Sword and Shield: Perceptions of law in empowering and protecting HIV-positive men who have sex with men in Manila, Philippines

Legal protections for people living with HIV (PLHIV) are important for protecting human rights and combatting stigma. While much focus has been on the pernicious impacts of criminalisation of HIV transmission or nondisclosure, little research has accounted for the ways in which perception of protective laws may affect the everyday lives of PLHIV. The Philippines has the fastest growing HIV epidemic in the Asia & Pacific region, with HIV-positive men-who-have-sex-with-men (HIV+ MSM) bearing the majority of cases, and has recently revised their legal protections for PLHIV. We present findings from interviews with 21 HIV+ MSM in Manila, Philippines. Overall, participants viewed legal protections as both empowering and protective. Empowerment was achieved as protections helped participants manage internalised stigma, feel as if they had a weapon to fight discrimination, and perceive a more equitable climate around HIV within broader society. While participants felt as though the law sent positive signals that the government wanted to protect PLHIV, they doubted the actual legal process of bringing suits, leading to harms. Overall, this research presents ways in which legal protections can considered in interventions to empower PLHIV and also identifies opportunities to improve research and advocacy in settings with similarly protective laws.

Mapping Community-Engaged Implementation Strategies with Transgender Scientists, Stakeholders, and Trans-Led Community Organizations

PURPOSE OF REVIEW

Pre-exposure prophylaxis (PrEP) represents one of the most effective methods of prevention for HIV, but remains inequitable, leaving many transgender and nonbinary (trans) individuals unable to benefit from this resource. Deploying community-engaged PrEP implementation strategies for trans populations will be crucial for ending the HIV epidemic.

RECENT FINDINGS

While most PrEP studies have progressed in addressing pertinent research questions about gender-affirming care and PrEP at the biomedical and clinical levels, research on how to best implement gender-affirming PrEP systems at the social, community, and structural levels remains outstanding. The science of community-engaged implementation to build gender-affirming PrEP systems must be more fully developed. Most published PrEP studies with trans people report on outcomes rather than processes, leaving out important lessons learned about how to design, integrate, and implement PrEP in tandem with gender-affirming care. The expertise of trans scientists, stakeholders, and trans-led community organizations is essential to building gender-affirming PrEP systems.

Transgender-specific developmental milestones and associated experiences of violence, discrimination, and stigma among Filipinx transgender women who are sexually active with men

BACKGROUND

For transgender people, reaching transgender (trans)-specific developmental milestones, including recognizing and expressing one's identity, plays an integral role in overall health, wellbeing, and the pursuit of gender affirmation. Yet trans people continue to face minority stressors, including structural violence (i.e., discrimination, violence, and stigma), which may interfere with the achievement of these milestones. Among trans women specifically, however, potential associations between gender developmental milestones and structural violence are not well characterized in the literature. In a sample of Filipinx (i.e., an inclusive term for describing non-binary genders in the Philippines) trans women who are sexually active with men (trans-WSM), we thus sought to: (a) describe the mean ages at which gender developmental milestones occur and (b) examine the associations between structural violence and mean ages at which at which Filipinx trans-WSM experience trans-specific developmental milestones.

METHODS

Using data from Project #ParaSaAtin, an online survey of Filipinx trans-WSM (n = 139), we mapped age-estimates per trans-specific milestones and then tested whether structural violence is associated with the mean age at which trans women experience trans-specific developmental milestones.

RESULTS

Overall, participants who reported higher levels of discrimination, stigma, and violence also experienced a later age for nearly each milestone (i.e., initial self-awareness of transfeminine identity, transfeminine expression in private, transfeminine expression in public, first consensual oral/vaginal/anal sex with a cisgender male partner, first consensual oral/vaginal/anal sex with a cisgender male partner as a trans women, and hormone integration) (all p-values <0.05). Of note, the single exception to this pattern was the non-significant association between stigma and initial disclosure of transfeminine identification to another person.

CONCLUSION

Results are consistent with psychological literature outlining a temporal sequence of developmental milestones among young trans-WSM. For young trans-WSM in the Philippines, data from this study demonstrate significant associations between structural violence and the achievement of developmental milestones. These findings highlight the need for trauma-informed, strengths-based programming and institutional policies that measure and mitigate anti-trans violence.

Collective Coping Strategies for HIV-Related Challenges Among Men Who Have Sex With Men in Manila, Philippines

Contextual factors, such as cultures of collectivism versus individualism, shape HIV coping strategies; despite this, little research regarding collective coping strategies applied to HIV exists. This may be important for the growing HIV epidemic in the Philippines, which has a collectivistic culture and where men who have sex with men (MSM) account for a majority of the cases. Fifteen semistructured, in-depth interviews with HIV-positive MSM and 6 interviews with community-based organization workers were conducted between June and August 2017. Data were analyzed using thematic framework analysis. Three strategies were identified: peer support, spirituality, and support from existing relationships. Each form of collective coping had unique mechanisms and benefits for dealing with HIV. Overall, helping MSM with HIV find a collective identity after an HIV diagnosis enables management of HIV-related challenges. Policies and research interventions that improve access to collective identities for MSM with HIV may improve management of HIV-related challenges.

Predictors of PrEP awareness, PrEP discussion and interest in long-acting injectable PrEP among Filipina transfeminine adults

INTRODUCTION

Transfeminine adults are impacted by the HIV epidemic in the Philippines, and newly approved modalities of pre-exposure prophylaxis (PrEP), including long-acting injectable (LAI-PrEP), could be beneficial for this group. To inform implementation, we analysed PrEP awareness, discussion and interest in taking LAI-PrEP among Filipina transfeminine adults.

METHODS

We utilized secondary data from the #ParaSaAtin survey that sampled Filipina transfeminine adults (n = 139) and conducted a series of multivariable logistic regressions with lasso selection to explore factors independently associated with PrEP outcomes, including awareness, discussion with trans friends and interest in LAI-PrEP.

RESULTS

Overall, 53% of Filipina transfeminine respondents were aware of PrEP, 39% had discussed PrEP with their trans friends and 73% were interested in LAI-PrEP. PrEP awareness was associated with being non-Catholic (p = 0.017), having previously been HIV tested (p = 0.023), discussing HIV services with a provider (p<0.001) and having high HIV knowledge (p = 0.021). Discussing PrEP with friends was associated with older age (p = 0.040), having experienced healthcare discrimination due to transgender identity (p = 0.044), having HIV tested (p = 0.001) and having discussed HIV services with a provider (p < 0.001). Very interested in LAI-PrEP was associated with living in Central Visayas (p = 0.045), having discussed HIV services with a provider (p = 0.001) and having discussed HIV services with a sexual partner (p = 0.008).

CONCLUSIONS

Implementing LAI-PrEP in the Philippines requires addressing systemic improvements across personal, interpersonal, social and structural levels in healthcare access, including efforts to create healthcare settings and environments with providers who are trained and competent in transgender health and can address the social and structural drivers of trans health inequities, including HIV and barriers to LAI-PrEP.