The Role of Gender-Affirming Hormone Therapy in Anal Human Papilloma Virus Persistence (HPV) and Systemic and Mucosal Immunity in Transgender Women with and without HIV - Transgender women (TGW) are disproportionately affected by anal high-risk human papillomavirus (HR-HPV) and HIV. Anal cancer, caused by persistent HR-HPV, is the 6th most common cancer in TGW in the United States. HIV alters HPV immunity and potentiates HPV persistence, thus increasing cancer risk. The peripheral and mucosal immune response against anal HPV is linked to the regression of high-grade anal dysplasia – the precursor to anal cancer. In cisgender women, estrogen may alter the immune response against HPV-infected cells, increase HPV persistence, and facilitate the progression to cervical cancer. In cisgender men and TGW, higher testosterone levels have been linked to a higher prevalence of anal HPV. However, in TGW, who often use androgen blockers and estrogen supplementation as gender affirming hormones (GAH), there is a critical gap in understanding the effect of GAH on HPV immunity and persistence, and consequentially the progression to anal dysplasia, particularly in people with HIV. This gap hinders the research into urgently needed novel HPV immunotherapies targeting anal dysplasia in TGW. We will conduct a secondary analysis of samples from TGW and cisgender men who have sex with men from our HPV natural history cohorts. In one of these cohorts, of 80 TGW in Washington DC, we found a high prevalence of HR-HPV (73%) and anal dysplasia (48%). In Aim 1, we will assess the effect of GAH on systemic HPV16 immunity using flow cytometry. We will compare, cross-sectionally in people with natural infection (1a) and longitudinally in response to the HPV 9-valent vaccine (1b), immune markers, the proportion of peripheral HPV-specific CD4 T-cells, and L1- specific antibodies (1a and 1b), and CD8 T-cells (1a), between 60 TGW on GAH and 60 assigned male controls not on GAH, stratified by HIV status. In Aim 2, we will assess the effect of GAH on the mucosal HPV16 immune response. Using confocal microscopy on anal tissue of participants with anal HPV16 infection, we will compare quantitative and qualitative characteristics of immune cells from 40 TGW on GAH and 40 assigned male controls not on GAH, stratified by HIV status and lesion type. In Aim 3, we will examine the effect of GAH on anal HR-HPV persistence defined as the detection, on HPV whole-genome sequencing (NGS), of the same HR-HPV sublineage at an initial timepoint and at 6, 12, and 18-months. We will compare HPV persistence between 60 TGW on GAH and 60 assigned male controls not on GAH, stratified by HIV status. The proposed work will provide training in sex-steroids biology, interpreting results of HPV NGS and immunological techniques, and academic skills needed for a career in translational clinical research under the mentorship of Drs. Gaykalova, Kottilil, Klein, Lisco, and Rosenthal. This data will inform shared decision- making discussions with TGW, provide guidance for optimal anal cancer screening and treatment of anal dysplasia in TGW on GAH and cisgender women, and guide the study of HPV immunotherapies for anal dysplasia in TGW by explaining the role of GAH on immunological and virological research endpoints.
