Transgender health and hepatitis C

Introduction

While there is no evidence that being transgender is an independent risk factor for hepatitis C, some transgender sub-populations may be at increased risk. Rates of HIV and injection drug use are higher among transgender people, and transgender people may inject hormones or soft tissue fillers such as silicone.[1] Sharing or use of contaminated needles, syringes, or vials represents a possible risk factor for infection with blood borne pathogens, including hepatitis C, though the actual prevalence of needle sharing among transgender people is believed to be low.[2,3] Nevertheless, patient education for transgender people using injectable hormones should include advice to use sterile syringes only once without sharing. Providers should screen all transgender people for hepatitis C risk factors and perform an antibody screen in those determined to be at risk, as per current guidelines. All transgender people who inject soft tissue fillers should be screened for hepatitis C.

Chronic HCV and hormone therapy

Chronic Hepatitis C is not a contraindication to hormone therapy. Both estrogen and testosterone undergo hepatic metabolism, and routine monitoring of hepatic function has been recommended. However, neither hormone has been associated with hepatic injury or abnormal liver function tests. Monitoring of liver function in patients with chronic hepatitis C infection should proceed as routinely recommended by disease stage and risk factors for progression dictate. Non-oral forms of hormone therapy avoid first pass through liver metabolism and may be preferred for patients with liver disease, though there is no specific evidence to support this recommendation.[4]

Hepatic dysfunction and malignancies have been noted with oral methyltestosterone. However, methyltestosterone is no longer available in most countries and should no longer be used as part of a gender affirming hormone regimen. Oral testosterone undecanoate gel caps available outside the United States were not associated with hepatic dysfunction in a 10-year safety study among non-transgender males.[5] No published data is available on clinical outcomes among transgender individuals with chronic viral hepatitis taking hormone therapy.

Chronic HCV treatment and hormone therapy

The American Association for the Study of Liver Diseases recommends treatment for all patients with chronic HCV infection, except those with short life expectancies owing to comorbid conditions.[6] Antiviral medications used for treatment of hepatitis C vary based on HCV genotype, stage of disease, and HCV treatment history; most are metabolized via the same cytochrome P450 pathway as oral estrogens.[7] The table below summarizes currently known drug interactions between estrogens and hepatitis C antivirals.

Co-administration of estradiol with boceprevir, ombitasvir/paritaprevir/ritonavir, dasabuvir, or telaprevir could potentially increase estradiol exposure; however, co-administration has not been studied. Co-administration of ethinyl estradiol with boceprevir or telaprevir was found to decrease estrogen levels.[8] Elevated liver enzymes were seen in cisgender women taking ethinyl estradiol with OBV/PTV/r and concomitant use (with or without DSV) is not recommended. In summary, ethinyl estradiol is contraindicated with ombitasvir/paritaprevir/ritonavir. There is no evidence on potential interactions between HCV anti-viral meds and 17-beta estradiol, and providers should consider avoiding OBV/PTV/r with or without DSV in patients using estradiol.[8] Transgender women on estrogen therapy should be closely monitored when starting or stopping HCV treatment.

References

1. Reback CJ, Fletcher JB. HIV prevalence, substance use, and sexual risk behaviors among transgender women recruited through outreach. AIDS Behav. 2014 Jul;18(7):1359-67.
2. Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N, et al. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav. 2008 Jan;12(1):1-17.
3. Wallace PM, Rasmussen S. Analysis of adulterated silicone: implications for health promotion. Int J Transgenderism. 2010 Oct 12;12(3):167-75.
4. Knezevich EL, Viereck LK, Drincic AT. Medical management of adult transsexual persons. Pharmacotherapy. 2012 Jan;32(1):54-66.
5. Gooren LJ. A ten-year safety study of the oral androgen testosterone undecanoate. J Androl. 1994 Jun;15(3):212-5.
6. AASLD/IDSA HCV Guidance Panel. Hepatitis C guidance: AASLD-IDSA recommendations for testing, managing, and treating adults infected with hepatitis C virus. Hepatol Baltim Md. 2015 Sep;62(3):932-54.
7. Menon RM, Badri PS, Wang T, Polepally AR, Zha J, Khatri A, et al. Drug-drug interaction profile of the all-oral anti-hepatitis C virus regimen of paritaprevir/ritonavir, ombitasvir, and dasabuvir. J Hepatol. 2015 Jul;63(1):20-9.
8. University of Liverpool. HEP Drug Interaction Checker. HEP Drug Interactions. [cited 2016 May 24].