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HRT and PrEP: Approaching Safe Sex in a Body to Call Home, Explained by FOLX

Any gender identity—not just cisgender men—can get HIV and any gender can take PrEP, including transgender, non-binary, intersex, and gender-variant people on hormone replacement therapy (HRT). Read on to learn about this HIV prevention method.

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Not all sex is the same. That’s one of the many beautiful parts of our community. While our sex can be expansive and innovative, it is possible for anyone of any gender to get HIV (human immunodeficiency virus). Though some people have been categorized as having an “increased risk” of contracting HIV, we recognize that this language has been used against LGBTQ+ people and the types of sex queer people have. Therefore, we avoid language around “risk” and “risky behavior” and focus more on who might have a higher chance of getting HIV regardless of gender or sexuality. Some folks do have a higher likelihood of contracting the virus, and knowing what those bodies and sex acts look like can help you play it safe and remain HIV negative.

To reemphasize, all gender identities (including transgender people) can take PrEP (pre-exposure prophylaxis). Even cisgender women, just like trans women, are eligible to take PrEP depending on their medical history, risk factors, and recommendations of their healthcare provider. However, some anatomies might have a higher probability of HIV exposure during sex:

  • Those with a penis who are having anal or vaginal sex with parter(s) with or without a penis
  • Those without a penis who are having anal or vaginal sex with partner(s) with a penis
  • Those who inject recreational drugs and might share needles

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Fortunately, there are medications for HIV prevention. PrEP is a medication used to prevent or stop HIV from taking hold and spreading throughout the body. In this article, we're providing transgender health information for those on hormone replacement therapy and PrEP. Daily PrEP (such as Truvada or tenofovir) is 99% effective at preventing HIV infection through anal or vaginal sexual activity and at least 74% effective when exposed to HIV through injection drug use.

PrEP doesn't decrease the effectiveness of HRT.

Rest assured: you can take PrEP while still maintaining the same effects that hormones (testosterone, progesterone and/or estrogen) have on your body. A new study published in the journal Clinical Infection Diseases and presented at the AIDS 2020 conference found that, after four weeks of PrEP daily dosing, estradiol or testosterone levels weren't affected.

There aren’t many large-scale, generously-funded studies that look into the impact of drug interactions between hormone replacement therapy and any associated medications.

Unfortunately, there aren’t many large-scale studies into gender-affirming healthcare at all. For trans women and other transfeminine people on feminizing hormone therapy, such as those who take anti-androgen spironolactone or finasteride as a testosterone blocker, there are some questions around PrEP levels as they relate to hormone levels, but the research needs to be expanded. One study has shown that taking estrogen may decrease the amount of PrEP in the bloodstream, and therefore may decrease how effectively PrEP protects you from acquiring HIV.

We don't recommend anyone taking estrogen to use PrEP-on-demand (PrEP 2-1-1) because that medication is not as effective as continual daily PrEP. Given the possible decrease in PrEP with estrogen, PrEP 2-1-1 may not provide adequate, quality protection against HIV.

Whether on E or T,  be sure to stay consistent with PrEP!

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Fortunately, PrEP doesn't decrease the effectiveness of HRT. You can continue taking PrEP without it interfering with your transition or affecting your overall quality of life. However, you should aim to follow these basic guides, regardless of your gender:

  • Make sure to take PrEP as consistently as possible—every 24 hours. This will keep a steady supply of PrEP in your bloodstream.
  • Continue to use barrier methods, such as condoms, in addition to PrEP as additional protection against HIV.

That said, you still may experience general side effects (nausea, headache, diarrhea, and more) of PrEP meds. Be sure to check in with your healthcare provider if you think you're experiencing side effects.

As a general practice, we also recommend routine HIV testing for those who fall under the above categories. Because getting tested can sometimes be emotionally triggering, we recommend those who get tested to find a buddy to go with you or a support system for afterwards. 

If you’re interested in being prescribed daily PrEP with TDF/FTC with FOLX, the process begins here. For existing FOLX members interested in adding a PrEP prescription to their plan, reach out to your clinician through your Athena patient portal or reach out to our member advocates at support@folxhealth.com. For those who want to know more, read up on all things sexual health here, and feel free to reach out to us at support@folxhealth.com.