussions with their patients regarding starting or restarting testosterone therapy in the postpartum period, including referral to and/or coordination with a gender-affirming care specialist as needed.

References

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