Viral suppression among transgender people enrolled in Medicaid living in New York City went up after receiving gender-affirming surgery, according to research presented to CROI 2021. Gender-affirming surgery was associated with improved viral suppression among groups who tend to have low rates of viral suppression – Black, young, transgender people living in very high poverty areas.

Researchers compared viral suppression outcomes among transgender people accessing Medicaid who received any form of gender-affirming surgery, those not accessing Medicaid and cisgender men and women.

Of the 1730 transgender people living with HIV enrolled in Medicaid, just under 11% accessed gender-affirming surgery during the study period.

For transgender people enrolled in Medicaid, there was a 13% increase in viral suppression between 2013 and 2017, with 75% achieving viral suppression by 2017. However, viral suppression for this group on the whole remained lower than transgender people not enrolled in Medicaid (83%), cisgender women (82%) and cisgender men (86%).

Transgender people who received gender-affirming surgery were the exception: by 2017, 85% had achieved viral suppression. In this group, 57% were Black, 22% were aged 20-29 and 44% lived in high poverty areas.

Viral suppression went from 66% two years before surgery to 77% one year before. It increased to 86% one year after surgery and remained high at 88% two years after surgery.

Anecdotal evidence suggests surgeons commonly require individuals to be virally suppressed prior to surgery. The data suggest that viral suppression that is achieved is sustained over time.

Two studies presented at CROI 2021 looked at the interaction between gender-affirming hormone therapy (GAHT) and HIV pre-exposure prophylaxis (PrEP). In both studies, young trans men and women aged 16-24 who were already taking GAHT – half of them women taking oestrogen and half of them men taking testosterone – then started taking directly observed daily oral PrEP using tenofovir/emtricitabine.

The first study focused on levels of GAHT and provided reassurance that levels are not significantly lower, either in men or women.

The second study looked at the effect of GAHT on PrEP levels. Although intracellular levels of the PrEP drugs tenofovir disoproxil fumarate and emtricitabine were lower in trans women than in trans men, they were still within the range of levels seen in similar studies of directly observed PrEP conducted in cisgender people.