Transgender Men and Pregnancy

Transgender people have experienced significant advances in societal acceptance despite experiencing continued stigma and discrimination. While it can still be difficult to access quality health care, and there is a great deal to be done to create affirming health care organizations, there is growing interest around the United States in advancing transgender health. 

The focus of this commentary is to provide guidance to clinicians caring for transgender men or other gender nonconforming people who are contemplating, carrying, or have completed a pregnancy. Terms transgender and gender nonconforming specifically refer to those whose gender identity (e.g., being a man) differs from their female sex assigned at birth. Many, if not most transgender men retain their female reproductive organs and retain the capacity to have children. 

Review of their experience demonstrates the need for preconception counseling that includes discussion of stopping testosterone while trying to conceive and during pregnancy, and anticipating increasing experiences of gender dysphoria during and after pregnancy. The clinical aspects of delivery itself fall within the realm of routine obstetrical care, although further research is needed into how mode and environment of delivery may affect gender dysphoria. Postpartum considerations include discussion of options for chest (breast) feeding, and how and when to reinitiate testosterone. 

A positive perinatal experience begins from the moment transgender men first present for care and depends on comprehensive affirmation of gender diversity.

Full article at:   http://goo.gl/Fo1LMb

By:  Juno Obedin-Maliver1,2 and Harvey J Makadon3,4

¹Department of Medicine, University of California San Francisco, San Francisco, CA, USA

²Department of Gynecology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA

³National LGBT Health Education Center, The Fenway Institute, Boston, MA, USA

⁴Harvard Medical School, Boston, MA, USA

Harvey J Makadon, National LGBT Health Education Center, The Fenway Institute, 1340 Boylston Street, Boston, MA, USA

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A Risk Score to Identify HIV-Infected Women Most Likely to Become Lost to Follow-Up in the Postpartum Period

Access to lifelong combination antiretroviral therapy (cART) is expanding among HIV-infected pregnant and breastfeeding women throughout sub-Saharan Africa (SSA). For this strategy to meaningfully improve maternal HIV outcomes, retention in HIV care is essential. 

We developed a risk score to identify women with high likelihood of loss to follow-up (LTFU) at 6 months postpartum from HIV care, using data from public health facilities in Lusaka, Zambia. LTFU was defined as not presenting for HIV care within 60 days of the last scheduled appointment. We used logistic regression to assess demographic, obstetric and HIV predictors of LTFU and to develop a simple risk score. Sensitivity and specificity were assessed at each risk score cut-point. 

Among 2029 pregnant women initiating cART between 2009 and 2011, 507 (25%) were LTFU by 6 months postpartum. Parity, education, employment status, WHO clinical stage, duration of cART during pregnancy and number of antenatal care visits were associated with LTFU (p-value < .10). A risk score cut-point of 11 (42nd percentile) had 85% sensitivity (95% CI 82%, 88%) and 22% specificity (95% CI 20%, 24%) to detect women LTFU and would exclude 20% of women from a retention intervention. A risk score cut-point of 18 (69th percentile) identified the 23% of women with the highest probability of LTFU and had sensitivity 32% (95% CI 28%, 36%) and specificity 80% (95% CI 78%, 82%). 

A risk score approach may be useful to triage a subset of women most likely to be LTFU for targeted retention interventions.

Purchase full article at:   http://goo.gl/YZW67P

By:  Bengtson AM1, Chibwesha CJ2, Westreich D1, Mubiana-Mbewe M3, Chi BH2,3, Miller WC1,4, Mapani M2, Pence BW1, Musonda P5, Stringer JS2, Pettifor A1.

• 1 Department of Epidemiology , University of North Carolina , Chapel Hill , NC , USA.
• 2 Department of Obstetrics and Gynecology , University of North Carolina , Chapel Hill , NC , USA.
• 3 Centre for Infectious Disease Research , Zambia , Africa.
• 4 Department of Medicine , University of North Carolina , Chapel Hill , NC , USA.
• 5 Department of Public Health, University of Zambia School of Medicine , Lusaka , Zambia , Africa. 
• AIDS Care. 2016 Feb 17:1-11

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Treatment Failure, Drug Resistance, and CD4 T-Cell Count Decline among Postpartum Women on Antiretroviral Therapy in South Africa

Background: We assessed HIV RNA suppression, resistance, and CD4 T-cell count 12 months postpartum among pregnant women retained in care in an observational cohort study.

Methods: We prospectively followed two groups of HIV-infected pregnant women—with or without tuberculosis—recruited from prenatal clinics in South Africa. Women who received antiretroviral therapy during pregnancy and reported being on therapy 12 months postpartum were included. Serum samples from women with HIV viremia 12 months postpartum were tested for drug resistance.

Results: Of 103 women in the study, median age and CD4 T-cell count at enrollment were 29 years [interquartile range (IQR): 26–32] and 317 cells per cubic millimeter (IQR: 218–385), respectively; 43 (42%) had tuberculosis at baseline. During pregnancy, 87% of the women achieved an HIV RNA <400 copies per milliliter compared with 71% at 12 months postpartum (P < 0.001). Factors independently associated with an HIV RNA <400 copies per milliliter at 12 months were age ≥30 years, detectable plasma efavirenz concentration, and HIV RNA <400 copies per milliliter while pregnant; there was a trend toward both a detectable viral load and peripartum depression. HIV drug resistance results were available from 25 women, and 12 (48%) had major drug resistance mutations. CD4 T-cell count declined a median of 13 cells per cubic millimeter (IQR: −66 to 140) from delivery to 12 months in women with viremia at 12 months.

Conclusions: Success with maintaining virologic control declined postpartum among HIV-infected women who remained in care and on antiretroviral therapy, and CD4 T-cell count decline and drug resistance were common.

Purchase full article at:   http://goo.gl/7AHRIQ

By:   Hoffmann, Christopher J. MD, MPH^*; Cohn, Silvia MS^*; Mashabela, Fildah BSN^†; Hoffmann, Jennifer D. MPH, MSN^*; McIlleron, Helen PhD^‡; Denti, Paolo PhD^‡; Haas, David W. MD^§; Dooley, Kelly E. MD^*; Martinson, Neil A. MBBCh, MPH^*,†; Chaisson, Richard E. MD^*

doi: 10.1097/QAI.0000000000000811 

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Use of HIV Counseling & Testing & Family Planning Services among Postpartum Women in Kenya

Addressing the postnatal needs of new mothers is a neglected area of care throughout sub-Saharan Africa. The study compares the effectiveness of integrating HIV and family planning (FP) services into postnatal care (PNC) with stand-alone services on postpartum women’s use of HIV counseling and testing and FP services in public health facilities in Kenya.

Data were derived from samples of women who had been assigned to intervention or comparison groups, had given birth within the previous 0–10 weeks and were receiving postnatal care, at baseline and 15 months later. Descriptive statistics describe the characteristics of the sample and multivariate logistic regression models assess the effect of the integrated model of care on use of provider-initiated testing and counseling (PITC) and FP services.

At the 15-month follow-up interviews, more women in the intervention than comparison sites used implants (15 % vs. 3 %; p < 0.001), while injectables were the most used short-term method by women in both sites. Women who wanted to wait until later to have children (OR = 1.3; p < 0.01; 95 % CI: 1.1–1.5), women with secondary education (OR = 1.2; p < 0.05; 95 % CI: 1.0–1.4), women aged 25–34 years (OR = 1.2; p < 0.01; 95 % CI: 1.1–1.4) and women from poor households (OR = 1.6; p < 0.001; 95 % CI: 1.4–1.9) were associated with FP use. Nearly half (47 %) and about one-third (30 %) of mothers in the intervention and comparison sites, respectively, were offered PITC. Significant predictors of uptake of PITC were seeking care in a health center/dispensary relative to a hospital, having a partner who has tested for HIV and being poor.

An integrated delivery approach of postnatal services is beneficial in increasing the uptake of PITC and long-acting FP services among postpartum women. Also, interventions aimed at increasing male partners HIV testing have a positive effect on the uptake of PITC and should be encouraged.

Full article at:  http://goo.gl/k60PZL

By: James Kimani^1*, Charlotte E Warren¹, Timothy Abuya¹, Charity Ndwiga¹, Susannah Mayhew², Anna Vassall³, Richard Mutemwa² and Ian Askew¹

¹Population Council, General Accident Insurance House, Ralph Bunche Road, Nairobi, Kenya

²London School of Hygiene & Tropical Medicine, Department of Global Health and Development, 15-17 Tavistock Place, London WC1H 9SH, UK

³London School of Hygiene & Tropical Medicine, Department of Population Studies, Keppel Street, London WC1E 7HT, UK

 

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Incidence & Risk Factors for Intimate Partner Violence During the Postpartum Period

Below:  Theoretical-conceptual hierarchical model of risk factors for incidence of intimate partner violence postpartum

Below:   Incidence of psychological, physical and sexual violence by intimate partner postpartum. Recife, PE, Northeastern Brazil

The incidence of violence during postpartum was 9.3% (95%CI 7.0;12.0). Isolated psychological violence was the most common (4.3%; 95%CI 2.8;6.4). The overlapping of psychological with physical violence occurred at 3.3% (95%CI 2.0;5.3) and with physical and/or sexual in almost 2.0% (95%CI 0.8;3.0) of cases. The risk of partner violence during postpartum was increased for women with a low level of education (RR = 2.6; 95%CI 1.3;5.4), without own income (RR = 1.7; 95%CI 1.0;2.9) and those who perpetrated physical violence against their partner without being assaulted first (RR = 2.0; 95%CI 1.2;3.4), had a very controlling partner (RR = 2.5; 95%CI 1.1;5.8), and had frequent fights with their partner (RR = 1.7; 95%CI 1.0;2.9).

The high incidence of intimate partner violence during postpartum and its association with aspects of the relationship’s quality between the couple, demonstrated the need for public policies that promote conflict mediation and enable forms of empowerment for women to address the cycle of violence.

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