HIV Among Trans People

Introduction For example, someone assigned the male sex at birth may identify as a female and live her life accord- Globally, trans communities are among the most ingly. She may thus identify as a transgender woman heavily impacted by HIV, yet they are among the (in Anglophone communities in North America, least recognized within policy, the least served Europe and Oceania), une femme transsexuelle (in by programs, and the least supported by fund- Francophone communities in North America and ing at national, regional, and international levels. Europe), hijra (in Asia) or travesti (in Latin America). A Available data indicate a significant HIV burden trans individual from a North American Indigenous within trans communities. A series of interwo- community may identify themselves as two-spirited, ven factors contribute to vulnerability, including which is an umbrella term used by many nations for biological, behavioural, structural and social deter- various gender identities. minants of health. The recent UNAIDS 2016–2021 Strategy, On the Fast-Track to End AIDS, identifies The differences between the terms above run trans people as one of the key populations requir- deeper than translation; they refer to different ing specific attention. realities. For instance, the feminizing techniques used by a trans woman are likely to differ depend- Who Are Trans People? ing on where she lives. Travestis in Brazil are more likely to inject silicone into their bodies to empha- The terms ‘trans’ or ‘transgender’ are broad size curves than their Canadian counterparts. The umbrella terms encompassing those whose differences of the relationship between gender gender identity and expression does not conform and sexuality from place to place is also crucial to to the norms and expectations traditionally asso- consider. Whereas in North America trans com- ciated with the sex assigned to them at birth. This munities tend to deliberately distinguish sex and can include people whose gender expression, gender from sexuality (and from homosexuality in outward appearance, and/or anatomy does not fit particular), this is not the case everywhere. into conventional expectations of male or female. They may express their genders in a variety of While “transgender” has gained popularity in some masculine, feminine and/or androgynous ways. Anglophone parts of the world as an umbrella term that brings together all trans persons, many Trans people may identify differently in dif- resist this terminology, in part because it focuses ferent cultures. Some of the commonly used too narrowly on gender. In this document, “trans” terms include: transgender, trans woman (or will be used as an imperfect alternative, unless the transwoman or male-to-female transgender or context requires a different or more specific term. MTF), trans man (or transman or female-to-male transgender or FTM), transsexual, bigender, HIV in Trans Communities gender fluid, genderqueer, hijra (India), kathoey (Thailand), waria (Indonesia). Globally, trans people are identified as one of the populations most disproportionately affected by HIV, although prevalence ranges widely between The lack of inclusion of trans status within much of countries and regions, as well as between particu- epidemiology and surveillance data, and the rela- lar groups of trans people. Domestically, there are tive dearth of research related to HIV within trans no national data on the number of trans people communities overall renders much of the com- living in Canada, nor are trans people included as munity invisible. This process of erasure seems a distinct identity category in national data on HIV. particularly acute for some segments of the trans community, including transmen, transwomen not Worldwide HIV prevalence rates among trans- engaged in sex work, and members of the com- women are estimated to be 19%. Transwomen munity whose gender identity does not fit into the are 49 times more likely to be HIV-positive than all binary categories of male or female. It is also true adults of reproductive age, a finding that remains for trans communities from Africa, Eastern Europe consistent across high-income, middle-income, and Central Asia, where few studies have been and low-income settings, though there is a nota- conducted so far. ble lack of data from Africa, Eastern Europe and Central Asia.1,2 Among transwomen, sex workers Determinants of HIV Risk Among tend to have some of the highest HIV prevalence Trans People rates (27%), and are 4 times more likely to be HIV-positive than cisgender* female sex work- Several studies have identified a range of determi- ers.3 However, studies estimating HIV prevalence nants of HIV risk among trans people, though the among transwomen tend to include an over- level of evidence to support the extent to which sampling of sex workers. It is therefore difficult many of these determinants have an impact on to generalize HIV prevalence rates to the broader HIV risk varies greatly. community of transwomen.4,5,6 The most direct factors linked to HIV risk include When available, HIV prevalence rates among biological and behavioural factors, such as engag- transmen tend to be lower. In studies with ing in condomless receptive anal or genital laboratory-confirmed HIV serostatus, rates range intercourse, substance use, and needle sharing for from 0% to 4%. However, there have been so few drug use and hormone or silicone injections. The such studies that meta-analyses have not been effects of hormones on genital and anal mucosal conducted to estimate an overall HIV prevalence lining, and the effects of genital surgery on HIV risk rate for transmen.7,8,9,10 Emerging data suggest remain unknown. that transmen who have sex with men may be at higher risk.11 Some of the more contextual factors that lead to HIV risk include structural and social determinants Domestically, among participants in an Ontario of health, such as stigma and discrimination, vio- study called the Trans PULSE Project, self- lence, engagement in sex work, criminalization, reported HIV prevalence was 3% for transwomen the intersection of racism and transphobia, men- and 0.6% for transmen. However, given wide tal health problems such as depression, difficulty confidence intervals and the high proportion of accessing appropriate healthcare, and lack of tar- trans people who had never been tested for HIV geted HIV information.14,15,16,17,18,19,20,21,22,23,24 Some (46%), estimates should be interpreted with cau- of these contextual factors are discussed below. tion.12,13 In fact, when combined with the fact that HIV surveillance data in Canada do not capture trans status, HIV prevalence among trans people * Cisgender refers to someone whose gen- in Ontario—let alone Canada—cannot currently der identity aligns with the sex they were be accurately estimated. assigned at birth.

2 ·· Stigma and discrimination. For many trans self-esteem among trans people and participa- people, stigma and discrimination are among tion in high-risk sexual behaviours. the most commonly experienced barriers to ·· Problematic access to healthcare. Trans accessing healthcare and employment. people often have limited access to healthcare ·· Violence. Trans people face high rates of vio- and problematic encounters with healthcare lence, often from a variety of sources. Violence providers. Obtaining gender-appropriate iden- can come from members of their family of origin tification can be difficult in many contexts, and in relation to expressing the desire to transi- lack of gender-conforming identification can tion. It can also be experienced in the context of often be a barrier to healthcare services. Trans sex work and intimate partner violence, both of people commonly report experiencing verbal which can lead to forced sex and difficulty nego- abuse, discrimination, insensitivity, and lack of tiating safer sex, leading in turn to increased knowledge from healthcare providers, as well HIV risk. as overemphasis on HIV. Services are often pro- ·· Sex work. Difficulty finding employment vided at the same location as they are to gay, because of stigma and discrimination may lead lesbian and bisexual patients, despite these to engagement in sex work, which increases HIV groups having quite different healthcare needs. risk (e.g., multiple partners, condomless recep- Some trans people refuse HIV testing because tive anal intercourse). In some cases sex work of the misconception that they will be refused is seen as part of the cultural norm or a rite of hormones or medically cleared for sex reassign- passage for transwomen. For both transwomen ment surgery if they are found to be HIV-positive. and transmen, it can also be means to afford ·· Lack of targeted HIV information. There is expensive hormones and sex reassignment sur- often a lack of targeted HIV information tailored gery, which are often not covered by public or to the needs of trans people. Available HIV private health insurance. information is often inadequate or incongruent ·· Criminalization. The criminalization of sexual information, usually targeted to gay men, with and gender minorities, sex work and drug use whom transwomen do not necessarily iden- contributes to stigma, discrimination and vio- tify. Non-English speakers and recently arrived lence against key populations, including by immigrants face additional barriers to accessing state actors, and is a key barrier to an evidence- HIV information. informed, rights-based response to HIV with ·· Living with HIV. Trans people living with HIV face trans communities. particular challenges. For example, little is known ·· Intersection of racism and transphobia. In about the interactions between the hormones some studies, there tend to be higher rates of used by some trans people and antiretroviral HIV prevalence among some racialized commu- treatments. Considering the importance of hor- nities of transwomen than others. For example, mones for some trans people, this information is in the US, they tend to be higher among African- urgently needed. Furthermore, the side effects American transwomen that among those who from HIV treatment can be lived differently by are White or Hispanic. Racism and transphobia trans people than by non-trans persons. For interact to increase odds of HIV-related sexual example, lipodystrophy, the redistribution of risk behaviour, above and beyond the individual body fats, can lead to a loss of fat in the cheeks. contributions of racism and transphobia. This masculinizes the facial feature, a compro- mise that many transwomen find challenging. ·· Mental health issues. Studies have found Furthermore, finding comprehensive health care an association between depression and low is rendered more complicated for trans people

3 living with HIV as it becomes harder to find doc- to UNAIDS that their national AIDS strategies did tors competent in both types of care. not address trans people.25

All of these factors are strongly interwoven, such The newly released UNAIDS 2016–2021 Strategy, that it seems difficult to determine which among On the Fast Track to end AIDS, identifies trans people them is more important. It is also difficult to as one of the most vulnerable populations, along determine directionality and causality between with men who have sex with men, sex workers, these determinants. and people who inject drugs. The UNAIDS Strategy lays out goals and targets that must be reached by These determinants tend to play out differently for 2020 in order to end AIDS as a public health threat different subpopulations within the transgender by 2030. This includes targeted efforts to ensure community. Studies suggest that determinants equitable access to comprehensive HIV services of HIV vulnerability (and as a result, HIV preva- and to create an enabling environment, supportive lence) may be more present among transwomen legislation and policy, community empowerment, than transmen. For transwomen, they may be and strategies to address trans-specific stigma more present among those who are engaged in and discrimination.26 sex work; for transmen, among those who have sex with men. Among all trans people, they may An increasing number of projects at local, national, be more present among those who engage in regional and global levels address HIV in trans sexual activities within communities or network communities, including the following three case where HIV prevalence in high (e.g., men who have studies, described briefly as examples. sex with men), and for those who are also part of Indigenous and racialized communities. SWING (Thailand): Integrated Sexual Despite the generally high HIV prevalence rates Health Care observed among some segments of the trans community, research suggests that there may be Service Worker IN Group (SWING) offers significant proportions of the trans community screening, diagnosis, and treatment for that are at little to no risk of HIV in a given year, sexually transmitted infections for male and since they are not sexually active nor do they share transgender sex workers, including migrants. needles. Among those who are sexually active, They also offer mobile clinics, as well as edu- significant risk may come from activities that are cational opportunities, including English often assumed not to occur, such as receptive language classes and vocational training. It genital sex for transmen and insertive genital sex serves as a drop-in centre where workers can for transwomen. eat, use the Internet, prepare for the evening, and take part in HIV-related information games The Global Response and sessions. Besides treatment and prevention services, SWING also provides access to The 2014 UNAIDS Gap Report identifies trans com- legal services.27 munities as a key population that is particularly vulnerable to HIV. As we have seen for example, Atlacatl (El Salvador): Ensuring Dignity of transwomen are 49 times more likely to be liv- Communities ing with HIV than all adults of reproductive age. The organization Atlacatl has successfully Despite this heightened HIV burden, trans people implemented a programme called Life with are severely underserved relative to their health Dignity (Vida Digna). Vida Digna employs the needs. Indeed, 61% of countries recently reported

4 methodology of Participatory Community Conclusion Assessment, along with activities that encour- Addressing the global HIV epidemic in trans com- age participants to examine stigma and munities will require a multifaceted response. In discrimination at all levels, from the individual the first place, it is crucial that we continue to pro- to the national. They help participants connect duce HIV-related knowledge about different trans with human rights issues and provide tools communities in different parts of the world. to tackle stigma and discrimination through official channels. Two Vida Digna partner Specifically, collecting epidemiology and sur- organizations participated in the drafting of veillance data among trans populations would a new law on sexual and reproductive health improve understanding of HIV prevalence and rights to ensure that the rights of transgender incidence within this community. Population-level women were addressed in El Salvador. Due to health surveys and other quantitative and quali- the efforts of these organizations, the draft law tative research methods would provide greater now refers to issues such as hormone regimes accuracy about factors that lead to HIV risk, and transgender women’s rights to see special- including how determinants of HIV vulnerability ist doctors—an important step in encouraging intersect and impact specific groups within the the state to address gender identity issues trans community (transwomen and transmen; sex formally.28 workers; Indigenous and racialized communities; urban and rural communities; HIV-positive and IRGT: A Global Network of Transgender HIV-negative) across various regions. Women and HIV As underlined by UNAIDS, this is best done in For over a decade, the Global Fund to Fight conjunction with trans communities themselves. AIDS, Tuberculosis, and Malaria has been The projects and programs highlighted in the one of the world’s largest donors in the HIV section above reflect a movement to incorporate epidemic. Through engagement with pro- trans voices into contemporary policymaking and cesses such as country dialogues and Country healthcare realities. Continued and enhanced Coordinating Mechanisms (CCMs), transgen- trans community engagement in the develop- der activists and organizations have helped to ment and implementation of research efforts and increase funding and programmatic focus on interventions would help to ensure that research, transgender needs related to HIV prevention healthcare delivery, and HIV prevention efforts are and treatment. However, extensive barriers focussed on the needs of trans communities. remain to sufficiently addressing transgender needs in the HIV epidemic, and little work has Endnotes been done to document good practices for engaging key donors such as the Global Fund. 1 Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz To address this gap, the IRGT published Most TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Impacted, Least Served: Ensuring Engagement of Infect Dis. 2013 Mar;13(3):214–22. Transgender People in Global Fund Processes, 2 Poteat T. HIV in Transgender Populations: Charted and a report that offers recommendations for Uncharted Waters. Conference on Retroviruses and improving policies and fostering a more Opportunistic Infections (CROI) Plenary presentation. In enabling environment for transgender people Boston; 2016. to participate in and engage with Global Fund 3 Operario D, Soma T, Underhill K. Sex work and HIV status 29 among transgender women: systematic review and meta- processes. analysis. J Acquir Immune Defic Syndr. 2008;48.

5 4 Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz Have Sex with Men: Results from Ontario, Canada. Int J TE, Beyrer C. Worldwide burden of HIV in transgender Transgenderism. 2013 Apr;14(2):66–74. women: a systematic review and meta-analysis. Lancet 20 Grant, Jaime M, Lisa A. Mottet, Justin Tanis, Jack Harrison, Infect Dis. 2013 Mar;13(3):214–22. Jody L. Herman, Mara Keisling. Injustice at Every Turn: 5 Bauer GR, Scheim AI. Sampling bias in transgender stud- A Report of the National Transgender Discrimination ies. Lancet Infect Dis. 2013 Oct;13(10):832. Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011. 6 Baral SD, Poteat T, Guadamuz TE, Beyrer C. Sampling bias in transgender studies—authors’ reply. Lancet Infect Dis. 21 Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann 2013 Oct;13(10):832–3. MS, Crepaz N. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a 7 Reisner SL, Murchison GR. A global research synthesis of systematic review. AIDS Behav. 2008;12. HIV and STI biobehavioural risks in female-to-male transgender adults. Glob Public Health. 2016 Jan 20;1–22. 22 Marcellin RL, Bauer GR, Scheim AI. Intersecting impacts of transphobia and racism on HIV risk among trans persons 8 Giami A, Le Bail J. HIV infection and STI in the trans of colour in Ontario, Canada. Ethn Inequalities Health Soc population: a critical review. Rev Dépidémiologie Santé Care. 2013 Nov 29;6(4):97–107. Publique. 2011 Aug;59(4):259–68. 23 9 Bauer GR, Redman N, Bradley K, Scheim AI. Sexual Bauer G, et al. “I Don’t Think this is Theoretical; This is our Health of Trans Men Who Are Gay, Bisexual, or Who Lives”: How Erasure Impacts Health Care for Transgender Journal of the Association of Nurses in AIDS Care Have Sex with Men: Results from Ontario, Canada. Int J People”, , 20:5, 348–361. 2009. Transgenderism. 2013 Apr;14(2):66–74. 24 10 Poteat T. HIV in Transgender Populations: Charted and Namaste, V. 2010. “Dix Choses à Savoir sur les Trans’ et le Transcriptases: VIH et virus des Hépatites Uncharted Waters. Conference on Retroviruses and VIH”, . 143,11–13, 2010. Opportunistic Infections (CROI) Plenary presentation. In Boston; 2016. 25 UNAIDS. The 2014 Gap Report: Transgender People. Revised in October 2015. 11 WHO. Policy brief: Transgender people and HIV. World Health Organization (WHO); 2015. 26 UNAIDS 2016–2021 Strategy: On the Fast-Track to End AIDS. 2015. 12 Bauer GR, Travers R, Scanlon K, Coleman TA. High het- erogeneity of HIV-related sexual risk among transgender 27 UNAIDS and Stop AIDS Alliance. Communities deliver: The people in Ontario, Canada: a province-wide respondent- critical role of communities in reaching global targets to driven sampling survey. BMC Public Health. 2012;12:292. end the AIDS epidemic. 2015. 13 Bauer GR, Redman N, Bradley K, Scheim AI. Sexual 28 UNAIDS and Stop AIDS Alliance. Communities deliver: The Health of Trans Men Who Are Gay, Bisexual, or Who critical role of communities in reaching global targets to Have Sex with Men: Results from Ontario, Canada. Int J end the AIDS epidemic. 2015. Transgenderism. 2013 Apr;14(2):66–74. 29 IRGT: A Global Network of Trans Women & HIV. Most 14 Reisner SL, Murchison GR. A global research synthesis of Impacted, Least Served: Ensuring the Meaningful HIV and STI biobehavioural risks in female-to-male trans- Engagement of Transgender People in Global Fund gender adults. Glob Public Health. 2016 Jan 20;1–22. Processes. 2015. 15 Giami A, Le Bail J. HIV infection and STI in the trans population: a critical review. Rev Dépidémiologie Santé Publique. 2011 Aug;59(4):259–68. ICAD would like to thank Marc-André LeBlanc 16 De Santis JP. HIV infection risk factors among male-to- and Nandita Vinod Bijur for their assistance in female transgender persons: a review of the literature. J developing this fact sheet. Assoc Nurses AIDS Care JANAC. 2009 Oct;20(5):362–72. 17 Poteat T, Wirtz AL, Radix A, Borquez A, Silva-Santisteban A, Deutsch MB, et al. HIV risk and preventive interventions in transgender women sex workers. The Lancet. 2015 Jan 23;385(9964):274–86. 18 Bauer GR, Travers R, Scanlon K, Coleman TA. High het- erogeneity of HIV-related sexual risk among transgender people in Ontario, Canada: a province-wide respondent- driven sampling survey. BMC Public Health. 2012;12:292. PO Box 4612, Station E, Ottawa, ON K1S 5H8 19 Bauer GR, Redman N, Bradley K, Scheim AI. Sexual Phone: 613-233-7440 Health of Trans Men Who Are Gay, Bisexual, or Who Email: [email protected]