WHO highlights transgender and HIV issues with new policy brief

7 October 2015 — Worldwide, transgender people are disproportionately affected by HIV compared to the general population. It is estimated that HIV prevalence among transgender women is 49 times higher than in the general adult population, with a pooled HIV prevalence of 19%1.

This can be attributed to a range of factors including sexual behaviour, culture, religion, and socioeconomic and legal impediments. These factors are 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 including gender-affirming care2, 3, 4.

According to Rafaelly Wiest, President of Brazilian Trans Group Marcela Prado and presenter at the International AIDS Society (IAS) Conference: "In many countries, transgender people experience stigma, discrimination and are seen as 'sick', and are then classified in a mental health category."

In 2014, with the launch of the Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations, WHO made a "remarkable imprint on history when it comes to transgender health and HIV advocacy among transgender women — in particular separating transgender people from men who have sex with men," in the words of Kate Montecarlo, founder and chair of the Association of Transgender People in the Philippines.

At the IAS Conference in Vancouver, Canada on 20 July 2015, WHO launched the first ever Policy brief: Transgender people and HIV. The launch was co-hosted by WHO, IAS, Linkages Across the Continuum of HIV Services for Key Populations Affected by HIV, the Pan-American Health Organization, the United Nations Population Fund, and the Center of Excellence for Transgender Health (CoE). This was one of the only events at the conference to cover the health-care needs of transgender people.

The WHO policy brief is intended as a resource for governments, donors and implementers, to help them identify what needs to be done to address HIV among transgender people. In particular, it provides a critical package of health services and strategies to create an enabling environment for transgender people, including decriminalization/legal recognition, addressing stigma and discrimination, empowering the community, and addressing violence.

Presenters at the conference highlighted that although it may seem like a small step, WHO’s policy brief and leadership are critical to moving transgender health issues forward.

JoAnne Keatley, Director of CoE who chaired the session, underscored that "the policy brief is a very positive first step and within WHO’s mission to educate governments on the health-care needs of transgender populations". Likewise, Ayden Scheim, a presenter and researcher on trans-men issues, stated: "What WHO is doing is important because there is finally attention to transgender people and health issues."

While the policy brief and session covered many critical issues and highlighted the progress that has been made, Montecarlo says, "there's more work to be done". And as Keatley notes, there is a need for many other "additional documents to provide governments with frameworks to help them role out country plans that focus on creating healthy communities that include transgender people."

Notably, the reality of the challenges and discrimination that transgender people face were highlighted leading up to the conference, and in the public response to the launch of the policy brief on social media. Two speakers, Po Kimani from Kenya and Kate Montecarlo from the Philippines, were originally scheduled to present, but were denied entry visas. Some people using social media voiced negative views toward transgender people and WHO.

In response, Keatley said, "The fact the visas were denied is a reflection of the transphobia that governments practice against trans-people." Such challenges need to be anticipated more in the future. It was suggested that guidance to international conference organizers and organizations needs to be disseminated to provide additional support.

As highlighted in the policy brief and conference session, more research and guidance is needed on how to work in legally constrained settings, to de-pathologize transgender identity, and to improve access to health care as a prerequisite for HIV prevention, diagnosis, treatment and care for transgender people. WHO hopes the new policy brief will help country policy-makers and the public gain better perspectives on the disproportionate HIV rates among transgender people, and the need to improve health-care services among this population, if we are to overcome the global burden of HIV.

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• Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C (2013). Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis. Mar;13(3):214-22. doi: 10.1016/S1473-3099(12)70315–8.
• Nemoto T, Operario D, Keatley J, Villegas D (2004). Social context of HIV risk behaviours among male-to-female transgenders of colour. AIDS Care. 16(6):724–35.
• Poteat T, Wirtz AL, Radix A, Borquez A, Silva-Santisteban A (2014). HIV risk and preventive interventions in transgender women sex workers. Lancet. 385(9964):274−286.
• Poteat T, Reisner SL, Radix A (2014). HIV epidemics among transgender women. Curr Opin HIV AIDS. 9(2):168–73.

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