Transgender people are one of the groups most affected by the HIV epidemic. There are an estimated 25 million transgender people living around the world.1 The term transgender refers to people whose gender identity and expression are different to social expectations of their biological sex at birth. They may see themselves as male, female, gender non-conformist, or one of a spectrum other genders. Transgender people have diverse sexual orientation and behaviours.
The global picture of HIV among transgender people is varied – with HIV prevalence ranging from 8% to 68%.2 Transgender people are among the groups most affected by HIV, particularly in Latin America and Asia and the Pacific.
Generally, HIV prevalence among transgender women (people who are assigned male at birth but identify as being women) is higher than transgender men (people who are assigned female at birth but identify as being men). However, very little is known about transgender men and their vulnerability to HIV. Globally, it is estimated that around 19% of transgender women are living with HIV.3They are 49 times more likely to be living with HIV than the general population.4
What puts transgender people at risk of HIV?
Social, economic and legal exclusion
In addition, the high costs associated with transition healthcare can put extra pressure on transgender people to make money.11 Sex workers sometimes get paid more for unprotected sex, and often feel under pressure not to use a condom, which makes them highly vulnerable to HIV.
There are high rates of unprotected anal sex among transgender women, which carries a high risk of HIV transmission.12 Several factors contribute to this. Stigma and discrimination, leading to low self-esteem and disempowerment, can make it harder for transgender people to insist on condom use.13
In many settings, condom use is often controlled by the insertive sexual partner, so many transgender women who have sex with men can feel unable to instigate condom use.14 Gender-changing hormones, which some transgender women use, can lead to erectile dysfunction, increasing the likelihood of taking the receptive role during sex.15
There are other social factors that make transgender people more likely to engage in high-risk sex. Studies have shown that some transgender people who want to affirm their gender identity through sex, or who fear rejection from sexual partners can be more likely to agree to unprotected sex.16
The stress of social isolation may also lead to a much higher rate of drug and alcohol use among transgender people that can affect their judgement of risk and make them less likely to use condoms.
It is common for transgender people to obtain injectable hormones, the most common form of gender enhancement, and carry out the injecting themselves.
Without counselling on safe injecting practices, people going through this process may be very vulnerable to HIV transmission because of the risk of sharing needles with others.17
HIV prevention for transgender people
Transgender people can have very diverse HIV prevention needs. Targeted prevention approaches that respond to the specific needs of individuals are essential to reducing HIV infections. In addition, prevention initiatives that empower transgender people and enable them to take the lead in meeting the needs of their own community are the most effective.18
Sexual health care for transgender people is often inadequate, with many policy makers and service providers failing to address the needs of transgender women as a population distinct from men who have sex with men.19 Only 39% of countries in 2014 had specific programmes targeting transgender people in their national HIV strategies.20
India is one country where HIV services have been successfully targeted at transgender people – reaching an estimated 83% of the transgender population. They have also made marked steps in officially recognising transgender people, also called Hijras, as a third gender. This means that local authorities need to ensure that they have health and social programmes that meet their needs and has given them the right to vote.21
Providing welfare, employment initiatives and housing can help address the factors that make transgender people more likely to engage in high-risk sex.22 Services for other needs should also be provided, such as mental health counselling and support for a sex change operation.
More broadly, policies that affect the lives of transgender people should be gender affirming, aiming to support transgender people to live congruent with their gender identity. Health workers, particularly primary care providers, need sufficient training to understand and respond to the complex health and rights needs of transgender people.
Successful HIV prevention programmes for transgender people
Case study: Linking transgender people to tailored health and human rights services, El Salvador
El Salvador is estimated to have over 2,000 transgender people – more than a quarter of whom live in the capital city, San Salvador.23 They are one of the country’s most stigmatised groups, and are regularly subject to human rights violations, including hate crimes.24 Nearly half of the transgender women in San Salvador report that their main income is from selling sex, and HIV prevalence among transgender women in the city is estimated at 16.2% compared to less than 1% among the general population.25
Case study: TLBz Sexperts, Thailand
TBLz Sexperts is a project that uses social media for HIV prevention in Thailand. The website provides a space where transgender people can talk about issues or topics that are relevant to them, such as fashion, sex or socialising. The project then uses this space to advise users on safer sex.28 29
The project was created in response to transgender people being a ‘hard to reach’ group in Thailand. Although there is a large population of transgender women in Thailand, they are often a closed community. As the project leader Nada Chaiyajit states, "transgender people only wanted to engage with inner circles".30
It was therefore imperative that HIV prevention messages came from within the community. Many transgender people were already sharing video clips and using the internet to socialise, so it made sense to create an internet forum to discuss topics such as how the Thai constitution affects transgender people’s human rights in a way that was accessible to the audience.
"The best part is we know exactly what we are." - Nada Chaiyajit transgender activist from Chiang Mai, who leads the TLBz Sexpert programme 31
Online peer counselling has the potential to be adapted by transgender people to meet the different sexual health needs of different community settings.
Case study: Tamil Nadu Transgender Welfare Board, India
In Tamil Nadu, a southern state of India, transgender women, or ‘Aravanis’, have a history that goes back centuries.32 However, in the present day they face many of the structural factors that put transgender people at risk of HIV. One study in India found that 46% of transgender women reported being subjected to forced sex. Many Aravanis also consume alcohol excessively, to "manage rough clients" or "forget worries".33
In 2008, the state government established a ‘Transgender Welfare Board’ to address the problems faced by the community. The scheme ensures access to education, providing different forms of income generation such as land, and putting housing and health measures in place.
Many transgender people have now been issued with official identity cards stating their gender as ‘Aravani’, addressing the barrier to healthcare faced by transgender people who don’t have official identification. They also run an official ‘Transgender Day’, promoting the culture, tradition and healthcare of transgender people, and therefore self-esteem.34
Tamil Nadu is also the only state to provide free sex reassignment surgery.35 States in India such as Tamil Nadu that have a history of transgender people organising groups to advocate for their own rights, tend to also have the highest standards of care and the most community-based organisations that meet transgender people’s needs.36
This demonstrates that while the welfare board provides a good example of state-level practice that could be replicated across South Asia, there is also a real need to support the formation and organising of groups of transgender people who can lead the way in addressing their own HIV-related needs.
Access to HIV testing and antiretroviral treatment for transgender people
Generally, data on transgender access to HIV treatment and testing services is scarce. In India, where there are successful targeted interventions, 9 out of 10 transgender people have access to HIV testing.
One study of people living with HIV in the United States of America (USA) found that only 59% of transgender participants, compared to 82% of those with a birth-assigned gender, were accessing ART.37 HIV-related stigma also creates barriers to getting tested for many transgender people. In a study in the USA, 73% of transgender women who tested HIV-positive were unaware of their status.38
As with access to HIV prevention advice, transgender people may delay seeking testing and treatment due to transphobia and insensitivity among healthcare professionals.39
"Yes I tested and was not of the best as the person who pricked me urged me to change my life, as I being like I am is immoral, she said." - Transgender person, South Africa 40
Depression and isolation are often associated with a poor adherence to HIV treatment. A lack of supportive relationships can affect important aspects of living healthily with HIV, such as remembering to take medication. One study found that transgender people living with HIV were less likely to report adherence to treatment of above 90% compared to patients who weren’t transgender.41 The study found that many transgender people found it difficult to take regular medication alongside other treatments such as hormone therapy.
Barriers to HIV prevention for transgender people
Transgender people will often experience social exclusion and marginalisation in the society that they live, and critically from family and friends. In Latin America, between 44% and 70% of transgender woman were either thrown out, or felt the need to leave their homes. In the Philippines, paternal rejection during transitioning of transgender women is reported to be as high as 40%.42
This can exclusion can affect people's self-esteem and self-worth, contributing to depression, anxiety, substance abuse and self-harm.43 In a national study of transgender people in the USA, 41% of participants reported attempting suicide, compared with 1·6% of the general population. A national Australian study found that 56% of transgender people had been diagnosed with depression at some point in their lives, four times the rate for the general population. The study found that 38% had been diagnosed with anxiety, around 50% higher than the background rate.44
Lack of social safety nets also make transgender people particularly vulnerable to economic instability and homelessness. A survey from the USA found that unemployment rates for transgender people were twice the national average.45
General isolation and social exclusion also affect access to treatment. Transgender people can be afraid to get tested if they don’t have a strong support network to help them cope:
"No, I won’t test. Who will take care of me when I test positive? I have no-one." - Transgender person, South Africa 46
Lack of recognition of gender identity
Many countries do not legally recognise the gender of transgender people, meaning they often lack official identification, passports and travel rights, welfare entitlements and the right to marry.47 They may also find it difficult to access education and employment. For transgender women facing criminal prosecution, incarceration with male inmates can also put them at risk of sexual assault.48
Healthcare system discrimination
Discrimination from healthcare providers, a lack of knowledge about transgender needs and the refusal of many national health systems or health insurance providers to cover their care all contribute to situations where it is difficult for transgender people to receive adequate treatment. This can also encourage discrimination within healthcare services, making it hard to access sexual health services.
"Nine out of ten trans people do not consult doctors even in case of serious illness, because of the mistreatment they know they will face in health services." - Campaigner in Venezuela 51
Transgender peoples’ access to health care is further complicated by the fact that their experiences have been classified as a mental disorder, meaning they must accept this stigmatised diagnosis when accessing health services. The World Health Organization (WHO) has proposed that references to transgender people in their health diagnosis literature be placed in a chapter called ‘conditions relating to sexual health’ and removed from the list of mental disorders. This has been welcomed by the global transgender community, clinicians and researchers. 52
In 2015, 76 countries still had laws that prohibit same-sex sexual activity, which can also affect transgender people, hindering their ability to access information about HIV risk and prevention.53
For example, if a transgender woman is legally recognised as a man because she was assigned male at birth, sex with a birth-assigned man would be illegal. She may risk prosecution if she discusses her own sexual history with a healthcare professional.54
Laws such as these can legitimise acts of stigma, discrimination and violence against individuals.55 This can put transgender people at a greater risk of sexual abuse and violence, and HIV infection.56
In some cases, police shut down organisations that provide HIV prevention services on the basis that these services aid illicit activity such as sex work.57 In addition, most countries do not have laws that will criminalise acts of discrimination towards transgender people.
Violence and transphobia
Non-lethal violence against transgender people is also widespread. A national study in the USA found that 35% of five to 18 year olds who identified as transgender experienced physical violence, and 12% were victims of sexual violence. In the same study, 7% of transgender adults had been physically assaulted at work, and 6% sexually assaulted.63
The way forward
There is a critical lack of data and limited funding for and research about transgender people and what drives their vulnerability to HIV.64
More effort is needed by researchers, governments and NGOs to collaborate to find ways to combat HIV among transgender communities – particularly in places where their legal rights are not respected. Initiatives should be developed in partnership with transgender communities, and should link health with advocacy, social justice, and human rights.65
Although it is vital that transgender people around the world are informed about safer sex and how to protect themselves from HIV, until their rights are protected by law and respected by society they will continue to be vulnerable to HIV. Interventions that have focused exclusively on sexual health have not achieved expected results as they failed to address the social exclusion that leads to high-risk behaviours.66
As well as protection by law, transgender people need better access to housing, employment and education if they are not to be driven towards high-risk behaviour.67They must be able to access transgender specific healthcare services and sexual health information, free from fear of criminalisation and discrimination.
Photo credit: Photo by Gates Foundation/CC BY-NC-ND 2.0. Photos are used for illustrative purposes. They do not imply any health status or behaviour on the part of the people in the photo.
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