1
|
de Villiers L, Swartz L, Bock P, Seeley J, Stangl AL, Bond V, Hargreaves J, Hoddinott G. HIV and gender identity expression among transfeminine people in the Western Cape, South Africa - a thematic analysis of data from the HPTN 071 (PopART) trial. BMC Public Health 2024; 24:1807. [PMID: 38971729 PMCID: PMC11227193 DOI: 10.1186/s12889-024-19215-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 06/20/2024] [Indexed: 07/08/2024] Open
Abstract
INTRODUCTION Transfeminine people in South Africa have a high HIV risk due to structural, behavioural, and psychosocial factors. Transfeminine people and feminine identifying men who have sex with men (MSM) are often conflated or grouped with transgender or MSM categories in HIV service programming, although they don't necessarily identify as either. We aimed to investigate gender expression among feminine identifying people who were assigned male at birth. We examined how local conceptualizations of sexuality and gender intersect with the key population label of 'transgender' imported into local HIV programming. METHODS A qualitative cohort nested within the HPTN 071 (PopART) trial included longitudinal, in-depth interviews with eight transfeminine people (four who disclosed as living with HIV). Data were collected approximately every six weeks between January 2016 and October 2017. We used a combination of thematic analysis and case study descriptions to explore gender identification among participants. RESULTS Of the eight participants, only one accepted 'transgender' as a label, and even she used varying terms at different times to describe her identity. For participants, a feminine identity included dressing in normatively feminine clothes; using feminine terms, pronouns and names; and adopting stereotypically feminine mannerisms. Participants would switch between typically feminine and masculine norms in response to contextual cues and audience. For example, some participants accepted identification as masculine gay men amongst their family members. Among peers, they expressed their identity through typically more effeminate gender characteristics, for example self-identifying as "femgay". With partners they often also took on a feminine identity role, for example identifying as women in sexual and romantic relationships (meaning they viewed and expressed themselves as the feminine partner in the relationship). CONCLUSIONS Our findings are amongst the first exploratory and descriptive data of transfeminine people in South Africa. We show how transfeminine people navigate fluid gender identities that could pose a challenge for accessing and utilizing HIV services that are currently set up for transgender individuals or MSM. More work needs to be done to understand and respond to the diverse and shifting ways people experience their gender identities in this high HIV burden context.
Collapse
Affiliation(s)
- Laing de Villiers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa.
- Pivot Collective, Cape Town, South Africa.
| | - Leslie Swartz
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Janet Seeley
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Anne L Stangl
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Hera Solutions, Baltimore, MD, USA
| | - Virginia Bond
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - James Hargreaves
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Group for Research on Infectious Diseases, Department of Human Biological and Translational Medical Sciences, University of Namibia, Windhoek, Namibia
| |
Collapse
|
2
|
Jessani A, Berry-Moreau T, Parmar R, Athanasakos A, Prodger JL, Mujugira A. Healthcare access and barriers to utilization among transgender and gender diverse people in Africa: a systematic review. BMC GLOBAL AND PUBLIC HEALTH 2024; 2:44. [PMID: 38948028 PMCID: PMC11208260 DOI: 10.1186/s44263-024-00073-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 06/14/2024] [Indexed: 07/02/2024]
Abstract
Background Transgender and gender diverse (TGD) people face significant challenges in accessing timely, culturally competent, and adequate healthcare due to structural and systemic barriers, yet there is a lack of research exploring the access and utilization of healthcare services within African TGD communities. To address this gap, this systematic review explored: (1) barriers to accessing healthcare services and gender-affirming hormone therapy (GAHT) faced by TGD people, (2) demographic and societal factors correlated with the utilization of healthcare services and GAHT, (3) common healthcare and support services utilized by TGD people, and (4) patterns of accessing healthcare services and GAHT within TGD communities. Methods A systematic literature search was conducted in PubMed, Embase, and Scopus in September 2023. Eligible studies included peer-reviewed original research, reports, and summaries published in the English language assessing health service accessibility and utilization of TGD people in Africa between January 2016 and December 2023. Results From 2072 potentially relevant articles, 159 were assessed for eligibility following duplicate removal, and 49 were included for analysis. Forty-five articles addressed barriers to accessing healthcare services and GAHT, seven focused on demographic and societal factors correlated with the utilization of healthcare services and GAHT, 16 covered common healthcare and support services utilized by TGD people, and seven examined patterns of accessing healthcare services and GAHT. Findings suggested a limited availability of health services, inadequate knowledge of TGD healthcare needs among healthcare providers, a lack of recognition of TGD people in healthcare settings, healthcare-related stigma, and financial constraints within African TGD communities. An absence of studies conducted in Northern and Central Africa was identified. Conclusions TGD people in Africa encounter significant barriers when seeking healthcare services, leading to disparity in the utilization of healthcare and resulting in a disproportionate burden of health risks. The implications of these barriers highlight the urgent need for more high-quality evidence to promote health equity for African TGD people. Trial registration PROSPERO CRD42024532405. Supplementary Information The online version contains supplementary material available at 10.1186/s44263-024-00073-2.
Collapse
Affiliation(s)
- Abbas Jessani
- Department of Dentistry, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
| | - Teagan Berry-Moreau
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
| | - Reeya Parmar
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
| | - Alexia Athanasakos
- Department of Dentistry, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
| | - Jessica L. Prodger
- Department of Dentistry, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
| | - Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, WA USA
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| |
Collapse
|
3
|
Dada D, Abu-Ba'are GR, Turner D, Mashoud IW, Owusu-Dampare F, Apreku A, Ni Z, Djiadeu P, Aidoo-Frimpong G, Zigah EY, Nyhan K, Nyblade L, Nelson LE. Scoping review of HIV-related intersectional stigma among sexual and gender minorities in sub-Saharan Africa. BMJ Open 2024; 14:e078794. [PMID: 38346887 PMCID: PMC10862343 DOI: 10.1136/bmjopen-2023-078794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 01/09/2024] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVES Sexual and gender minority (SGM) populations in sub-Saharan Africa (SSA) are disproportionately impacted by HIV and often face multiple HIV-related stigmas. Addressing these stigmas could reduce SGM HIV vulnerability but little is known about how the stigmas operate and intersect. Intersectional stigma offers a lens for understanding the experiences of stigmatised populations and refers to the synergistic negative health effects of various systems of oppression on individuals with multiple stigmatised identities, behaviours or conditions. This review aims to (1) assess how often and in what ways an intersectional lens is applied in HIV-related stigma research on SGM populations in SSA and (2) understand how intersectional stigma impacts HIV risk in these populations. DESIGN Scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews. DATA SOURCES Public health and regional databases were searched in 2020 and 2022. ELIGIBILITY CRITERIA Articles in French and English on HIV-related stigma and HIV outcomes among men who have sex with men, women who have sex with women and/or transgender individuals in SSA. DATA EXTRACTION AND SYNTHESIS Articles were screened and extracted twice and categorised by use of an intersectional approach. Study designs and stigma types were described quantitatively and findings on intersectional stigma were thematically analysed. RESULTS Of 173 articles on HIV-related stigma among SGM in SSA included in this review, 21 articles (12%) applied an intersectional lens. The most common intersectional stigmas investigated were HIV and same-sex attraction/behaviour stigma and HIV, same-sex attraction/behaviour and gender non-conformity stigma. Intersectional stigma drivers, facilitators and manifestations were identified across individual, interpersonal, institutional and societal socioecological levels. Intersectional stigma impacts HIV vulnerability by reducing HIV prevention and treatment service uptake, worsening mental health and increasing exposure to HIV risk factors. CONCLUSION Intersectional approaches are gaining traction in stigma research among SGM in SSA. Future research should prioritise quantitative and mixed methods investigations, diverse populations and intervention evaluation.
Collapse
Affiliation(s)
- Debbie Dada
- School of Nursing, Yale University, New Haven, Connecticut, USA
- St Michael's Hospital Centre for Urban Health Solutions, Toronto, Ontario, Canada
| | - Gamji R Abu-Ba'are
- Center for Interdisciplinary Research on AIDS, School of Public Health, Yale University, New Haven, Connecticut, USA
- Behavioral, Sexual, and Global Health Lab, University of Rochester, Rochester, New York, USA
| | | | | | | | | | - Zhao Ni
- School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Pascal Djiadeu
- St Michael's Hospital Centre for Urban Health Solutions, Toronto, Ontario, Canada
- School of Public Health, University of Toronto Dalla Lana, Toronto, Ontario, Canada
| | - Gloria Aidoo-Frimpong
- Center for Interdisciplinary Research on AIDS, School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Edem Yaw Zigah
- Behavioral, Sexual, and Global Health Lab, University of Rochester, Rochester, New York, USA
| | - Kate Nyhan
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, Connecticut, USA
| | - Laura Nyblade
- Research Triangle Institute, Research Triangle Park, North Carolina, USA
| | - LaRon E Nelson
- School of Nursing, Yale University, New Haven, Connecticut, USA
- St Michael's Hospital Centre for Urban Health Solutions, Toronto, Ontario, Canada
| |
Collapse
|
4
|
Mcinziba A, Bock P, Hoddinott G, Seeley J, Bond V, Fidler S, Viljoen L. Managing household income and antiretroviral therapy adherence among people living with HIV in a low-income setting: a qualitative data from the HPTN 071 (PopART) trial in South Africa. AIDS Res Ther 2023; 20:54. [PMID: 37542278 PMCID: PMC10401727 DOI: 10.1186/s12981-023-00549-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/18/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND South Africa is reported to have the highest burden of HIV with an estimated 8.2 million people living with HIV (PLHIV) in 2021- despite adopting the World Health Organisation (WHO) universal HIV test and treat (UTT) recommendations in 2016. As of 2021, only an estimated 67% (5.5 million) of all PLHIV were accessing antiretroviral therapy (ART), as per recorded clinic appointments attendance. Studies in sub-Saharan Africa show that people living in low-income households experience multiple livelihood-related barriers to either accessing or adhering to HIV treatment including lack of resources to attend to facilities and food insecurity. We describe the interactions between managing household income and ART adherence for PLHIV in low-income urban and semi-urban settings in the Western Cape, South Africa. METHODS We draw on qualitative data collected as part of the HPTN 071 (PopART) HIV prevention trial (2016 - 2018) to provide a detailed description of the interactions between household income and self-reported ART adherence (including accessing ART and the ability to consistently take ART as prescribed) for PLHIV in the Western Cape, South Africa. We included data from 21 PLHIV (10 men and 11 women aged between 18 and 70 years old) from 13 households. As part of the qualitative component, we submitted an amendment to the ethics to recruit and interview community members across age ranges. We purposefully sampled for diversity in terms of age, gender, and household composition. RESULTS We found that the management of household income interacted with people's experiences of accessing and adhering to ART in diverse ways. Participants reported that ART adherence was not a linear process as it was influenced by income stability, changing household composition, and other financial considerations. Participants reported that they did not have a fixed way of managing income and that subsequently caused inconsistency in their ART adherence. Participants reported that they experienced disruptions in ART access and adherence due to competing household priorities. These included difficulties balancing between accessing care and/or going to work, as well as struggling to cover HIV care-related costs above other basic needs. CONCLUSION Our analysis explored links between managing household income and ART adherence practices. We showed that these are complex and change over the course of treatment duration. We argued that mitigating negative impacts of income fluctuation and managing complex trade-offs in households be included in ART adherence support programmes.
Collapse
Affiliation(s)
- Abenathi Mcinziba
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Janet Seeley
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Virginia Bond
- School of Medicine, University of Zambia, Ridgeway Campus, Zambart, Lusaka, Zambia
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Department of Medicine, Imperial College, London, UK
| | - Lario Viljoen
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| |
Collapse
|
5
|
Folayan MO, Zuñiga RAA, Virtanen JI, Ellakany P, Al-Tammemi AB, Quadri MFA, Jafer M, Ara E, Ayanore MA, Gaffar B, Aly NM, Idigbe I, Lusher J, Ezechi OC, Nguyen AL, Tantawi ME. A multi-country study of the associations between HIV vulnerability status, perception of COVID-19 related stigma and post-traumatic stress symptoms during the first wave of the pandemic. BMC Public Health 2023; 23:1025. [PMID: 37254073 DOI: 10.1186/s12889-023-15933-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 05/18/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND This study investigated the associations between COVID-19 related stigma and post-traumatic stress symptoms (PTSS); and the associations between PTSS and COVID-19 related stigma, HIV status, COVID-19 status and key HIV population status. METHODS This was a secondary analysis of data of 12,355 study participants generated through an online survey that recruited adults from 152 countries between July and December 2020. The dependent variables were COVID-19-related stigma and PTSS. The independent variables were HIV status (positive/negative), transaction sex (yes/no), use of psychoactive drugs (yes/no), and vulnerability status (transaction sex workers, people who use psychoactive drugs, living with HIV, and COVID-19 status). The confounding variables were age, sex at birth (male/female), level of education, sexual minority individuals (yes/no) and country income level. Multivariable logistic regression analyses were conducted to determine associations between the dependent and independent variables after adjusting for confounders. RESULTS There were 835 (6.8%) participants who experienced COVID-19 related stigma during the pandemic and 3,824 (31.0%) participants reported PTSS. Respondents who were living with HIV (AOR: 1.979; 95%CI: 1.522-2.573), tested positive for COVID-19 (AOR: 3.369; 95%CI: 2.692-4.217), engaged in transactional sex (AOR: 1.428; 95%CI: 1.060-1.922) and used psychoactive drugs (AOR: 1.364; 95%CI: 1.053-1.767) had significantly higher odds of experiencing COVID-19 related stigma. Individuals with vulnerability status (AOR:4.610; 95%CI: 1.590-13.368) and who experienced COVID-19 related stigma (AOR: 2.218; 95%CI: 1.920-2.561) had significantly higher odds of PTSS. CONCLUSION Individuals with vulnerability status may be at increased risk for COVID-19 related stigma. Key and vulnerable populations who were living with HIV and who experienced stigma may be at a higher risk of experiencing PTSS. Populations at risk for PTSS should be routinely screened and provided adequate support when they contract COVID-19 to reduce the risk for poor mental health during COVID-19 outbreaks and during future health crisis with similar magnitude as the COVID-19 pandemic.
Collapse
Affiliation(s)
- Morenike Oluwatoyin Folayan
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria.
- Department of Child Dental Health, Obafemi Awolowo University, Ile-Ife, Nigeria.
| | - Roberto Ariel Abeldaño Zuñiga
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria
- Postgraduate Department, University of Sierra Sur, Oaxaca, Mexico
- Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
| | - Jorma I Virtanen
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria
- Faculty of Medicine, University of Turku, Turku, Finland
| | - Passent Ellakany
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria
- Department of Substitutive Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Ala'a B Al-Tammemi
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria
- Applied Science Research Center, Applied Science Private University, Amman, Jordan
- Migration Health Division, International Organization for Migration, Amman, Jordan
| | - Mir Faeq Ali Quadri
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria
- Department of Oral Health Sciences, University of Washington, Washington, USA
| | - Mohammed Jafer
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria
- Dental Public Health Division, Faculty of Dentistry, Jazan University, Jizan, Saudi Arabia
| | - Eshrat Ara
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria
- Department of Psychology, Government College for Women, MA Road, Jizan, J&K, India
| | - Martin Amogre Ayanore
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria
- Department of Health Policy Planning and Management, Fred N. Binka School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | - Balgis Gaffar
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria
- Department of Preventive Dental Sciences, College of Dentistry, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Nourhan M Aly
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria
- Department of Pediatric Dentistry and Dental Public Health, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | - Ifeoma Idigbe
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria
- Clinical Sciences Department, Nigerian Institute of Medical Research, Lagos, Nigeria
| | - Joanne Lusher
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria
- Provosts Group, Regent's University London, London, UK
| | - Oliver C Ezechi
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria
- Centre for Reproductive and Population Health Studies, Nigerian Institute of Medical Research Yaba, Lagos, Nigeria
| | - Annie L Nguyen
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria
- Department of Family Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Maha El Tantawi
- Mental Health and Wellness Study Group, Ile-Ife, Nigeria
- Department of Pediatric Dentistry and Dental Public Health, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| |
Collapse
|
6
|
Cloete A, Mabaso M, Savva H, van der Merwe LLA, Naidoo D, Petersen Z, Kose Z, Mthembu J, Moyo S, Skinner D, Jooste S, Fellows IE, Shiraishi RW, Mwandingi SL, Simbayi LC. The HIV care continuum for sexually active transgender women in three metropolitan municipalities in South Africa: findings from a biobehavioural survey 2018-19. Lancet HIV 2023:S2352-3018(23)00059-0. [PMID: 37119825 DOI: 10.1016/s2352-3018(23)00059-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/06/2023] [Accepted: 03/08/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND Despite high HIV prevalence in transgender women in sub-Saharan Africa, to our knowledge no study presents data across the HIV care continuum for this population in the region. The aim of this study was to estimate HIV prevalence and present data to develop the HIV care continuum indicators for transgender women in three South African metropolitan municipalities. METHODS Biobehavioural survey data were collected among sexually active transgender women in the metropolitan municipalities of Johannesburg, Buffalo City, and Cape Town, South Africa. Transgender women (aged ≥18 years, self-reporting consensual sex with a man in the 6 months before the survey) were recruited using respondent-driven sampling (RDS). An interviewer-administered questionnaire was used to determine awareness of HIV status; blood specimens were collected on dried blood spots to test for HIV antibodies, antiretroviral treatment (ART) exposure, and viral load suppression. Population-based estimates of HIV 95-95-95 cascade indicators were derived by use of individualised RDS weights with RDS Analyst software. Multivariate stepwise backward logistic regression modelling was used to determine factors associated with each cascade indicator. All eligible participants were included in the final analysis. FINDINGS Between July 26, 2018, and March 15, 2019, we enrolled 887 sexually active transgender women: 323 in Johannesburg, 305 in Buffalo City, and 259 in Cape Town. HIV prevalence was highest in Johannesburg where 229 (74·1%) of 309 tests were positive (weighted prevalence estimate 63·3%, 95% CI 55·5-70·5), followed by Buffalo City where 121 (43·7%) of 277 were positive (46·1%, 38·7-53·6), and then Cape Town where 122 (48·4%) of 252 were positive (45·6%, 36·7-54·7). In Johannesburg, an estimated 54·2% (95% CI 45·8-62·4) of transgender women with HIV knew their positive status, in Cape Town this was 24·2% (15·4-35·8), and in Buffalo City this was 39·5% (27·1-53·4). Among those who knew their status, 82·1% (73·3-88·5) in Johannesburg, 78·2% (57·9-90·3) in Cape Town, and 64·7% (45·2-80·2) in Buffalo City were on ART. Of those on ART, 34·4% (27·2-42·4) in Johannesburg, 41·2% (30·7-52·6) in Cape Town, and 55·0% (40·7-68·4) in Buffalo City were virally suppressed. INTERPRETATION Innovative strategies are needed to inform efforts to diagnose and to treat transgender women living with HIV promptly to achieve viral load suppression. Differentiated HIV services tailored to transgender women of race groups other than Black South African, and those with low education attainment and low outreach exposure, innovative testing, and adherence strategies should be developed to improve the HIV cascade for South African transgender women. FUNDING The US President's Emergency Plan For AIDS Relief and US Centers for Disease Control and Prevention.
Collapse
Affiliation(s)
- Allanise Cloete
- Human and Social Capabilities Division, Human Sciences Research Council, Cape Town, South Africa.
| | - Musawenkosi Mabaso
- Human and Social Capabilities Division, Human Sciences Research Council, Durban, South Africa
| | - Helen Savva
- Prevention Branch, CDC, Pretoria, South Africa
| | - L Leigh-Ann van der Merwe
- Social, Health, and Empowerment Feminist Collective of Transgender Women of Africa, East London, South Africa
| | - Dhee Naidoo
- Department of Anthropology and Archaeology, University of Pretoria, Pretoria, South Africa; The Durban LGBTI Community and Health Centre, Durban, KwaZulu-Natal, South Africa
| | - Zaino Petersen
- Human and Social Capabilities Division, Human Sciences Research Council, Cape Town, South Africa
| | - Zamakayise Kose
- Research Support Department, North-West University, Potchefstroom, South Africa
| | - Jacqueline Mthembu
- Human and Social Capabilities Division, Human Sciences Research Council, Cape Town, South Africa
| | - Sizulu Moyo
- Human and Social Capabilities Division, Human Sciences Research Council, Cape Town, South Africa; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Donald Skinner
- School of Public Health, Stellenbosch University, Stellenbosch, South Africa
| | - Sean Jooste
- Human and Social Capabilities Division, Human Sciences Research Council, Cape Town, South Africa
| | - Ian E Fellows
- Health Informatics, Data Management, and Statistics Branch, Division of Global HIV and TB, CDC, Atlanta, GA, USA
| | - Ray W Shiraishi
- Health Informatics, Data Management, and Statistics Branch, Division of Global HIV and TB, CDC, Atlanta, GA, USA
| | | | - Leickness C Simbayi
- Human and Social Capabilities Division, Human Sciences Research Council, Cape Town, South Africa; Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
7
|
De Villiers L, Swartz L, Bock P, Seeley J, Stangl AL, Bond V, Hargreaves J, Hoddinott G. HIV and gender identity expression among transfeminine women in the Western Cape, South Africa - a thematic analysis of data from the HPTN 071 (PopART) trial. RESEARCH SQUARE 2023:rs.3.rs-2486896. [PMID: 36798211 PMCID: PMC9934773 DOI: 10.21203/rs.3.rs-2486896/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction Transfeminine women in South Africa have a high HIV risk due to structural, behavioural, and psychosocial factors. Transfeminine women and feminine identifying men who have sex with men (MSM) are often conflated or grouped with transgender or MSM categories in HIV service programming, although they don't necessarily identify as either. We aimed to investigate gender expression among feminine identifying people who were assigned male at birth. We examined how local conceptualizations of sexuality and gender intersect with the key population label of 'transgender' imported into local HIV programming. Methods A qualitative cohort nested within the HPTN 071 (PopART) trial included longitudinal, in-depth interviews with eight transfeminine women (four who disclosed as living with HIV). Data were collected approximately every six weeks between January 2016 and October 2017. We discuss gender identification presented in participants' daily lives and in relation to HIV service access. Results Of the eight participants, only one accepted 'transgender' as a label, and even she used varying terms at different times to describe her identity. For participants, a feminine identity included dressing in normatively feminine clothes; using feminine terms, pronouns and names; and adopting stereotypically feminine mannerisms. Participants would switch between typically feminine and masculine norms in response to contextual cues and audience. For example, some participants accepted identification as masculine gay men amongst their family members, but amongst peers, they expressed a more effeminate identity and with partners they took on a feminine identity. Conclusions Our findings are amongst the first exploratory and descriptive data of transfeminine women in South Africa. We show how transfeminine women navigate fluid gender identities that could pose a challenge for accessing and utilizing HIV services that are currently set up for transgender individuals or MSM. More work needs to be done to understand and respond to the diverse and shifting ways people experience their gender identities in this high HIV burden context.
Collapse
|
8
|
Tun W, Pulerwitz J, Shoyemi E, Fernandez A, Adeniran A, Ejiogu F, Sangowawa O, Granger K, Dirisu O, Adedimeji AA. A qualitative study of how stigma influences HIV services for transgender men and women in Nigeria. J Int AIDS Soc 2022; 25 Suppl 1:e25933. [PMID: 35818868 PMCID: PMC9274359 DOI: 10.1002/jia2.25933] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 05/05/2022] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Transgender men and women in Nigeria experience many barriers in accessing HIV prevention and treatment services, particularly given the environment of transphobia (including harassment, violence and discrimination) and punitive laws in the country. HIV epidemic control in Nigeria requires improving access to and quality of HIV services for key populations at high risk, including transgender men and women. We assessed how stigma influences HIV services for transgender people in Lagos, Nigeria. METHODS In-depth interviews (IDIs) and focus group discussions were conducted with transgender men (n = 13) and transgender women (n = 25); IDIs were conducted with community service organization (CSO) staff (n = 8) and healthcare providers from CSO clinics and public health facilities (n = 10) working with the transgender population in March 2021 in Lagos. Content analysis was used to identify how stigma influences transgender people's experiences with HIV services. RESULTS AND DISCUSSION Three main findings emerged. First, gender identity disclosure is challenging due to anticipated stigma experienced by transgender persons and fear of legal repercussions. Fear of being turned in to authorities was a major barrier to disclose to providers in facilities not affiliated with a transgender-inclusive clinic. Providers also reported difficulty in eliciting information about the client's gender identity. Second, respondents reported lack of sensitivity among providers about gender identity and conflation of transgender men with lesbian women and transgender women with being gay or men who have sex with men, the latter being more of a common occurrence. Transgender participants also reported feeling disrespected when providers were not sensitive to their pronoun of preference. Third, HIV services that are not transgender-inclusive and gender-affirming can reinforce stigma. Both transgender men and women spoke about experiencing stigma and being refused HIV services, especially in mainstream public health facilities, as opposed to transgender-inclusive CSO clinics. CONCLUSIONS This study highlights how stigma impedes access to appropriate HIV services for transgender men and women, which can have a negative impact along the HIV care continuum. There is a need for transgender-inclusive HIV services and competency trainings for healthcare providers so that transgender clients can receive appropriate and gender-affirming HIV services.
Collapse
Affiliation(s)
- Waimar Tun
- Social and Behavioral Science Research, Population Council, Washington, DC, USA
| | - Julie Pulerwitz
- Social and Behavioral Science Research, Population Council, Washington, DC, USA
| | | | | | | | | | | | - Krista Granger
- Social and Behavioral Science Research, Population Council, Washington, DC, USA
| | - Osasuyi Dirisu
- Policy Innovation Unit, Nigerian Economic Summit Group, Lagos, Nigeria
| | | |
Collapse
|
9
|
van der Merwe LLA, Cloete A, Skinner D. How HIV advocacy can be used to ensure quality transgender health care: lessons from South Africa. Lancet 2022; 399:1099-1101. [PMID: 35131042 DOI: 10.1016/s0140-6736(22)00177-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/23/2021] [Indexed: 11/19/2022]
Affiliation(s)
- L Leigh-Ann van der Merwe
- Social, Health and Empowerment Feminist Collective of Transgender Women of Africa, East London, South Africa.
| | - Allanise Cloete
- Human and Social Capabilities Division, Human Sciences Research Council, Pretoria, South Africa
| | - Donald Skinner
- Human and Social Capabilities Division, Human Sciences Research Council, Pretoria, South Africa
| |
Collapse
|
10
|
Kim SS, DeMarco RF. The Intersectionality of HIV-Related Stigma and Tobacco Smoking Stigma With Depressive and Anxiety Symptoms Among Women Living With HIV in the United States: A Cross-sectional Study. J Assoc Nurses AIDS Care 2022; 33:523-533. [PMID: 34999667 DOI: 10.1097/jnc.0000000000000323] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT This study examined the intersectionality of HIV-related stigma, tobacco smoking stigma, and mental health among women living with HIV who were daily smokers. This secondary analysis used baseline data from 2 pilot smoking cessation studies. Participants received either an HIV-tailored or an attention-control intervention focused on smoking cessation as an outcome. There were significant positive relationships between HIV-related stigma and depressive and anxiety symptoms. In contrast, tobacco smoking stigma had no significant relationship with either of the symptoms when HIV-related stigma was controlled. However, there was a significant interaction effect (β = 1.37, p = .02) of tobacco smoking stigma with internalized HIV-related stigma on anxiety symptoms. Tobacco smoking stigma worsened anxiety symptoms for women who had high internalized HIV-related stigma. Health care providers should understand the effect of HIV-related stigma on mental health and address the intersectionality of HIV-related stigma with other socially disapproved behaviors, such as tobacco smoking.
Collapse
Affiliation(s)
- Sun S Kim
- Sun S. Kim, PhD, APRN-BC, is an Associate Professor, Robert and Donna Manning College of Nursing and Health Sciences, University of Massachusetts Boston, Massachusetts, USA. Rosanna F. DeMarco, PhD, RN, FAAN, is a Professor and Associate Dean for Academic Affairs, College of Nursing and Health Sciences, University of Massachusetts Boston, Massachusetts, USA
| | | |
Collapse
|
11
|
Dunaway K, Brion S, Hale F, Alesi J, Assan H, Chung C, Moroz S, Namiba A, Ouma J, Owomugisha IB, Ross V, Strachan S, Tholanah M, Yuvaraj A, Welbourn A. What will it take to achieve the sexual and reproductive health and rights of women living with HIV? WOMEN'S HEALTH 2022; 18:17455057221080361. [PMID: 35225088 PMCID: PMC8891932 DOI: 10.1177/17455057221080361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article outlines progress in realizing the sexual and reproductive health and rights of women and girls living with HIV over the last 30 years from the perspective of women living with HIV. It argues that the HIV response needs to go beyond the bio-medical aspects of HIV to achieve our sexual and reproductive health and rights, and considers relevant Joint United Nations Programme on HIV/AIDS (UNAIDS), World Health Organization, United States President’s Emergency Plan for AIDS Relief (PEPFAR), Global Fund and other guidelines, what engagement there has been with women living with HIV and whether guidelines/strategies have been adopted. It has been written by women living with HIV from around the world and a few key supporters. Co-authors have sought to collate and cite materials produced by women living with HIV from around the world, in the first known effort to date to do this, as a convergence of evidence to substantiate the points made in the article. However, as the article also argues, research led by women living with HIV is seldom funded and rarely accepted as evidence. Combined with a lack of meaningful involvement of women living with HIV in others’ research on us, this means that formally recognized evidence from women’s own perspectives is patchy at best. The article argues that this research gap, combined with the ongoing primacy of conventional research methods and topics that exclude those most affected by issues, and the lack of political will (and sometimes outright opposition) in relation to gender equality and human rights, adversely affect policies and programmes in relation to women’s rights. Thus, efforts to achieve an ethical, effective and sustainable response to the pandemic are hindered. The article concludes with a call to action to all key stakeholders.
Collapse
Affiliation(s)
| | | | | | | | - Happy Assan
- Tanzania Network of People who Use Drugs (TaNPUD), Dar es Salaam, Tanzania
| | | | | | | | - Joyce Ouma
- Global Network of Young People Living with HIV (Y+ Global), Capetown, South Africa
| | | | - Violeta Ross
- Latin American & Caribbean Movement of Positive Women, Asunción, Paraguay
| | | | | | | | | |
Collapse
|
12
|
Mahy MI, Sabin KM, Feizzadeh A, Wanyeki I. Progress towards 2020 global HIV impact and treatment targets. J Int AIDS Soc 2021; 24 Suppl 5:e25779. [PMID: 34546655 PMCID: PMC8454678 DOI: 10.1002/jia2.25779] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 07/19/2021] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Over the past 20 years, the response to the HIV epidemic has achieved remarkable results. These results have often been motivated by targets adopted by countries through United Nations (UN) Political Declarations on HIV. The 2016 political declaration included two impact targets, to achieve a 75% decline in new HIV infections and AIDS-related deaths between 2010 and 2020, and to reach the 90-90-90 testing and treatment targets by 2020. Our objective is to summarize progress towards these targets using robust and comparable HIV estimates released by UNAIDS in July 2021. In addition, we comment on the importance of targets and the modelled estimates required to quantify those targets. DISCUSSION The UNAIDS estimates indicate that at the global and regional levels, the 2020 targets were missed: new infections declined by 31% and AIDS-related deaths declined by 47% between 2010 and 2020, compared to a target of 75% decline for both indicators. Similarly, no region achieved the 90-90-90 testing and treatment targets. Some countries, in diverse settings, achieved these targets showing that the targets were not overly ambitious if the right funding, policies and evidence-informed interventions at the right scale were in place. The 2021 UN Political Declaration on HIV, adopted on 8 June 2021, has set out a new set of ambitious but achievable targets for 2025. The 2025 targets and the required actions to reach those targets are described in the Global AIDS Strategy 2021-2026, which provides a framework to reprioritize HIV responses by reducing inequalities and building on the achievements of multiple Sustainable Development Goals. The Strategy encourages countries to monitor progress against targets for different geographic areas and populations to maximize equitable services and ensure accountability and also to understand why targets are being missed. CONCLUSIONS The UNAIDS epidemiological estimates provide information that promote accountability and estimate progress towards global targets at the national level. Additional strategic information and analyses are required to identify the populations that are furthest from the targets and the programmes and policies that are keeping countries from meeting their targets.
Collapse
Affiliation(s)
- Mary I. Mahy
- Strategic Information DepartmentUNAIDSGenevaSwitzerland
| | | | - Ali Feizzadeh
- Strategic Information DepartmentUNAIDSGenevaSwitzerland
| | - Ian Wanyeki
- Strategic Information DepartmentUNAIDSGenevaSwitzerland
| |
Collapse
|