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.

Trans gender and diverse (TGD) population are of high priority for STI/HIV according to (WHO) last year.

TGD are of greater risk for discrimination, stigma and neglect.

Currently TGD are not mentioned in the National or State and Territory STI/HIV strategies. They need to be included for the collection of data and future research

*What should inclusive Clinical care look like for TGD population?

Many have to access multiple services to have healthcare needs met. There is no particular one-stop-shop.

Shared care is needed with client involvement in all aspects of their care, keeping it open and empowering.

TGD people need sexual health care amalgamated with their hormone therapy reviews. It brings them to test more regularly if needed.

Not all TGD medically transition.

National standards of care differ around the world.

EQUONOX Victoria supplies a one-stop-shop and uses the Informed Consent model. It has Psychological practitioners through to a GP Prescriber which improves access to care with less waiting time.

Good access to care improves health quality

TGD have a higher risk of suicidality, as much as 50%

Research is needed to help provide best practice.

GP'S need to be up-skilled in the area instead of passing people on by referral due to ignorance.

How can this be done? Certainly through Med School training, but also practicing GPs

We need to change registration forms and Notification forms to start collecting data and build better relationships with workforce development

A good resource video "PrEP 4 Trans"

Dr Power began her presentation with a brief outline of Stigma, stating that “stigma is a social product”, rather than something that is an innate part of who we are as people.

Her research focussed on findings that have emerged from the HIV futures study, which began in 1997 and is repeated and added to every two years. In this aspect of the study, Dr Power measured the social impact of enacted stigma that people living with HIV encountered, assessing levels of internalised stigma and also anticipated stigma. Ultimately, the study is intended to show the relationship between stigma and health outcomes; seeking to find ways to use the data toward strategies to combat stigma.

Participants in the research were surveyed through the most recent HIV futures 8 study. Questions repeated those of previous studies, but also new questions were developed using language that participants of previous studies had used to describe the impact of stigma.

Findings highlighted a significant increase in disclosure related fears, with isolation and social withdrawal being a dominant theme. People living with HIV who reported lower perceived stigma reported higher levels of social support, higher levels of disclosure and good relationships with the healthcare professionals they engaged with.

Stigma encountered within the workplace and anxiety about unintended disclosure at work featured highly in participant responses. Dr Power explained that these findings enables strategising toward combatting stigma through workplace focused initiatives. Even though the workplace often dominates people’s ability to move through life and is entrenched with hierarchies, workplaces are also structures through which to communicate. The findings of Dr Power’s research provides good evidence for resilience through workplace social support programs.

The Talk was presented by Mr Joel Murray, Senior Officer Policy and Research from Living Positive Victoria 

Reference from Reform of the Sex Work Act 1994 ( VIC ); Policy Statement

Introduction 

Living Positive Victoria, The Victorian AIDS Council, Scarlet Alliance: Australian Sex Workers Association and Vixen Collective: Victoria's Peer - only Sex Worker organisation, are supportive of the full decriminalisation of sex work in Victoria.

The Position statement deals with the narrower issue of sex workers living with HIV, but it should be seen as part of a broader call for full decriminalisation of sex work. Law regarding commercialised Sex should mirror those of other consensual sexual activity. This statement summarises the case for reform of the Sex Work Act 1994 ( VIC )

Background

Sex work in Victoria has been regulated via a licensing system since 1986. A licensed system allows for the establishment of Brothels and escort agencies. Similarly sex workers are required to be registered in order to work legally in brothels and escort agencies. It is currently illegal for as person living with HIV ( PLHIV )to undertake sex work. 

The knowledge of HIV in 1986 was limited - WHO advised governments around the world that Sex workers were an at- risk population. Therefore, to not allow PLHIV to engage in sex work was seen at time to be in the interest of Public health. 

However, in 1994 when the current statute was enacted, increased knowledge of HIV and treatment, the advancement of human rights of PLHIV and the sex industry's considerable efforts in health promotion, demonstrated that provisions within the statute that disallowed PLHIV from undertaking sex work were not justified on Public health grounds.

Issues

Public Health and Human Rights 

The prohibition on HIV positive sex workers does nothing to protect public health, but rather forces HIV positive sex workers to work illegally, potentially harming HIV response by driving HIV underground. 

The Equal Opportunity Act 2010 sets out attributes on the basics of which discrimination is unlawful according to Victorian law.

Barriers to accessing health and HIV specific services

Criminalisaiton of sex workers living with HIV establishes a barrier to access services, treatment, care and support. ALL PLHIV should be able to access education and effective antiretroviral treatment to further reduce risk of HIV transmission. 

Stigma and discrimination 

Sex workers living with HIV face the potential for multiple levels of stigma and discrimination depending on their personal circumstances and how they wish to identify. To identify as both living with HIV and being a sex worker is to face at least twice the level of discrimination. 

Sex work and HIV in Australia 

In Australia, significant efforts have been undertaken to ensure the widespread adoption of safer sex practices in the sex industry. This has resulted in lower rates of STIs among sex workers compared to general population. In addition, there have been no documented cases of HIV transmission from a sex worker to a client in Australia. 

Inconsistent laws between Australian jurisdictions relating to sex work by PLHIV, may cause a person to unintentionally break the law simply by going about their work in a state or territory has different laws to their place of residence.

Policy Context

This position is supported by a number of Australian and international policy contexts, including but not limited to

• Victorian HIV Strategy 2017 - 2020
• Seventh National HIV Strategy 2014 - 2017
• AIDS 2014 Melbourne Declaration; nobody left behind
• UNAIDS Guidance Note on HIV and Sex Work
• UNAIDS 2016 - 2021 Strategy 
• UN General Assembly Political Declaration on HIV and AIDS 2001,2006,2011 and
• The Ottawa Charter for Health Promotion

This was an interactive session and panel discussion based on various case studies that may be met within the clinical area of working with people living with HIV.

The backdrop to various discussions was some information indicating indicating the link between HIV, discrimination and legal issues. This is further complicated by recent changes in legislation in NSW as well as the disparity in legislation throughout Australia, with potential for further confusion due to lack of uniformity across the states.

currently, it appears to be abundantly clear for example that sexual transmission of HIV with an undetectable viral load does not occur. Not as clear however is what precautions a person must take when having a sexual relationship with a person who does not have ZhIV, even in the e end of an undetectable viral load. 

various case presentations highlighted some of the ethical issues around transmission of HIV and overall, supported the clinicians need to support their patients by engaging well with them, using research evidence to provide up to date information but also being aware that medical advice is not the same as legal advice. Various situations may occur therefore that medical advice requires back up with advice and input  from agencies such as those that care for refugees or  legal organisations for people living with HIV. 

The session provided plenty of 'food for thought' for conversations within the clinical setting.