Involvement of African men and transgender women who have sex with men in HIV research: progress, but much more must be done

Unique HIV Risk Factors and Prevention Needs for Transgender Women and Cisgender Men Who Have Sex with Men in Bangkok, Thailand

Background

Transgender women (TGW) and cisgender men who have sex with men (cis-MSM) are often grouped together as key populations. We evaluated behavioral and other characteristics that may distinguish TGW from cis-MSM in Bangkok, Thailand.

Methods

We enrolled into an 18-month cohort cis-MSM and TGW 18-35 years of age without HIV, who reported anal intercourse plus condomless anal intercourse, multiple partners, transactional sex, and/or sexually transmitted infection. Robust multivariable Poisson regression was used to estimate adjusted prevalence ratios (aPRs) and confidence intervals (95% CIs) for associations with being a TGW. Among TGW, logistic regression with generalized estimating equations was used to estimate adjusted odds ratios (aORs) and 95% CIs for associations with taking hormones and having undergone gender affirmation surgery (GAS).

Results

From 2017 to 2019, 660 cis-MSM and 348 TGW were enrolled. Compared to cis-MSM, TGW were more likely to be attracted to mostly/only men (aPR: 3.79, 95% CI: 1.57-9.13), have a higher monthly income (aPR: 1.25, 95% CI: 1.04-1.50), have lived in their current residence for <1 year (aPR: 1.21, 95% CI: 1.01-1.46), have engaged in sex work (aPR: 1.48, 95% CI: 1.23-1.77), and be less likely to have ever undergone HIV testing (aPR: 0.83, 95% CI: 0.70-0.98). Among TGW, 149 (42.8%) were taking hormones and 33 (9.5%) had undergone GAS. GAS was more common among TGW who ever used methamphetamines (aOR: 1.55, 95% CI: 1.00-2.41) and those >23 years (18-20-year olds aOR: 0.17, 95% CI: 0.05-0.55; 21-23-year olds aOR: 0.36, 95% CI: 0.20-0.65).

Conclusions

TGW and cis-MSM are unique populations; tailored, gender-affirming, differentiated models of HIV prevention and care are necessary to address vulnerabilities specific to each key population.

Factors associated with the retention of travestis and transgender women living with HIV in a peer navigation intervention in São Paulo, Brazil

Travestis and transgender women (TrTGW) constitute the groups with the highest HIV prevalence in the world, with higher probability of infection compared with the general population and lower adherence to prevention and treatment strategies than other vulnerable groups. Considering these challenges, this study describes the factors associated with the retention of TrTGW with HIV to the TransAmigas project. Participants were recruited from April 2018 to September 2019 in a public health service in São Paulo, Brazil. A total of 113 TrTGW were randomly assigned to either a peer navigation intervention (75) or a control group (38) and followed up for nine months. To analyze the association between the selected variables and the outcome ("retention at nine months", regardless of contact at three months, defined by the "full completion of the final questionnaire"), bivariate and multivariate logistic regression models were used. Peer contact forms were qualitatively assessed to validate and complement the previous selection of quantitative component variables. Of the 113 participants, 79 (69.9%) participated in the interview after nine months, of which 54 (72%) were from the intervention group and 25 (66%) from the control group. In the final multivariate model, contact at three months (adjusted odds ratio - aOR = 6.15; 95% confidence interval - 95%CI: 2.16-17.51) and higher schooling level (≥ 12 years) (aOR = 3.26; 95%CI: 1.02-10.42) remained associated with the outcome, adjusted by race/skin color, age ≤ 35 years, and HIV serostatus disclosure. Future studies with TrTGW should include contact at regular intervals, with additional efforts aimed at participants with lower schooling level.

Implementation and effectiveness of transgender stigma reduction interventions in sub-Saharan Africa: a scoping review

Background

The transgender or trans population is one of the most marginalized social groups globally, frequently experiencing ill-treatment and discrimination. This is disproportionately higher in sub-Saharan Africa where trans people experience stigma even in healthcare settings. There is limited evidence concerning the implementation and outcomes of interventions to mitigate this stigma. Therefore, this scoping review aimed to describe interventions and determine their effectiveness in reducing transgender stigma in sub-Saharan Africa.

Methods

Searches (completed November 01, 2021, and re-run May 2022) were conducted in MEDLINE (via PubMed), Cochrane Library including the Cochrane Central Register of Controlled Trials, EBSCOhost, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Web of science, clinicaltrials.gov, and online grey literature sources to identify publications that described interventions to reduce transgender stigma in sub-Saharan Africa.

Results

From 877 literature search results, 23 full-text articles were assessed. Data were extracted from the four (4) eligible papers. Only one study explicitly mentioned transgender people. Second, while two studies incorporated conceptual frameworks, they did not show how the frameworks guided the study. The four studies implemented unique interventions at various socio-ecological levels to address individual and interpersonal and structural stigma. Each study utilized a different methodological approach, and the interventions were all evaluated qualitatively.

Conclusions

There is a paucity of transgender stigma reduction interventions implemented in Sub-Saharan Africa with limited evidence of interventions delivered to mitigate stigma at interpersonal and structural levels. Future anti-transgender stigma research should consider reporting details about the core components and descriptions of the interventions. Additionally, the use of validated measures of stigma and the evaluation of interventions for implementation outcomes would be helpful.

Whose rights are being violated when receiving HIV and sexual and reproductive health services in Nigeria?

Background

In Nigeria, vulnerability status may increase the risk for the violation of human rights while receiving health care. The present study determined the proportion and profile of people who reported rights violation while accessing HIV and sexual and reproductive health (SRH) services.

Methods

This was a cross sectional study with data collected between February and March 2021. The dependent variables were patients’ rights to autonomy: right to privacy and confidentiality of medical records; right to be treated with respect, regardless of gender, race, religion, ethnicity, allegations of crime, disability or economic circumstances; right to decline or consent to participation in medical research, experimental procedures or clinical trials; right to quality care in accordance to prevailing standards; and right to complain and express dissatisfaction regarding services received. The independent variables were sexual identity (heterosexual/straight, gay, lesbian, bisexual, queer), HIV status (positive, negative, do not know), living with disability (yes/no), and access point to HIV services (public or donor funded/private). Five multivariate regression models were developed to determine associations between the dependent and independent variable after adjusting for age, education level (no formal education, primary, secondary, tertiary), sex (male, female, intersex), marital status (single, married, separated/divorced, cohabiting) and gender identity (male, female, transgender).

Results

Complete data from 2119 study participants were analysed. Transgender individuals had significantly higher odds of experiencing violation of their rights to privacy and confidentiality of medical records (AOR:1.70), right to be treated with respect (AOR:1.71), right to complain and express dissatisfaction regarding services received (AOR:1.57) and right to decline consent to participate in medical research, experimental research, experimental procedures or clinical trials (AOR:1.81) compared to individuals who were males.

Conclusion

A high proportion of recipients of HIV and SRH services in Nigeria reported rights violations. Transgender individuals appear to have higher risk and those in spousal relationships have lower risk for rights violations. Studies are needed to learn how to improve rights-based HIV and SRH service delivery in Nigeria especially for transgender individuals.

Associations of gender identity with sexual behaviours, social stigma and sexually transmitted infections among adults who have sex with men in Abuja and Lagos, Nigeria

Introduction

Sexual and gender minority populations are disproportionately affected by the global syndemic of HIV and other sexually transmitted infections (STIs). We hypothesized that transgender women (TGW) and non‐binary individuals in Nigeria have more STIs than cis‐gender men who have sex with men (cis‐MSM), and that experiences of stigma and sexual practices differ between these three groups.

Methods

From 2013 to 2020, TRUST/RV368 enrolled adults assigned male sex at birth who reported anal sex with men in Abuja and Lagos, Nigeria. Participants were tested for STIs and completed questionnaires about sexual behaviours and social stigma every 3 months. Participants were categorized as cis‐MSM, TGW or non‐binary/other based on self‐reported gender identity. Gender group comparisons were made of HIV, gonorrhoea and chlamydia prevalence and incidence; stigma indicators; and condom use during anal sex.

Results

Among 2795 participants, there were 2260 (80.8%) cis‐MSM, 284 (10.2%) TGW and 251 (9.0%) non‐binary/other individuals with median age of 23 years (interquartile range 20–27). HIV prevalence among cis‐MSM, TGW and non‐binary/other participants was 40.8%, 51.5% and 47.6%, respectively (p = 0.002). HIV incidence was 8.7 cases per 100 person‐years (PY) (95% confidence interval [CI] 6.9–10.8), 13.1 cases/100 PY (95% CI 6.5–23.4) and 17.6 cases/100 PY (95% CI 9.8–29.0, p = 0.025), respectively. Anorectal gonorrhoea incidence was lower in cis‐MSM than TGW (22.2 [95% CI 19.6–25.0] vs. 35.9 [95% CI 27.3–46.3]). TGW were more likely than cis‐MSM to report being affected by stigma, including assault (47.2% vs. 32.3%), fear of walking around (32.4% vs. 19.2%) and healthcare avoidance (25.0% vs. 19.1%; all p < 0.05). TGW were more likely to report always using condoms than non‐binary/other individuals (35.3% vs. 26.2%, p = 0.041) during receptive anal sex.

Conclusions

Sexual and gender minorities in Nigeria have heterogeneous sexual behaviours and experiences of social stigma that may influence the vulnerability to HIV and other STIs. There is a need for tailored interventions that acknowledge and are informed by gender. Further research is needed, particularly among understudied non‐binary individuals, to better understand disparities and inform tailored interventions to improve outcomes among these communities.

High-risk behaviors and factors for HIV and sexually transmitted infections among transgender people in Gaborone, Botswana: results from a national survey

Introduction

key populations and transgender people in particular are at a high risk of HIV infection. However, very little is known about risk behaviors of transgender people in Botswana. The aim of this study was to determine the prevalence of high-risk behaviors for HIV and sexually transmitted infections (STIs) among transgender people in Botswana.

Methods

data from the Botswana 2017 Biological and Behavioral Surveillance Survey of HIV/STIs among select key populations (BBSS-2) was used. The cross sectional survey documented behavioral risk factors for these infections. This paper only focused on the analysis of the transgender data. Descriptive analysis was done with IBM Statistical Software for the Social Sciences (SPSS) version 24.

Results

there were 56 transgender people identified of which 12 (21.4%) were transgender women. The median age was 24 (interquartile range (IQR) 22-28). Among transgender women, 2 (16.7%) reported concurrent sexual partners and 9 (75%) reported condom use at last intercourse. However, only 7 (58.3%) reported consistent lubricant use. About 45% of the respondents did not know the HIV status of their last male partner. Only one of the transgender women reported intercourse with at least 1 female in the last month. About a third reported that they had STI symptoms in the past year. Alcohol use was reported in 50% of respondents while 83% had disclosed gender identity and had been accepted by their families. However, 25% reported discrimination by a healthcare worker.

Conclusion

the high-risk behaviors were frequent among transgender women. This study underlines the need for sustained efforts to reach this key population.