Case 4: Transgender Women and HIV

Question | Discussion | References | CME Credit

Authors: Lynn E. Connolly, MD, PhD
Lori Kohler, MD

Case last updated: May 2, 2006

A 43-year-old Latina transgender (male-to-female) woman is referred to your care after testing positive for HIV during a recent visit to the county sexually transmitted diseases (STD) clinic. She has lived as a woman for the last ten years. For financial reasons, she has received only intermittent medical care for the past several years, relying predominantly on underground estrogen injections to maintain female secondary sexual characteristics. She has not undergone gender reassignment surgery. Initial laboratory studies reveal a CD4 count of 209 cells/mm3 and an HIV RNA level of 156,000 copies/ml. She is otherwise healthy. The patient is interested in both medically administered hormonal therapy and antiretroviral therapy, and after evaluation there are no concerns regarding adherence.

Which one of the following statements is TRUE regarding gender reassignment hormonal therapy in a HIV-infected male-to-female transgender woman?

	Doses of estrogens required for gender reassignment hormonal therapy are typically much lower than doses used for hormone replacement therapy in postmenopausal women.
	Considering this woman’s age, oral ethinyl estradiol (Estinyl) would be preferred over a transdermal estradiol patch. The oral estrogen treatment would have a significantly lower risk of causing thromboembolic complications than a transdermal estradiol patch.
	Anti-androgen therapy with spironolactone (Aldactone) is often used as part of hormonal gender reassignment therapy to further decrease male secondary sexual characteristics.
	No hormonal therapy should be given. The patient needs antiretroviral therapy and the co-administration of antiretroviral therapy and gender reassignment hormonal therapy is contraindicated.