What to know about PrEP for transgender individuals

Preexposure prophylaxis (PrEP) is a medication to help prevent contracting HIV. People who have a high risk of HIV exposure may choose to take PrEP. It is also safe for transgender people.
PrEP is highly effective in preventing HIV-negative people from contracting HIV. People who are at high risk of HIV exposure can take PrEP before exposure to protect against HIV.
HIV
PrEP is safe for transgender people and safe to take alongside gender-affirming hormones and other gender-affirming procedures.
safe
This article discusses taking PrEP alongside hormones, as well as how to take it, what it costs, and how to access it.
PrEP and gender-affirming hormones
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Truvada and Descovy are both PrEP medications. The type of hormone a person is taking will affect which PrEP medication they can take.
According to PleasePrEPMe, Truvada does not reduce hormone levels. Although Descovy is also unlikely to affect hormone levels, researchers still need to study it further.
PleasePrEPMe
Testosterone is safe to take with PrEP. Truvada is safe for people of all gender identities. However, there is currently limited research on Descovy, which does not currently have approval for those taking testosterone.
limited research
A 2020 study looked at the interaction between testosterone and PrEP in 24 transgender men who were HIV-negative and had been taking testosterone for at least 6 months.
2020 study
testosterone
After 4 weeks, there were no changes in concentrations of free and total testosterone, and PrEP remained at a level that would provide a high level of protection against HIV.
It is safe to take estrogen alongside PrEP. Both Truvada and Descovy have approval for those taking estrogen.
estrogen
have approval
The same 2020 study mentioned above looked at the effects of Truvada on 24 HIV-negative, transgender women who had been taking estradiol for at least 6 months.
2020 study
After 4 weeks of taking PrEP daily, there was no effect on estradiol levels. PrEP also remained at a level that would be highly effective against HIV.
Taking PrEP alongside feminizing hormones will not cause fat redistribution in the face or body.
will not
Some studies note that high doses of feminizing hormones may lower the levels of tenofovir, a component of some forms of PrEP.
studies
However, the World Professional Association for Transgender Health (WPATH) suggests that doctors can safely prescribe PrEP and gender-affirming hormone therapy together.
suggests
WPATH notes that researchers have not extensively studied the interactions between PrEP and gender-affirming hormone therapy. However, recent studies suggest there are minimal interactions between the two treatments.
minimal interactions
PrEP and sexually transmitted infections (STIs)
Although PrEP protects against HIV, it does not protect against any other STIs.
Using protection correctly, such as condoms or dental dams, and undergoing regular testing is important in protecting against STIs.
While using PrEP, people can get regular testing for HIV and other STIs every 3 months.
3 months
PrEP and contraception
It is safe for transgender people to take PrEP alongside contraception methods such as hormonal birth control.
safe
contraception
According to a 2020 update of the Centers for Disease Control and Prevention (CDC)’s recommendations for contraceptive use, people at high risk of developing HIV are eligible for all forms of hormonal contraception. This update also mentioned there is no evidence of drug interactions between PrEP and hormonal contraceptives.
2020 update
If a person is concerned about how PrEP will affect their choice of hormonal contraception, they can speak with a healthcare professional.
If a person has not undergone an orchidectomy or vasectomy, they will need to use contraceptives for penetrative vaginal sex with a partner who could become pregnant and is not using contraceptives.
It is important to note that gender-affirming hormone therapy is not effective as a contraceptive. This includes:
not effective
estradiol
gonadotropin-releasing hormone (GnRH)
analogs
finasteride
cyproterone acetate (not available in the United States)
PrEP and pregnancy
According to the Terrence Higgins Trust (THT), PrEP is safe to take:
Terrence Higgins Trust (THT)
when trying to conceive
during the pregnancy
while chestfeeding or breastfeeding
Who should consider taking PrEP?
People may want to consider PrEP if they are HIV-negative and at risk of HIV exposure. This includes people who:
have a sexual partner who is HIV-positive
do not consistently use condoms and are unsure of the HIV status of any sexual partners
engage in sex work
have recently had a bacterial STI
use injection drugs and share drug equipment or have an injecting partner who is HIV-positive
In some cases, PrEP may not be suitable for people to take. This includes people who:
have an unknown HIV status, as PrEP is only suitable for HIV-negative people
have any signs or symptoms of acute HIV infection
have reduced kidney function
have an unknown hepatitis B or hepatitis B vaccination status
hepatitis B
Taking PrEP
Before taking PrEP, it is important that people know their HIV status. People can go to a local testing center or sexual health clinic and get a full sexual health screen.
People will need an HIV test and a test to check kidney function to make sure that it is safe for them to take PrEP.
There are two ways to take PrEP: daily dosing or on-demand dosing. Daily dosing is suitable for anyone who is taking gender-affirming hormones.
According to the THT, daily PrEP may be the best option for people assigned female at birth and people taking testosterone. If people are taking testosterone, daily PrEP may decrease natural lubrication and reduce tissue thickness in the vagina.
THT
This can make it more likely for those having penetrative sex to have small tears, which increases the risk of exposure to HIV.
Daily dosing is also the only option for anyone receiving penetrative vaginal sex. This is because PrEP levels need to be high enough in vaginal tissues to ensure sufficient protection against HIV.
For daily doses of PrEP, people will need to take the medication for 7 days before it will provide full protection against HIV.
On-demand dosing, or event-based dosing, is for people who are not taking gender-affirming hormones and have a risk of HIV from anal sex.
People take on-demand PrEP before and after they have sex.
The on-demand dosage is as follows:
follows
2 tablets 2–24 hours before having sex
2 tablets 24 hours after the first dose
1 tablet 24 hours after the second dose
It is important for those having sex for an extended period of time, for example, over a few days, to continue taking the pill every 24 hours. A person should do this until they have 2 sex-free days.
2 sex-free days
If a person assigned male at birth is not taking gender-affirming hormones and is only having anal sex, they can also take PrEP on-demand dosing.
Where to get PrEP
People can talk with a healthcare professional about getting PrEP, or go to a sexual health clinic.
If people are finding it difficult to access PrEP, they may want to use an online resource such as PrEP Daily to talk with a PrEP navigator who can help connect people to a professional who can provide PrEP.
PrEP Daily
People can use this search tool to find a local PrEP provider. People may also want to locate PrEP through an online prescriber.
search tool
online prescriber
People can also find HIV testing and PrEP through the CDC.
CDC
If a person wants to stop taking PrEP
If people want to stop taking daily PrEP, they will need to continue taking the medication for 7 days after they last had sex without a protective barrier.
7 days
If people are taking on-demand PrEP, they will need to continue taking the medication for 2 days after they last had sex without a condom or other barrier method.
If people want to restart PrEP, they will require a HIV test beforehand.
If people have a hepatitis B infection, they will need to speak with a healthcare professional before stopping PrEP.
Paying for PrEP
If people have health insurance, it may cover the costs of PrEP.
health insurance
People may still have to pay part of the cost at a pharmacy, known as the prescription copay. There are copay assistance programs available to help people pay these costs.
If people do not have health insurance and have an annual income of less than $63,000, they may be eligible for free PrEP. People can find out more about applying for financial assistance for PrEP from the San Francisco Aids Foundation or via the Please PrEP Me website.
San Francisco Aids Foundation
Please PrEP Me website
Frequently asked questions
The following section answers common questions about PrEP and gender-affirming hormone therapy.
It is safe to take PrEP alongside gender-affirming hormone therapy. Most forms of PrEP have approval for people receiving gender-affirming hormone therapy, with reports of minimal interactions.
minimal
It is safe to take most forms of PrEP while on testosterone. Descovy is still being researched and does not yet have approval for people taking testosterone.
Truvada does not reduce or increase hormone levels in transgender individuals. According to the CDC, there are no significant interactions between PrEP and hormone therapy or hormone-based birth control.
CDC
It is safe to take PrEP while on birth control. The CDC recommends that people at high risk of developing HIV should be eligible for all forms of hormonal contraception.
CDC
Summary
PrEP is a form of medication to help prevent people from contracting HIV.
It is safe for transgender individuals regardless of the hormones they are taking and whether they have undergone gender-affirming procedures. However, the type of hormone a person is taking may affect which PrEP medication they can have.
It is important to note that PrEP does not reduce the chance of contracting other STIs, and a person should use additional contraceptive measures. A person can discuss their options with a healthcare professional.