Consistent with observations from clinicians working with transgender women living with HIV, we found significantly lower ART adherence among transgender female respondents, who were less likely than their nontransgender counterparts to report adherence rates that were 90% or greater. This finding has clinical significance for the management of HIV among transgender women. Evidence from other investigations found that, depending on specific regimen characteristics and baseline levels of adherence, a 10% increase in adherence may have been associated with as much as a halving of viral loads and a 20% to 30% decreased risk of progression to AIDS, suggesting that the magnitude of the effect observed in our study has potentially important clinical ramifications (Bangsberg et al., 2000
; Hogg et al., 2002
Transgender women reported significantly lower self-ratings on the Integration subscale of the adherence self-efficacy measure than comparison respondents. Failure to integrate treatment into one’s life has been identified in prior research as a consistent obstacle to medication adherence (Chesney, 2000
; Johnson et al., 2003
). Given the multitude of reports that transgender people often avoid seeking health care due to previous negative experiences in interactions with providers (Clements et al., 1999
; Kenagy, 2005
; Lombardi, 2007
; Sanchez et al., 2009
), it makes sense that transgender female respondents would report less confidence in their ability to keep appointments and adhere to treatment plans, especially when medication regimens interfere with daily life.
No differences in depression were found between transgender women and the comparison group. Because a majority of respondents in the comparison group identified as gay or bisexual (55%), it may be the case that both transgender women and gay and bisexual men and women have significantly elevated rates of depression when compared to the general population. This finding has been reported in the literature on depression in lesbian, gay, and bisexual populations (Cochran, Mays, & Sullivan, 2003
) as well as among transgender adults (Israel & Tarver, 1997
), and may account for the lack of difference between the groups in this study.
Although we did not find differences in reports of side effects attributed to HIV medications, transgender women may present a more complicated side effect profile due to hormone use, which was not assessed in the present study. There have been some preliminary discussions among clinicians who serve HIV-infected transgender women regarding possible interactions between ART and hormone treatment (Vázquez, 2008a
), but the studies that have examined these drug interactions have all been conducted with nontransgender female participants who were taking oral contraceptives (Panel on Antiretroviral Guidelines for Adults and Adolescents, 2009
). Several antiretroviral medications have been shown to alter the levels of estrogen in the blood, thus requiring adjusted levels of hormones to achieve the same treatment effect and/or to avoid unnecessary risks and side effects (Connolly & Kohler, 2006
). It is unclear whether transgender women in our study perceived any interactions between their hormone treatment and ART or how their perceptions may have influenced rates of adherence or reporting of side effects.
Some evidence has suggested that transition-related health care, especially hormone treatment, is more highly prioritized by many transgender women than primary care, including HIV-related care and treatment (Kammerer, Mason, Connors, & Durkee, 2001
). Many transgender women are unable to access hormone treatment through a health care provider and must pay large sums of money to obtain hormones from street markets. They often desire quick results, especially individuals who are in early transition and, because they self-administer hormones without medical supervision, they often take higher doses of estrogen than is considered safe (Sanchez et al., 2009
). Considering the multiple barriers to obtaining and monitoring hormone treatment, transgender women would likely consider an ART-related drug interaction that lowers estrogen levels as highly undesirable. In addition, the combination of ART and hormone use may mean that additional monitoring of blood levels is needed to determine whether dosages need to be adjusted. Given the pervasiveness of transgender women’s aversion to seeking health care services due to fear or previous negative experiences (Transgender Law Center’s Health Care Access Project, 2004
; Lombardi, 2007
), further medical attention may not be readily accepted by many patients.
Limitations and Future Directions
The small number of transgender women in the sample limited our study. The method of determining gender identity may have inadvertently excluded some respondents who either did not wish to identify as transgender due to fear of stigma or other reasons or did not feel that their gender identity was adequately represented by the options provided. Future studies should include more substantive sample sizes and more comprehensive and sensitive assessments of transgender identities.
Future studies of adherence among transgender women should also assess whether or not respondents are currently using hormones and their perceptions of interactions between their hormone treatment and HIV medications. Similarly, the measure of adherence used in this study was self-report and only inquired about medication adherence over the previous 3 days; longer timeframes and more objective measures of adherence may yield more robust findings. Finally, given the relatively small number of transgender respondents, there was limited statistical power to examine multiple predictors of adherence such as age, race/ethnicity, education, housing status, time on regimen, health care utilization patterns, history of incarceration, and substance use.
Findings from this study suggest that culturally appropriate interventions that address lack of adherence self-efficacy may facilitate higher rates of ART adherence and thereby result in better clinical outcomes for transgender women with HIV. Training for health care providers to increase cultural competency to work with transgender patients, increase patient trust, and promote positive interactions between patients and providers may help to cultivate an atmosphere that is more conducive to fostering greater adherence self-efficacy and medication adherence among transgender women living with HIV.
Clinicians who serve transgender women have found that hormone treatment can serve as an incentive for patients to seek and adhere to ART (Zevin & Martinez, 2007
). Integration of hormone treatment into HIV care may augment adherence as well as decrease the prevalence of self-administered hormone use among members of this population (Grimaldi & Jacobs, 1998