Increasingly, trans and gender diverse people are being identified by global organisitions as a population in need of HIV resources, however as often as they are identified they are still not included in meaningful ways.
"There has probably never been a population both more heavily impacted and less discussed at scientific meetings the the transgender population around the world" (Poteat, 2016).
Decades of joint advocacy has ensured the inclusion of trans and gender diverse people at ASHM. The task ahead is to ensure sustainable and equitable strategies for these communities and that they are led by tans and gender diverse people.
Globally, the prevalence data shows that 19.15 of trans women worldwide are estimated to be living with HIV (Baral et al, 2013). There is limited empirical evidence about prevalence among trans men, and no data about HIV among non-binary people. The "absence of evidence due to lack of resource allocation and or proper research is usually considered as 'evidence of absence', naturalizing the gaps in data collection and analysis" (IRGT, 2016). Less than 40% of countries report that their national HIV/AIDS strategies address trans and gender diverse people (Poteat et al, 2016).
There is a lack of data across countries, with the majority of data sitting in the global north. Often, sampling often includes only very particular populations.
In terms of the Australian experience, the Kirby Institute's analysis of ACCESS data (Callender et al, 2017), of 696 patients recorded as transgender, 29% were women, 32% were men and 40% did not have their gender identity captured. Of these patients, 5.2% were HIV positive. Prevalence among trans women was 8.9% and trans men 4.5%. Taylor Square Private Clinic reported prevalence as 4.5% among trans women and 0% among trans men (Pell, Prone and Viahakis, 2011). The Private Lives 2 Study found 1.4% of trans women live with HIV (Leonard et al, 2011).
The most comprehensive data of HIV prevalence among trans women (8.9%) is probably not accurate because of inadequate data collection methods.
HIV risk factors for these populations:
- Receptive vaginal sex can pose a different level of risk for trans women (Cornelisse et al, 2017)
- Stigma, discrimination, social exclusion from employment and education (Poteat et al, 2014)
- Trans women more likely to report sex work (13%) than other cisgender patient groups (9%) and are more likely to report injecting drug use than gay and bisexual men (7% vs 4%) (Callander et al, 2017)
- By contrast, trans men were no more likely than other groups to report sex work or injecting drug use (3%) (Callander et al, 2017)
- HIV risk among tans men is similar to HIV risk for cisgender men (CSRH, 2016)
- Research into trans women's experiences in Australian's men's prisons found that incarceration increases risk factors of HIV including physical and sexual violence (Wilson et al, 2016)
For transgender and gender diverse sex-workers, there are other intersecting social and cultural factors that impact upon their risk of contracting HIV.
Barriers to prevention include invisibilising methodological approaches, a lack of cultural competence, social and systemic barriers, geographical barriers, under representation in targeted health promotion strategies and legal barriers that perpetuate pathologisation. There is a low workforce literacy and systemic barriers (particularly legal) that exacerbate narrow clinical models and ultimately leads to entrenched mistrust among trans and gender diverse people.
"Other barriers to health and health care are the numerous socioeconomic determinants of health that legally, economically, and socially marginalize trans people. These include discrimination in employment, education, housing, and relationship recognition; police harassment, often as a result of actual or assumed association with sex work; and identity document policies that deny many trans people legal recognition in their true gender. They also include aspects of structural violence such as racism, violence against women, and poverty" (Open Society Foundation, 2013).
Both policy and legal environments need to be opened up and there needs to be a continuance of critique of systems that perpetuate structural violence.