The World Health Organisation has released a report offering guidance on HIV and other health issues for trans women, treating them as a separate group than ‘men who have sex with men’ for the first time. Read about some of its findings and recommendations for health care for trans men here The WHO says worldwide, transgender women bear an extraordinarily heavy burden of HIV, but have been neglected in the global HIV response: A systematic review and meta-analysis found a pooled HIV prevalence of 19 per cent among transgender women in the 15 countries with available, laboratory-confirmed data. Transgender women had odds of HIV infection 49 times greater than the general population. Country reports in the UNAIDS Gap Report 2014 suggest that HIV prevalence among transgender women sex workers is nine times higher than for non-transgender female sex workers and three times higher than for male sex workers . The WHO says HIV vulnerability among transgender people “is embedded in the structural contexts of stigma and discrimination in employment, education, housing and health care”. Many studies have demonstrated multiple co-occurring health problems among transgender women, including high rates of violence and victimization, substance use, sexual abuse and assault, and depression with suicidal ideation and attempts is associated with structural and social inequalities such as widespread stigma and discrimination, lack of access to identity documents that match gender expression, high prevalence of unemployment and underemployment, street-based sex work with low pay and no legal protections, homelessness and lack of access to health services, included gender-affirming care . The report says many transgender women have partners who are at high risk for HIV. It says trans women who seek psychological affirmation of their gender from partners may be more willing to have condomless sex, thereby increasing their vulnerability to HIV. It also points to research showing many trans people prioritise access to and use of hormone therapy over HIV care and treatment. “Therefore, access to hormone therapy is an important entry point into HIV care and treatment for transgender people.” Recommendations In a nutshell, the WHO says transgender people should have the same access to HIV care and treatment as other populations – and these services should be welcoming and competent in the care of transgender individuals. It says funding must be dedicated to interventions tailored for transgender people, particularly transgender women, who bear the brunt of the HIV disease burden. It is important for condoms and lubricants to be available for all transgender people who have penetrative sex, regardless of the gender identity of their sexual partners. Sexual behaviour and identity vary among transgender people, as it does in the non-transgender population. Condom programmes should avoid making assumptions about the sex of transgender people’s partners as well as about their sexual positioning or orientations. The global health advisory body says voluntary HIV testing and counselling should be routinely offered to transgender people in both the community and clinical settings. In addition to provider-initiated testing and counselling, community-based HIV testing and counselling is recommended and should be linked to prevention, care and treatment services. These services should be acceptable to and accessible by transgender people. Transgender people should be involved in the design and implementation of services. Services led by transgender people may be more acceptable to the community It says while several studies have demonstrated the efficacy of pre-exposure prophylaxis (PrEP) among men who have sex with men, the number of transgender women included in these studies was too small to determine if there are differences. However, where acceptable and appropriate, PrEP may be considered an additional intervention in the HIV prevention package for transgender women and particularly for transgender people who have sex with male partners and those who are in serodiscordant relationships. The organisation says the impact of stigma on mental health has been well documented. The stress of societal stigma and discrimination against transgender people, as well as the stigma of HIV, can lead to self-stigma and related mental health problems among transgender people living with HIV. Transgender people living with HIV should be screened routinely for mental health disorders and have access to appropriate management in a non-stigmatizing, gender-affirming setting with the clear understanding that transgender identity itself should not be considered a mental illness. The WHO also points out that transgender people have multiple health needs beyond HIV, and may be at higher risk of TB and viral hepatitis, so holistic care and screening are needed. It says healthcare providers should be sensitive to and knowledgeable about the specific sexual and reproductive health needs, concerns and desires of transgender people. Routine STI screening, diagnosis and treatment is an important part of comprehensive HIV prevention and care for transgender people. Taking a sexual history is an important part of performing an appropriate sexual health exam; it is particularly important when determining what parts of the body need to be screened for STIs. When discussing sexual practices, health-care providers should avoid making assumptions about the anatomy or sexual behaviour of transgender people. Open-ended questions allow for responses that the provider may not have anticipated. At the same time, it is important with transgender people, as with all others, to only ask questions that are relevant to providing health care to the person. Likewise, the physical exam should be conducted in a respectful, private setting and only when indicated. In particular, genital examination and specimen collection can be uncomfortable or upsetting, whether or not the person has undergone genital reconstructive surgery. Some transgender people may be uncomfortable with their anatomy or use terms to refer to their genitals that may be unfamiliar to the provider. Whenever possible and appropriate, providers should consider using language that the transgender person uses to describe themselves and their body. Many transgender people have been victims of physical and sexual violence and may find genital exams particularly difficult physically and psychologically. Health care providers should take this into consideration when providing care to transgender people. The WHO says healthcare systems need to be knowledgeable about transgender health issues and provide quality, respectful services to transgender people. It says access to comprehensive, integrated, quality health services, including HIV services, that respond to transgender needs must be improved. Services must respond to the particular health needs of transgender people, including integrated delivery of sound advice on safer gender-affirmation treatment and services, mental health and substance use. The specific needs of transgender people in terms of HIV prevention, diagnostic testing, treatment and care should be addressed, and the transgender community should be engaged in service provision. It says effective HIV prevention outreach programmes linking to HIV testing and treatment services are urgently needed in the transgender community. The WHO says governments and donors need to work together with transgender communities to develop and adequately fund an evidence-based national HIV plan that specifically addresses the needs of transgender people. Read the full WHO report here Stats collection in NZ In New Zealand, the AIDS Epidemiology Group at Otago University provides public information about people infected with HIV on a regular basis, with data collected by sex, means of infection and region. Transgender people are included with men who have sex with men. “The decision to include transsexuals with the males in the published figures was taken many years ago to avoid the possibility that individual transsexuals - if diagnosed with HIV - might feel identifiable in the published data,” explains Assistant Research Fellow Bible Lee. “In the early 1990s we reported one transsexual injecting drug user and had feedback that the person felt identified. We made a decision at that time not to provide a special category for transsexuals. We realise that the assignment of male is not necessarily correct.” Lee says a separate report from findings of a study of HIV prevalence among sexual health clinic attenders, did identify transsexual as a specific group, as there was no risk of perceived identification. NZAF services and outreach The NZAF's Shaun Robinson The New Zealand AIDS Foundation says it welcomes the WHO focus on transgender men and women. It says while there is always more that can be done, it’s confident its response to HIV in New Zealand is inclusive and responsive. “Developing inclusive and supportive communities is essential for building an HIV resilient New Zealand,” says Executive Director Shaun Robinson. “Our community development work, for example through the Hui Takatāpui and Love Life Fono, recognises that sexual minorities, including transgender people, are some of the communities most at risk of HIV and are often the silent voices. “There were specific transgender workshops at the 2014 Hui Takatāpui and these programmes provide the opportunity for transgender men and women to speak up and be heard,” Robinson says. “Our relationships with Sexual Health Services, Rainbow Youth, Outline and Transgender Support Network are also part of our response.” Robinson says transgender people are a priority group for the NZAF’s health services, alongside people living with HIV, gay and bisexual men, and heterosexual Africans. “We work with transgender community through all aspects of our work and recognise the well-being, identity and sexual health needs of transgender people. We welcome the focus that has been given to these issues by WHO and will continue to work with the Rainbow community, HIV and sexual health sectors to improve our support for transgender people.” Jacqui Stanford - 13th August 2015